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Kehamilan & Diabetes

Ramadina, SpOG

Pendahuluan
Gestational diabetes / Diabetes Mellitus Gestasional (DMG) complicates 2-5% of 2all pregnancies  Most cases are characterized by postprandial hyperglycemia resulting from impaired insulin release and an exaggeration of the insulin resistance seen in normal pregnancies


Pendahuluan
These patients can be treated with diet therapy and have not been found to be at increased risk for intrauterine fetal death.  However if fasting glucose levels are elevated not only will insulin therapy be required but such hyperglycemia also places these women at increased risk of still birth


Pendahuluan
Up to 50% of gestational diabetics will go on to develop overt DM later in life  Controlling blood sugars helps decrease fetal macrosomia


Patofisiologi DMG
Awal kehamilan homeostasis glukosa estrogen & progesteron  Hiperplasia sel Beta dan sekresi insulin  Penggunaan glukosa perifer maternal fasting blood sugars


Patofisiologi DMG
State of accelerated starvation exists katabolisme protein & renal gluconeogenesis  As pregnancy advances lipids become an important maternal fuel  As human placental lactogen rises lipolysis is stimulated in fat tissue


Patofisiologi DMG
Glycerol and Free fatty acids are released for maternal utilization and the glucose and amino acids can be used for the fetus  Pregnant women become relatively insulin resistant but in normal circumstances insulin secretion is increased


Patofisiologi DMG
Persistently elevated levels of glucose will stimulate the fetal pancreas, resulting in beta cell hyperplasia and fetal hyperinsulinemia  Insulin does not cross the placenta


Komplikasi (Ibu & Kehamilan)


Fetal macrosomia  Intrauterine fetal death  Polihidramnion  Insiden preeclampsia  Cesarean section  Insiden distosia bahu  Diabetic retinopathy


Komplikasi (Janin)
Hiperbilirubinemi  Hipoglikemi  Hipokalasemi  Polisitemia  Birth injury  Transient tachypnea of the newborn


Pre-existing diabetes


Fetal risks Malformations Caudal regression syndrome Cardiac anomalies CNS anomalies Skeletal abnormalities Genitourinary abnormalities

Kalsifikasi diabetes dalam kehamilan (White)


A1A1- Carbohydrate intolerance on a 3 hour glucose tolerance test  A2- Same as A1 except requires insulin A2 B- Age of onset over 20 and for a duration of less than 10 years  C- Age of onset between 10-19 or duration 10of 10-19 years 10

Klasifikasi diabetes (Lanjutan)


D- Age of onset less than 10 years old or duration of more than 20 years (benign retinopathy)  F- Nephropathy  R- Proliferative retinopathy  H- Heart disease


Penapisan gestational diabetes


Screen all patients (risk factor screening misses 50% of patients)  1 hour post glucosa 50mg (fasting not required) @24-28 weeks @24 Value of over 140mg/dl should undergo a 3 hour GTT (100gram of carbohydrate loading 3 days prior)


Screening for gestational diabetes




3 hour GTT Fasting 95 1 hour 180 2 hour 155 3 hour 140 2 elevated values abnormal (elevated fasting alone is diagnostic and requires insulin)

Screening for Gestational Diabetes


A value of 200mg/dl is probably consistent with diabetes and a 3 hr GTT may be bypassed and start treatment  Glycosuria correlates poorly with gestational diabetes but when it is repetitive testing should be performed


Screening for gestational diabetes


High risk patients may be screened in 1st or 2nd trimester especially if pre-existing prediabetes is suspected  Risk factors include obesity (BMI> 30), previous makrosomi (4000 g), previous IUFD, previous GDM, advanced maternal age, riw keluarga, ethnicity  Re-screen at 24-28 weeks if negative Re24

Screening for gestational diabetes


Patients with one elevated value on the 3 hr GTT have some degree of glucose intolerance and should be re-screened in 4 reweeks or placed on a diet  These patients do have a higher incidence of macrosomia than non diabetic patients


Screening for diabetes


Patients that are obese, or were diagnosed early or required insulin should be rereassessed for the persistence of glucose intolerance  15% will remain glucose intolerant after delivery


Penatalaksanaan DMG
Monitoring gula darah  Diet  Insulin  Anti diabetes oral  Pengawasan antepartum  Pengawasan intrapartum & cara persalinan  Pengawasan postpartum


Diet
30kcal/kg lean body mass (3 meal perday) + 3 snack)  Obese patients 25kcal/kg  Underweight patients 35kcal/kg  Exercise is encouraged 20-30 min per 20session 3-4 times a week 3

Insulin
Gula darah puasa > 105 mg/dl & 2 jam postprandial > 120 mg/dl  Kerja sama dengan internist dalam menentukan dosis insulin (0,7 U/ kg BB per hari)


ADO
Chlorpropamide, Tolbutamide tidak direkomendasikan (crossing placenta)  Alternative ADO yang lain = Glyburide (oral hypoglycemic agent)  It does not cross the placenta  Tidak diberikan pada trimester 1


ADO
There were no differences in maternal complication or neonatal outcomes with Glyburide and only 10% of the patients required insulin. (metformin may be safe)  Well designed studies found no association between oral hypoglycemic agents and congenital malformations


Antenatal monitoring of gestational diabetics


Gula darah yang tidak terkontrol  Terapi insulin  Hipertensi  Usia gestasi 32 minggu  Nonstress test, Profil biofisik


Rekomendasi ACOG 2001

Antenatal monitoring of gestational diabetics


NST weekly at 32 weeks then twice weekly at 36 weeks  Ultrasound evaluation if patient insulin dependantdependant- Non reactive NSTs, large fundal height, prior macrosomic fetus


Timing of delivery
Await spontaneous labor  Induce around 40 weeks if needed  If estimated fetal weight is 4500grams or more offer elective cesarean section  Check blood sugars in labor keep below 100mg/dl  Usually diet controlled pt wont need insulin in labor


Pengawasan postpartum
Cek GD 6 mg postpartum  Gd puasa (2 kali) atau 2 jam postprandial (75 g glukosa)  Laktasi memperbaiki kadar gula darah  Anjuran kontrasepsi  Anjuran diet dan olahraga


Prognosis


Ibu :  Baik (tanpa komplikasi, terdeteksi dini, provider kompeten)  Buruk (komplikasi pembuluh darah atau ginjal) Bayi :  Buruk (lama penyakit, insufisiensi plasenta, prematuriats, gawat napas, cacat bawaan, ditosia bahu