referat

Diabetes mellitus in pregnancy

Supervisor:
dr. Gioseffi Purnawarman, SpOG

By:
Dede Satria Sabarudin (406171004)

Midwifery clinical work SCIENCE AND CONTENT

GENERAL HOSPITAL Ciawi
UNIVERSITY MEDICAL FACULTY TARUMANAGARA
4 DECEMBER PERIOD 2017-10 FEBRUARY 2018

1
 VALIDITY SHEET

Referat:
Diabetes Mellitus In Pregnancy

Arranged by :
Dede Satria Sabarudin (406171004)
Faculty of Medicine, University of Tarumanagara

As one of the requirements for the exam Registrar of Obstetrics and Gynecology
Hospital Ciawi

Ciawi, January 2018

Dr. Gioseffi Purnawarman, SpOG

VALIDITY SHEET

2
 Referat:
Diabetes Mellitus In Pregnancy

Arranged by :
Dede Satria Sabarudin (406171004)
Faculty of Medicine, University of Tarumanagara

As one of the requirements for the exam Registrar of Obstetrics and Gynecology
Hospital Ciawi

Knowing,
SMF head

Dr. Freddy Dinata, SpOG

3
 table of contents

Chapter I Introduction

a. Background ......................................................................................................... 5
b. Epidemiology................................................. .................................................. ..... 7

Chapter II Discussion

a. Definition and classification ................................................................................ 9

b. pathophysiology .................................................................................................. 10
c. The effect of diabetes on pregnancy .............................................. ................... 12
d. Diagnosis ................................................. ........................................................ ......
15
e. Diabetes pragestasi ................................................ ................................................19
f. Gestational diabetes mellitus ............................................................................... 26

Chapter III closing

Conclusion ............................................................................................................................. 34

Bibliography .......................................................................................................................... .35

4
 PART I
PRELIMINARY

a. Background
The prevalence of women diagnosed with diabetes increased throughout the year. The
increase was mostly due to an increase in type 2 diabetes is commonly found in obese people
are often called diabesity. With the increasing prevalence of type 2 diabetes mellitus in general
and more specifically at the young age resulted in increased incidence of diabetes in pregnancy.
DM uncontrolled during pregnancy lead to an increased risk of miscarriage in the first
trimester, congenital abnormalities, especially heart defects and abnormalities of the central
nervous system, increased fetal death, preterm labor, pre-eclampsia, ketoacidosis,
polyhydramnios, macrosomia, birth trauma, especially nerve damage brakhialis, delayed lung
maturation , respiratory distress syndrome, jaundice, hypoglycemia, hypocalcemia, increased
perinatal mortality. Long-term risks include obesity, type 2 diabetes and low IQ. Exposure in
utero due to maternal hyperglycemia resulting in hyperinsulinemia in the fetus, resulting in an
increase in the fat cells of the fetus that would lead to obesity and insulin resistance in
childhood-anak.1
Diabetes Mellitus is one of the medical complications that often occur during
pregnancy. Increased mortality and perinatal morbidity in pregnancies DM directly correlated
with the conditions of hyperglycemia in the mother.
Congenital abnormalities of the fetus at this time is one of the causes of perinatal death
in 10% of cases of pregnancy with diabetes mellitus type 1 and type 2, which is not well-
regulated. Babies with macrosomia will be a delay of fetal lung maturation which ultimately
also increase the incidence of RDS. The incidence of intrauterine fetal death that occurs in the
cases of pregnancy with diabetes were also associated with the conditions of hyperglycemia
ending with lactic acidosis.
In recent years an increase in the incidence of DM with cause is not yet clear, but
environmental factors and a genetic predisposition pengaruh.Kehamilan holds itself gives the
adverse implications for mothers with pregnancy DM.Pada increased production of hormones
antagonisinsulin, among others: progesterone , estrogen,Human Placenta Lactogen (HPL),
which causes insulin resistance due to impaired glucose tolerance.

