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. akaria! "#. $G
R%MA& "AK' %"A A*GKAA* %DARA D$K+R +"*A,A* A*AR'K"A -AK%LA" K+D$K+RA* %*'+R"'A" R'"AK' +R'$D+ /2 "++M+R 20// 1 /8 *$+M+R 20//
LEMBAR PENGESAHAN
Nama
: Rainy Anjani Anjani
Fakultas
: Kedokteran Umum
Tingkat
: Universitas Trisakti Jakarta
Bidang Pendidikan
: Ilmu Kandungan dan Kebidanan
Periode Ke Keaniteraan raan Klinik
: !" !" #e #etemb ember "$ "$!! % !& No Novemb ember "$ "$!!
Judul
: 'iabetes (ellitus )estasional
'iajukan
: !! November "$!!
Pembimbing
: *etkol Kes dr+ ,akaria- #+ .)
Tela/ Tela/ 'ieriksa dan 'isa/kan Tanggal Tanggal (engeta/ui :
Ketua #(F Ilmu Kandungan dan Kebidanan
Pembimbing
R#PAU R#PAU dr+ 0sna1an Antariksa Jakarta
*etkol Kes dr+ ,akaria- #+ .)
*etkol Kes dr+ ,akaria- #+ .)
2
LEMBAR PENGESAHAN
Nama
: Rainy Anjani Anjani
Fakultas
: Kedokteran Umum
Tingkat
: Universitas Trisakti Jakarta
Bidang Pendidikan
: Ilmu Kandungan dan Kebidanan
Periode Ke Keaniteraan raan Klinik
: !" !" #e #etemb ember "$ "$!! % !& No Novemb ember "$ "$!!
Judul
: 'iabetes (ellitus )estasional
'iajukan
: !! November "$!!
Pembimbing
: *etkol Kes dr+ ,akaria- #+ .)
Tela/ Tela/ 'ieriksa dan 'isa/kan Tanggal Tanggal (engeta/ui :
Ketua #(F Ilmu Kandungan dan Kebidanan
Pembimbing
R#PAU R#PAU dr+ 0sna1an Antariksa Jakarta
*etkol Kes dr+ ,akaria- #+ .)
*etkol Kes dr+ ,akaria- #+ .)
2
DAFTAR ISI
LEMBAR PENGESAHAN........... PENGESAHAN..................... ..................... ..................... ..................... ..................... ..................... ............................ ................. II
JOURNAL GESTA GESTATIONAL DIABETES MELLITUS
BACKGROUND.......... BACKGROUND ..................... ..................... ..................... ..................... ..................... ...................... ..................... ..................... .................... ......... 1 EPIDEMIOLOGY.......... EPIDEMIOLOGY ..................... ..................... ..................... ...................... ..................... ..................... ..................... ..................... ................... ........ 2 CLASSIFICATION........... CLASSIFICATION ..................... ..................... ..................... ..................... ...................... ..................... ..................... ........................... ................2 2 RISK FACTORS........... FACTORS..................... ..................... ..................... ..................... ..................... ..................... ..................... .............................. ....................2 2 PATHOPHYSIOLOGY.......... PATHOPHYSIOLOGY ..................... ..................... ..................... ..................... ..................... ..................... ................................. ....................... 3 SCREENING.......... SCREENING ..................... ...................... ..................... ..................... ..................... ..................... ..................... .................................. ........................ 5 PATHWAYS........... PATHWAYS ..................... ..................... ..................... ..................... ...................... ..................... ..................... ..................... ......................... ............... 6 MANAGEMENT.......... MANAGEMENT .................... ..................... ...................... ..................... ..................... ..................... ..................... ..................... .................... .......... 8 LIFESTYLE........... LIFESTYLE ..................... ..................... ..................... ..................... ..................... ..................... ............................................... .................................... 9 MEDICATION........... MEDICATION ..................... ..................... ..................... ..................... ..................... ..................................................... ........................................... 9 PROGNOSIS........... PROGNOSIS ...................... ..................... ..................... ..................... ..................... ..................... ..................... ..................... ..................... ...........10 10 COMPLICATIONS........... COMPLICATIONS ..................... ..................... ...................... ..................... ..................... ..................... ..................... ..................... .............. .... 11 REFERENCES........... REFERENCES ..................... ..................... ..................... ..................... ..................... ..................... ..................... ..................... .................... ......... 12
JURNAL DIABETES MELLITUS GESTASIONAL GESTASIONAL
KATA PENGANTAR.......... PENGANTAR.................... ..................... ..................... ..................... ...................... ..................... ..................... ..................... ............... ..... II BAB I.......... I..................... ..................... ..................... ...................... ..................... ..................... ..................... ..................... .................................. ....................... 1 PENDAHULUAN.......... PENDAHULUAN .................... ..................... ..................... ..................... ..................... ..................... ..................... ..................... .................... .........1 1 BAB II........... II..................... ..................... ..................... ..................... ..................... ..................... ...................... ..................... ................................ ...................... 2 DIABETES MELLITUS GEST GESTASIONAL ASIONAL........... ..................... ..................... ..................... ..................... ..................... ...................2 .........2 II. 1. 1. DEFINISI DEFINISI.......... .................... ..................... ..................... ..................... ..................... ..................... ..................... ................................ ...................... 2 II. 2. EPIDEMIOLOGI EPIDEMIOLOGI......... .................... ..................... ..................... ...................... ..................... ..................... ..................... ....................... .............2 2 II. 3. 3. KLASIFIKASI KLASIFIKASI.......... .................... ..................... ..................... ..................... ..................... ..................... ..................... ........................... .................2 2 II. . . FAKTOR FAKTOR RISIKO R ISIKO.......... ..................... ..................... ..................... ..................... ..................... ..................... ................................ ...................... 3 II. !. METODE SKRINING.......... SKRINING ..................... ..................... ..................... ..................... ..................... ..................... .......................... ................! ! II. 8. MANA"EMEN.......... MANA"EMEN ..................... ..................... ..................... ..................... ..................... ...................... .................................. ....................... 10 II. 9. GAYA HIDUP.......... HIDUP ..................... ..................... ..................... ..................... ..................... ............................................. .................................. 10
3
II. 1O. MEDIKASI.......... MEDIKASI.................... ..................... ..................... ..................... ...................... ..................... .................................... .......................... 11 II. 11. PROGNOSIS.......... PROGNOSIS ..................... ..................... ..................... ..................... ..................... ..................... ..................... ....................... ............ 12 II. 12. KOMPLIKASI........... KOMPLIKASI..................... ..................... ..................... ..................... ..................... ..................... ..................... ...................... ............ 13
Gestational Diabetes Mellitus
Thomas A. Buhanan! and Anny ". #iang$ !
Departments of Mediine% Obstetris and Gyneology% and Physiology and Biophysis% and $
Department of Pre&enti&e Mediine% 'ni&ersity of Southern (alifornia )ek Shool of Mediine% *os Angeles% (alifornia% 'SA. Address orrespondene to: Thomas A. Buhanan% +oom ,,-$ G"% !$-- orth State Street% *os Angeles% (alifornia /--0/1/2!3% 'SA. Phone: 42$25 $$,16,2$7 8a9: 42$25 $$,1$3/,7 1mail: buhanan;us.edu.
Published Marh !% $--<
Gestational diabetes 4or gestational diabetes mellitus% GDM5 is a ondition in =hih =omen =ithout pre&iously diagnosed diabetes e9hibit high blood gluose le&els during pregnany 4espeially during third trimester of pregnany5. Gestational diabetes is aused =hen the body of a pregnant =oman does not serete e9ess insulin re>uired during pregnany leading to inreased blood sugar le&els. ?!@ Gestational diabetes generally has fe= symptoms and it is most ommonly diagnosed by sreening during pregnany. Diagnosti tests detet inappropriately high le&els of gluose in blood samples. Gestational diabetes affets 21!- of pregnanies% depending on the population studied. ?$@ As =ith diabetes mellitus in pregnany in general% babies born to mothers =ith gestational diabetes are typially at inreased risk of problems suh as being large for gestational age 4=hih may lead to deli&ery ompliations5% lo= blood sugar % and aundie. Gestational diabetes is a treatable ondition and =omen =ho ha&e ade>uate ontrol of gluose le&els an effeti&ely derease these risks. Comen =ith gestational diabetes are at inreased risk of de&eloping type $ diabetes mellitus 4or% &ery rarely% latent autoimmune diabetes or Type !5 after pregnany% as =ell as ha&ing a higher inidene of pre1elampsia and aesarean setion7?2@ their offspring are prone to de&eloping hildhood obesity% =ith type $ diabetes later in life. Most patients are treated only =ith diet modifiation and moderate e9erise but some take anti1diabeti drugs% inluding insulin.?2@
+#ideioloy Gestational diabetes affets 21!- of pregnanies% depending on the population studied.?$@
4lassi5iation Gestational diabetes is formally defined as any degree of gluose intolerane =ith onset or first reognition during pregnany. This definition akno=ledges the possibility that patients may ha&e pre&iously undiagnosed diabetes mellitus% or may ha&e de&eloped diabetes oinidentally =ith pregnany. Chether symptoms subside after pregnany is also irrele&ant to the diagnosis. ?6@?<@ The Chite lassifiation% named after Prisilla Chite ?,@ =ho pioneered in researh on the effet of diabetes types on perinatal outome% is =idely used to assess maternal and fetal risk. Et distinguishes bet=een gestational diabetes 4type A5 and diabetes that e9isted prior to pregnany 4pregestational diabetes5. These t=o groups are further subdi&ided aording to their assoiated risks and management. ?3@ There are $ subtypes of gestational diabetes 4diabetes =hih began during pregnany5:
Type A!: abnormal oral gluose tolerane test 4OGTT5 but normal blood gluose le&els during fasting and $ hours after meals7 diet modifiation is suffiient to ontrol gluose le&els
Type A$: abnormal OGTT ompounded by abnormal gluose le&els during fasting andFor after meals7 additional therapy =ith insulin or other mediations is re>uired
Risk -ators (lassial risk fators for de&eloping gestational diabetes are the follo=ing:?0@?/@
A pre&ious diagnosis of gestational diabetes or prediabetes% impaired gluose tolerane% or impaired fasting glyaemia
A family history re&ealing a first degree relati&e =ith type $ diabetes Maternal age 1 a =omans risk fator inreases as she gets older 4espeially for =omen o&er 2< years of age5
thni
bakground
4those
=ith
higher
risk
fators
inlude Afrian1
Amerians% Afro1(aribbeans% ati&e Amerians% "ispanis% Paifi Eslanders% and people originating from South Asia5
Being o&er=eight% obese or se&erely obese inreases the risk by a fator $.!% 2., and 0.,% respeti&ely.
A pre&ious pregnany =hih resulted in a hild =ith a high birth =eight 4H/-th entile% or H6--- g 40 lbs !$.0 oI55
En addition to this% statistis sho= a double risk of GDM in smokers. Polyysti o&arian syndrome is also a risk fator% although rele&ant e&idene remains ontro&ersial. Some studies ha&e looked at more ontro&ersial potential risk fators% suh as short stature. ?0@?!-@?!!@?!$@ About 6-1,- of =omen =ith GDM ha&e no demonstrable risk fator7 for this reason many ad&oate to sreen all =omen. Typially =omen =ith gestational diabetes e9hibit no symptoms 4another reason for uni&ersal sreening5% but some =omen may demonstrate inreased thirst% inreased urination% fatigue% nausea and &omiting% bladder infetion% and blurred &ision.?!2@
at7o#7ysioloy
ffet of insulin on gluose uptake and metabolism. Ensulin binds to its reeptor 4!5 on the ell membrane =hih in turn starts many protein ati&ation asades 4$5. These inlude: transloation of Glut16 transporter to the plasma membrane and influ9 of gluose 425% glyogen synthesis 465% glyolysis 4<5 and fatty aid synthesis 4,5.
