76284506 Referat Jadi GDM

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Gestational Diabetes Mellitus Disusun Guna Memenuhi Tugas dan Melengkapi Syarat Dalam Menempuh Program

Studi Profesi Dokter

Disusun Oleh :

Rainy Anjani (030.06.208)

Pembimbing :

Letkol Kes dr. Zakaria, Sp. OG

RUMAH SAKIT PUSAT ANGKATAN UDARA

DOKTER ESNAWAN ANTARIKSA

FAKULTAS KEDOKTERAN UNIVERSITAS TRISAKTI

PERIODE 12 SEPTEMBER 2011 18 NOVEMBER 2011


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LEMBAR PENGESAHAN

Nama : Rainy Anjani

Fakultas : Kedokteran Umum

Tingkat : Universitas Trisakti Jakarta

Bidang Pendidikan : Ilmu Kandungan dan Kebidanan

Periode Kepaniteraan Klinik : 12 September 2011 18 November 2011

Judul : Diabetes Mellitus Gestasional

Diajukan : 11 November 2011

Pembimbing : Letkol Kes dr. Zakaria, Sp. OG

Telah Diperiksa dan Disahkan Tanggal Mengetahui :

Ketua SMF Ilmu Kandungan dan Kebidanan Pembimbing

RSPAU dr. Esnawan Antariksa Jakarta

Letkol Kes dr. Zakaria, Sp. OG Letkol Kes dr. Zakaria, Sp. OG


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DAFTAR ISI

LEMBAR PENGESAHAN ........................................................................................................................... ii

JOURNAL GESTATIONAL DIABETES MELLITUS

BACKGROUND ......................................................................................................................................... 1

EPIDEMIOLOGY ....................................................................................................................................... 2

CLASSIFICATION ...................................................................................................................................... 2

RISK FACTORS .......................................................................................................................................... 2

PATHOPHYSIOLOGY ................................................................................................................................ 3

SCREENING .............................................................................................................................................. 5

PATHWAYS .............................................................................................................................................. 6

MANAGEMENT........................................................................................................................................ 8

LIFESTYLE ................................................................................................................................................. 9

MEDICATION ........................................................................................................................................... 9

PROGNOSIS ........................................................................................................................................... 10

COMPLICATIONS ................................................................................................................................... 11

REFERENCES .......................................................................................................................................... 12

JURNAL DIABETES MELLITUS GESTASIONAL

KATA PENGANTAR................................................................................................................................... ii

BAB I ........................................................................................................................................................ 1

PENDAHULUAN ....................................................................................................................................... 1

BAB II ....................................................................................................................................................... 2

DIABETES MELLITUS GESTASIONAL ........................................................................................................ 2

II. 1. DEFINISI ........................................................................................................................................... 2

II. 2. EPIDEMIOLOGI ................................................................................................................................ 2

II. 3. KLASIFIKASI ...................................................................................................................................... 2

II. 4. FAKTOR RISIKO ................................................................................................................................ 3

II. 7. METODE SKRINING .......................................................................................................................... 7

II. 8. MANAJEMEN ................................................................................................................................. 10


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II. 9. GAYA HIDUP .................................................................................................................................. 10

II. 1O. MEDIKASI .................................................................................................................................... 11

II. 11. PROGNOSIS ................................................................................................................................. 12

II. 12. KOMPLIKASI................................................................................................................................. 13


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Gestational Diabetes Mellitus

Thomas A. Buchanan 1 and Anny H. Xiang 2 1Departments of Medicine, Obstetrics and Gynecology, and Physiology andBiophysics, and2Department of Preventive Medicine, University of Southern California Keck Schoolof Medicine, Los Angeles, California, USA.

Address correspondence to: Thomas A. Buchanan, Room 6602 GNH, 1200 NorthState Street, Los Angeles, California 90089-9317, USA. Phone: (323) 226-4632;Fax: (323) 226-2796; E-mail: [email protected].

Published March 1, 2005

Gestational diabetes (or gestational diabetes mellitus, GDM) is a condition in whichwomen without previously diagnosed diabetes exhibit high blood glucose levelsduring pregnancy (especially during third trimester of pregnancy). Gestationaldiabetes is caused when the body of a pregnant woman does not secrete excessinsulin required during pregnancy leading to increased blood sugar levels. [1]

Gestational diabetes generally has few symptoms and it is most commonlydiagnosed by screening during pregnancy. Diagnostic tests detect inappropriatelyhigh levels of glucose in blood samples. Gestational diabetes affects 3-10% ofpregnancies, depending on the population studied .[2]

As with diabetes mellitus in pregnancy in general, babies born to mothers withgestational diabetes are typically at increased risk of problems such as being largefor gestational age (which may lead to delivery complications), low blood sugar, and jaundice. Gestational diabetes is a treatable condition and women who haveadequate control of glucose levels can effectively decrease these risks.

