BAB I PENDAHULUAN
1 .1
Latar Bela elakang ang Diabet Diabetes es Mellit Mellitus us Gestas Gestasion ional al (DMG) (DMG) didei dideinis nisika ikan n sebaga sebagaii ganggua gangguan n tolera toleransi nsi glukosa berbagai tingkat !ang diketa"ui #erta$a kali saat "a$il tan#a $e$bedakan a#aka" #enderita #erlu $enda#at insulin atau tidak. Pada ke"a$ilan tri$ester #erta$a kadar glukosa akan turun antara %%&'% dan "al ini $eru#akan res#on ter"ada# trans#ortasi glukosa dari ibu ke anin. *ebagian besar DMG asi$to$atis se"ingga diagnosis ditentukan se+ara kebetulan #ada saat #e$eriksaan rutin. Di Indonesia insiden DMG sekitar 1,-&,' dan sekitar /0&'0 anita !ang #erna" $engala$i DMG #ada #enga$atan lanut #as+a #ersalinan akan $engida# diabetes $ellitus atau ganggua gangguan n tolera toleransi nsi glukos glukosa. a. Pe$eri Pe$eriksa ksaan an #en!ari #en!aring ng da#at da#at dilakuk dilakukan an dengan dengan #e$eri #e$eriksa ksaan an glukosa dara" seaktu dan 2 a$ #ost #randial (##). Bila (##). Bila hasilnya belum dapat memastikan diagnosis diagnosis DM, dapat diikuti dengan test toleransi toleransi glukosa oral. DM ditegakkan ditegakkan apabila kadar glukosa darah sewaktu melebihi 200 mg%. Jika didapatkan nilai di bawah 100 mg% berarti bukan DM dan bila nilainya diantara 100-200 mg% belum pasti DM . Pada anita "a$il, sa$#ai saat saat ini ini #e$er #e$erik iksa saan an !ang !ang terb terbai aik k adal adala" a" denga dengan n test test tant tantang angan an gluk glukos osaa !ait !aitu u denga dengan n #e$bebanan %0 gra$ glukosa dan kadar glukosa dara" diukur 1 a$ ke$udian. 3ika kadar gluko glukosa sa dara dara" " sete setela la" " 1 a$ a$ #e$be #e$beban banan an $ele $elebi bi"i "i 1/0 $g $g $aka $aka dila dilan nut utkan kan denga dengan n #e$eriksaan test tolesansi glukosa oral. Gangguan DM teradi 2 dari se$ua anita "a$il, keadian keadian $eningkat $eningkat sealan sealan dengan u$ur ke"a$ilan, ke"a$ilan, teta#i tidak tidak $eru#akan $eru#akan ke+enderungan ke+enderungan orang orang dengan dengan ganggua gangguan n toleran toleransi si glokus glokusa, a, 2% ke$ung ke$ungkina kinan n akan berke$ berke$ban bang g $enad $enadii DM. DM gestasional $eru#akan keadaan !ang #erlu ditangani dengan #roessional, karena da#at $e$#engaru"i ke"idu#an anin4 ba!i di$asa !ang akan datang, uga saat #ersalinan !elayanan "esehatan #bu di $asilitas Dasar dan u&ukan, 201', hal 202( Hi#ertensi $eru#akan tekanan dara" di atas batas nor$al, "i#ertensi ter$asuk dala$ $asala" global !ang $elanda dunia.Menurut data 5H6 ()o ()orld rld *ealth +rganiation +rganiation)) #ada ta"un 2012 u$la" kasus "i#ertensi ada 7- uta kasus. 8asus ini di#erkirakan akan se$akin tinggi #ada ta"un 202% dengan u$la" 1,1% $il!ar kasus atau sekitar 2- dari total #enduduk 1
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dunia. *e+ara global, 70 ke$atian ibu "a$il !ang tergolong dala$ #en!ebab ke$atian ibu se+ara langsung, !aitu disebabkan karena teradi #erdara"an (2%) biasan!a #erdara"an #as+a #ersalinan, "i#ertensi #ada ibu "a$il "a $il (12), #artus $a+et (7), aborsi abo rsi (1) dan karena sebab lain (9) (5H6, 2012).