The preise mehanisms underlying gestational diabetes remain unkno=n. The hallmark of GDM is inreased insulin resistane. Pregnany hormones and other fators are thought to interfere =ith the ation of insulin as it binds to the insulin reeptor . The interferene probably ours at the le&el of the ell signaling path=ay behind the insulin reeptor. Sine insulin promotes the entry of gluose into most ells% insulin resistane pre&ents gluose from entering the ells properly. As a result% gluose remains in the bloodstream% =here gluose le&els rise. More insulin is needed to o&erome this resistane7 about !.<1$.< times more insulin is produed than in a normal pregnany.?!6@ Ensulin resistane is a normal phenomenon emerging in the seond trimester of pregnany% =hih progresses thereafter to le&els seen in non1pregnant patients =ith type $ diabetes. Et is thought to seure gluose supply to the gro=ing fetus. Comen =ith GDM ha&e an insulin resistane they annot ompensate =ith inreased prodution in the J1ells of the panreas. Plaental hormones% and to a lesser e9tent inreased fat deposits during pregnany% seem to mediate insulin resistane during pregnany. (ortisol and progesterone are the main ulprits% but human plaental latogen% prolatin and estradiol ontribute too.?!6@ Et is unlear =hy some patients are unable to balane insulin needs and de&elop GDM% ho=e&er a number of e9planations ha&e been gi&en% similar to those in type $ diabetes: autoimmunity% single gene mutations% obesity% and other mehanisms.?!<@ Beause gluose tra&els aross the plaenta 4through diffusion failitated by G*'T2 arriers5% the fetus is e9posed to higher gluose le&els. This leads to inreased fetal le&els of insulin 4insulin itself annot ross the plaenta5. The gro=th1stimulating effets of insulin an lead to e9essi&e gro=th and a large body 4marosomia5. After birth% the high gluose en&ironment disappears% lea&ing these ne=borns =ith ongoing high insulin prodution and suseptibility to lo= blood gluose le&els 4hypoglyemia5.?!,@
"reenin $--, C"O Diabetes riteria?!3@
2 7our luose
-astin luose
mmolFl4mgFdl5
mmolFl4mgFdl5
*oral
K3.0 4K!6-5
K,.! 4K!!-5
'#aired 5astin lyaeia
K3.0 4K!6-5
L ,.!4L!!-5 K3.-4K!$,5
'#aired tolerane
L3.0 4L!6-5
K3.- 4K!$,5
L!!.! 4L$--5
L3.- 4L!$,5
4ondition
luose
Diabetes ellitus
A number of sreening and diagnosti tests ha&e been used to look for high le&els of gluose in plasma or serum in defined irumstanes. One method is a step=ise approah =here a suspiious result on a sreening test is follo=ed by diagnosti test. Alternati&ely% a more in&ol&ed diagnosti test an be used diretly at the first antenatal &isit in high1risk patients 4for e9ample in those =ith polyysti o&arian syndrome or aanthosis nigrians5.?!,@ Tests for gestational diabetes
on1hallenge blood gluose tests
8asting gluose test
$1hour postprandial 4after a meal5 gluose test
+andom gluose test
Sreening gluose hallenge test Oral gluose tolerane test 4OGTT5 on1hallenge blood gluose tests in&ol&e measuring gluose le&els in blood samples =ithout hallenging the subet =ith gluose solutions. A blood gluose le&el is determined =hen fasting% $ hours after a meal% or simply at any random time. En ontrast% hallenge tests in&ol&e drinking a gluose solution and measuring gluose onentration thereafter in the blood7 in diabetes% they tend to remain high. The gluose solution has a &ery s=eet taste =hih some =omen find unpleasant7 sometimes% therefore% artifiial fla&ours are added. Some =omen may e9periene nausea during the test% and more so =ith higher gluose le&els.?!0@?!/@
at7ays There are different opinions about optimal sreening and diagnosti measures% in part due to differenes in population risks% ost1effeti&eness onsiderations% and lak of an e&idene base to support large national sreening programs. The most elaborate regime entails a random blood gluose test during a booking &isit% a sreening gluose hallenge test around $6N$0 =eeks gestation% follo=ed by an OGTT if the tests are outside normal limits. Ef there is a high suspiion% =omen may be tested earlier.?<@?$-@ En the 'nited States% most obstetriians prefer uni&ersal sreening =ith a sreening gluose hallenge test. En the 'nited )ingdom% obstetri units often rely on risk fators and a random blood gluose test. The Amerian Diabetes Assoiation and the Soiety of Obstetriians and Gynaeologists of (anada reommend routine sreening unless the patient is lo= risk 4this means the =oman must be younger than $< years and ha&e a body mass inde9 less than $3% =ith no personal% ethni or family risk fators5 The (anadian Diabetes Assoiation and the Amerian (ollege of Obstetriians and Gyneologists reommend uni&ersal sreening. The '.S. Pre&enti&e Ser&ies Task 8ore found that there is insuffiient e&idene to reommend for or against routine sreening. ?<@?!,@?$-@?$!@?$$@?$2@?$6@?$<@
on1(hallenge Blood Gluose Tests
Chen a plasma gluose le&el is found to be higher than !$, mgFdl 43.- mmolFl5 after fasting% or o&er $-- mgFdl 4!!.! mmolFl5 on any oasion% and if this is onfirmed on a subse>uent day% the diagnosis of GDM is made% and no further testing is re>uired. These tests are typially performed at the first antenatal &isit. They are patient1 friendly and ine9pensi&e% but ha&e a lo=er test performane ompared to the other tests% =ith moderate sensiti&ity% lo= speifiity and high false positi&e rates. ?<@?$,@?$3@?$0@
Sreening Gluose (hallenge Test The sreening gluose hallenge test 4sometimes alled the OSulli&an test5 is performed bet=een $6N$0 =eeks% and an be seen as a simplified &ersion of the oral gluose tolerane test 4OGTT5. Et in&ol&es drinking a solution ontaining <- grams of gluose% and measuring blood le&els ! hour later.?$/@ Ef the ut1off point is set at !6- mgFdl 43.0 mmolFl5% 0- of =omen =ith GDM =ill be deteted. Ef this threshold for further testing is lo=ered to !2- mgFdl% /- of GDM ases =ill be deteted% but there =ill also be more =omen =ho =ill be subeted to a onse>uent OGTT unneessarily.?<@
Oral Gluose Tolerane Test The OGTT should be done in the morning after an o&ernight fast of bet=een 0 and !6 hours. During the three pre&ious days the subet must ha&e an unrestrited diet 4ontaining at least !<- g arbohydrate per day5 and unlimited physial ati&ity. The subet should remain seated during the test and should not smoke throughout the test. ?2-@ The test in&ol&es drinking a solution ontaining a ertain amount of gluose% and dra=ing blood to measure gluose le&els at the start and on set time inter&als thereafter.?2-@ The diagnosti riteria from the ational Diabetes Data Group 4DDG5 ha&e been used most often% but some enters rely on the (arpenter and (oustan riteria% =hih set the utoff for normal at lo=er &alues. (ompared =ith the DDG riteria% the (arpenter and (oustan riteria lead to a diagnosis of gestational diabetes in <6 perent more pregnant =omen% =ith an inreased ost and no ompelling e&idene of impro&ed perinatal outomes.?2!@ The follo=ing are the &alues =hih the Amerian Diabetes Assoiation onsiders to be abnormal during the !-- g of gluose OGTT:
8asting blood gluose le&el L/< mgFdl 4<.22 mmolF*5
! hour blood gluose le&el L!0- mgFdl 4!- mmolF*5
$ hour blood gluose le&el L!<< mgFdl 40., mmolF*5
2 hour blood gluose le&el L!6- mgFdl 43.0 mmolF*5
An alternati&e test uses a 3< g gluose load and measures the blood gluose le&els before and after ! and $ hours% using the same referene &alues. This test =ill identify fe=er =omen =ho are at risk% and there is only a =eak onordane 4agreement rate5 bet=een this test and a 2 hour !-- g test. ?2$@ The gluose &alues used to detet gestational diabetes =ere first determined by OSulli&an and Mahan 4!/,65 in a retrospeti&e ohort study4using a !-- grams of gluose OGTT5 designed to detet risk of de&eloping type $ diabetes in the future. The &alues =ere set using =hole blood and re>uired t=o &alues reahing or e9eeding the &alue to be positi&e. ?22@ Subse>uent information led to alterations in OSulli&ans riteria. Chen methods for blood gluose determination hanged from the use of =hole blood to &enous plasma samples% the riteria for GDM =ere also hanged.
'rinary Gluose Testing Comen =ith GDM may ha&e high gluose le&els in their urine 4gluosuria5. Although dipstik testing is =idely pratied% it performs poorly% and disontinuing routine dipstik testing has not been sho=n to ause underdiagnosis =here uni&ersal sreening is performed. Enreasedglomerular filtration rates during pregnany ontribute to some <- of =omen ha&ing gluose in their urine on dipstik tests at some point during their pregnany. The sensiti&ity of gluosuria for GDM in the first $ trimesters is only around !- and the positi&e prediti&e &alue is around $-.?26@?2<@?2,@
Manaeent The goal of treatment is to redue the risks of GDM for mother and hild. Sientifi e&idene is beginning to sho= that ontrolling gluose le&els an result in less serious fetal ompliations 4suh as marosomia5 and inreased maternal >uality of life. 'nfortunately% treatment of GDM is also aompanied by more infants admitted to neonatal =ards and more indutions of labour % =ith no pro&en derease in esarean setion rates or perinatal mortality. These findings are still reent and ontro&ersial. ?23@?20@?2/@ A repeat OGTT should be arried out $N6 months after deli&ery% to onfirm the diabetes has disappeared. After=ards% regular sreening for type $ diabetes is ad&ised.?0@
Ef a diabeti diet or G.E. Diet% e9erise% and oral mediation are inade>uate to ontrol gluose le&els% insulin therapy may beome neessary. The de&elopment of marosomia an be e&aluated during pregnany by using sonography. Comen =ho use insulin% =ith a history of stillbirth% or =ith hypertension are managed like =omen =ith o&ert diabetes. ?!2@
Li5estyle (ounselling before pregnany 4for e9ample% about pre&enti&e foli aid supplements5 and multidisiplinary management are important for good pregnany outomes. Most =omen an manage their GDM =ith dietary hanges and e9erise. Self monitoring of blood gluose le&els an guide therapy. Some =omen =ill need antidiabeti drugs% most ommonly insulin therapy.?6-@ Any diet needs to pro&ide suffiient alories for pregnany% typially $%--- 1 $%<-kal =ith the e9lusion of simple arbohydrates. The main goal of dietary modifiations is to a&oid peaks in blood sugar le&els. This an be done by spreading arbohydrate intake o&er meals and snaks throughout the day% and using slo=1 release arbohydrate soureskno=n as the G.E. Diet. Sine insulin resistane is highest in mornings% breakfast arbohydrates need to be restrited more. Engesting more fiber in foods =ith =hole grains% or fruit and &egetables an also redue the risk of gestational diabetes. ?0@?!2@?6!@ +egular moderately intense physial e9erise is ad&ised% although there is no onsensus on the speifi struture of e9erise programs for GDM.?0@?6$@ Self monitoring an be aomplished using a handheld apillary gluose dosage system. (ompliane =ith these gluometer systems an be lo=. Target ranges ad&ised by the Australasian Diabetes in Pregnany Soiety are as follo=s:?0@ ?62@
fasting apillary blood gluose le&els K<.< mmolF*
! hour postprandial apillary blood gluose le&els K0.- mmolF*
$ hour postprandial blood gluose le&els K,.3 mmolF*
+egular blood samples an be used to determine "bA! le&els% =hih gi&e an idea of gluose ontrol o&er a longer time period.?0@
+esearh suggests a possible benefit of breastfeeding to redue the risk of diabetes and related risks for both mother and hild.?66@
Mediation Ef monitoring re&eals failing ontrol of gluose le&els =ith these measures% or if there is e&idene of ompliations like e9essi&e fetal gro=th% treatment =ith insulin might beome neessary. The most ommon therapeuti regime in&ol&es premeal fast1 ating insulin to blunt sharp gluose rises after meals. (are needs to be taken to a&oid lo= blood sugar le&els 4hypoglyemia5 due to e9essi&e insulin inetions. Ensulin therapy an be normal or &ery tight7 more inetions an result in better ontrol but re>uires more effort% and there is no onsensus that it has large benefits. ?0@?!,@?6<@?6,@
There is some e&idene that ertain oral glyemi agents might be safe in pregnany% or at least% are signifiantly less dangerous to the de&eloping fetus than poorly ontrolled diabetes. Glyburide% a seond generation sulfonylurea% has been sho=n to be an effeti&e alternati&e to insulin therapy. En one study% 6 of =omen needed supplemental insulin to reah blood sugar targets.Metformin has sho=n promising results% =ith its oral format being muh more popular than insulin inetions.Treatment of polyysti o&arian syndrome =ith metformin during pregnany has been noted to derease GDM le&els. A reent randomiIed ontrolled trial of metformin &ersus insulin sho=ed that =omen preferred metformin tablets to insulin inetions% and that metformin is safe and e>ually effeti&e as insulin. ?<-@ Se&ere neonatal hypoglyemia =as less ommon in insulin1treated =omen% but preterm deli&ery =as more ommon. Almost half of patients did not reah suffiient ontrol =ith metformin alone and needed supplemental therapy =ith insulin7 ompared to those treated =ith insulin alone% they re>uired less insulin% and they gained less =eight. Cith no long1term studies into hildren of =omen treated =ith the drug% here remains a possibility of long1term ompliations from metformin therapy% although follo=1up at the age of !0 months of hildren born to =omen =ith polyysti o&arian syndrome and treated =ith metformin re&ealed no de&elopmental abnormalities. ?2@?63@?60@?6/@?<-@?