Women with gestational diabetes are at increased risk of developing type 2 diabetesmellitus (or, very rarely, latent autoimmune diabetes or Type 1) after pregnancy, aswell as having a higher incidence of pre-eclampsia and caesarean section ;[3] theiroffspring are prone to developing childhood obesity, with type 2 diabetes later in life.Most patients are treated only with diet modification and moderate exercise but sometake anti-diabetic drugs, including insulin .[3]
http://en.wikipedia.org/wiki/Diabetes_mellitushttp://en.wikipedia.org/wiki/Hyperglycemiahttp://en.wikipedia.org/wiki/Pregnancyhttp://en.wikipedia.org/wiki/Symptomshttp://en.wikipedia.org/wiki/Screening_(medicine)http://en.wikipedia.org/wiki/Glucosehttp://en.wikipedia.org/wiki/Gestational_diabetes#cite_note-emedicine-1http://en.wikipedia.org/wiki/Gestational_diabetes#cite_note-emedicine-1http://en.wikipedia.org/wiki/Gestational_diabetes#cite_note-emedicine-1http://en.wikipedia.org/wiki/Diabetes_mellitus_in_pregnancyhttp://en.wikipedia.org/wiki/Macrosomiahttp://en.wikipedia.org/wiki/Macrosomiahttp://en.wikipedia.org/wiki/Hypoglycemiahttp://en.wikipedia.org/wiki/Jaundicehttp://en.wikipedia.org/wiki/Glycemic_controlhttp://en.wikipedia.org/wiki/Type_2_diabetes_mellitushttp://en.wikipedia.org/wiki/Type_2_diabetes_mellitushttp://en.wikipedia.org/wiki/Latent_autoimmune_diabeteshttp://en.wikipedia.org/wiki/Diabetes_mellitus_type_1http://en.wikipedia.org/wiki/Pre-eclampsiahttp://en.wikipedia.org/wiki/Caesarean_sectionhttp://en.wikipedia.org/wiki/Gestational_diabetes#cite_note-ap01-2http://en.wikipedia.org/wiki/Gestational_diabetes#cite_note-ap01-2http://en.wikipedia.org/wiki/Gestational_diabetes#cite_note-ap01-2http://en.wikipedia.org/wiki/Childhood_obesityhttp://en.wikipedia.org/wiki/Type_2_diabeteshttp://en.wikipedia.org/wiki/Anti-diabetic_drugshttp://en.wikipedia.org/wiki/Insulinhttp://en.wikipedia.org/wiki/Gestational_diabetes#cite_note-ap01-2http://en.wikipedia.org/wiki/Gestational_diabetes#cite_note-ap01-2http://en.wikipedia.org/wiki/Gestational_diabetes#cite_note-ap01-2http://en.wikipedia.org/wiki/Gestational_diabetes#cite_note-ap01-2http://en.wikipedia.org/wiki/Insulinhttp://en.wikipedia.org/wiki/Anti-diabetic_drugshttp://en.wikipedia.org/wiki/Type_2_diabeteshttp://en.wikipedia.org/wiki/Childhood_obesityhttp://en.wikipedia.org/wiki/Gestational_diabetes#cite_note-ap01-2http://en.wikipedia.org/wiki/Caesarean_sectionhttp://en.wikipedia.org/wiki/Pre-eclampsiahttp://en.wikipedia.org/wiki/Diabetes_mellitus_type_1http://en.wikipedia.org/wiki/Latent_autoimmune_diabeteshttp://en.wikipedia.org/wiki/Type_2_diabetes_mellitushttp://en.wikipedia.org/wiki/Type_2_diabetes_mellitushttp://en.wikipedia.org/wiki/Glycemic_controlhttp://en.wikipedia.org/wiki/Jaundicehttp://en.wikipedia.org/wiki/Hypoglycemiahttp://en.wikipedia.org/wiki/Macrosomiahttp://en.wikipedia.org/wiki/Macrosomiahttp://en.wikipedia.org/wiki/Diabetes_mellitus_in_pregnancyhttp://en.wikipedia.org/wiki/Gestational_diabetes#cite_note-emedicine-1http://en.wikipedia.org/wiki/Glucosehttp://en.wikipedia.org/wiki/Screening_(medicine)http://en.wikipedia.org/wiki/Symptomshttp://en.wikipedia.org/wiki/Pregnancyhttp://en.wikipedia.org/wiki/Hyperglycemiahttp://en.wikipedia.org/wiki/Diabetes_mellitus


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Epidemiology

Gestational diabetes affects 3-10% of pregnancies, depending on the populationstudied .[2]

Classification

Gestational diabetes is formally defined as "any degree of glucose intolerance withonset or first recognition during pregnancy". This definition acknowledges thepossibility that patients may have previously undiagnosed diabetes mellitus, or mayhave developed diabetes coincidentally with pregnancy. Whether symptoms subsideafter pregnancy is also irrelevant to the diagnosis. [4][5]

The White classification, named after Priscilla White [6] who pioneered in research on

the effect of diabetes types on perinatal outcome, is widely used to assess maternaland fetal risk. It distinguishes between gestational diabetes (type A) and diabetesthat existed prior to pregnancy (pregestational diabetes). These two groups arefurther subdivided according to their associated risks and management .[7]

There are 2 subtypes of gestational diabetes (diabetes which began duringpregnancy):

Type A1: abnormal oral glucose tolerance test (OGTT) but normal blood glucoselevels during fasting and 2 hours after meals; diet modification is sufficient tocontrol glucose levels

Type A2: abnormal OGTT compounded by abnormal glucose levels duringfasting and/or after meals; additional therapy with insulin or other medications isrequired

Risk Factors

Classical risk factors for developing gestational diabetes are the following :[8][9]

A previous diagnosis of gestational diabetes or prediabetes, impaired glucosetolerance, or impaired fasting glycaemia

A family history revealing a first degree relative with type 2 diabetes Maternal age - a woman's risk factor increases as she gets older (especially for

women over 35 years of age) Ethnic background (those with higher risk factors include African-

Americans, Afro-Caribbeans, Native Americans, Hispanics, Pacific Islanders, andpeople originating from South Asia)

Being overweight, obese or severely obese increases the risk by a factor 2.1, 3.6and 8.6, respectively.
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A previous pregnancy which resulted in a child with a high birth weight (>90thcentile, or >4000 g (8 lbs 12.8 oz))

In addition to this, statistics show a double risk of GDM in smokers. Polycysticovarian syndrome is also a risk factor, although relevant evidence remainscontroversial. Some studies have looked at more controversial potential risk factors,such as short stature. [8][10 ][11][12]

About 40-60% of women with GDM have no demonstrable risk factor; for this reasonmany advocate to screen all women. Typically women with gestational diabetesexhibit no symptoms (another reason for universal screening), but some women maydemonstrate increased thirst, increased urination, fatigue, nausea and vomiting, bladder infection, and blurred

vision .[13]

Pathophysiology

Effect of insulin on glucose uptake and metabolism. Insulin binds to its receptor(1) on the cell membrane which in turn starts many protein activation cascades(2). These include: translocation of Glut-4 transporter to the plasmamembrane and influx of glucose (3), glycogen synthesis (4), glycolysis (5)and fatty acid synthesis (6).

