Perinatal mortality has not decreased in type 1 diabetic pregnancies during the last 30 years. Fetal deaths are five times and neonatal deaths three times higher compared with the general population. Chronic intrauterine hypoxia caused by maternal diabetes is the most likely cause of stillbirths during the last weeks of pregnancy. Both fetal hyperglycemia and hyperinsulinemia can independently cause fetal chronic hypoxia by increasing fetal oxygen consumption. Fetal chronic hypoxia can be detected antenatally by measuring amniotic fluid erythropoietin concentration. Prepregnancy visits for advice and glycemic control should be increased among diabetic women. Furthermore, pregnancy surveillance should be enhanced and therapeutic strategies changed in order to improve perinatal outcome among diabetic pregnancies.