ronosis Gestational diabetes generally resol&es one the baby is born. Based on different studies% the hanes of de&eloping GDM in a seond pregnany are bet=een 2- and 06% depending on ethni bakground. A seond pregnany =ithin ! year of the pre&ious pregnany has a high rate of reurrene.?<$@ Comen diagnosed =ith gestational diabetes ha&e an inreased risk of de&eloping diabetes mellitus in the future. The risk is highest in =omen =ho needed insulin
treatment% had antibodies assoiated =ith diabetes 4suh as antibodies against glutamate dearbo9ylase% islet ell antibodies andFor insulinoma antigen1$5% =omen =ith more than t=o pre&ious pregnanies% and =omen =ho =ere obese 4in order of importane5. Comen re>uiring insulin to manage gestational diabetes ha&e a <- risk of de&eloping diabetes =ithin the ne9t fi&e years. Depending on the population studied% the diagnosti riteria and the length of follo=1up% the risk an &ary enormously. The risk appears to be highest in the first < years% reahing a plateau thereafter.One of the longest studies follo=ed a group of =omen fromBoston% Massahusetts7 half of them de&eloped diabetes after , years% and more than 3- had diabetes after $0 years. En a retrospeti&e study in a&ao =omen% the risk of diabetes after GDM =as estimated to be <- to 3- after !! years. Another study found a risk of diabetes after GDM of more than $< after !< years. En populations =ith a lo= risk for type $ diabetes% in lean subets and in patients =ith auto1 antibodies% there is a higher rate of =omen de&eloping type ! diabetes. ?22@?<2@?<6@?<<@?<,@?<3@ (hildren of =omen =ith GDM ha&e an inreased risk for hildhood and adult obesity and an inreased risk of gluose intolerane and type $ diabetes later in life. ?<0@ This risk relates to inreased maternal gluose &alues. ?
4o#liations GDM poses a risk to mother and hild. This risk is largely related to high blood gluose le&els and its onse>uenes. The risk inreases =ith higher blood gluose le&els.?,2@ Treatment resulting in better ontrol of these le&els an redue some of the risks of GDM onsiderably.?62@ The t=o main risks GDM imposes on the baby are gro=th abnormalities and hemial imbalanes after birth% =hih may re>uire admission to a neonatal intensi&e are unit. Enfants born to mothers =ith GDM are at risk of being both large for gestational age 4marosomi5?,2@ and small for gestational age. Marosomia in turn inreases the risk of instrumental deli&eries 4e.g. foreps% &entouse and aesarean setion5 or problems during &aginal deli&ery 4suh as shoulder dystoia5. Marosomia may affet !$ of normal =omen ompared to $- of patients =ith GDM.?!,@ "o=e&er% the e&idene for eah of these ompliations is not e>ually strong7 in the "yperglyemia and Ad&erse Pregnany Outome 4"APO5 study for e9ample% there =as an inreased risk for babies to be large but not small for gestational age. ?,2@ +esearh into ompliations for GDM is diffiult beause of the many onfounding
fators 4suh as obesity5. *abelling a =oman as ha&ing GDM may in it self inrease the risk of ha&ing a aesarean setion.?,6@?,<@ eonates are also at an inreased risk of lo= blood gluose 4hypoglyemia5% aundie% high red blood ell mass 4polyythemia5 and lo= blood alium 4hypoalemia5 and magnesium 4hypomagnesemia5.?,,@ GDM also interferes =ith maturation% ausing dysmature babies prone torespiratory distress syndrome due to inomplete lung maturation and impaired surfatant synthesis.?,,@ 'nlike pre1gestational diabetes% gestational diabetes has not been learly sho=n to be an independent risk fator for birth defets. Birth defets usually originate sometime during the first trimester 4before the !2th =eek5 of pregnany% =hereas GDM gradually de&elops and is least pronouned during the first trimester. Studies ha&e sho=n that the offspring of =omen =ith GDM are at a higher risk for ongenital malformations.?,3@?,0@?,/@ A large ase1ontrol study found that gestational diabetes =as linked =ith a limited group of birth defets% and that this assoiation =as generally limited to =omen =ith a higher body mass inde9 4L $< kgFmQ5. ?3-@ Et is diffiult to make sure that this is not partially due to the inlusion of =omen =ith pre1e9istent type $ diabetes =ho =ere not diagnosed before pregnany. Beause of onfliting studies% it is unlear at the moment =hether =omen =ith GDM ha&e a higher risk of preelampsia.?3!@ En the "APO study% the risk of preelampsia =as bet=een !2 and 23 higher% although not all possible onfounding fators =ere orreted.?,2@
Re5erenes !+
2'iabetes Blue 3ir4le #ymbol2+ International 'iabetes Federation+ !5 (ar4/ "$$6+
"+
T/omas
R
(oore-
('
et
al+
'iabetes
(ellitus
and
Pregnan4y+med7"89 at e(edi4ine+ ;ersion: Jan "5- "$$< udate+ 8+
'onovan-
PJ
="$!$>+ 2'rugs
?or
gestational
diabetes2+Australian
Pres4riber =88>: !9!%9+ 9+
(et@ger B0- 3oustan 'R =0ds+>+ Pro4eedings o? t/e Fourt/ International orks/o3on?eren4e on )estational 'iabetes (ellitus+ 'iabetes 3are !&C "! =#ul+ ">: B!%B!65+
<+
Ameri4an 'iabetes Asso4iation+ )estational 'iabetes (ellitus+ 'iabetes 3are "$$9C "5: #&&$+ P(I' !96886
6+
/ite P+ Pregnan4y 4omli4ating diabetes+ Am J (ed !9C 5: 6$+ P(I' !<86$68
5+
)abbe #+)+- Niebyl J+R+- #imson J+*+ .B#T0TRI3#: Normal and Problem Pregnan4ies+ Fourt/ edition+ 3/ur4/ill *ivingstone- Ne1 Dork- "$$"+ I#BN $998 $6<5"!
&+
Ross )+ )estational diabetes+ Aust Fam P/ysi4ian"$$6C 8<=6>: 8"6+ P(I' !65
+
3/u #D- 3allag/an (- Kim #D- #4/mid 3E- *au J- 0ngland *J- 'iet@ P(+ (aternal obesity and risk o? gestational diabetes mellitus+ 'iabetes 3are "$$5C 8$=&>: "$5$6+ P(I' !59!65&6
!$+
0ngland *J- *evine RJ- ian 3- et al+ )lu4ose toleran4e and risk o? gestational diabetes mellitus in nulliarous 1omen 1/o smoke during regnan4y+ Am J 0idemiol "$$9C !6$=!">: !"$<!8+ P(I' !<<&8858
!!+
Toulis KA- )oulis ')- Kolibianakis 0- ;enetis 3A- Tarlat@is B3- Paadimas I+ Risk o? gestational diabetes mellitus in 1omen 1it/ oly4ysti4 ovary syndrome+ Fertility and #terility"$$&Cdoi:!$+!$!67j+?ertnstert+"$$&+$6+$9< P(I': !&5!$5!8
!"+
(a R(- *ao TT- (a 3*- et al+ Relations/i bet1een leg lengt/ and gestational diabetes mellitus in 3/inese regnant 1omen+'iabetes 3are "$$5C 8$=!!>: "6$!+ P(I' !566696&
!8+
A3.)+ Pre4is ;+ An Udate on .bstetri4s and )yne4ology++ A3.) =!9>+
+ !5$+ I#BN $!<958""9+ !9+
3arr 'B- )abbe #+ )estational 'iabetes: 'ete4tion- (anagement- and Imli4ations+ 3lin 'iabetes !&C !6=!>: 9+
!<+
Bu4/anan
TA-
Giang
AE+
)estational
diabetes
mellitus+ J
3lin
Invest "$$: 9&<%9!+ P(I' !<56
Kelly *- 0vans *- (essenger '+ 3ontroversies around gestational diabetes+ Pra4ti4al in?ormation ?or ?amily do4tors+ 3an Fam P/ysi4ian "$$
!5+
2'e?inition
and
'iagnosis
o?
'iabetes
(ellitus
and
Intermediate
Eyergly4emia2 =d?>+ orld Eealt/ .rgani@ation+ 111+1/o+int+ "$$6+ Retrieved "$!!$""$+ !&+
#ievenier J*- Jenkins 'J- Josse R)- ;uksan ;+ 'ilution o? t/e 5<g oral glu4ose toleran4e test imroves overall tolerability but not rerodu4ibility in subje4ts 1it/ di??erent body 4omositions+'iabetes Res 3lin Pra4t "$$!C : &5<+ P(I' !!!6<6&&
!+
Ree4e 0A- Eol?ord T- Tu4k #- Bargar (- .3onnor T- Eobbins J3+ #4reening ?or gestational diabetes: one/our 4arbo/ydrate toleran4e test er?ormed by a virtually tasteless olymer o? glu4ose+ Am J .bstet )yne4ol !&5C !<6=!>: !8" 9+ P(I' 85595
"$+
Berger E- 3rane J- Farine '- et al+ #4reening ?or gestational diabetes mellitus+ J .bstet )ynae4ol 3an "$$"C "9: &9%!"+P(I' !"9!5$<
"!+
)abbe #)- )regory RP- Po1er (*- illiams #B- #4/ulkin J+ (anagement o? diabetes mellitus by obstetri4iangyne4ologists+.bstet )yne4ol "$$9C !$8=6>: !"" 89+ P(I' !
""+
(ires )J- illiams F*- Earer ;+ #4reening ra4ti4es ?or gestational diabetes mellitus in UK obstetri4 units+ 'iabet (ed!C !6=">: !8&9!+ P(I' !$""8$5
"8+
3anadian
'iabetes
Asso4iation
3lini4al
Pra4ti4e
)uidelines
0Hert
3ommittee+ 3anadian 'iabetes Asso4iation "$$8 3lini4al Pra4ti4e )uidelines ?or t/e Prevention and (anagement o? 'iabetes in 3anada+ 3an J 'iabetes "$$8C "5 =#ul ">: !%!9$+ "9+
)abbe #)- )raves 3R+ (anagement o? diabetes mellitus 4omli4ating regnan4y+ .bstet )yne4ol "$$8C !$"=9>: &<56&+P(I' !9<
"<+
Eillier TA- ;es4o KK- Pedula K*- Beil T*- /itlo4k 0P- Pettitt 'J =(ay "$$&>+ 2#4reening ?or gestational diabetes mellitus: a systemati4 revie1 ?or t/e U+#+ Preventive
#ervi4es
Task
For4e2+Ann+
Intern+
(ed+ !9& =!$>:
566%
5<+ P(I' !&9$6&+ "6+
Agar1al ((- '/att )#+ Fasting lasma glu4ose as a s4reening test ?or gestational !665"58
diabetes
mellitus+ Ar4/
)yne4ol
.bstet "$$5C"5<=">:
&!5+ P(I'
"5+
#a4ks 'A- 3/en - oldeTsadik )- Bu4/anan TA+ Fasting lasma glu4ose test at t/e ?irst renatal visit as a s4reen ?or gestational diabetes+ .bstet )yne4ol "$$8C !$!=6>: !!5"$8+P(I' !"5&<"<
"&+
Agar1al ((- '/att )#- Punnose J- ,ayed R+ )estational diabetes: ?asting and ostrandial glu4ose as ?irst renatal s4reening tests in a /ig/risk oulation+ J Rerod (ed "$$5C<"=9>: "8$<+ P(I' !5<$685$
"+
Boyd 0+ (et@ger- (+'+- #usan A+ Biastre- R+'+- *+'+N+- 3+'+0+- Beverly )ardner- R+'+- *+'+N+- 3+'+0+ ="$$6>+ 2/at I need to kno1 about )estational 'iabetes2+ National
'iabetes
In?ormation
3learing/ouse+
National
'iabetes
In?ormation 3learing/ouse+ Retrieved "$$6!!"5+ 8$+
)lu4ose toleran4e test+ (edlinePlus- November &- "$$6+
8!+
3arenter (- 3oustan 'R+ 3riteria ?or s4reening tests ?or gestational diabetes+ Am J .bstet )yne4ol !&"C !99=5>: 56&58+P(I' &8$5!!