The precise mechanisms underlying gestational diabetes remain unknown. Thehallmark of GDM is increased insulin resistance. Pregnancy hormones and otherfactors are thought to interfere with the action of insulin as it binds to the insulinreceptor. The interference probably occurs at the level of the cell signaling pathway

behind the insulin receptor. Since insulin promotes the entry of glucose into mostcells, insulin resistance prevents glucose from entering the cells properly. As a
http://en.wikipedia.org/wiki/Smokinghttp://en.wikipedia.org/wiki/Polycystic_ovarian_syndromehttp://en.wikipedia.org/wiki/Polycystic_ovarian_syndromehttp://en.wikipedia.org/wiki/Short_staturehttp://en.wikipedia.org/wiki/Gestational_diabetes#cite_note-ACHOISreview-7http://en.wikipedia.org/wiki/Gestational_diabetes#cite_note-ACHOISreview-7http://en.wikipedia.org/wiki/Gestational_diabetes#cite_note-controversial-10http://en.wikipedia.org/wiki/Gestational_diabetes#cite_note-controversial-10http://en.wikipedia.org/wiki/Thirsthttp://en.wikipedia.org/wiki/Urinationhttp://en.wikipedia.org/wiki/Fatigue_(medical)http://en.wikipedia.org/wiki/Nauseahttp://en.wikipedia.org/wiki/Vomitinghttp://en.wikipedia.org/wiki/Cystitishttp://en.wikipedia.org/wiki/Blurred_visionhttp://en.wikipedia.org/wiki/Blurred_visionhttp://en.wikipedia.org/wiki/Gestational_diabetes#cite_note-precis-12http://en.wikipedia.org/wiki/Gestational_diabetes#cite_note-precis-12http://en.wikipedia.org/wiki/Gestational_diabetes#cite_note-precis-12http://en.wikipedia.org/wiki/Plasma_membranehttp://en.wikipedia.org/wiki/Plasma_membranehttp://en.wikipedia.org/wiki/Glycogenhttp://en.wikipedia.org/wiki/Glycolysishttp://en.wikipedia.org/wiki/Fatty_acidhttp://en.wikipedia.org/wiki/Insulin_resistancehttp://en.wikipedia.org/wiki/Insulin_receptorhttp://en.wikipedia.org/wiki/Insulin_receptorhttp://en.wikipedia.org/wiki/Cell_signalinghttp://en.wikipedia.org/wiki/Cell_signalinghttp://en.wikipedia.org/wiki/Insulin_receptorhttp://en.wikipedia.org/wiki/Insulin_receptorhttp://en.wikipedia.org/wiki/Insulin_resistancehttp://en.wikipedia.org/wiki/Fatty_acidhttp://en.wikipedia.org/wiki/Glycolysishttp://en.wikipedia.org/wiki/Glycogenhttp://en.wikipedia.org/wiki/Plasma_membranehttp://en.wikipedia.org/wiki/Plasma_membranehttp://en.wikipedia.org/wiki/Gestational_diabetes#cite_note-precis-12http://en.wikipedia.org/wiki/Blurred_visionhttp://en.wikipedia.org/wiki/Blurred_visionhttp://en.wikipedia.org/wiki/Cystitishttp://en.wikipedia.org/wiki/Vomitinghttp://en.wikipedia.org/wiki/Nauseahttp://en.wikipedia.org/wiki/Fatigue_(medical)http://en.wikipedia.org/wiki/Urinationhttp://en.wikipedia.org/wiki/Thirsthttp://en.wikipedia.org/wiki/Gestational_diabetes#cite_note-controversial-10http://en.wikipedia.org/wiki/Gestational_diabetes#cite_note-controversial-10http://en.wikipedia.org/wiki/Gestational_diabetes#cite_note-ACHOISreview-7http://en.wikipedia.org/wiki/Gestational_diabetes#cite_note-ACHOISreview-7http://en.wikipedia.org/wiki/Short_staturehttp://en.wikipedia.org/wiki/Polycystic_ovarian_syndromehttp://en.wikipedia.org/wiki/Polycystic_ovarian_syndromehttp://en.wikipedia.org/wiki/Smoking


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result, glucose remains in the bloodstream, where glucose levels rise. More insulin isneeded to overcome this resistance; about 1.5-2.5 times more insulin is producedthan in a normal pregnancy .[14]

Insulin resistance is a normal phenomenon emerging in the second trimester ofpregnancy, which progresses thereafter to levels seen in non-pregnant patients withtype 2 diabetes. It is thought to secure glucose supply to the growing fetus. Womenwith GDM have an insulin resistance they cannot compensate with increasedproduction in the -cells of the pancreas. Placental hormones, and to a lesser extentincreased fat deposits during pregnancy, seem to mediate insulin resistance duringpregnancy. Cortisol and progesterone are the main culprits, but human placentallactogen, prolactin and estradiol contribute too .[14]

It is unclear why some patients are unable to balance insulin needs and developGDM, however a number of explanations have been given, similar to those in type 2diabetes: autoimmunity, single gene mutations, obesity, and other mechanisms .[15]

Because glucose travels across the placenta (through diffusionfacilitated by GLUT3 carriers), the fetus is exposed to higher glucose levels. Thisleads to increased fetal levels of insulin (insulin itself cannot cross the placenta). Thegrowth-stimulating effects of insulin can lead to excessive growth and a large body(macrosomia) . After birth, the high glucose environment disappears, leaving thesenewborns with ongoing high insulin production and susceptibility to low bloodglucose levels (hypoglycemia) .[16]
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Screening

2006 WHO Diabetes criteria[17]

Condition2 hour glucose

mmol/l(mg/dl)

Fasting glucose

mmol/l(mg/dl)

Normal


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Oral glucose tolerance test (OGTT)

Non-challenge blood glucose tests involve measuring glucose levels in bloodsamples without challenging the subject with glucose solutions. A blood glucoselevel is determined when fasting, 2 hours after a meal, or simply at any random time.In contrast, challenge tests involve drinking a glucose solution and measuringglucose concentration thereafter in the blood; in diabetes, they tend to remain high.The glucose solution has a very sweet taste which some women find unpleasant;sometimes, therefore, artificial flavours are added. Some women may experiencenausea during the test, and more so with higher glucose levels .[18][19]

Pathways

There are different opinions about optimal screening and diagnostic measures, inpart due to differences in population risks, cost-effectiveness considerations, andlack of an evidence base to support large national screening programs. The mostelaborate regime entails a random blood glucose test during a booking visit, ascreening glucose challenge test around 24 28 weeks' gestation, followed by anOGTT if the tests are outside normal limits. If there is a high suspicion, women maybe tested earlier .[5][20]