Hasil dari *D8I (*ur:ei De$ograi dan 8ese"atan Indonesia) ta"un 2012, $en!atakan ba"a se#anang ta"un 2009&2012 kasus ke$atian ibu $elonak naik. Pada ta"un 2012 A8I $en+a#ai %- #er 100.000 #enduduk atau $eningkat sekitar %9 bila dibandingkan dengan kondisi #ada ta"un 2009, !aitu sebesar 227 #er 100.000 #enduduk. Hal ini disebabkan karena teradin!a bu$il risti risti (ibu (ibu "a$il "a$il dengan dengan risiko risiko tinggi tinggi)) !ang sala" sala" satun!a satun!a adala" adala" terken terkenaa "i#ert "i#ertens ensii dala$ dala$ ke"a$ilan (*D8I, 2012).
8e$enterian 8e$enterian 8ese"atan $enelaskan $enelaskan ba"a "i#ertensi "i#ertensi $eru#akan #en!akit #en!akit !ang berba"a!a, berba"a!a, teruta$a a#abila teradi #ada anita !ang sedang "a$il. Hal ini da#at $en!ebabkan ke$atian bagi ibu dan bagi ba!i !ang akan dila"irkan. 8arena tidak ada geala atau tanda k"as sebagai #eringatan dini.Hi#ertensi dala$ ke"a$ilan atau !ang disebut dengan preeklampsia dengan preeklampsia,, keadian ini #ersentasen!a 12 dari ke$atian ibu di seluru" dunia.8e$enkes ta"un ta" un 201 $en!atakan $en !atakan ba"a "i#ertensi $eningkatkan angka ke$atian dan kesakitan #ada ibu "a$il (8e$enkes, 201).
;a"un ;a"un 2012 A8I beru$ beru$la" la" 11',/ 11',/ #er 100.000 100.000 kela"i kela"iran ran "idu#, "idu#, keadia keadian n ini $engala $engala$i $i #eningkatan bila dibandingkan dengan A8I #ada ta"un 2011 !ang u$la"n!a sebesar 11',01 #er #e r 100.000 kela"iran "idu#. A8I #ada ibu "a$il teradi #ada aktu nias sebesar %9,-, ke$udian teradi #ada usia ak"ir ke"a$ilan sebesar 2/,9/ dan #ada aktu #ersalinan sebesar 19,. *e$entara itu berdasarkan kelo$#ok u$ur, ke$atian terban!ak teradi #ada ibu "a$il usia 20&/ ta"un sebesar '',-', ke$udian #ada kelo$#ok u$ur <% ta"un sebesar 2','9 dan #ada kelo$#ok u$ur =20 ta"un sebesar ',9 ', 9 (Proil 3ateng, 2012).
8asus tertinggi "i#ertensi teradi #ada seluru" ila!a" 3aa ;enga" dengan u$la" %%/.991
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1.2 1.2
>u$ >u$usan usan Masal asala" a" 1. A#a deinis deinisii dari dari diabetes diabetes $ellitus $ellitus gestas gestasional ional ? 2. A#a dein deinisi isi "i#e "i#erte rtensi nsi dala$ dala$ ke"a$ ke"a$ila ilan? n? . Bagai$ana Bagai$ana #enatalak #enatalaksanaan sanaan dari diabete diabetess $ellitu $ellituss gestasiona gestasional? l? /. Bagai$ana Bagai$ana #enatala #enatalaksanaan ksanaan dari "i#ertensi "i#ertensi dala$ ke"a$ilan? ke"a$ilan? %. Bagai$ Bagai$ana ana #enatalak #enatalaksan sanaan aan kasus diabetes diabetes gestas gestasion ional al dala$ dala$ ke"a$i ke"a$ilan lan di la#anga la#angan n bersesuaian dengan teori? '. Bagai$ Bagai$ana ana #entalaks #entalaksanaa anaan n kasus kasus "i#ert "i#ertens ensii dala$ dala$ ke"a$il ke"a$ilan an di la#anga la#angan n berses bersesuai uaian an dengan teori?
1 .
;uuan 1. Untuk $engeta"ui $engeta"ui deini deinisi si dari dari diabetes diabetes $ellit $ellitus us gestasi gestasional. onal. 2. Untuk $engeta"ui $engeta"ui deinisi deinisi dari "i#ertensi "i#ertensi dala$ ke"a$ilan. ke"a$ilan. . Untuk $engeta $engeta"ui "ui #enatalaks #enatalaksanaan anaan dari dari diabetes diabetes $ellit $ellitus us gestasiona gestasional. l. /. Untu $engeta $engeta"ui "ui #enatalak #enatalaksanaan sanaan dari "i#ert "i#ertensi ensi dala$ dala$ ke"a$il ke"a$ilan. an. %. Untu Untuk k $eng $enget eta"u a"uii keses kesesua uaia ian n #enat #enatal alak aksa sanaa naan n dari dari diab diabet etes es $elli $ellitu tuss gest gestas asio iona nall dila#angan dan teori. '. Untu Untuk k $enge $engeta ta"ui "ui keses kesesua uaia ian n #enat #enatal alaks aksana anaan an dari dari "i#e "i#ert rten ensi si dala dala$ $ ke"a$ ke"a$il ilan an di la#angan dan teori.