8"+
(ello )- 0lena P- .gnibene A- 3ioni R- Tondi F- Pe@@ati P- Pratesi (#4arselli )- (esseri )+ *a4k o? 4on4ordan4e bet1een t/e 5<g and !$$g glu4ose load tests ?or t/e diagnosis o? gestational diabetes mellitus+ 3lin 3/em "$$6C <"=>: !65&9+ P(I' !6&58"<
88+
2)estational 'iabetes2+ 'iabetes (ellitus Pregnan4y )estational 'iabetes+ Armenian (edi4al Net1ork+ "$$6+ Retrieved "$$6!!"5+
89+
R/ode (A- #/airo E- Jones . 8rd+ Indi4ated vs+ routine renatal urine 4/emi4al reagent stri testing+ J Rerod (ed "$$5C<"=8>: "!9+ P(I' !596<"&
8<+
Alto A+ No need ?or gly4osuria7roteinuria s4reen in regnant 1omen+ J Fam Pra4t "$$: 5&&8+ P(I' !6"666$9
86+
Ritterat/ 3- #iegmund T- Rad NT- #tein U- Bu/ling KJ+ A44ura4y and in?luen4e o? as4orbi4 a4id on glu4osetest 1it/ urine di sti4ks in renatal 4are+ J Perinat (ed "$$6C 89=9>: "&<&+ P(I' !6&<6&!6
85+
3ro1t/er 3A- Eiller J0- (oss JR et al+- Australian 3arbo/ydrate Intoleran4e #tudy in Pregnant omen =A3E.I#> Trial )rou+ 0??e4t o? treatment o? gestational diabetes mellitus on regnan4y out4omes+ N 0ngl J (ed "$$
8&+
#ermer (- Naylor 3'- )are 'J et al+ Ima4t o? in4reasing 4arbo/ydrate intoleran4e on maternal?etal out4omes in 8685 1omen 1it/out gestational diabetes+ T/e Toronto TriEosital )estational 'iabetes Proje4t+ Am J .bstet )yne4ol !: !96<6+ P(I' 568!65"
8+
Tu??nell 'J- est J- alkins/a1 #A+ Treatments ?or gestational diabetes and imaired glu4ose toleran4e in regnan4y+ 3o4/rane 'atabase o? #ystemati4 Revie1s "$$8- Issue 8+ Art+ No+: 3'$$88<+ P(I' !"!56<
9$+
Kaoor N- #ankaran #- Eyer #- #/e/ata E+ 'iabetes in regnan4y: a revie1 o? 4urrent eviden4e+ 3urr .in .bstet )yne4ol"$$5C !=6>: <&6<$+ P(I' !&$$5!8&
9!+
2Eealt/y 'iet 'uring Pregnan4y2+ Retrieved "! January "$!!+
9"+
(ottola (F+ T/e role o? eHer4ise in t/e revention and treatment o? gestational diabetes mellitus+ 3urr #orts (ed Re "$$5C 6=6>: 8&!6+ P(I' !&$$!6!!
98+
*anger .- Rodrigue@ 'A- Genakis 0(- (4Farland (B- Berkus ('Arrendondo
F+ Intensi?ied versus
4onventional management o? gestational
diabetes+ Am J .bstet )yne4ol !9C !5$=9>: !$8696+P(I' &!66!&5 99+
Taylor J#- Ka4mar J0- Not/nagle (- *a1ren4e RA+ A systemati4 revie1 o? t/e literature asso4iating breast?eeding 1it/ tye " diabetes and gestational diabetes+ J Am 3oll Nutr "$$: 8"$6+ P(I' !6!""<<
9<+
Na4/um ,- Ben#/lomo I- einer 0- #/alev 0+ T1i4e daily versus ?our times daily insulin dose regimens ?or diabetes in regnan4y: randomised 4ontrolled trial+ B(J !C 8!=5"!>: !""85+
96+
alkins/a1 #A+ ;ery tig/t versus tig/t 4ontrol ?or diabetes in regnan4y =ITE'RAN>+ 3o4/rane
'atabase
#yst
Rev "$$5C=">:
3'$$$""6+ P(I'
!56866"8 95+
Kremer 3J- 'u?? P+ )lyburide ?or t/e treatment o? gestational diabetes+ Am J .bstet )yne4ol "$$9C !$=<>: !98&+ P(I' !
9&+
*anger .- 3on1ay '*- Berkus ('- Genakis 0(- )on@ales .+ A 4omarison o? glyburide and insulin in 1omen 1it/ gestational diabetes mellitus+ N 0ngl J (ed+ "$$$C898=!6>:!!89&+ P(I' !!$86!!&
9+
#immons '- alters BN- Ro1an JA- (4Intyre E'+ (et?ormin t/eray and diabetes in regnan4y+ (ed J Aust "$$9C !&$=>: 96"9+ P(I' !
<$+
Ro1an JA- Eague (- )ao - Battin (R- (oore (PC (i) Trial Investigators+ (et?ormin versus insulin ?or t/e treatment o? gestational diabetes+ N 0ngl J (ed+ "$$&C8<&=!>:"$$8!<+ P(I' !&968856
)lue4k 3J- )oldenberg N- Praniko?? J- *o?tsring (- #ieve *- ang P+ Eeig/t- 1eig/t- and motorso4ial develoment during t/e ?irst !& mont/s o? li?e in !"6 in?ants born to !$ mot/ers 1it/ oly4ysti4 ovary syndrome 1/o 4on4eived on and 4ontinued met?ormin t/roug/ regnan4y+ Eum Rerod+ "$$9C!=6>:!8"8 8$+P(I' !
<"+
Kim 3- Berger 'K- 3/amany #+ Re4urren4e o? gestational diabetes mellitus: a systemati4 revie1+ 'iabetes 3are "$$5C 8$=<>: !8!9+ P(I' !5"$$85
<8+
*bner K- Kno?? A- Baumgarten A- et al+ Predi4tors o? ostartum diabetes in 1omen 1it/ gestational diabetes mellitus+ 'iabetes"$$6C <<=8>: 5"5+ P(I' !6<$<"9<
<9+
JLrvelL ID- Juutinen J- Koskela P et al+ )estational diabetes identi?ies 1omen at risk ?or ermanent tye ! and tye " diabetes in ?ertile age: redi4tive role o? autoantibodies+ 'iabetes 3are"$$6C "=8>: 6$5!"+ P(I' !6<$<
<<+
Kim 3- Ne1ton K(- Kno RE+ )estational diabetes and t/e in4iden4e o? tye " diabetes: a systemati4 revie1+ 'iabetes 3are+ "$$"C"<=!$>:!&6"&+ P(I' !"8
<6+
#tein/art JR- #ugarman JR- 3onnell FA+ )estational diabetes is a /erald o?
NI''( in Navajo 1omen+ Eig/ rate o? abnormal glu4ose toleran4e a?ter )'(+ 'iabetes 3are+ !5C"$=6>:985+P(I' !65!$9 <5+
*ee AJ- Eis4o4k RJ- ein P- alker #P- Perme@el (+ )estational diabetes mellitus: 4lini4al redi4tors and longterm risk o? develoing tye " diabetes: a retrose4tive 4o/ort study using survival analysis+ 'iabetes 3are+ "$$5C8$=9>:&5& &8+ P(I' !58"<9
<&+
Boney 3(- ;erma A- Tu4ker R- ;o/r BR+ (etaboli4 syndrome in 4/ild/ood: asso4iation
1it/
birt/
1eig/t-
maternal
obesity-
mellitus+ Pediatri4s "$$: e"$6+P(I' !<59!8<9
and
gestational
diabetes
<+
Eillier TA- Pedula K*- #4/midt ((- (ullen JA- 3/arles (A- Pettitt 'J+ 3/ild/ood obesity and metaboli4 imrinting: t/e ongoing e??e4ts o? maternal /yergly4emia+ 'iabetes 3are "$$5C 8$=>: ""&5"+ P(I' !5
6$+
(et@ger B0+ *ongterm .ut4omes in (ot/ers 'iagnosed it/ )estational 'iabetes (ellitus and T/eir .??sring+ 3lin .bstet )yne4ol "$$5C <$=9>: 5" + P(I' !5&"89$
6!+
Perrin (3- Terry (B- Klein/aus K- et al+ )estational diabetes and t/e risk o? breast 4an4er among 1omen in t/e Jerusalem Perinatal #tudy+ Breast 3an4er Res Treat "$$5 M0ub+ P(I' !5956<&
6"+
Perrin (3- Terry (B- Klein/aus K- et al+ )estational diabetes as a risk ?a4tor ?or an4reati4 4an4er: a rose4tive 4o/ort study+ B(3 (ed "$$5C <: "<+ Full teHt at P(3: !55$<&"8
68+
EAP. #tudy 3ooerative Resear4/ )rou+ Eyergly4emia and adverse regnan4y out4omes+ N 0ngl J (ed+ "$$&C8<&=!>:!!"$$"+ P(I' !&96885<
69+
Naylor 3'- #ermer (- 3/en 0- Farine '+ #ele4tive s4reening ?or gestational diabetes mellitus+ Toronto Tri/osital )estational 'iabetes Proje4t Investigators+ N 0ngl J (ed !5C 885="">: !<!%!<6+ P(I' 85!&<<
6<+
Jovanovi4Peterson *- Bevier - Peterson 3(+ T/e #anta Barbara 3ounty Eealt/ 3are #ervi4es rogram: birt/ 1eig/t 4/ange 4on4omitant 1it/ s4reening ?or and treatment o? glu4oseintoleran4e o? regnan4y: a otential 4oste??e4tive interventionO AmJ Perinatol !5C !9=9>: ""!&+ P(I' "<8"
66+
Jones 3+ )estational diabetes and its ima4t on t/e neonate+ Neonatal Net1+ "$$!C"$=6>:!5"8+ P(I' !"!99!!<
65+
Allen ;(- Armson BA- ilson R'- et al+ Teratogeni4ity asso4iated 1it/ re eHisting and gestational diabetes+ J .bstet )ynae4ol 3an"$$5C "=!!>: "589+ P(I' !55595
6&+
(artne@Fras (*- Fras JP- Bermejo 0- Rodrgue@Pinilla 0- Prieto *- Fras J*+ Pregestational maternal body mass indeH redi4ts an in4reased risk o? 4ongenital mal?ormations
in
in?ants
o?
mot/ers
(ed "$$: 55<&!+ P(I' !<!$68!
