Type E: overt diabetes mellitus with calcified pelvic vessels.

Women who use insulin, with a history of stillbirth, or with hypertension are managed like women with overt diabetes.

About 80 million other Americans are insulin resistant to a lesser extent but have not yet developed overt diabetes, Dr. Goldfine said.

Dr. Kenneth J. Leveno, chief of obstetrics at Parkland Memorial Hospital, the public hospital that serves Dallas, said that midwives should not be allowed to supervise the second pregnancy of a woman who had overt diabetes in her first pregnancy.