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BAB II ;IN3AUAN ;E6>I
A. Diabetes Diabetes Mellitus Mellitus Gestasiona Gestasionall 1. Deinisi Diabet Diabetes es $elitu $elituss gestas gestasion ional al adala" adala" keadaan keadaan intole intoleran ransi si karbo" karbo"idr idrat at !ang !ang $e$iliki aitan atau #erta$a kali dite$ukan #ada ke"a$ilan. 2. Pato Patoi isi siol olog ogis is Dala$ ke"a$ilan teradi #eruba"an $etabolis$e endokrin dan karbo"idrat !ang $enunang #e$asokan $akanan bagi anin serta #ersia#an untuk $en!usui. Glukosa da#at berdiusi se+ara teta# $elalui #lasenta ke#ada anin se"ingga kadarn!a dala$ dara" anin "a$#ir $en!eru#ai kadar dara" ibu. Insulin ibu tidak da#at $en+a#ai anin, se"ingga kadar gula dara" ibu $e$#engaru"i kadar dara" anin. Pengendalian kadar gula dara" dara" teruta$ teruta$aa di#enga di#engaru" ru"ii ole" ole" insuli insulin, n, di sa$#in sa$#ing g "or$on "or$on estrog estrogen, en, steroi steroid, d, dan #lasenta laktogen. Akibat la$batn!a resorbsi $akanan $aka teradi "i#erglike$ia !ang relati relati la$a la$a dan ini $en!ebab $en!ebabkan kan kebutu" kebutu"an an insuli insulin n $eningka $eningkat.M t.Men enela elang ng ater$ ater$ kebutu"an insulin $eningkat "ingga $en+a#ai kali dari keadaan nor$al.Hal ini disebut tekanan diabetoenik dala$ ke"a$ilan. *e+ara isiologis tela" teradi resistensi insulin, !aitu bila ia dita$ba" dengan insulin eksogen ia tidak $uda" $enadi "i#oglike$ia. @ang $enad $enadii $asala $asala" " adala" adala" bila bila seoran seorang g ibu tidak tidak $a$#u $a$#u $ening $eningkatk katkan an insuli insulin, n, se"i se"ingg nggaa ia rela relati ti "i#oi "i#oins nsul ulin in !ang !ang $enga $engaki kibat batkan kan "i#er "i#ergl glik ike$ e$ia ia atau atau diabe diabete tess ke"a$ilan. Glukosa !ang tidak $asuk ke sel tubu" akan terti$bun di dala$ dara". *etela" $en+a#ai kadar tertentu, glukosa tersebut uga akan $un+ul dala$ air seni, #ada"al air seni seni !ang !ang nor$al nor$al tidak tidak $engand $engandung ung glukos glukosa. a. 3ika 3ika glukos glukosaa terda#a terda#att dala$ dala$ air seni, seni, gluk glukos osaa ters terseb ebut ut akan akan $ena $enari rik k lebi lebi" " ban! ban!ak ak air air bers bersa$ a$an an! !a deng dengan an de$ de$ikia ikian n $en!ebabkan berta$ba"n!a :olu$e air seni. 8arena teradi #engeluaran air seni !ang berlebi"an, tubu" ke"ilangan ban!ak +airan, se"ingga teradi rasa "aus !ang berlebi"an. 8etika sel tidak terda#at +uku# glukosa dikarenakan kurangn!a u$la" insulin, $eski sebenarn!a dala$ dara" terda#at glukosa !ang berlebi"an, bole" dikatakan sel&sel