In the United States, most obstetricians prefer universal screening with a screeningglucose challenge test. In the United Kingdom, obstetric units often rely on risk

factors and a random blood glucose test. The American Diabetes Association andthe Society of Obstetricians and Gynaecologists of Canada recommend routinescreening unless the patient is low risk (this means the woman must be youngerthan 25 years and have a body mass index less than 27, with no personal, ethnic orfamily risk factors) The Canadian Diabetes Association and the American College ofObstetricians and Gynecologists recommend universal screening. The U.S.Preventive Services Task Force found that there is insufficient evidence torecommend for or against routine screening .[5][16 ][20][21 ][22][23 ][24][25]

Non-Challenge Blood Glucose Tests

When a plasma glucose level is found to be higher than 126 mg/dl (7.0 mmol/l) afterfasting, or over 200 mg/dl (11.1 mmol/l) on any occasion, and if this is confirmed ona subsequent day, the diagnosis of GDM is made, and no further testing is required.These tests are typically performed at the first antenatal visit. They are patient-friendly and inexpensive, but have a lower test performance compared to the othertests, with moderate sensitivity, low specificity and high false positive rates. [5][26 ][27][28]
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Screening Glucose Challenge Test

The screening glucose challenge test (sometimes called the O'Sullivan test) isperformed between 24 28 weeks, and can be seen as a simplified version of the oralglucose tolerance test (OGTT). It involves drinking a solution containing 50 grams ofglucose, and measuring blood levels 1 hour later .[29]

If the cut-off point is set at 140 mg/dl (7.8 mmol/l), 80% of women with GDM will bedetected. If this threshold for further testing is lowered to 130 mg/dl, 90% of GDMcases will be detected, but there will also be more women who will be subjected to aconsequent OGTT unnecessarily .[5]

Oral Glucose Tolerance Test

The OGTT should be done in the morning after an overnight fast of between 8 and14 hours. During the three previous days the subject must have an unrestricted diet(containing at least 150 g carbohydrate per day) and unlimited physical activity. Thesubject should remain seated during the test and should not smoke throughout thetest. [30]

The test involves drinking a solution containing a certain amount of glucose, anddrawing blood to measure glucose levels at the start and on set time intervals

thereafter .[30] The diagnostic criteria from the National Diabetes Data Group (NDDG) have beenused most often, but some centers rely on the Carpenter and Coustan criteria, whichset the cutoff for normal at lower values. Compared with the NDDG criteria, theCarpenter and Coustan criteria lead to a diagnosis of gestational diabetes in 54percent more pregnant women, with an increased cost and no compelling evidenceof improved perinatal outcomes .[31]

The following are the values which the American Diabetes Association considers to

be abnormal during the 100 g of glucose OGTT:

Fasting blood glucose level 95 mg/dl (5.33 mmol/L) 1 hour blood glucose level 180 mg/dl (10 mmol/L) 2 hour blood glucose level 155 mg/dl (8.6 mmol/L) 3 hour blood glucose level 140 mg/dl (7.8 mmol/L)

An alternative test uses a 75 g glucose load and measures the blood glucose levelsbefore and after 1 and 2 hours, using the same reference values. This test will
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identify fewer women who are at risk, and there is only a weak concordance(agreement rate) between this test and a 3 hour 100 g test .[32]

The glucose values used to detect gestational diabetes were first determined byO'Sullivan and Mahan (1964) in a retrospective cohort study( using a 100 grams ofglucose OGTT) designed to detect risk of developing type 2 diabetes in the future.The values were set using whole blood and required two values reaching orexceeding the value to be positive .[33] Subsequent information led to alterations inO'Sullivan's criteria. When methods for blood glucose determination changed fromthe use of whole blood to venous plasma samples, the criteria for GDM were alsochanged.

Urinary Glucose Testing

Women with GDM may have high glucose levels in their urine (glucosuria) . Although dipstick testing is widely practiced, it performs poorly, and discontinuingroutine dipstick testing has not been shown to cause underdiagnosis where universalscreening is performed. Increased glomerular filtration rates during pregnancycontribute to some 50% of women having glucose in their urine on dipstick tests atsome point during their pregnancy. The sensitivity of glucosuria for GDM in the first 2trimesters is only around 10% and the positive predictive value is around20% .[34][35 ][36]

Management

The goal of treatment is to reduce the risks of GDM for mother and child. Scientificevidence is beginning to show that controlling glucose levels can result in lessserious fetal complications (such as macrosomia) and increased maternal quality oflife. Unfortunately, treatment of GDM is also accompanied by more infants admittedto neonatal wards and more inductions of labour, with no proven decreasein cesarean section rates or perinatal mortality. These findings are still recent andcontroversial. [37][38 ][39]

A repeat OGTT should be carried out 2 4 months after delivery, to confirm thediabetes has disappeared. Afterwards, regular screening for type 2 diabetes isadvised .[8]

If a diabetic diet or G.I. Diet, exercise, and oral medication are inadequate to controlglucose levels, insulin therapy may become necessary.

The development of macrosomia can be evaluated during pregnancy byusing sonography. Women who use insulin, with a history of stillbirth, or withhypertension are managed like women with overt diabetes .[13]
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Lifestyle

Counselling before pregnancy (for example, about preventive folic acid supplements)and multidisciplinary management are important for good pregnancy outcomes. Mostwomen can manage their GDM with dietary changes and exercise. Self monitoring ofblood glucose levels can guide therapy. Some women will need antidiabetic drugs, most commonly insulin therapy .[40]

Any diet needs to provide sufficient calories for pregnancy, typically 2,000 - 2,500kcal with the exclusion of simple carbohydrates. The main goal of dietary

modifications is to avoid peaks in blood sugar levels. This can be done by spreadingcarbohydrate intake over meals and snacks throughout the day, and using slow-release carbohydrate sources known as the G.I. Diet. Since insulin resistance ishighest in mornings, breakfast carbohydrates need to be restricted more. Ingestingmore fiber in foods with whole grains, or fruit and vegetables can also reduce the riskof gestational diabetes. [8][13 ][41]

Regular moderately intense physical exercise is advised, although there is noconsensus on the specific structure of exercise programs for GDM . [8][42]