Several evidence-based identification and assessment 2

5
1. In women with type 1 diabetes mellitus (preexisting DM) increases the risk of
preeclampsia
2. DM type 1 who have been there before pregnancy (preexisting DM) will increase the
risk of congenital abnormalities ten times
3. The risk of congenital fetal abnormalities associated with glucose regulation. With
good regulation then the risk of congenital abnormalities together with without DM
4. HbA1C as a parameter of success regulation of blood glucose levels should reach
normal levels (≤6%) or as close to normal (≤ 7%)
5. Monitoring of the fetus (NST, FBP) every week that started at 32 weeks and twice a
week from 34-36 weeks will lower neonatal death
6. Risk factors for GDM include older age (> 30 years), family history of diabetes,
obesity, ethnicity and cigarette smokers
7. Screening and diagnosis is done universally DMG (ACOG) using One Step Approach
(WHO) with a load of 75 g OGTT glucose anhydrous
8. gluosa good control during pregnancy showed a decrease in the incidence of
macrosomia and neonatal hypoglycemia
9. The higher the glucose levels associated with increased incidence of macrosomia and
section sesarean
10. Women with GDM should be screened for diabetes 6-12 weeks postpartum to
anticipate the occurrence of DM settled
11. The most important of DMG treatment is diet. Calories eaten depends on the
mother's weight before pregnancy
12. There is no standard number of times sugar levels should be checked in patients with
GDM. The goal is to determine whether the target sugar level has been reached.
Common target used is achieved fasting glucose levels less than 95 mg / dl and 2-hour
glucose levels after eating less than 120 mg / dl
13. Delivery in GDM is affected by gestational age, babies, rude uncontrolled blood
sugar. Mothers with GDM are at increased risk of uncontrolled fetal lung immaturity
and respiratory distress syndrome (RDS), but GDM risk in a controlled equal to the non-
diabetic population. RDS risk becomes equal to the mother without GDM at the age of
38.5 weeks. The study by Piper, et al no RDS after 37 weeks' gestation despite a jain
lung examination results showed immaturity

6
 14. Indications of childbirth at the age of 37-38 weeks include: do not obtain adequate
control of blood sugar levels, patient noncompliance, a history of previous fetal death,
their hypertension. Women with controlled blood sugar levels, better patient compliance
and better fetal growth should wait until 40-41 weeks of spontaneous labor.
15. Macrosomia and shoulder dystocia occurs more frequently in women with diabetes
compared with the general popuasi. Most of shoulder dystocia occur in women with
diabetes with birth weight infants> 4000 grams.
16. Recommend performed elective cesarean section if the estimated birth weight more
than 4250 grams. With this implementation dystocia will be reduced to 80% in women
with diabetes, and reduced shoulder dystocia in infants weighing> 4000 grams of 19%
to 7%.

b. Epidemiology
Incidence of Diabetes Mellitus in pregnancy about 2% - 3%. From other literature it is
said that diabetes mellitus present in 1-2% of pregnant women, and only 10% of these women
are known to suffer from diabetes mellitus before pregnancy, thus it can be concluded most of
what happened in pregnancy is gestational diabetes mellitus. Research Professor MF John
Adam in Ujung Pandang in two different periods, obtaining Gestational Diabetes Mellitus
incidence is much higher in those with high risk (4.35%) and 1.67% of the entire population of
pregnant women. Meanwhile, in a second study he found 3% in the high risk group and 1.2%
of all pregnant women. Hospital DR. Kariadi Semarang by Praptohardjo soeparto U and P,
1975,
Given the dangers of pregnancy complications with diabetes mellitus, it is necessary if
it were made a diagnosis as early as possible. Several groups of pregnant women have been
known to have a high risk of developing diabetes mellitus during pregnancy. And risk factors
are useful criteria in clinical screening during antenatal care.
Women who have a high risk of diabetes Gestational are women aged over 30 years,
obesity with a body mass index ≥ 30 kg / m2, family history of diabetes (mother or father), had
suffered from GDM before, never given birth big> 4000 g , the glucosuria, a history of
congenital defects, history of stillbirth, miscarriage, infertility history, hypertension. 3