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Untuk Untuk $enda# $enda#atka atkan n energ energii !ang dibutu dibutu"kan "kan,, sel !ang !ang Ckela#a Ckela#aran ran ini $ulai $ulai $e$e+a"kan le$ak dan #rotein !ang ada di dala$ tubu".Hal ini $engakibatkan turunn!a berat badan dan rasa lela". 3ika kadar glukosa dala$ dara" sangat tinggi, bebera#a orang $enadi $uda" tersinggung. *elain itu, tubu" uga $enadi rentan ter"ada# ineksi. ;idak se$ua #enderita diabetes $engala$i geala ini dan bebera#a orang lainn!a ba"kan tidak $engala$i geala a#a #un #ada keadaan ini, baru diketa"ui ba"a $ereka tern!ata $enderita #en!akit DM dari #e$eriksaan laboratoriu$ rutin. >esi >esist sten ensi si insu insuli lin n uga uga da#a da#att dise diseba babk bkan an ole" ole" adan! adan!aa "or$ "or$on on estr estrog ogen, en, #rogesteron, kortisol, #rolaktin, dan #lasenta laktogen.Hor$on tersebut $e$#engaru"i rese#tor insulin #ada sel, se"ingga $engurangi ainitas insulin (Prairo"ardo, 1--9). . Diagn agnosis & *e$ua *e$ua ibu ibu "a$il "a$il dianu dianurk rkan an untu untuk k $en $enal alan anii #e$er #e$erik iksa saan an untuk untuk $eli $eli"a "att adan! adan!aa diabetes diabetes $elitus $elitus gestasional gestasional,, na$un aktu dan enis #e$eriksaann!a #e$eriksaann!a bergantung bergantung &
#ada aktor risiko !ang di$iliki ibu. Faktor risiko risiko diabetes diabetes $elitus $elitus gestasi gestasional onal $eli#ut $eli#uti i obesita obesitas, s, adan!a adan!a ria!at ria!at diabetes diabetes $elitus gestasional sebelu$!a, glukosuria, adan!a ria!at keluarga dengan diabetes, abortus berulang, adan!a ria!at $ela"irkan dengan +a+at baaan atau ba!i /000
&
gra$, dan adan!a ria!at #reekla$#sia. Pasi Pasien en deng dengan an akt aktor or risi risiko ko ters terseb ebut ut #erl #erlu u di#e di#eri riks ksaa lebi lebi" " lan lanut ut sesu sesuai ai stan standa dar r diagnos diagnosis is diabet diabetes es $elitu $elituss di kunung kunungan an antenat antenatal al #erta$ #erta$a. a. Diagnos Diagnosis is diabet diabetes es $elitus ditegakkan bila kadar glukosa dara" seaktu 200 $g4dl (disertai geala klasik "i#erglike$ia) A;AU kadar glukosa dara" #uasa 12' $g4dl A;AU kadar glukosa 2 a$ setela" ;;G6 200 $g4dl A;AU kadar HbA1 ',%. Hasil !ang lebi" lebi" renda" renda" #erlu #erlu dikon dikonir$ ir$asi asi dengan dengan $elakuk $elakukan an #e$eri #e$eriksa ksaan an ;;G6 ;;G6 di usia usia
&
ke"a$ilan antara 2/&27 $inggu. Pe$e Pe$eri riks ksaa aan n kon konir ir$a $asi si dan dan #e$e #e$eri riks ksaa aan n untu untuk k ibu ibu "a$i "a$ill tan# tan#aa akt aktor or risi risiko ko dilakukan #ada usia ke"a$ilan 2/&27 $inggu, dengan +ara sebagai berikut a) Minta ibu ibu untuk $akan $akan $akanan $akanan !ang +uku# +uku# karbo"idr karbo"idrat at sela$a sela$a "ari, "ari, ke$udian ke$udian ber#uasa sela$a 7&12 a$ sebelu$ dilakukan #e$eriksaan. b) Periksa kadar kad ar glukosa dara" #uasa dari d ari dara" :ena di #agi "ari, ke$udian ke $udian diikuti
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8adar gula dara" setela" 1 a$ 170 $g4dl, A;AU 8adar gula dara" setela" 2 a$ 1% $g4dl
Penegakan Diagnosa a.
b.