1it/
gestational
diabetes+ 'iabet
6+
#avona;entura 3- )att (+ 0mbryonal risks in gestational diabetes mellitus+ 0arly Eum 'ev "$$9C 5=!>: <68+ P(I' !<998&
5$+
3orrea A- )ilboa #(- Besser *(- et al+ =#etember "$$&>+2'iabetes mellitus and birt/ de?e4ts2+ Ameri4an journal o? obstetri4s and gyne4ology ! =8>: "85+e!% +doi:!$+!$!67j+ajog+"$$&+$6+$"&+ P(I' !&6595<"+
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. akaria! "#. $G
R%MA& "AK' %"A A*GKAA* %DARA D$K+R +"*A,A* A*AR'K"A -AK%LA" K+D$K+RA* %*'+R"'A" R'"AK' +R'$D+ /2 "++M+R 20// 1 /8 *$+M+R 20//
21
KATA PENGANTAR
Puji syukur enulis anjatkan keada Tu/an Dang (a/a 0sa yang tela/ memberikan berka/ dan ra/matNya se/ingga enulis daat menyelesaikan re?erat mengenai Q)estational 'iabetes (ellitus guna memenu/i sala/ satu ersyaratan dalam menemu/ Keaniteraan Klinik Bagian Imu Kandungan dan Kebidanan Fakultas Kedokteran Universitas Trisakti di R#PAU dr+ 0sna1an Antariksa Jakarta eriode !" setember % !& November "$!!+ 'isaming itu- makala/ ini ditunjukan untuk menamba/ engeta/uan bagi yang memba4anya+ Pada kesematan ini enulis ingin menyamaikan u4aan terima kasi/ yang sebesar % besarnya keada i/ak yang tela/ membantu dalam menyelesaikan makala/ ini- yaitu: !+ Kolonel Kes 'r+ Benny T+- #+.T- selaku Keala R#PAU dr+ 0sna1an Antariksa Jakarta "+ *etkol Kes 'r+ ,akaria- #+.)- selaku ketua #(F Ilmu Kandungan dan Kebidanan R#PAU dr+ 0sna1an Antariksa Jakarta+ 8+ Kolonel Kes 'r+ Frits (+R+- #+.)- selaku embimbing Keaniteraan Klinik Ilmu Kandungan dan Kebidanan R#PAU dr+ 0sna1an Antariksa Jakarta+ 9+ Ibu % ibu bidan selaku era1at Bagian Ilmu Kandungan dan Kebidanan R#PAU dr+ 0sna1an Antariksa Jakarta+ <+ Rekan % rekan Anggota Keaniteraan Klinik di Bagian Ilmu Kandungan dan Kebidanan R#PAU dr+ 0sna1an Antariksa Jakarta+
Penulis menyadari makala/ ini masi/ jau/ dari semurna+ .le/ karena itu- kritik dan saran yang membangun sangat di/arakan enulis agar re?erat ini daat enjadi lebi/ baik+ Penulis mo/on maa? yang sebesar % besarnya aabila banyak terdaat kesala/an mauun kekurangan dalam makala/ ini+ Ak/ir kata- enulis ber/ara semoga makala/ ini daat berman?aat k/ususnya bagi enulis sendiri mauun emba4a umumnya+ Jakarta- November "$!! Penulis 22
BAB I PENDAHULUAN
)estational diabetes =diabetes melitus gestasional atau- )'(> adala/ suatu kondisi di mana 1anita yang tana sebelumnya didiagnosis diabetes menunjukkan eningkatan kadar glukosa dara/ selama ke/amilan =terutama selama trimester ketiga ke/amilan>+ )estational diabetes ini disebabkan ketika tubu/ seorang 1anita /amil tidak mengeluarkan insulin yang dibutu/kan selama ke/amilan se/ingga terjadi eningkatan kadar gula dara/+ M! )estational diabetes umumnya memiliki beberaa gejala dan /al ini aling sering didiagnosis dengan skrining selama masa ke/amilan+ )estational diabetes memengaru/i 8 !$S dari ke/amilan- tergantung ada oulasi yang diteliti+
M"
#eerti gestational diabetes mellitus ada umumnya- bayi yang la/ir dari ibu dengan diabetes gestasional biasanya memunyai eningkatan risiko masala/ seerti bayi besar untuk usia ke/amilan =yang
daat
menyebabkan
komlikasi
kela/iran>- gula
dara/
renda/ =/ioglikema>- dan enyakit kuning + )estational diabetes adala/ suatu kondisi yang daat diobati dan 1anita yang tela/ mengontrol kadar gulanya se4ara e?ekti? daat menurunkan risiko ini+ anita dengan diabetes gestasional memunyai eningkatan risiko diabetes melitus tie " =atau- sangat jarang- diabetes autoimun laten atau Tie !> setela/ ke/amilan- serta memiliki insiden yang lebi/ tinggi reeklamsia dan kela/iran dengan oerasi 4aesar + #edangkan keturunan mereka rentan untuk ertumbu/an obesitas- dan atau dengan diabetes tie " di kemudian /ari+ Kebanyakan asien diobati /anya dengan modi?ikasi diet dan ola/ raga tetai beberaa mengambil obat antidiabetes- termasuk insulin+ M8
1
BAB II DIABETES MELLITUS GESTASIONAL
II. 1
DEFINISI
)estational diabetes =diabetes melitus gestasional atau- )'(> adala/ suatu kondisi di mana 1anita yang tana sebelumnya didiagnosis diabetes menunjukkan eningkatan kadar glukosa dara/ selama ke/amilan =terutama selama trimester ketiga ke/amilan>+ )estational diabetes ini disebabkan ketika tubu/ seorang 1anita /amil tidak mengeluarkan insulin yang dibutu/kan selama ke/amilan se/ingga terjadi eningkatan kadar gula dara/+ M!
II. 2.
EPIDEMIOLOGI
)estational diabetes memengaru/i 8!$S dari ke/amilan- tergantung ada oulasi yang diteliti+ M"
II. 3
KLASIFIKASI
)estational diabetes se4ara resmi dide?inisikan sebagai 2setia tingkat intoleransi glukosa dengan onset atau diakui ertama kali selama ke/amilan2+ 'e?inisi ini menyatakan kemungkinan ba/1a asien mungkin tela/ terdiagnosis diabetes mellitus sebelumnya+
M9 M<
Klasi?ikasi /ite- ole/ Pris4illa /ite yang memeloori dalam enelitian tentang engaru/ jenis diabetes ada /asil erinatal- se4ara global digunakan untuk menilai risiko ibu dan janin+ Ini membedakan antara diabetes gestasional =tie A> dan diabetes yang ada sebelum ke/amilan =diabetes regestational>+ Kedua kelomok ini kemudian dibagi lagi sesuai dengan risiko yang terkait dan manajemennya+
2
M6M5
Ada " subtie diabetes gestasional:
Tie A!: tes toleransi glukosa oral yang abnormal =TT).> tetai kadar glukosa dara/ uasa dan " jam setela/ makan normal- modi?ikasi diet memadai untuk mengontrol kadar glukosa+ Tie A": TT). yang abnormal ditamba/ ole/ kadar glukosa dara/ uasa dan 7 atau " jam sesuda/ makan abnormalC memerlukan terai tamba/an dengan insulin atau obat lain+
II. 4.
FAKTOR RISIKO
Faktor risiko klasik untuk gestational diabetes adala/ sebagai berikut:
M& M
#ebelumnya didiagnosis gestational diabetes atau radiabetes- toleransi glukosa terganggu- atau gula dara/ uasa terganggu
(emunyai ri1ayat keluarga dengan diabetes tie "
Usia ibu- ?aktor risiko meningkat ada 1anita usia tua =terutama bagi 1anita di atas 8< ta/un>
*atar belakang etnis =mereka yang memiliki ?aktor risiko tinggi termasuk A?rika Amerika- A?roKaribia- enduduk asli Amerika- Eisanik - Keulauan Pasi?ik - dan orang orang yang berasal dari Asia #elatan>
Kelebi/an berat badan - obesitas atau sangat gemuk meningkatkan risiko
Ri1ayat ke/amilan sebelumnya erna/ mela/irkan seorang anak dengan berat kela/iran yang tinggi = 9$$$ g> #elain itu- statistik menunjukkan risiko ganda )'( ada erokok + #indrom ovarium
olikistik juga meruakan ?aktor risiko- 1alauun bukti yang relevan masi/ kontroversial+ Beberaa enelitian tela/ meli/at adanya ?aktor risiko otensial yang lebi/ kontroversialseerti era1akan endek + M&M!$M!!M!" 3
Namun sekitar 9$6$S 1anita dengan )'( tidak memiliki ?aktor risiko- karena alasan ini banyak endaat
untuk menskrining semua 1anita+ Biasanya 1anita dengan
diabetes gestasional tidak menunjukkan gejala 7asimtomatik se/ingga dijadikan alasan lain untuk skrining universal- tetai beberaa 1anita mungkin menunjukkan eningkatan /aus eningkatan buang
air
ke4il- kelela/an- mual dan munta/- in?eksi
kandung
kemi/-
dan engli/atan kabur + M!8
II. 5. PATOFISIOLOGI
0?ek insulin ada utake glukosa dan metabolisme+ =!> Insulin berikatan dengan resetor ada membran sel yang ada ak/irnya mulai mengaktivasi kaskade rotein =">+ Ini termasuk: translokasi )*UT9 transorter ke membran lasma dan masuknya glukosa =8>- sintesis glikogen =9>-glikolisis =<> dan sintesis asam lemak =6>+ (ekanisme yang mendasari gestational diabetes samai saat ini teta tidak diketa/ui+ 3iri )'( adala/ meningkatnya resistensi insulin+ Eormon ke/amilan dan ?aktor ?aktor lain diangga insulin ole/ resetor insulin se/ingga teriikat ada resetor insulin+ Karena ?ungsi insulin mendorong masuknya glukosa ke dalam sel- dan damak dari resetor insulin sala/ mengenali /ormon ke/amilan- terjadila/ resistensi insulin yang berdamak ada tidak masuknya glukosa ke dalam selsel+ Akibatnya- glukosa teta berada dalam aliran dara/- se/ingga kadar glukosa dara/ menjadi meningkat+ #e/ingga lebi/ banyak insulin
dibutu/kan untuk mengatasi resistensi iniC keadaan ini menyebabkan tubu/ !-<"-< kali lebi/ banyak membutu/kan insulin dariada ada ke/amilan normal
M!9
Resistensi insulin adala/ ?enomena normal yang mun4ul ada trimester kedua ke/amilan+ Eal ini diduga untuk mengamankan asokan glukosa untuk ertumbu/an janin+ anita dengan )'( memiliki resistensi insulin yang tidak daat dikomensasi dengan eningkatan roduksi insulin di sel ankreas+ Eormon lasenta- dan meningkatnya deosito lemak
selama
ke/amilan
tamaknya
memediasi
ke/amilan+ Kortisol dan rogesteron adala/
enyebab
manusia - rolaktin dan estradiol juga berkontribusi+
resistensi utama-
insulin
selama
tai laktogen
lasenta
M!9
Tidak jelas mengaa beberaa asien tidak mamu untuk menyeimbangkan kebutu/an insulin se/ingga menjadi )'(- namun sejumla/ enjelasan tela/ diberikan- miri dengan yang terjadi ada diabetes tie ": autoimunitas - mutasi gen tunggal- obesitas- dan mekanisme lainnya+M!< Karena
erjalanan
glukosa
melintasi
lasenta
=melalui di?usi
di?asilitasi ole/ )*UT8 oerator>- maka janin terkena kadar glukosa lebi/ tinggi+ Eal ini menyebabkan eningkatan tingkat insulin janin =insulin itu sendiri tidak daat melintasi lasenta>+ #e/ingga
daat
menyebabkan
ertumbu/an
berlebi/an
dan
tubu/
besar
=makrosomia>+ #etela/ la/ir- lingkungan dengan kadar glukosa yang tinggi meng/ilangsedangkan bayi yang baru la/ir ini terbiasa dengan roduksi insulin terus menerus tinggi se/ingga menyebabkan kadar glukosa dara/ bayi renda/ =/ioglikemia>+ M!6
5
II 6. SKRINING
Kriteria 'iabetes E. "$$6 M!5
2 ja !"#$osa
P#asa !"#$osa
mmol 7 l =mg 7 dl>
mmol 7 l =mg 7 dl>
V5-& =V!9$>
V6+! =V!!$>
V5-& =V!9$>
W 6+! =W !!$> V5+$ =V!"6>
W 5-& =W !9$>
V5+$ =V!"6>
W !!-! =W "$$>
W 5+$ =W !"6>
Kondisi
No%a"
G#"a da%a& '#asa ()%!an!!#
Gan!!#an (o")%ansi !"#$osa
Dia*)()s )""i(#s
6
#ejumla/ skrining dan tes diagnostik tela/ digunakan untuk mendeteksi tingginya kadar glukosa dalam lasma atau serum+ #ala/ satu metode adala/ endekatan berta/a di mana /asil yang men4urigakan ada tes skrining akan diikuti dengan uji diagnostik+ Atau- tes diagnostik daat digunakan langsung ada kunjungan antenatal ertama untuk asien berisiko tinggi
=misalnya
ada
asien
dengan sindrom
ovarium
olikistik atau
a4ant/osis
nigri4ans>+ M!6
Tes untuk diabetes gestasional
)lukosa dara/ tes Nontantangan
Tes )lukosa Puasa
Tes glukosa " jam ostrandial =setela/ makan>
Uji glukosa 1aktu a4ak
#krining glukosa uji tantangan Tes toleransi glukosa oral =TT).>
Tes dara/ nontantangan- mengukur kadar glukosa dalam samel dara/ tana menantang subjek dengan larutan glukosa+ Tingkat glukosa dara/ ditentukan saat uasa- " jam setela/ makan- atau /anya ada 1aktu a4ak+ #ebaliknya- tes tantangan menuntut asien meminum larutan glukosa dan engukuran konsentrasi glukosa dalam dara/ setela/nya- ada diabetes- mereka 4enderung teta tinggi+ *arutan glukosa memiliki rasa sangat manis yang untuk beberaa 1anita tidak menyenangkan- ole/ karena itu- terkadang erlu ditamba/kan erasa buatan+ Beberaa 1anita mungkin mengalami mual selama tes+ M!& M!