7
 CHAPTER II

DISCUSSION

a. Definition and classification

Diabetes mellitus is a metabolic disease with diverse causes, characterized by
chronic hyperglycemia and changes in the metabolism of carbohydrates, fats and protein
due to a defect in insulin secretion or work, or both. 1

American Diabetes Association (ADA) Outlines a classification of diabetes mellitus

in general based on etiology (Perkeni 2006, ADA 2007)
I. DM type 1
(Beta cell damage that leads to absolute insulin deficiency).
a. Mediated Immuned
b. idiopathic
II. DM type 2
(There was an insulin resistance with relative insulin deficiency up to a disturbance in
insulin secretion is accompanied insulin resistance)
III. DM type-specific
a. Genetic abnormalities Beta cell function
b. Genetic abnormalities of insulin
c. Disorders of the exocrine pancreas
d. endocrinopathy
e. Drug / Chemical Induced
f. Infection
g. Other forms of immune-mediated diabetes mellitus are rare.
h. Genetic abnormalities that accompany DM
IV. Gestational diabetes mellitus

Diabetes is a common medical complication in pregnancy, there are two kinds of

pregnant women with diabetes, namely: 1

 Pregnant women with diabetes are already known since before the women were
pregnant (pregestasional).
 Pregnant women with diabetes had happened during pregnancy (gestational diabetes
mellitus).
8
 Diabetes in pregnancy is impaired glucose tolerance in various levels occurring or
first detected in pregnancy regardless of whether the patient needs to receive insulin or not.
The diagnosis of diabetes is often made for the first time in pregnancy because the patient
for the first time come to the doctor or diabetes is becoming more apparent by the
pregnancy. Diabetes showed a tendency to become more severe in pregnancy and the need
for insulin increases.

b. pathophysiology
Maternal adaptation for pregnant women showed a typical characteristic that is the
fasting hypoglycemia, postprandial hyperglycemia, insulin resistance (Figure 1).

Figure 1. Adaptation maternal in carbohydrate metabolism during pregnancy.

9
Pathophysiology DM pragestasi equal to the pathophysiology of diabetes mellitus type 1 or 2.
Hyperglycemia and consequently when perikonsepsi cause organ growth

Figure 2. Potential Teratology (Hypothesis Freinkel)

Hyperglycemia in third trimester causing delays surfactant synthesis by pneumocytes II
cells, thus causing a delay in the maturation of the lung (Lung Maturation Delayed) which
resulted in the occurrence of postnatal RDS. 3
Macrosomia caused by the high influx of glucose into the fetal circulation that
stimulates the Langerhans beta cell hyperplasia of the fetus, causing fetal hiperinsulin which in
turn will lead to viseromegaly (Hypothesis Pedersen) (Figure 3)

Figure 3. Hypothesis Pedersen

Pathophysiology of long-term complications of gestational diabetes is through
the mechanisms of fetal programming of Barker stating that the threat on certain critical
period will be accommodated (adaptation of the fetus) that carry a lifetime. Babies who
have IUGR would more easily develop into diabetes, heart problems and other

10
 cardiovascular diseases. Likewise, macrosomia babies will be easier developing
diabetes and obesity later. 3