Anamnesis ( Data Subjektif )
&
>ia!at keluarga dengan DM
&
;erda#at ;erda#at kelu"an trias #en!akit gula
&
>ia!at ke"a$ilan dengan DMG
&
>ia!at #ersalinan dengan ba!i besar
&
>ia!at 6bstetri buruk
&
Urine sering diraang se$ut (Manuaba,1--7)
Data Objektif
&
;FU 2 +$ dari ukuran nor$al #ada tri$ester 2 J
&
Glukosa urine 1 K #ada 2 kali #e$eriksaan
&
Adan!a ketonuria, bakteri #ada urine (Manuaba,1--7)
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/. ;and ndaa Dan Dan Ge Gea ala la 1 *er *ering ing ken+ ken+ing ing #ada $al $ala$ a$ "ar "arii ( #ol! #ol!uri uriaa ) 2 *e *ela lalu lu $e $eras rasaa "aus "aus ( #ol! #ol!di di#s #sia ia))
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%. Fakt Faktor or #red #redis is#os #osis isii 6bes 6besit itas as,, ria ria!a !att
into intole lera rans nsii
gluk glukos osa, a,
ria ria! !at
DMG DMG
#ada #ada
ke"a ke"a$i $ila lan n
sebelu$n!a,ria!at diabetes #ada keluarga.
'. 8l 8las asiii ika kasi si 8lasiikasi diabetes $ellitus dala$ ke"a$ilan adala" sebagai berikut 1. DM !ang $e$ang $e$ang suda" diketa" diketa"ui ui sebelu$ sebelu$n!a n!a dan ke$udian ke$udian $enadi $enadi "a$il "a$il (DM Ha$il DMH DM #ragestasional). *ebagian besar ter$asuk golongan IDDM (Insulin De#endent DM). Diab Diabet etes es #rag #rages esta tasi si,, arti artin!a n!a suda" suda" dike diketa ta"ui "ui diabe diabete tess $elli $ellitu tuss ke$u ke$udi dian an "a$il.Mereka tan#a ko$#likasi atau dengan ko$#likasi !ang ringan.Mereka dengan ko$#likasi berat, k"ususn!a retino#ati, nero#ati dan "i#ertensi.Diabetes Pragestasi adala" adala" diabete diabetess !ang !ang terad teradii sebelu$ sebelu$ konse# konse#si si dan terus terus berlan berlanut ut setela setela" " $asa $asa "a$il.Diabetes #ragestasi da#at beru#a diabetes ti#e 1 (tergantung insulin) dan ti#e II (tidak tergantung insulin), !ang $ungkin disertai atau tidak disertai #en!akit :askuler, retino#ati, nero#ati, dan ko$#likasi diabeti+ lainn!a.8ondisi diabetogenik ke"a$ilan #ada siste$ $etaboli+ !ang terganggu sela$a $asa #ragestasi $e$iliki i$#likasi !ang signiikan.Ada#un "or$one !ang nor$al ter"ada# ke"a$ilan $e$#engaru"i kontrol glike$ia #ada #asien diabeti+ #ragestasi.8e"a$ilan uga da#at $e$#er+e#at ke$auan ke$auan ko$#likasi ko$#likasi :askuler diabetes. diabetes. *ela$a *ela$a tri$ester tri$ester #erta$a, se$entara se$entara kadar glukosa dara" $aternal dala$ kondisi nor$al $enurun, dan res#on insulin ter"ada# glukosa $eningkat, kontrol glike$ia $eningkat. Dosis insulin untuk klien diabeti+
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Gestasional ( DMG) adala" kelainan #adda $etabolis$e karbo"idrat dari a+tor !ang $e$beratkan !ang teradi sela$a ke"a$ilan ( Maril!n, 2001). Disebut diabetes gestasional bila gangguan toleransi glukosa
8elas
Diabetes Pragestasional Usia 6nset
Durasi (ta"un)
Pen!akit :askuler
;era#i
A
*etia# usia
*etia# aktu
;idak ada
A&1, Han!a diet
B
20 ta"un
10 ta"un
;idak ada
Insulin
10
10 "ing "ingga ga 1-
;idak ada
Insulin
"ingga
ta"un
1-
ta"un
D
>etino#at
10 ta"un
20 ta"un
i benigna
n
*etia# usia
*etia# aktu
Nero#ati
Insulin
*etia# usia
*etia# aktu
>etino#ati
Insulin
F
>
#rolierati *etia# usia
*etia# aktu
Insulin
Insuli
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Lebi"
dari
$g4dl 10% Lebi" dari 120 $g4dl.
