Because the metabolic changes in normal pregnancy are diabetogenic, pregnancy imposes a severe stress on the metabolic milieu of diabetic patients. Moreover, some patients with long-standing diabetes have vascular complications, including renal insufficiency and hypertension, that represent separate risk factors for optimal fetal development. During the past two to three decades, maternal mortality has been eliminated and perinatal deaths have been reduced in all classes of diabetic patients, including those with diabetic nephropathy, to a level approaching that of normal pregnant women. Fetal and neonatal morbidity have also been reduced, although rates of congenital abnormalities and respiratory disease syndrome remain high. In patients with significant vascular complications, such as nephropathy and retinopathy, pregnancy evidently does not alter the natural course of these complications. With meticulous metabolic control and fetal surveillance, however, women with diabetic nephropathy without severe renal insufficiency or severe hypertension can anticipate a pregnancy outcome similar to that of other insulin-dependent diabetic patients.