INS and Hyperglycemia: Metformin seems to be an effective alternative to insulin, if diet modification inadequately controls hyperglycaemia; however, supplemental insulin may be required in up to 50% of women.59 There is a need to cease further small RCTs in this area and conduct large well-designed RCTs that clarify the most effective treatment across a range of outcomes, including those that are likely to be important to women such as quality of life measurements and those identified by the Cochrane Pregnancy and Childbirth Group as being essential for trials and reviews of diabetes in pregnancy.