$g4dl
9. 8o$#lika kassi
Komplikasi pad maternal
Komplikasi pada janin
Hi#ertensi 10&20
8e$atian #erinatal tinggi
Hidraa$nion 20&2%
8elainan +ongenital '
Bakteriuria 9&10
Makroso$ia
Persalinan distosia 10&1%
Hi#oglike$i
8e$atian $aternal arang
Hi#okalse$ia
Gangguan :askuler se"ingga
Hi#erbilirubine$ia
$eni$bulkan #ree+la$#sia
*!ndro$e gaat na#as
8e$atian intra uterin
Abortus berulang 4 tan#a sebab 3anin $akroso$ia +enderung
Da#at teradi inertilitas
E$esis dan "!#ere$esis berat
o#erati transoabdo$inal Da$#ak lain Da$#ak lain kol kolest estrol rol tin tinggi ggi dan #ertolongan #erto longan #ersa #ersalina lina #er:agina$ #er:agina$ "!#ertensi adala"
>etino#ati
$en!ebabkan #ertolongan #ersalinan
!ang #aling berba"a!a adala" distosia ba"u.
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ter)adinya trauma la"ir$ indr#m apirai me!#neum dan "iperteni pulm#nal pulm#nal periten. periten.* *rauma rauma la"ir biaanya biaanya ter)adi ter)adi a!ibat dit#ia dit#ia ba"u$ ba"u$ e"ing e"ingga ga dapat dapat menye menyebab! bab!an an +ra!tu +ra!turr "umer "umeru$ u$ !la,i! !la,i!ula ula$$ pali -rb yara+ +reni!u$ +reni!u$ ba"!an !ematian )anin. .
/e!i /e!ita tarr 2&05 2&05&' &' bay bayii deng dengan an ibu ibu DMG DMG men menga gala lami mi "ip "ip#g #gli li! !emia emia GD GD 3& mgdl pada 24 )am pertama etela" la"ir dan biaanya ter)adi pada bayi ma!r##mia.
d.
amb ambat atan an per pertu tumb mbu" u"an an )an )anin in %bu %bu DMG DMG deng dengan an !#mpl #mpli! i!a aii , ,a a!u !ula larr a!an memberi!an bayi dengan (( renda" pada !e"amilan 3704& ming minggu gu.. al al ini ini dapa dapatt ter) ter)ad adii )uga )uga !aren arena a adan adanya ya peru peruba ba"a "an n metab#li! ibu elama maa aal peralinan.
e.
a aat ba baaan aan Ke)adi )adian an aa aatt baa baaan an adal adala" a" 4$1 4$1' (%DM (%DMG G. aat aat baaan ter)adi paling banya! pada !e"amilan dengan DMG yang tida!
terpantau
ebelum
!e"amilan
dan
pada
trimeter
pertama.ima pulu" peren !ematian perinatal diebab!an !elainan )antung *($ *($ /D$ /D$ !elainan gin)al agenei gin)al$ !elainan aluran erna itu in,eru$ yndr#me !#l#n !iri !eil$ !elainan neur#l#gi dan !elet.Ke!erapan aat baaan ringan lebi" bear$ menapai e!itar 2&'. +.
ip# ip#! !ale alemi mi dan dan "ip# "ip#ma magn gne eemi emia a (ayi (ayi di!at di!ata! a!an an "ip# "ip#! !ale alemi mia a bila bila
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".
P#liitemia "emat#l#gi
i.
; ;! !ia perinatal ;!ia perinatal ter)adi adi pada ada 25'$ mung!in diebab!an #le" ma!r##mia$ prematurita$ penya!it ,a!ulat ibu yang menyebab!an "ip#!ia intrauterin atau pada bayi yang la"ir dengan e!i# earea.
).
/yndr#m gaat na+a ne#natal Ke)adian indr#m gaat na+a ne#natal ber!#lerai dengan ting!at pengendalin !adar glu!#a ibu DMG. ng!a !e)adian indr#m gaat na+a )ela e!ali menurun pada ibu DMG dengan !adar glu!#a dara" yang ter!endali bai!. /ebagi /ebagian an lagi lagi gaat gaat na+a na+a ini di dieba ebab! b!an an !arena !arena prem prematu aturit rita$ a$ dengan pr#du!i ur+a!tan paru belum u!up atau bayi dila"ir!an dengan e!i# earea. earea.