c. The effect of diabetes on pregnancy

In terms of clinical, central overview of carbohydrate metabolism can be
summarized in simple terms. If a woman becomes pregnant, she needs more insulin to
maintain normal carbohydrate metabolism. If he is unable to produce more insulin to
meet the demands, he may have diabetes that result in changes in the metabolism of
carbohydrates. Blood glucose levels in pregnant women is a measure of its ability to
provide a response to the challenges of pregnancy. Maternal blood glucose levels to be
reflected in the fetal glucose levels, because glucose crosses the placenta with ease.
Insulin does not cross the placental barrier, so that excess insulin production by the
mother or the fetus remain together resulting in glucosuria circumstances.
Hormonal changes that occur widely in hehamilan in the retention of the
metabolic state of mothers with advancing gestational age. These hormones may be
responsible, directly or indirectly, induce peripheral insulin resistance and contributes
to cell changes pancreatic β. Ovary, adrenal cortex of the fetus, placenta, maternal
adrenal cortex and pancreas are involved in the onset of these hormonal changes, which
have an influence on the metabolism of carbohydrates. Particularly important is the
progressive increase of circulating estrogen that was first produced by the ovaries until
week 9 of intra uterine life and afterwards by the placenta. Most of estrogen formed by
the placenta is in the form of free estriol, conjugated in the liver into glukoronida and
more soluble sulfates, which dieskresikan in the urine. Estrogen does not have any effect
on glucose transport, but affects an increase in insulin(Insulin binding). Progesterone is
produced by the corpus luteum during pregnancy, especially during the first 6 weeks.
Trophoblast mother synthesizes progesterone and cholesterol and is a major contributor
to the plasma progesterone levels were increased sedentary during pregnancy.
Progesterone also reduce the ability of insulin to suppress endogenous glucose
production. Human Placental Lactogen (HPL) is another important placental hormone
that affects the metabolism of carbohydrates. Levels in the mother's blood increases
berlahan-land throughout pregnancy, peaking at term. HPL is one of the main hormones
responsible for insulin sensitivity with increasing gestational age. HPL levels increased
in terms of hypoglycemia and hyperglycemia decreased in the state. In other words,

11
HPL is an antagonist to insulin. HPL suppress glucose transport maximum but do not
alter the binding of insulin. After childbirth and expulsion of the placenta, maternal HPL
levels quickly disappeared, hormonal regulation back normal.1
The adrenal cortex is involved in a progressive increase in free cortisol during
pregnancy. In late pregnancy, maternal cortisol concentrations estimated to be 2.5 times
higher than non-pregnant state. Some researchers reported that the rate of hepatic
glucose production increases and decreases insulin sensitivity in the delivery of a large
number kortisol.1
Changes in carbohydrate metabolism during pregnancy as a result of hormonal
changes above. In some circumstances obtain a glucose tolerance test, among others;
mild hypoglycemia during fasting, post-prandial hyperglycemia and hyperinsulinemia.
Fasting plasma glucose concentration during the decline may be due to an increase of
plasma levels of insulin. But this can not be explained by changes in insulin metabolism
because the half-life of insulin during pregnancy has not changed.
Increased plasma levels of insulin in normal pregnancy is associated with
changes in the unique response to glucose ingestion. For example, after eating in
pregnant women obtained an extension of hyperglycemia, hyperinsulinemia, and
suppression of glucagon. This mechanism seems designed to maintain posprandial
glucose supply to the fetus. This response is consistent with the statement that
pregnancy-induced peripheral resistance to insulin, which is reinforced with three
observations:
1. The increase in insulin response to glucose
2. The reduction of the peripheral glucose uptake
3. The response suppression of glycogen
The mechanism responsible for insulin resistance is not complete understood.
Some researchers have reported significant decreases in insulin sensitivity (40-80%)
with increasing gestational age. Normal fetus has an immature system in the regulation
of blood glucose levels. Normal fetus is a passive recipient of glucose from the mother.
Glucose crosses the placental barrier through the process of diffusion and fetal glucose
levels very close to maternal glucose levels.
Glucose transport mechanism protects the fetus against maternal high levels,
experience boredom by maternal glucose level of 10 mmol / l or more so that the fetal
glucose levels peak at 8-9 mmol / l. this ensures that in normal pregnancy the fetal

12
 pancreas is not stimulated excessively by posprandial peak maternal blood glucose
levels. When the high maternal glucose levels exceed normal limits / uncontrolled will
cause large amounts of glucose from the mother cross the placenta to the fetus and
hyperglycemia occurs in the fetus. But maternal insulin levels can not reach the fetus,
so the glucose levels mother who affect glucose levels in the fetus. Fetal pancreatic beta
cells and then will adjust to the high levels of blood glucose. This will lead to fetal
hyperinsulinemia which is proportional to blood glucose levels mother and fetus.
Hyperinsulinemia are responsible for the occurrence of macrosomia due to increased
body fat.

Maternal influence can be subdivided during pregnancy, during labor and during nifas.3

During pregnancy:

- Abortion. The risk is increased in uncontrolled diabetes.