!
II. +. METODE SKRINING
Ada endaat yang berbeda tentang skrining yang otimal dan tes diagnostik- sebagian karena erbedaan dalam risiko oulasi- ertimbangan e?ektivitas biaya- dan kurangnya dasar bukti untuk mendukung rogram besar skrining nasional+ #krining ini memerlukan tes yang glukosa dara/ a4ak selama kunjungan- tes skrining glukosa dengan tantangan sekitar ke/amilan "9"& minggu- diikuti dengan TT). jika tes berada di luar batas normal+ Jika ada ke4urigaan yang tinggi- 1anita /amil daat diuji sebelum 1aktunya+
M< M"$
'i Amerika #erikat - dokter kandungan menyukai skrining universal dengan tes glukosa skrining dengan tantangan+ 'i Inggris- unit kebidanan sering mengandalkan ada ?aktor?aktor
risiko
Association and
dan
glukosa
the Society
tes
of
dara/
a4ak
=)'#>+ The American
Obstetricians
and
Diabetes
Gynaecologists
of
Canada merekomendasikan skrining rutin ke4uali untuk asien dengan risiko renda/ =ini berarti 1anita /arus lebi/ muda dari "< ta/un dan memiliki indeks massa tubu/ kurang dari "5- dengan tidak memiliki ?aktor?aktor risiko ribadi etnis atau keluarga>+ The Canadian Diabetes Association and the American College of Obstetricians and Gynecologists merekomendasikan
skrining
yang
universal+ The US
Preventive
Services
Task
Force menemukan ba/1a erlu ada 4uku bukti untuk merekomendasikan seseorang untuk skrining rutin+ M< M!6 M"$ M"! M"" M"8 M"9 M"<
T#$ %&'()$* +*,*- )/**%* Ketika kadar glukosa lasma ditemukan lebi/ tinggi dari !"6 mg7dl =5-$ mmol7l> setela/ uasa- atau lebi/ dari "$$ mg7dl =!!-! mmol7l> ada setia kesematan- dan jika /asil tes ini dikon?irmasi ada /ari berikutnya- diagnosis )'( daat ditegakkan dan tidak ada engujian lebi/ lanjut yang dierlukan+ Tes ini biasanya dilakukan ada kunjungan antenatal ertama+ M< M"6 M"5 M"&
S(,% #$ %&'()$* **%*
8
#krining glukosa uji tantangan =disebut juga tes .#ullivan> dilakukan ada usia ke/amilan antara "9"& minggu- dan daat dili/at sebagai versi seder/ana dari tes toleransi glukosa oral =TT).>+ Ini membutu/kan asien minum larutan yang mengandung <$ gram glukosa- dan mengukur kadar glukosa dara/ ! jam kemudian+
M"
Jika cutoff !oint ditetakan sebesar !9$ mg7dl =5-& mmol7l>- &$S dari 1anita dengan )'( akan terdeteksi+ M< Jika ambang batas ini untuk engujian lebi/ lanjut diturunkan menjadi !8$ mg7dl- maka $S dari kasus )'( akan terdeteksi+
T#$ T)&#,*$ G&'()$* O,*& TTGO TT). /arus dilakukan ada agi /ari setela/ uasa semalam antara & dan !9 jam+ #elama tiga /ari sebelumnya asien /arus memiliki ola makan terbatas =yang mengandung setidaknya !<$ gram karbo/idrat er /ari> dan aktivitas ?isik terbatas+ #ubjek /arus teta duduk selama tes dan tidak bole/ merokok selama tes+ M8$ Tes ini memerlukan asien minum larutan yang mengandung sejumla/ glukosa- dan mengambil dara/ untuk mengukur kadar glukosa ada a1al dan ada interval mengatur 1aktu setela/nya+ Kriteria diagnostik dari "ational Diabetes Data Grou! #"DDG$ adala/ yang aling sering digunakan- tetai beberaa usat bergantung ada kriteria 3arenter dan 3oustan- yang menetakan cutoff untuk gula dara/ normal ada nilai yang lebi/ renda/+ 'ibandingkan dengan kriteria N'')- kriteria 3arenter dan 3oustan mengara/ ke diagnosis gestational diabetes ada <9 S lebi/ 1anita /amil- dengan eningkatan biaya dan tidak ada bukti kuat dari /asil erinatal meningkat+ M8! Berikut ini adala/ nilainilai yang American Diabetes Association angga abnormal dari TT). glukosa+
Tingkat glukosa dara/ uasa W < mg 7 dl =<-88 mmol 7 *>
)lukosa dara/ ! jam W !&$ mg 7 dl =!$ mmol 7 *>
)lukosa dara/ " jam W !<< mg 7 dl =&-6 mmol 7 *> 9
)lukosa dara/ 8 jam W !9$ mg 7 dl =5-& mmol 7 *>
#ebua/ tes alternati? menggunakan beban glukosa 5< g dan ukuran kadar glukosa dara/ sebelum dan setela/ ! dan " jam- menggunakan nilainilai re?erensi yang sama+ Tes ini akan mengidenti?ikasi 1anita yang berisiko lebi/ sedikit- dan /anya ada konkordansi lema/ =tingkat erjanjian> antara tes ini dan 8 jam !$$ g tes+
M8"
Nilai glukosa yang digunakan untuk mendeteksi gestational diabetes ertama kali ditentukan ole/ .#ullivan dan (a/an =!69> dalam studi ko/ort retrosekti? =menggunakan !$$ gram glukosa TT).> yang diran4ang untuk mendeteksi risiko engembangan diabetes tie " di masa dean+ Nilainilai yang ditetakan menggunakan seluru/ dara/ dan dierlukan dua nilai men4aai atau melebi/i nilai menjadi ositi?+ In?ormasi selanjutnya menyebabkan eruba/an dalam kriteria .#ullivan+ Bila metode untuk enentuan glukosa dara/ beruba/ dari enggunaan seluru/ dara/ untuk samel lasma vena- kriteria untuk )'( juga beruba/+ M88
P#%'4* %&'()$* ', anita dengan )'( mungkin memiliki tingkat glukosa yang tinggi dalam urin mereka =glukosuria>+ Peningkatan tingkat
?iltrasi
glomerulus selama
ke/amilan
memberikan
kontribusi sekitar <$S 1anita memiliki glukosa dalam urin mereka ada tes distik di beberaa titik selama ke/amilan mereka+ #ensitivitas dari glukosuria untuk )'( ada " trimester ertama /anya sekitar !$S dan nilai redikti? ositi? adala/ sekitar "$S+ M89 M8< M86
II. 8. MANA"EMEN Tujuan engobatan adala/ untuk mengurangi risiko )'( untuk ibu dan anak+ Bukti ilmia/ mulai menunjukkan ba/1a mengendalikan kadar glukosa daat mengurangi risiko komlikasi janin
=seerti makrosomia > dan eningkatan kualitas /idu ibu+ #ayangnya10
engobatan )'( juga disertai ole/ banyaknya bayi berada di unit era1atan neonatal dan membutu/kan er/atian+ Temuantemuan ini masi/ baru dan kontroversial+ M85 M8& M8 #ebua/ TT). ulang /arus dilakukan "9 bulan setela/ mela/irkan- untuk mengkon?irmasi diabetes tela/ meng/ilang+ #etela/ itu- disarankan untuk skrining rutin diabetes tie "+ M& Jika diet diabetes atau )I 'iet - ola/raga- dan engobatan oral tidak memadai untuk mengontrol kadar glukosa- terai insulin mungkin menjadi erlu+ Perkembangan
makrosomia
daat
dievaluasi
selama
ke/amilan
dengan
menggunakan sonogra?i +anita yang menggunakan insulin- dengan ri1ayat la/ir mati- atau dengan /iertensi dikelola sama seerti 1anita dengan diabetes+ M!8
II. ,. GA-A HIDUP
Konseling sebelum ke/amilan =misalnya- tentang sulemen asam ?olat > dan manajemen multidisilin sangat enting untuk /asil ke/amilan yang baik+ Kebanyakan 1anita daat mengelola )'( mereka dengan eruba/an ola makan dan ola/raga+ Pemantauan kadar glukosa dara/ daat memandu terai+ Beberaa 1anita akan membutu/kan terai obat antidiabetes- dan yang aling sering insulin terai+ M9$ #etia ola makan memerlukan kalori yang 4uku untuk ke/amilan- biasanya "+$$$ "+<$$ kkal dengan enge4ualian dari karbo/idrat seder/ana+ Tujuan utama dari modi?ikasi diet adala/ untuk meng/indari un4ak kadar gula dara/+ Eal ini daat dilakukan dengan membagi asuan karbo/idrat saat makan dan makanan ringan seanjang /ari- dan menggunakan slo%release carbohydrate sources atau yang dikenal sebagai )I 'iet+ Karena resistensi insulin tertinggi di agi /ari- saraan karbo/idrat erlu lebi/ dibatasi+ (enelan lebi/ banyak serat dalam makanan dengan bijibijian- atau bua/bua/an dan sayuran juga daat mengurangi risiko gestational diabetes+
M& M!8 M9!