Self monitoring can be accomplished using a handheld capillary glucose dosagesystem. Compliance with these glucometer systems can be low. Target rangesadvised by the Australasian Diabetes in Pregnancy Society are as follows :[8] [43]

fasting capillary blood glucose levels


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avoid low blood sugar levels (hypoglycemia) due to excessive insulin injections.Insulin therapy can be normal or very tight; more injections can result in bettercontrol but requires more effort, and there is no consensus that it has large benefits. [8][16 ][45][46]

There is some evidence that certain oral glycemic agents might be safe inpregnancy, or at least, are significantly less dangerous to the developing fetus thanpoorly controlled diabetes. Glyburide, a second generation sulfonylurea, has beenshown to be an effective alternative to insulin therapy. In one study, 4% of womenneeded supplemental insulin to reach blood sugar targets .Metformin has shownpromising results, with its oral format being much more popular than insulininjections.Treatment of polycystic ovarian syndrome with metformin duringpregnancy has been noted to decrease GDM levels. A recent randomized controlledtrial of metformin versus insulin showed that women preferred metformin tablets to

insulin injections, and that metformin is safe and equally effective asinsulin .[50] Severe neonatal hypoglycemia was less common in insulin-treatedwomen, but preterm delivery was more common. Almost half of patients did notreach sufficient control with metformin alone and needed supplemental therapy withinsulin; compared to those treated with insulin alone, they required less insulin, andthey gained less weight. With no long-term studies into children of women treatedwith the drug, here remains a possibility of long-term complications from metformintherapy, although follow-up at the age of 18 months of children born to womenwith polycystic ovarian syndrome and treated with metformin revealed no

developmental abnormalities .[3][47 ][48][49 ][50][51]

Prognosis

Gestational diabetes generally resolves once the baby is born. Based on differentstudies, the chances of developing GDM in a second pregnancy are between 30 and84%, depending on ethnic background. A second pregnancy within 1 year of theprevious pregnancy has a high rate of recurrence .[52]

Women diagnosed with gestational diabetes have an increased risk of developingdiabetes mellitus in the future. The risk is highest in women who needed insulintreatment, had antibodies associated with diabetes (such as antibodiesagainst glutamate decarboxylase, islet cell antibodies and/or insulinoma antigen-2) ,women with more than two previous pregnancies, and women who were obese (inorder of importance). Women requiring insulin to manage gestational diabetes havea 50% risk of developing diabetes within the next five years. Depending on thepopulation studied, the diagnostic criteria and the length of follow-up, the risk canvary enormously. The risk appears to be highest in the first 5 years, reaching aplateau thereafter.One of the longest studies followed a group of womenfrom Boston, Massachusetts; half of them developed diabetes after 6 years, and
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more than 70% had diabetes after 28 years. In a retrospective studyin Navajo women, the risk of diabetes after GDM was estimated to be 50 to 70%after 11 years. Another study found a risk of diabetes after GDM of more than 25%after 15 years. In populations with a low risk for type 2 diabetes, in lean subjects and

in patients with auto-antibodies, there is a higher rate of women developing type 1diabetes. [33][53 ][54][55 ][56][57]

Children of women with GDM have an increased risk for childhood and adult obesityand an increased risk of glucose intolerance and type 2 diabetes later in life . [58] Thisrisk relates to increased maternal glucose values .[59] It is currently unclear how muchgenetic susceptibility and environmental factors each contribute to this risk, and iftreatment of GDM can influence this outcome .[60]

There are scarce statistical data on the risk of other conditions in women with GDM;in the Jerusalem Perinatal study, 410 out of 37962 patients were reported to haveGDM, and there was a tendency towards more breast and pancreatic cancer, butmore research is neede d to confirm this finding .[61][62]

Complications

GDM poses a risk to mother and child. This risk is largely related to high bloodglucose levels and its consequences. The risk increases with higher blood glucoselevels .[63] Treatment resulting in better control of these levels can reduce some of the

risks of GDM considerably .[43]

The two main risks GDM imposes on the baby are growth abnormalities andchemical imbalances after birth, which may require admission to a neonatal intensivecare unit. Infants born to mothers with GDM are at risk of being both large forgestational age (macrosomic )[63] and small for gestational age. Macrosomia in turnincreases the risk of instrumental deliveries (e.g. forceps, ventouse and caesareansection) or problems during vaginal delivery (such as shoulder dystocia) .Macrosomia may affect 12% of normal women compared to 20% of patients withGDM .[16] However, the evidence for each of these complications is not equally

strong; in the Hyperglycemia and Adverse Pregnancy Outcome (HAPO) study forexample, there was an increased risk for babies to be large but not small forgestational age .[63] Research into complications for GDM is difficult because of themany confounding factors (such as obesity). Labelling a woman as having GDM mayin it self increase the risk of having a caesarean section .[64][65]