- Preeclampsia, preeclampsia is associated with a poor control of perinatal mortality
- Hydramnios. Incidence is increased in uncontrolled diabetes. This is due to a large
placenta, the fetal congenital malformations and polyuria due to hyperglycemia.
- Preterm labor. Incidence increases with increased pelvic disproportion head,
malpresentation.
During labor:

- Maternity elongated due to a large baby

- shoulder dystocia
- Increased operative
- Ruptura the birth canal
- PPH

During postpartum:

- puerperal sepsis
- reduced lactation
- Increased morbidity maternal or
Effect on the fetus:

- The fetus died in the womb

13
 - macrosomia
- Lung maturation late
- birth trauma
- growth retardation
- congenital Malfromasi
- Increased neonatal mortality

d. diagnosis

Hyperglycemia in pregnancy could be caused by previous patients already suffering

from diabetes mellitus or diabetes mellitus called pregestational, or it can also be caused by
impaired glucose tolerance which occurs the first time during pregnancy is called gestational
diabetes mellitus. Diabetes mellitus has been known prior to pregnancy is no problem in
diagnosis. Another case of gestational diabetes mellitus, many diagnostic criteria used and
there is no consensus of all the experts of the diagnostic criteria which terbaik.5
Because of the prevalence of diabetes in pregnancy is high, then the optimal antepartum
care require a diagnostic test that is sensitive to all pregnant women. Diagnostic methods
should be quick and handy, O, Sullivan and Mahan malaporkan that a simple examination
of all pregnant women are more useful in nengidentifikasi patients who are at risk of
developing diabetes than other indicators such as family history, previous obstetric history
or obesitas.5
All experts agree that screening should be performed in all pregnant women, although
it is very difficult to implement. When the screening is only done on high-risk groups only,
50% are undiagnosed gestational diabetes mellitus.
Rersiko group high occurrence of gestational diabetes mellitus, are: 3
1. Suspicious obstetric history
 Several times miscarried
 Never having children die for no apparent reason
 Never give birth to babies with congenital defects
 Delivered the baby with BBL: 4000 g
 Never poisoning pregnancy
 Never experienced polyhydramnios
2. Maternal history of suspicious
 Age of mother during pregnancy more than 30 years
14
  History of diabetes in the family
 History previous DMG
 obesity
 Recurrent urinary tract infections during pregnancy
Screening is done for type 2 diabetes are not diagnosed at the first prenatal visit.
Screening is done at 28 weeks gestation or more with a note on the group of mothers with high
risk, screening is performed at 24 weeks gestation. Javanovic recommends screening was best
time in weeks 27-31 of pregnancy. Re-screening is done at 33-36 weeks of pregnancy, in
pregnant women with a high risk or a glucose tolerance test positif.5

1. How Screening and Diagnostic Criteria

1.1. How O'Sullivan Mahan
Screening and diagnosis criteria according to O'Sullivan Mahan DMG consists of two stages:
the first stage: called a glucose challenge test which is a screening test and the second stage:
the oral glucose tolerance test. Glucose tolerance tests performed 3 hours. Glucose tolerance
test is only performed on those who test positive glucose challenge.

Pregnant women

Glucose 50 Gram

<140 mg / dL > 140 mg / dL > / = 200 mg / dL

OGTT - 3 hours
Normal
100 grams of
glucose

Normal DMG

Figure 4. Method of screening according to O'Sullivan Mahan

This test is performed when the pregnant woman visited the clinic without having to

15
 fast. They were given a load with 50 grams of glucose dissolved in a glass of water. Is said
to be positive when venous blood sugar greater 140 mg / dL after an hour of administration.
When there is a positive result, followed by an oral glucose tolerance test. With a load
of 100 grams of glucose after fasting 12 hours, taken fasting blood glucose, blood glucose 1
hour, 2 hours, 3 hours postprandial. Normal when fasting blood glucose levels <105 mg /
dL, 1 hour postprandial <190 mg / dL, 2 hours postprandial <160 mg / dL, 3 hours
postprandial <140 mg / dL. Told gestational diabetes mellitus if at least two abnormal
numbers.