*ati/an ?isik se4ara teratur dan intens disarankan- meskiun tidak ada konsensus tentang struktur sesi?ik dari rogram lati/an untuk )'(+
11
M& M9"
Pemantauan diri daat di4aai dengan menggunakan sistem glukosa dara/ kailer+ Keatu/an dengan sistem ini glu4ometer bisa renda/ M98 Rentang Target disarankan ole/ The Australasian Diabetes in Pregnancy Society adala/ sebagai berikut: M&
Kadar glukosa dara/ uasa kailer V<-< mmol7*
Kadar glukosa dara/ kailer ! jam ostrandial V&-$ mmol7*
Kadar glukosa dara/ " jam ostrandial V6-5 mmol7*
#amel dara/ daat juga digunakan untuk menentukan kadar EbA!4 - yang memberikan gambaran tentang kontrol glukosa selama eriode 1aktu lebi/ lama+
M&
Penelitian menunjukkan kemungkinan man?aat menyusui untuk mengurangi risiko diabetes dan risiko terkait untuk ibu dan anak+
M99
II. 1O. MEDIKASI
Jika dnengan 4ara monitoring gagal mengontrol kadar glukosa- atau jika ada bukti komlikasi seerti ertumbu/an janin berlebi/an- engobatan dengan insulin mungkin menjadi erlu+ Regimen terai yang aling umum melibatkan insulin kerja 4eat sebelum makan untuk menurunkan glukosa yang meningkat tajam setela/ makan+ Pera1atan /arus dilakukan untuk meng/indari kadar gula dara/ renda/ =/ioglikemia> akibat suntikan insulin yang berlebi/an+ Terai insulin bisa normal atau sangat ketat+ M& M!6 M9< M96 Ada beberaa bukti ba/1a beberaa agen glikemik oral mungkin tidak aman ada ke/amilan+ Namun- glyburide- generasi kedua sul?onilurea- tela/ terbukti menjadi alternati? yang e?ekti? selain terai insulin+ 'alam satu studi- 9S eremuan membutu/kan insulin tamba/an yang untuk men4aai target gula dara/ normal+ (et?ormin juga tela/ menunjukkan /asil yang menjanjikan- dengan ?ormat oral yang jau/ lebi/ ouler dariada suntikan insulin+ Pengobatan sindrom ovarium olikistik dengan met?ormin selama ke/amilan tela/ ter4atat untuk mengurangi tingkat )'(+ #ebua/ uji 4oba se4ara a4ak met?ormin vs insulin
12
menunjukkan ba/1a eremuan lebi/ suka tablet met?ormin dibandingkan dengan suntikan insulin- dan met?ormin lebi/ aman dan sama e?ekti?nya dengan insulin+
M<$
Eioglikemia
neonatal yang ara/ jarang terjadi ada 1anita yang diobati dengan insulin- tetai kela/iran rematur lebi/ sering terjadi+ Eamir setenga/ dari asien tidak men4aai /asil yang 4uku dengan met?ormin saja dan membutu/kan terai tamba/an dengan insulin- dibandingkan dengan mereka yang diobati dengan insulin saja- berat badan mereka tidak bertamba/ banyak+ 'engan tidak adanya studi jangka anjang ada anakanak dari 1anita yang diobati dengan obat antidiabetes- namun teta memunyai kemungkinan komlikasi jangka anjang dari terai met?ormin- namun ada anakanak usia !& bulan yang la/ir dari ibu dengan sindrom ovarium olikistik dan diterai dengan met?ormin mengungkakan tidak ada kelainan erkembangan+ M8 M95 M9& M9 M<$ M
II. 11. PROGNOSIS )estational diabetes umumnya sembu/ setela/ bayi la/ir+ Berdasarkan studi yang berbedakemungkinan terjadinya )'( ada ke/amilan kedua adala/ antara 8$ dan &9S- tergantung ada latar belakang etnis+ Ke/amilan kedua dalam 1aktu ! ta/un dari ke/amilan sebelumnya memiliki tingkat kekambu/an yang lebi/ tinggi+
M<"
anita yang didiagnosis dengan diabetes gestational memiliki eningkatan risiko diabetes mellitus di masa dean+ Risiko tertinggi ada eremuan yang membutu/kan engobatan insulin- memiliki antibodi yang ber/ubungan dengan diabetes =seerti antibodi ter/ada glutamat dekarboksilase - antibodi sel islet dan 7 atau insulinoma antigen">- 1anita dengan ke/amilan lebi/ dari dua kali- dan 1anita yang obesitas+ anita yang membutu/kan insulin untuk mengelola diabetes gestasional memiliki risiko <$S akan terkena diabetes dalam lima ta/un ke dean+ Tergantung ada oulasi yang diteliti dan kriteria diagnostik risiko daat bervariasi+ Risiko tertinggi tamaknya dalam < ta/un ertama setela/nya+ #ala/ satu enelitian anjang mengikuti sekelomok eremuan dari Boston dan (assa4/usettssetenga/ dari mereka menderita diabetes setela/ 6 ta/un- dan lebi/ dari 5$S menderita diabetes setela/ "& ta/un+ 'alam sebua/ enelitian retrosekti? di Navajo- 1anita berisiko diabetes setela/ )'( dierkirakan <$ samai 5$S setela/ !! ta/un+ #tudi lain menemukan risiko diabetes setela/ )'( lebi/ dari "
13
renda/ untuk diabetes tie "- ada subyek raming dan ada asien dengan autoantibodi ada tingkat yang lebi/ tinggi ada 1anita menderita diabetes tie !+ M88 M<8M<9 M<< M<6 M<5 Anak dari ibu dengan )'( memiliki eningkatan risiko untuk obesitas de1asa dan eningkatan risiko intoleransi glukosa dan diabetes tie " di kemudian /ari+ Risiko ini berkaitan dengan eningkatan nilai glukosa ibu+ #aat ini belum jelas beraa banyak kerentanan genetik dan ?aktor lingkungan masingmasing berkontribusi ter/ada risiko inidan jika engobatan )'( daat memengaru/i /asil ini+
M<& M<M6$
Ada data statistik yang langka ada risiko kondisi lain ada 1anita dengan )'(dalam studi erinatal di Derusalem- 9!$ dari 85+6" asien dilaorkan memiliki )'(- dan ada ke4enderungan ke ara/ kanker ayudara dan ankreas yang lebi/- tetai dierlukan enelitian lebi/ lanjut untuk mengkon?irmasi temuan ini+ M6! M6"
II. 12. KOMPLIKASI
)'( menimbulkan risiko bagi ibu dan anak+ Risiko ini sebagian besar terkait dengan tingginya kadar glukosa dara/ dan konsekuensinya+ Risiko meningkat dengan kadar glukosa dara/ yang lebi/ tinggi+ Pengobatan yang memunyai /asil yang lebi/ baik ada tingkat ini daat mengurangi beberaa risiko )'(+ 'ua
risiko
utama
)'(
M98 M68
ada
bayi
adala/
kelainan
ertumbu/an
dan
ketidakseimbangan kimia setela/ kela/iran- yang mungkin memerlukan era1atan di unit intensi? neonatal + Bayi la/ir dari ibu dengan )'( beresiko menjadi besar untuk usia ke/amilan =makrosomia> mauun ke4il untuk usia ke/amilan+ (akrosomia meningkatkan risiko kela/iran instrumental =misalnya ?orses- ventouse dan oerasi 4aesar > atau masala/ selama ersalinan vagina =seerti distosia ba/u >+ (akrosomia daat terjadi ada !"S 1anita yang normal dibandingkan dengan "$S asien dengan )'(+ Namun- bukti untuk masing masing komlikasi tidak sama kuat- dalam studi &y!erglycemia and Adverse Pregnancy Outcome =EAP.> misalnya- ada eningkatan risiko bagi bayi untuk menjadi besar tetai tidak ke4il untuk usia ke/amilan+ Penelitian komlikasi untuk )'( sulit karena banyak
1
?aktor embaur =seerti obesitas>+ #eorang 1anita yang memiliki )'( daat meningkatkan risiko mela/irkan se4ara oerasi 4aesar+ M!6 M68 M69 M6< Peningkatan risiko ada neonatus juga terjadi seerti glukosa dara/ renda/ =/ioglikemia>- enyakit kuning- eningkatan jumla/ sel dara/ mera/ = olisitemia>- kalsium dara/ renda/ =/iokalsemia> dan magnesium dara/ renda/ = /yomagnesemia >+ )'( juga mengganggu
ematangan
ter/ada sindrom
janin-
gangguan
se/ingga
menyebabkan
ernaasan karena
bayi
aruaru
dysmature
belum
matang
rentan dan
gangguan sur?aktansintesis+ M66 Tidak seerti regestational diabetes- diabetes gestasional belum jelas terbukti menjadi ?aktor risiko indeenden untuk 4a4at la/ir + 3a4at la/ir biasanya berasal dari suatu 1aktu selama trimester ertama =sebelum minggu ke!8> ke/amilan- sedangkan )'( se4ara berta/a berkembang selama trimester ertama+ Penelitian tela/ menunjukkan ba/1a keturunan 1anita dengan )'( berada ada risiko tinggi untuk 4a4at ba1aan+ #ebua/ studi kasus menemukan ba/1a diabetes gestastional dikaitkan dengan
4a4at la/ir- dan ba/1a
asosiasi ini umumnya terbatas ada eremuan dengan indeks massa tubu/ lebi/ tinggi =W "< kg 7 mX>+ #ulit untuk memastikan ba/1a ini bukan disebabkan ole/ radiabetes tie " ada yang tidak didiagnosis sebelum ke/amilan+
M65 M6& M6 M5$
Karena studi yang saling bertentangan- tidak jelas ada saat aaka/ 1anita dengan )'( memiliki risiko lebi/ tinggi mengalami reeklamsia+ 'alam studi EAP.- risiko reeklamsia adala/ antara !8S dan 85S lebi/ tinggi+ M68 M5!
15
BAB III PENUTUP
Komlikasi ibu dan bayi ada enderita diabetes akan meningkat karena eruba/an metabolik+ Angka la/ir mati terutama ada kasus dengan diabetes tak terkendali daat terjadi !$ kali dalam normal+ 'ierkirakan kejadian diabetes dalam ke/amilan iala/ $-5 S- tetai seringkali sukar ditemukan karena renda/nya kemamuan deteksi kasus +M! Insidensi 'iabetes (elitus )estasional sangat tergantung dari 4ara enyaringan dan kriteria diagnosis 'iabetes (elitus )estasional yang diakai- disaming materi enyaringan yang dieriksa+ 'i Indonesia dengan menggunakan kriteria diagnosis 4ara .Ysullivan(a/an insidensi '() berkisar antara !-"-6 S+ #edikitnya ada 8 alasan mengaa enyaringan+ 'iabetes (elitus )estasional erlu dilaksanakan+ Keadaan /ierglikemi ada ibu daat mengakibatkan : M! M" !+ Angka kesakitan ada ibu sendiri yang tinggi dibandingkan oulasi normal+ "+ Angka kesakitan dan kematian erinatal yang meningkat+ 8+ Ri1ayat 'iabetes (elitus )estasional sebelumnya meruakan resiko tinggi untuk menjadi '( dikemudian /ari+
16
BAB I DAFTAR PUSTAKA
!+
2'iabetes Blue 3ir4le #ymbol2+ International 'iabetes Federation+ !5 (ar4/ "$$6+
"+
T/omas
R
(oore-
('
et
al+
'iabetes
(ellitus
and
Pregnan4y+med7"89 at e(edi4ine+ ;ersion: Jan "5- "$$< udate+ 8+
'onovan-
PJ
="$!$>+ 2'rugs
?or
gestational
diabetes2+Australian
Pres4riber =88>: !9!%9+ 9+
(et@ger B0- 3oustan 'R =0ds+>+ Pro4eedings o? t/e Fourt/ International orks/o3on?eren4e on )estational 'iabetes (ellitus+ 'iabetes 3are !&C "! =#ul+ ">: B!%B!65+
<+
Ameri4an 'iabetes Asso4iation+ )estational 'iabetes (ellitus+ 'iabetes 3are "$$9C "5: #&&$+ P(I' !96886
6+
/ite P+ Pregnan4y 4omli4ating diabetes+ Am J (ed !9C 5: 6$+ P(I' !<86$68
5+
)abbe #+)+- Niebyl J+R+- #imson J+*+ .B#T0TRI3#: Normal and Problem Pregnan4ies+ Fourt/ edition+ 3/ur4/ill *ivingstone- Ne1 Dork- "$$"+ I#BN $998 $6<5"!
&+
Ross )+ )estational diabetes+ Aust Fam P/ysi4ian"$$6C 8<=6>: 8"6+ P(I' !65
+
3/u #D- 3allag/an (- Kim #D- #4/mid 3E- *au J- 0ngland *J- 'iet@ P(+ (aternal
obesity
and
risk
o?
gestational
diabetes
mellitus+ 'iabetes
3are "$$5C 8$=&>: "$5$6+ P(I' !59!65&6 !$+
0ngland *J- *evine RJ- ian 3- et al+ )lu4ose toleran4e and risk o? gestational diabetes mellitus in nulliarous 1omen 1/o smoke during regnan4y+ Am J 0idemiol "$$9C !6$=!">: !"$<!8+ P(I' !<<&8858 1!
!!+
Toulis KA- )oulis ')- Kolibianakis 0- ;enetis 3A- Tarlat@is B3- Paadimas I+ Risk o? gestational diabetes mellitus in 1omen 1it/ oly4ysti4 ovary syndrome+ Fertility and #terility"$$&Cdoi:!$+!$!67j+?ertnstert+"$$&+$6+$9< P(I': !&5!$5!8
!"+
(a R(- *ao TT- (a 3*- et al+ Relations/i bet1een leg lengt/ and gestational
diabetes
mellitus
in
3/inese
regnant
1omen+'iabetes
3are "$$5C 8$=!!>: "6$!+ P(I' !566696& !8+
A3.)+ Pre4is ;+ An Udate on .bstetri4s and )yne4ology++ A3.) =!9>+ + !5$+ I#BN $!<958""9+
!9+
3arr 'B- )abbe #+ )estational 'iabetes: 'ete4tion- (anagement- and Imli4ations+ 3lin 'iabetes !&C !6=!>: 9+
!<+
Bu4/anan
TA-
Giang
AE+
)estational
diabetes
mellitus+ J
3lin
Invest "$$: 9&<%9!+ P(I' !<56
Kelly *- 0vans *- (essenger '+ 3ontroversies around gestational diabetes+ Pra4ti4al in?ormation ?or ?amily do4tors+ 3an Fam P/ysi4ian "$$
!5+
2'e?inition
and
'iagnosis
o?