Neonates are also at an increased risk of low blood glucose(hypoglycemia) , jaundice, high red blood cell mass (polycythemia) and low bloodcalcium (hypocalcemia) and magnesium (hypomagnesemia) .[66] GDM also interfereswith maturation, causing dysmature babies prone to respiratory distresssyndrome due to incomplete lung maturation and impaired surfactant synthesis .[66]
http://en.wikipedia.org/wiki/Navajo_peoplehttp://en.wikipedia.org/wiki/Type_2_diabeteshttp://en.wikipedia.org/wiki/Autoimmunityhttp://en.wikipedia.org/wiki/Type_1_diabeteshttp://en.wikipedia.org/wiki/Type_1_diabeteshttp://en.wikipedia.org/wiki/Gestational_diabetes#cite_note-AMN-32http://en.wikipedia.org/wiki/Gestational_diabetes#cite_note-AMN-32http://en.wikipedia.org/wiki/Gestational_diabetes#cite_note-antibodies-53http://en.wikipedia.org/wiki/Gestational_diabetes#cite_note-Navajo-55http://en.wikipedia.org/wiki/Gestational_diabetes#cite_note-Navajo-55http://en.wikipedia.org/wiki/Gestational_diabetes#cite_note-Metabolicsyndrome-57http://en.wikipedia.org/wiki/Gestational_diabetes#cite_note-Metabolicsyndrome-57http://en.wikipedia.org/wiki/Gestational_diabetes#cite_note-Metabolicsyndrome-57http://en.wikipedia.org/wiki/Gestational_diabetes#cite_note-imprinting-58http://en.wikipedia.org/wiki/Gestational_diabetes#cite_note-imprinting-58http://en.wikipedia.org/wiki/Gestational_diabetes#cite_note-imprinting-58http://en.wikipedia.org/wiki/Gestational_diabetes#cite_note-long-term-59http://en.wikipedia.org/wiki/Gestational_diabetes#cite_note-long-term-59http://en.wikipedia.org/wiki/Gestational_diabetes#cite_note-long-term-59http://en.wikipedia.org/wiki/Gestational_diabetes#cite_note-breast-60http://en.wikipedia.org/wiki/Gestational_diabetes#cite_note-breast-60http://en.wikipedia.org/wiki/Gestational_diabetes#cite_note-breast-60http://en.wikipedia.org/wiki/Gestational_diabetes#cite_note-HAPO2008-62http://en.wikipedia.org/wiki/Gestational_diabetes#cite_note-HAPO2008-62http://en.wikipedia.org/wiki/Gestational_diabetes#cite_note-HAPO2008-62http://en.wikipedia.org/wiki/Gestational_diabetes#cite_note-Langer1994-42http://en.wikipedia.org/wiki/Gestational_diabetes#cite_note-Langer1994-42http://en.wikipedia.org/wiki/Gestational_diabetes#cite_note-Langer1994-42http://en.wikipedia.org/wiki/Neonatal_intensive_care_unithttp://en.wikipedia.org/wiki/Neonatal_intensive_care_unithttp://en.wikipedia.org/wiki/Large_for_gestational_agehttp://en.wikipedia.org/wiki/Large_for_gestational_agehttp://en.wikipedia.org/wiki/Gestational_diabetes#cite_note-HAPO2008-62http://en.wikipedia.org/wiki/Gestational_diabetes#cite_note-HAPO2008-62http://en.wikipedia.org/wiki/Gestational_diabetes#cite_note-HAPO2008-62http://en.wikipedia.org/wiki/Small_for_gestational_agehttp://en.wikipedia.org/wiki/Forcepshttp://en.wikipedia.org/wiki/Ventousehttp://en.wikipedia.org/wiki/Caesarean_sectionhttp://en.wikipedia.org/wiki/Caesarean_sectionhttp://en.wikipedia.org/wiki/Shoulder_dystociahttp://en.wikipedia.org/wiki/Gestational_diabetes#cite_note-controversies-15http://en.wikipedia.org/wiki/Gestational_diabetes#cite_note-controversies-15http://en.wikipedia.org/wiki/Gestational_diabetes#cite_note-controversies-15http://en.wikipedia.org/wiki/Gestational_diabetes#cite_note-HAPO2008-62http://en.wikipedia.org/wiki/Gestational_diabetes#cite_note-HAPO2008-62http://en.wikipedia.org/wiki/Gestational_diabetes#cite_note-HAPO2008-62http://en.wikipedia.org/wiki/Gestational_diabetes#cite_note-Toronto-63http://en.wikipedia.org/wiki/Gestational_diabetes#cite_note-Toronto-63http://en.wikipedia.org/wiki/Gestational_diabetes#cite_note-Toronto-63http://en.wikipedia.org/wiki/Hypoglycemiahttp://en.wikipedia.org/wiki/Jaundicehttp://en.wikipedia.org/wiki/Red_blood_cellhttp://en.wikipedia.org/wiki/Polycythemiahttp://en.wikipedia.org/wiki/Hypocalcemiahttp://en.wikipedia.org/wiki/Hypomagnesemiahttp://en.wikipedia.org/wiki/Gestational_diabetes#cite_note-impactneonate-65http://en.wikipedia.org/wiki/Gestational_diabetes#cite_note-impactneonate-65http://en.wikipedia.org/wiki/Gestational_diabetes#cite_note-impactneonate-65http://en.wikipedia.org/wiki/Respiratory_distress_syndromehttp://en.wikipedia.org/wiki/Respiratory_distress_syndromehttp://en.wikipedia.org/wiki/Surfactanthttp://en.wikipedia.org/wiki/Gestational_diabetes#cite_note-impactneonate-65http://en.wikipedia.org/wiki/Gestational_diabetes#cite_note-impactneonate-65http://en.wikipedia.org/wiki/Gestational_diabetes#cite_note-impactneonate-65http://en.wikipedia.org/wiki/Gestational_diabetes#cite_note-impactneonate-65http://en.wikipedia.org/wiki/Surfactanthttp://en.wikipedia.org/wiki/Respiratory_distress_syndromehttp://en.wikipedia.org/wiki/Respiratory_distress_syndromehttp://en.wikipedia.org/wiki/Gestational_diabetes#cite_note-impactneonate-65http://en.wikipedia.org/wiki/Hypomagnesemiahttp://en.wikipedia.org/wiki/Hypocalcemiahttp://en.wikipedia.org/wiki/Polycythemiahttp://en.wikipedia.org/wiki/Red_blood_cellhttp://en.wikipedia.org/wiki/Jaundicehttp://en.wikipedia.org/wiki/Hypoglycemiahttp://en.wikipedia.org/wiki/Gestational_diabetes#cite_note-Toronto-63http://en.wikipedia.org/wiki/Gestational_diabetes#cite_note-Toronto-63http://en.wikipedia.org/wiki/Gestational_diabetes#cite_note-HAPO2008-62http://en.wikipedia.org/wiki/Gestational_diabetes#cite_note-controversies-15http://en.wikipedia.org/wiki/Shoulder_dystociahttp://en.wikipedia.org/wiki/Caesarean_sectionhttp://en.wikipedia.org/wiki/Caesarean_sectionhttp://en.wikipedia.org/wiki/Ventousehttp://en.wikipedia.org/wiki/Forcepshttp://en.wikipedia.org/wiki/Small_for_gestational_agehttp://en.wikipedia.org/wiki/Gestational_diabetes#cite_note-HAPO2008-62http://en.wikipedia.org/wiki/Large_for_gestational_agehttp://en.wikipedia.org/wiki/Large_for_gestational_agehttp://en.wikipedia.org/wiki/Neonatal_intensive_care_unithttp://en.wikipedia.org/wiki/Neonatal_intensive_care_unithttp://en.wikipedia.org/wiki/Gestational_diabetes#cite_note-Langer1994-42http://en.wikipedia.org/wiki/Gestational_diabetes#cite_note-HAPO2008-62http://en.wikipedia.org/wiki/Gestational_diabetes#cite_note-breast-60http://en.wikipedia.org/wiki/Gestational_diabetes#cite_note-breast-60http://en.wikipedia.org/wiki/Gestational_diabetes#cite_note-long-term-59http://en.wikipedia.org/wiki/Gestational_diabetes#cite_note-imprinting-58http://en.wikipedia.org/wiki/Gestational_diabetes#cite_note-Metabolicsyndrome-57http://en.wikipedia.org/wiki/Gestational_diabetes#cite_note-Navajo-55http://en.wikipedia.org/wiki/Gestational_diabetes#cite_note-Navajo-55http://en.wikipedia.org/wiki/Gestational_diabetes#cite_note-antibodies-53http://en.wikipedia.org/wiki/Gestational_diabetes#cite_note-antibodies-53http://en.wikipedia.org/wiki/Gestational_diabetes#cite_note-AMN-32http://en.wikipedia.org/wiki/Gestational_diabetes#cite_note-AMN-32http://en.wikipedia.org/wiki/Type_1_diabeteshttp://en.wikipedia.org/wiki/Type_1_diabeteshttp://en.wikipedia.org/wiki/Autoimmunityhttp://en.wikipedia.org/wiki/Type_2_diabeteshttp://en.wikipedia.org/wiki/Navajo_people