Pada ibu : a.
ipe iperten rteni i$$ Get Getat ati# i#na nall diab diabet ete e a!an a!an mening ning! !at! at!an rei ei!# ibu
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per pergera gera!a !an n
"#r "#rm#n m#n
inul inulin in
ter tereb ebut ut
meny menyeb ebab ab!a !an n
peni pening ng!a !ata tan n
reiteni inulin$ pr#du!i gula "ati dan penurunan t#lerani glu!#a lebi" ebi" ting inggi dar dari
glu! glu!# #a a
dal dalam dar dara" , ,ery ery
<
?#i #i$$
199 994 4$
#lling#rt"$ 1985$ @el#n$ 1994. 1. Pening Peningkat katan an estrog estrogen, en, #roges #rogester terone one dan HPL sela$a sela$a ke"a$il ke"a$ilan an $e$#ro $e$#roduks duksii da!a ta"an ter"ada# insulin #ada aringan $aternal, ole" karena itu sisa glukosa dara" dara" terangk terangkat at lebi" lebi" la$a la$a dari dari keadaan keadaan tidak tidak "a$il, "a$il, di$ana di$ana insuli insulin n !ang di#roduksi tidak +uku# untuk $engatasi resistensi !ang di sebabkan ole" HPL, se"ingga se"ingga kelebi"an kelebi"an konsentrasi konsentrasi glukosa terus berta$ba" berta$ba" !ang $en!ebabkan $en!ebabkan teradi DMG (Hania,1--%). 2. >es >esiste istens nsii insu insullin $er $eru#ak u#akan an
$eka $ekani niss$e
#eng #eng"e "e$a $ata tan n
gluk glukos osaa
unt untuk
$e$astikan su#lai glukosa #ada anin ter+uku#i. *ela$a tri$erter 2 J "or$on estrog estrogen, en, #roges #rogester terin, in, HPL kortis kortisol ol dan #rolak #rolaktin tin beker bekeraa sebaga sebagaii antagon antagonis is untuk $eningkatkan resistensi insulin. . Menelang Menelang ak"ir ak"ir ke"a$ilan ke"a$ilan kebutu"an kebutu"an insulin insulin $eningkat $eningkat 2&/ kali, kali, ika #an+reas #an+reas tidak +uku# $e$#roduksi insulin $aka akan $enadi #e$i+u teradin!a DMG.
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2. Pada uia !e"amil !e"amilan an 3& minggu$ pening! pening!atan atan "#rm#n "#rm#n inulin inulin ada pada punanya dan ulit di !endali!an alaupun ada "#rm#n P$ etr#gen$ pr#geter#ne dan !#rti#l. 3. Pertumbu"an ertumbu"an )anin )anin dan ibu membutu"!an membutu"!an !arb#"idr !arb#"idrat at yang lebi" banya! e"ingga ering di temu!an !et#i /eller$1993 0
Pengaru" Diabete Melitu pada )anin a. *ela$a *ela$a ke"a$ilan ke"a$ilan teradi teradi traser traser glukosa glukosa dari dari ibu ka#ada ka#ada anin $elalui $elalui #lasent #lasenta. a. b. Pada #ertenga"an ke"a$ilan dan se#anang ti$ester , ibu $en!i$#an +adangan $akanan untuk anin $elalui #eredaran oksigen !ang $engandung le$ak. +. Plasenta Plasenta akti akti $engiri$ $engiri$ glukosa glukosa ke anin anin se"ingga se"ingga bila bila teradi teradi #enurunan #enurunan trans transer er glukosa $engakibatkan ke$atian #ada anin.
A#abila anin $enda#at #asokan glukosa !ang berlebi", akan teradi "i#erinsuline$ia !ang akan $enguba" glukosa $enadi +adangan le$ak dan glikogen se"ingga $en!ebabkan
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0 0
;uuan #enatalaksanaan adala" $en+a#ai dan $e$#erta"ankan kadar glukosa dara" #uasa -% $g4dL dan kadar glukosa 2 a$ sesuda" $akan 120 $g4dL Pengaturan diet #erlu dilakukan untuk se$ua #asien 1. ;entukan ;entukan berat bdan ideal. ideal. BB BB ideal ideal -0 -0 (;B&100) (;B&100) 2. 8ebutu" 8ebutu"an an kalori kalori (BB ideal 2%) K 10&0 terga tergantu ntung ng akti:it akti:itas as isik isik K 00 kal untuk ke"a$ilan
. Bila Bila kege$u kege$ukan, kan, kalori kalori dikurang dikurangii 20&0 20&0 tergant tergantung ung tingkat tingkat kege$ukan kege$ukan.. Bila kurus, dita$ba" sekitar 20&0 sesuai kebutu"an untuk $eningkatkan BB •