'iabetes
(ellitus
and
Intermediate
Eyergly4emia2 =d?>+ orld Eealt/ .rgani@ation+ 111+1/o+int+ "$$6+ Retrieved "$!!$""$+ !&+
#ievenier J*- Jenkins 'J- Josse R)- ;uksan ;+ 'ilution o? t/e 5<g oral glu4ose toleran4e test imroves overall tolerability but not rerodu4ibility in subje4ts 1it/ di??erent body 4omositions+'iabetes Res 3lin Pra4t "$$!C : &5<+ P(I' !!!6<6&&
!+
Ree4e 0A- Eol?ord T- Tu4k #- Bargar (- .3onnor T- Eobbins J3+ #4reening ?or gestational diabetes: one/our 4arbo/ydrate toleran4e test er?ormed by a virtually tasteless olymer o? glu4ose+ Am J .bstet )yne4ol !&5C !<6=!>: !8" 9+ P(I' 85595
"$+
Berger E- 3rane J- Farine '- et al+ #4reening ?or gestational diabetes mellitus+ J .bstet )ynae4ol 3an "$$"C "9: &9%!"+P(I' !"9!5$<
18
"!+
)abbe #)- )regory RP- Po1er (*- illiams #B- #4/ulkin J+ (anagement o? diabetes mellitus by obstetri4iangyne4ologists+.bstet )yne4ol "$$9C !$8=6>: !"" 89+ P(I' !
""+
(ires )J- illiams F*- Earer ;+ #4reening ra4ti4es ?or gestational diabetes mellitus in UK obstetri4 units+ 'iabet (ed!C !6=">: !8&9!+ P(I' !$""8$5
"8+
3anadian
'iabetes
Asso4iation
3lini4al
Pra4ti4e
)uidelines
0Hert
3ommittee+ 3anadian 'iabetes Asso4iation "$$8 3lini4al Pra4ti4e )uidelines ?or t/e Prevention and (anagement o? 'iabetes in 3anada+ 3an J 'iabetes "$$8C "5 =#ul ">: !%!9$+ "9+
)abbe #)- )raves 3R+ (anagement o? diabetes mellitus 4omli4ating regnan4y+ .bstet )yne4ol "$$8C !$"=9>: &<56&+P(I' !9<
"<+
Eillier TA- ;es4o KK- Pedula K*- Beil T*- /itlo4k 0P- Pettitt 'J =(ay "$$&>+ 2#4reening ?or gestational diabetes mellitus: a systemati4 revie1 ?or t/e U+#+ Preventive
#ervi4es
Task
For4e2+Ann+
Intern+
(ed+ !9& =!$>:
566%
5<+ P(I' !&9$6&+ "6+
Agar1al ((- '/att )#+ Fasting lasma glu4ose as a s4reening test ?or gestational diabetes mellitus+ Ar4/ )yne4ol .bstet "$$5C"5<=">: &!5+ P(I' !665"58
"5+
#a4ks 'A- 3/en - oldeTsadik )- Bu4/anan TA+ Fasting lasma glu4ose test at t/e ?irst renatal visit as a s4reen ?or gestational diabetes+ .bstet )yne4ol "$$8C !$!=6>: !!5"$8+P(I' !"5&<"<
"&+
Agar1al ((- '/att )#- Punnose J- ,ayed R+ )estational diabetes: ?asting and ostrandial glu4ose as ?irst renatal s4reening tests in a /ig/risk oulation+ J Rerod (ed "$$5C<"=9>: "8$<+ P(I' !5<$685$
"+
Boyd 0+ (et@ger- (+'+- #usan A+ Biastre- R+'+- *+'+N+- 3+'+0+- Beverly )ardner- R+'+- *+'+N+- 3+'+0+ ="$$6>+ 2/at I need to kno1 about )estational 'iabetes2+ National
'iabetes
In?ormation
3learing/ouse+
In?ormation 3learing/ouse+ Retrieved "$$6!!"5+ 8$+
)lu4ose toleran4e test+ (edlinePlus- November &- "$$6+
19
National
'iabetes
8!+
3arenter (- 3oustan 'R+ 3riteria ?or s4reening tests ?or gestational diabetes+ Am J .bstet )yne4ol !&"C !99=5>: 56&58+P(I' &8$5!!
8"+
(ello )- 0lena P- .gnibene A- 3ioni R- Tondi F- Pe@@ati P- Pratesi (#4arselli )- (esseri )+ *a4k o? 4on4ordan4e bet1een t/e 5<g and !$$g glu4ose load tests ?or t/e diagnosis o? gestational diabetes mellitus+ 3lin 3/em "$$6C <"=>: !65&9+ P(I' !6&58"<
88+
2)estational 'iabetes2+ 'iabetes (ellitus Pregnan4y )estational 'iabetes+ Armenian (edi4al Net1ork+ "$$6+ Retrieved "$$6!!"5+
89+
R/ode (A- #/airo E- Jones . 8rd+ Indi4ated vs+ routine renatal urine 4/emi4al reagent stri testing+ J Rerod (ed "$$5C<"=8>: "!9+ P(I' !596<"&
8<+
Alto A+ No need ?or gly4osuria7roteinuria s4reen in regnant 1omen+ J Fam Pra4t "$$: 5&&8+ P(I' !6"666$9
86+
Ritterat/ 3- #iegmund T- Rad NT- #tein U- Bu/ling KJ+ A44ura4y and in?luen4e o? as4orbi4 a4id on glu4osetest 1it/ urine di sti4ks in renatal 4are+ J Perinat (ed "$$6C 89=9>: "&<&+ P(I' !6&<6&!6
85+
3ro1t/er 3A- Eiller J0- (oss JR et al+- Australian 3arbo/ydrate Intoleran4e #tudy in Pregnant omen =A3E.I#> Trial )rou+ 0??e4t o? treatment o? gestational diabetes mellitus on regnan4y out4omes+ N 0ngl J (ed "$$
8&+
#ermer (- Naylor 3'- )are 'J et al+ Ima4t o? in4reasing 4arbo/ydrate intoleran4e on maternal?etal out4omes in 8685 1omen 1it/out gestational diabetes+ T/e Toronto TriEosital )estational 'iabetes Proje4t+ Am J .bstet )yne4ol !: !96<6+ P(I' 568!65"
8+
Tu??nell 'J- est J- alkins/a1 #A+ Treatments ?or gestational diabetes and imaired glu4ose toleran4e in regnan4y+ 3o4/rane 'atabase o? #ystemati4 Revie1s "$$8- Issue 8+ Art+ No+: 3'$$88<+ P(I' !"!56<
9$+
Kaoor N- #ankaran #- Eyer #- #/e/ata E+ 'iabetes in regnan4y: a revie1 o? 4urrent eviden4e+ 3urr .in .bstet )yne4ol"$$5C !=6>: <&6<$+ P(I' !&$$5!8&
9!+
2Eealt/y 'iet 'uring Pregnan4y2+ Retrieved "! January "$!!+
20
9"+
(ottola (F+ T/e role o? eHer4ise in t/e revention and treatment o? gestational diabetes mellitus+ 3urr #orts (ed Re "$$5C 6=6>: 8&!6+ P(I' !&$$!6!!
98+
*anger .- Rodrigue@ 'A- Genakis 0(- (4Farland (B- Berkus ('Arrendondo F+ Intensi?ied versus 4onventional management o? gestational diabetes+ Am J .bstet )yne4ol !9C !5$=9>: !$8696+P(I' &!66!&5
99+
Taylor J#- Ka4mar J0- Not/nagle (- *a1ren4e RA+ A systemati4 revie1 o? t/e literature asso4iating breast?eeding 1it/ tye " diabetes and gestational diabetes+ J Am 3oll Nutr "$$: 8"$6+ P(I' !6!""<<
9<+
Na4/um ,- Ben#/lomo I- einer 0- #/alev 0+ T1i4e daily versus ?our times daily insulin dose regimens ?or diabetes in regnan4y: randomised 4ontrolled trial+ B(J !C 8!=5"!>: !""85+
96+
alkins/a1 #A+ ;ery tig/t versus tig/t 4ontrol ?or diabetes in regnan4y =ITE'RAN>+ 3o4/rane
'atabase
#yst
Rev "$$5C=">:
3'$$$""6+ P(I'
!56866"8 95+
Kremer 3J- 'u?? P+ )lyburide ?or t/e treatment o? gestational diabetes+ Am J .bstet )yne4ol "$$9C !$=<>: !98&+ P(I' !
9&+
*anger .- 3on1ay '*- Berkus ('- Genakis 0(- )on@ales .+ A 4omarison o? glyburide and insulin in 1omen 1it/ gestational diabetes mellitus+ N 0ngl J (ed+ "$$$C898=!6>:!!89&+ P(I' !!$86!!&
9+
#immons '- alters BN- Ro1an JA- (4Intyre E'+ (et?ormin t/eray and diabetes in regnan4y+ (ed J Aust "$$9C !&$=>: 96"9+ P(I' !
<$+
Ro1an JA- Eague (- )ao - Battin (R- (oore (PC (i) Trial Investigators+ (et?ormin versus insulin ?or t/e treatment o? gestational diabetes+ N 0ngl J (ed+ "$$&C8<&=!>:"$$8!<+ P(I' !&968856
)lue4k 3J- )oldenberg N- Praniko?? J- *o?tsring (- #ieve *- ang P+ Eeig/t- 1eig/t- and motorso4ial develoment during t/e ?irst !& mont/s o? li?e in !"6 in?ants born to !$ mot/ers 1it/ oly4ysti4 ovary syndrome 1/o 4on4eived on and 4ontinued met?ormin t/roug/ regnan4y+ Eum Rerod+ "$$9C!=6>:!8"8 8$+P(I' !
21
<"+
Kim 3- Berger 'K- 3/amany #+ Re4urren4e o? gestational diabetes mellitus: a systemati4 revie1+ 'iabetes 3are "$$5C 8$=<>: !8!9+ P(I' !5"$$85
<8+
*bner K- Kno?? A- Baumgarten A- et al+ Predi4tors o? ostartum diabetes in 1omen 1it/ gestational diabetes mellitus+ 'iabetes"$$6C <<=8>: 5"5+ P(I' !6<$<"9<
<9+
JLrvelL ID- Juutinen J- Koskela P et al+ )estational diabetes identi?ies 1omen at risk ?or ermanent tye ! and tye " diabetes in ?ertile age: redi4tive role o? autoantibodies+ 'iabetes 3are"$$6C "=8>: 6$5!"+ P(I' !6<$<
<<+
Kim 3- Ne1ton K(- Kno RE+ )estational diabetes and t/e in4iden4e o? tye " diabetes: a systemati4 revie1+ 'iabetes 3are+ "$$"C"<=!$>:!&6"&+ P(I' !"8
<6+
#tein/art JR- #ugarman JR- 3onnell FA+ )estational diabetes is a /erald o? NI''( in Navajo 1omen+ Eig/ rate o? abnormal glu4ose toleran4e a?ter )'(+ 'iabetes 3are+ !5C"$=6>:985+P(I' !65!$9
<5+
*ee AJ- Eis4o4k RJ- ein P- alker #P- Perme@el (+ )estational diabetes mellitus: 4lini4al redi4tors and longterm risk o? develoing tye " diabetes: a retrose4tive 4o/ort study using survival analysis+ 'iabetes 3are+ "$$5C8$=9>:&5& &8+ P(I' !58"<9
<&+
Boney 3(- ;erma A- Tu4ker R- ;o/r BR+ (etaboli4 syndrome in 4/ild/ood: asso4iation 1it/ birt/
1eig/t- maternal obesity- and gestational
diabetes
mellitus+ Pediatri4s "$$: e"$6+P(I' !<59!8<9 <+
Eillier TA- Pedula K*- #4/midt ((- (ullen JA- 3/arles (A- Pettitt 'J+ 3/ild/ood obesity and metaboli4 imrinting: t/e ongoing e??e4ts o? maternal /yergly4emia+ 'iabetes 3are "$$5C 8$=>: ""&5"+ P(I' !5
6$+
(et@ger B0+ *ongterm .ut4omes in (ot/ers 'iagnosed it/ )estational 'iabetes (ellitus and T/eir .??sring+ 3lin .bstet )yne4ol "$$5C <$=9>: 5" + P(I' !5&"89$
6!+
Perrin (3- Terry (B- Klein/aus K- et al+ )estational diabetes and t/e risk o? breast 4an4er among 1omen in t/e Jerusalem Perinatal #tudy+ Breast 3an4er Res Treat "$$5 M0ub+ P(I' !5956<&
22