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Unlike pre-gestational diabetes, gestational diabetes has not been clearly shown tobe an independent risk factor for birth defects. Birth defects usually originatesometime during the first trimester (before the 13th week) of pregnancy, whereasGDM gradually develops and is least pronounced during the first trimester. Studies

have shown that the offspring of women with GDM are at a higher risk for congenitalmalformations .[67][68 ][69] A large case-control study found that gestational diabeteswas linked with a limited group of birth defects, and that this association wasgenerally limited to women with a higher body mass index ( 25 kg/m) .[70] It isdifficult to make sure that this is not partially due to the inclusion of women with pre-existent type 2 diabetes who were not diagnosed before pregnancy.

Because of conflicting studies, it is unclear at the moment whether women with GDMhave a higher risk of preeclampsia .[71] In the HAPO study, the risk of preeclampsiawas between 13% and 37% higher, although not all possible confounding factors

were corrected .[63]

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[Epub]. PMID 17476589
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Gestational Diabetes Mellitus

Disusun Guna Memenuhi Tugas dan Melengkapi Syarat Dalam Menempuh Program

Studi Profesi Dokter

Disusun Oleh :

Rainy Anjani (030.06.208)

Pembimbing :

Letkol Kes dr. Zakaria, Sp. OG

RUMAH SAKIT PUSAT ANGKATAN UDARA

DOKTER ESNAWAN ANTARIKSA

FAKULTAS KEDOKTERAN UNIVERSITAS TRISAKTI

PERIODE 12 SEPTEMBER 2011 18 NOVEMBER 2011


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ii

KATA PENGANTAR

Puji syukur penulis panjatkan kepada Tuhan Yang Maha Esa yang telah memberikan

berkah dan rahmat-Nya sehingga penulis dapat menyelesaikan referat mengenai Gestational

Diabetes Mellitus guna memenuhi salah satu persyaratan dalam menempuh Kepaniteraan

Klinik Bagian Imu Kandungan dan Kebidanan Fakultas Kedokteran Universitas Trisakti di

RSPAU dr. Esnawan Antariksa Jakarta periode 12 september 18 November 2011.

Disamping itu, makalah ini ditunjukan untuk menambah pengetahuan bagi yang

membacanya.

Pada kesempatan ini penulis ingin menyampaikan ucapan terima kasih yang sebesar

besarnya kepada pihak yang telah membantu dalam menyelesaikan makalah ini, yaitu:

1. Kolonel Kes Dr. Benny T., Sp.OT, selaku Kepala RSPAU dr. Esnawan Antariksa

Jakarta

2. Letkol Kes Dr. Zakaria, Sp.OG, selaku ketua SMF Ilmu Kandungan dan Kebidanan

RSPAU dr. Esnawan Antariksa Jakarta.

3. Kolonel Kes Dr. Frits M.R., Sp.OG, selaku pembimbing Kepaniteraan Klinik IlmuKandungan dan Kebidanan RSPAU dr. Esnawan Antariksa Jakarta.

4. Ibu ibu bidan selaku perawat Bagian Ilmu Kandungan dan Kebidanan RSPAU dr.

Esnawan Antariksa Jakarta.

5. Rekan rekan Anggota Kepaniteraan Klinik di Bagian Ilmu Kandungan dan

Kebidanan RSPAU dr. Esnawan Antariksa Jakarta.

Penulis menyadari makalah ini masih jauh dari sempurna. Oleh karena itu, kritik dan

saran yang membangun sangat diharapkan penulis agar referat ini dapat enjadi lebih baik.

Penulis mohon maaf yang sebesar besarnya apabila banyak terdapat kesalahan maupun

kekurangan dalam makalah ini. Akhir kata, penulis berharap semoga makalah ini dapat

bermanfaat khususnya bagi penulis sendiri maupun pembaca umumnya.

Jakarta, November 2011

Penulis


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1

BAB I

PENDAHULUAN

Gestational diabetes (diabetes melitus gestasional atau, GDM) adalah suatu kondisi di

mana wanita yang tanpa sebelumnya didiagnosis diabetes menunjukkan peningkatan kadar

glukosa darah selama kehamilan (terutama selama trimester ketiga kehamilan). Gestational

diabetes ini disebabkan ketika tubuh seorang wanita hamil tidak mengeluarkan insulin yang

dibutuhkan selama kehamilan sehingga terjadi peningkatan kadar gula darah. [1]

Gestational diabetes umumnya memiliki beberapa gejala dan hal ini paling sering

didiagnosis dengan skrining selama masa kehamilan. Gestational diabetes mempengaruhi 3-

10% dari kehamilan, tergantung pada populasi yang diteliti. [2]

Seperti gestational diabetes mellitus pada umumnya, bayi yang lahir dari ibu dengan diabetes

gestasional biasanya mempunyai peningkatan risiko masalah seperti bayi besar untuk usia

kehamilan (yang dapat menyebabkan komplikasi kelahiran), gula darah

rendah (hipoglikema), dan penyakit kuning . Gestational diabetes adalah suatu kondisi yang

dapat diobati dan wanita yang telah mengontrol kadar gulanya secara efektif dapatmenurunkan risiko ini.