Asu#an #rotein !ang dianurkan adala" 1&1,% g4kgBB u Pe$berian insulin dilakukan di ru$a" sakit dan di#erti$bangkan bila #engaturan
•
diet sela$a 2 $inggu tidak $en+a#ai target kadar glukosa dara". Pe$berian insulin di$ulai dengan dosis ke+il !aitu 0,%&1,% unit4kgBB4
•
"ari. Pe$ant Pe$antaua auan n ibu ibu dan dan ani anin n dila dilakuk kukan an denga dengan n #e$er #e$erik iksa saan an tingg tinggii
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Penatalaksanaan dala$ ke"a$ilan a
Deteksi dini 8onseling #rakonse#si $en+aku# #enundaan ke"a$ilan '&12 bulan #ada ibu dengan
DM untuk $e$#erta"ankan stabilitas insulin dengan #enangana n dari internis. Pe$eriksaan reduksi urine dan kadar glukosa dara". 5aktu #e$eriksaan (Qarne!, 1--9)
0 0 0
;ri$ester 1 Minggu ke 27 Minggu ke /&' Pe$eriksaan reduksi urine $enggunakan $etode benedi+t 0 5arna biru erni" ke"iauan nor$al 0 5a 5arna rna "iau enda#an kuning 0 Enda#an kuning elas dan ban!ak 0 ;idak berarna, enda#an arna ingga 0 ;idak berarna, enda#an arna $era" bata sa$#ai ke+oklatan 0 ( >i!ani, 200') Persia#an #e$eriksaan Glukosa dara" (MNH,2002) 0 Makan dengan karbo"idrat +uku# $ini$al "ari sebelu$n!a 0 *e$al *e$ala$ a$ sebel sebelu$ u$ #e$e #e$eri riks ksaa aan n #uas #uasaa 7&12 7&12 a$, a$, #agi& #agiag #agii dia$ dia$bi bill
sedikit (K) 1 (K) 2 (K) (K) /
+ont +onto" o"
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R
Pengaturan skrining DM (Varne!"##$) %D Puasa
%D PP
&al ang
%''
dilakukan
K
&
G;;
2 Abnor$al 8onsultasi
K
&
G;;
2 Abnor$al DMG
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1) Deinisi Hi#ertensi adala" tekanan dara" sekurang&kurangn!a 1/0 $$Hg sistolik atau -0 $$Hg $$Hg diasto diastoli lik k #ada #ada dua kali kali #e$eri #e$eriksa ksaan an berar berarak ak /&' a$ #ada #ada anita anita !ang sebelu$n!a nor$otensi. Bila dite$ukan tekanan dara" tinggi (<1/04-0 $$Hg) #ada ibu "a$il, lakukan #e$eriksaan kadar #rotein urin dengan tes +elu# urin atau #rotein urin 2/ a$ dan tentukan diagnosis. 2) Fakt Faktor or #red #redis is#o #osi sisi si 8e"a$ilan ke$bar Pen!akit trooblas Hidra$nion Diabetes $elitus
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20 $inggu Proteinuria sa$#ai KK ;ekanan diastolik < 110 Hi#erreleksia Perekla$#sia berat N!eri ke#ala (tidak $$Hg #ada ke"a$ilan "ilang dengan 20 $inggu Proteinuria
abdo$en
(e#igastriu$) 6ede$a #aru
atas
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Hi#ert Hi#ertens ensii tan#a tan#a #rotei #roteinuri nuriaa !ang ti$bul ti$bul dari dari sebelu sebelu$ $ ke"a$i ke"a$ilan lan dan $eneta# setela" #ersalinan b. Diagnosis ;ekanan dara" <1/04-0 <1/0 4-0 $$Hg ;ekanan *uda" ada ria!a ria!att "i#ert "i#ertens ensii sebelu sebelu$ $ "a$il, "a$il, atau atau diketa" diketa"ui ui adan!a adan!a *uda" "i#ertensi #ada usia ke"a$ilan 20 $inggu ;idak ada #roteinuria (di#eriksa dengan tes +elu# urin) Da#at disertai keterlibatan organ lain, se#erti $ata, antung dan ginal
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. Hi#er Hi#erte tens nsii Gesta Gestasi siona onall a. Deinisi Hi#ert Hi#ert i tan
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11. Ibu !ang $enda#at tera#i anti"i#erte anti"i#ertensi nsi di $asa antenatal antenatal dianurkan dianurkan untuk $elanutkan tera#i anti"i#ertensi "ingga #ersalinan 12. ;era#i ;era#i anti"i#ertensi dianurkan untuk "i#ertensi #as+asalin berat. %) Pe$eri Pe$eriksa ksaan an #enun #enunang ang ta$ba"a ta$ba"an n
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