Wanita dengan diabetes gestasional mempunyai peningkatan risiko diabetes melitus

tipe 2 (atau, sangat jarang, diabetes autoimun laten atau Tipe 1) setelah kehamilan, serta

memiliki insiden yang lebih tinggi pre-eklampsia dan kelahiran dengan operasi caesar.

Sedangkan keturunan mereka rentan untuk pertumbuhan obesitas, dan atau dengan diabetes

tipe 2 di kemudian hari. Kebanyakan pasien diobati hanya dengan modifikasi diet dan olah

raga tetapi beberapa mengambil obat anti-diabetes, termasuk insulin. [3]
http://translate.googleusercontent.com/translate_c?hl=id&prev=/search%3Fq%3Dwikipedia%2Bindonesia%2Bdiabetes%2Bgestasional%26hl%3Did%26prmd%3Dimvns&rurl=translate.google.co.id&sl=en&twu=1&u=http://en.wikipedia.org/wiki/Diabetes_mellitus&usg=ALkJrhhliCX40G799q0s26r4ZwDO0a3c9Qhttp://translate.googleusercontent.com/translate_c?hl=id&prev=/search%3Fq%3Dwikipedia%2Bindonesia%2Bdiabetes%2Bgestasional%26hl%3Did%26prmd%3Dimvns&rurl=translate.google.co.id&sl=en&twu=1&u=http://en.wikipedia.org/wiki/Hyperglycemia&usg=ALkJrhhQvwNDqbKD-hqhLdDj7EguS54Swghttp://translate.googleusercontent.com/translate_c?hl=id&prev=/search%3Fq%3Dwikipedia%2Bindonesia%2Bdiabetes%2Bgestasional%26hl%3Did%26prmd%3Dimvns&rurl=translate.google.co.id&sl=en&twu=1&u=http://en.wikipedia.org/wiki/Pregnancy&usg=ALkJrhhyvBiR59fiZypMwB3_6JYtmzPftQhttp://translate.googleusercontent.com/translate_c?hl=id&prev=/search%3Fq%3Dwikipedia%2Bindonesia%2Bdiabetes%2Bgestasional%26hl%3Did%26prmd%3Dimvns&rurl=translate.google.co.id&sl=en&twu=1&u=http://en.wikipedia.org/wiki/Symptoms&usg=ALkJrhgDpiDGgSjBjb22m7-o9zbSGpme6ghttp://translate.googleusercontent.com/translate_c?hl=id&prev=/search%3Fq%3Dwikipedia%2Bindonesia%2Bdiabetes%2Bgestasional%26hl%3Did%26prmd%3Dimvns&rurl=translate.google.co.id&sl=en&twu=1&u=http://en.wikipedia.org/wiki/Screening_(medicine)&usg=ALkJrhiuSIBlja2H0K7frKQtu6ia7S3W1Qhttp://translate.googleusercontent.com/translate_c?hl=id&prev=/search%3Fq%3Dwikipedia%2Bindonesia%2Bdiabetes%2Bgestasional%26hl%3Did%26prmd%3Dimvns&rurl=translate.google.co.id&sl=en&twu=1&u=http://en.wikipedia.org/wiki/Gestational_diabetes&usg=ALkJrhhHrEJkVs-3e44XgYv3XJt0G86FPw#cite_note-emedicine-1http://translate.googleusercontent.com/translate_c?hl=id&prev=/search%3Fq%3Dwikipedia%2Bindonesia%2Bdiabetes%2Bgestasional%26hl%3Did%26prmd%3Dimvns&rurl=translate.google.co.id&sl=en&twu=1&u=http://en.wikipedia.org/wiki/Gestational_diabetes&usg=ALkJrhhHrEJkVs-3e44XgYv3XJt0G86FPw#cite_note-emedicine-1http://translate.googleusercontent.com/translate_c?hl=id&prev=/search%3Fq%3Dwikipedia%2Bindonesia%2Bdiabetes%2Bgestasional%26hl%3Did%26prmd%3Dimvns&rurl=translate.google.co.id&sl=en&twu=1&u=http://en.wikipedia.org/wiki/Gestational_diabetes&usg=ALkJrhhHrEJkVs-3e44XgYv3XJt0G86FPw#cite_note-emedicine-1http://translate.googleusercontent.com/translate_c?hl=id&prev=/search%3Fq%3Dwikipedia%2Bindonesia%2Bdiabetes%2Bgestasional%26hl%3Did%26prmd%3Dimvns&rurl=translate.google.co.id&sl=en&twu=1&u=http://en.wikipedia.org/wiki/Diabetes_mellitus_in_pregnancy&usg=ALkJrhgpULKxtlTkrhuOwdrewRKq7w621ghttp://translate.googleusercontent.com/translate_c?hl=id&prev=/search%3Fq%3Dwikipedia%2Bindonesia%2Bdiabetes%2Bgestasional%26hl%3Did%26prmd%3Dimvns&rurl=translate.google.co.id&sl=en&twu=1&u=http://en.wikipedia.org/wiki/Macrosomia&usg=ALkJrhjegEsPU5pDAURRrbjPkL7vD7TH5ghttp://translate.googleusercontent.com/translate_c?hl=id&prev=/search%3Fq%3Dwikipedia%2Bindonesia%2Bdiabetes%2Bgestasional%26hl%3Did%26prmd%3Dimvns&rurl=translate.google.co.id&sl=en&twu=1&u=http://en.wikipedia.org/wiki/Macrosomia&usg=ALkJrhjegEsPU5pDAURRrbjPkL7vD7TH5ghttp://translate.googleusercontent.com/translate_c?hl=id&prev=/search%3Fq%3Dwikipedia%2Bindonesia%2Bdiabetes%2Bgestasional%26hl%3Did%26prmd%3Dimvns&rurl=translate.google.co.id&sl=en&twu=1&u=http://en.wikipedia.org/wiki/Hypoglycemia&usg=ALkJrhjl0qOO3yY8ZO2Teg8lMMChNpbRNAhttp://translate.googleusercontent.com/translate_c?hl=id&prev=/search%3Fq%3Dwikipedia%2Bindonesia%2Bdiabetes%2Bgestasional%26hl%3Did%26p

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