1. 2. How to WHO
Since 1980 WHO has made a way of screening for diabetes mellitus. To detect diabetes
mellitus oral glucose tolerance test conducted with a load of 75 grams. Expressed diabetes
mellitus when the levels of fasting venous plasma glucose> 140 mg / dL or 2 hours after the
imposition of> 200 mg / dL. Blood glucose levels were normal fasting venous plasma <100
mg / dL two hours after the imposition of <140 mg / dL. Those who have blood glucose
levels between normal and diabetes mellitus called impaired glucose tolerance group.
Especially for pregnant women with impaired glucose tolerance should be treated as patients
with diabetes mellitus.

Venous Plasma Glucose Levels

Fasting 2 hours PP
Normal <100 > 140
Diabetes mellitus > / = 140 > / = 200
Impaired Glucose Tolerance 100-140 140-200
Figure 5. Blood glucose levels as criteria the diagnosis of diabetes mellitus according to the WHO

1. 3. How the American College of Obstetricians and Gynecologists

American College of Obstetricians and Gynecologists (1986) recommends that
screening is only necessary for women at high risk are older than 30 years, there is a family
history of diabetes, had delivered a baby macrosomia, infants with malformations and
stillbirths, pregnant women who are obese, hypertensive or glucosuria.
Meanwhile, as there is still lack of uniformity in making the diagnosis criteria for
gestational diabetes, the American College of Obstetricians and Gyenecologists (Hughes,

16
1972) makes standardization. A person is considered diabetic if their glucose tolerance test
showed the following results:
- Fasting : Normal or less than 100 mg%
- 1/2 hour : More than 150 mg%
- 1 hour : More than 160 mg%
- 2 hours : More than 160 mg%
- 3 hours : Normal or more than 120 mg%

1. 4. Method of ASEAN Study Group of Diabetes in Pregnancy (ASGOIP)

This uses a 50-g glucose challenge test, screening is positive when venous glucose levels
after 1 hour loading> 130 mg / dL. If positive screening was followed by an oral glucose
tolerance test 75 grams. Blood glucose levels are only taken 2 hours afterloading. Gestational
diabetes mellitus is declared when the blood glucose level is only taken 2 hours after loading.
Gestational diabetes mellitus is declared when venous plasma glucose levels 2 hours after
the imposition of> 140 mg / dL.

Pregnant women

Glucose 50 Gram

<130 mg / dL > 130 mg / dL

OGTT - 2hours
Normal
75 grams of glucose

Normal DMG

Figure 6. Method of screening according to ASGOIP

e. diabetes Pragestasi
Diabetes that occurs before the onset of pregnancy (diabetes type 1 and 2)

17
 Prenatal 6
Treatment before pregnancy aims to:
1. Regulation of glucose to lower the risk of congenital abnormalities of the fetus
and keguuguran. Wary of hypoglycemia.
2. Determine the vasculopathy with evaluations ophthalmology, coronary heart
disease, kidney function, thyroid function.
3. Extension of patients and the husband of a treatment plan in case of pregnancy
with diabetes.
4. Provision of folic acid for the prevention of the risk of a defect in the nervous
system of the fetus.
5. Counseling contraception.

Babies born to women with diabetes with uncontrolled blood glucose levels are
at risk for birth defects. High glucose levels in the first trimester, when fetal
organogenesis process begins, increasing the risk of miscarriages and birth defects.
Because the first trimester is very important for the growth of the fetus, is very important
for pregnant women with type 1 or 2 diabetes to control their blood sugar levels at the
time of planning a pregnancy. Blood glucose should be controlled from three to six
months prior to pregnancy. For women with diabetes, glucose levels monitored also
using a HbA1C, HbA1C levels should be less than 7%, accompanied by ideal weight
control, special diabetes diet, and physical activity.

In addition to blood sugar control, the preparation before the pregnancy must
be considered also are periodic checks of blood pressure, heart disease, kidney and eye
damage. In women with type 1 diabetes also performed a thyroid function test.

Pregnancy in women with diabetes should be planned, and therefore can be

used for birth control contraceptives such as IUDs (intrauterine devices), implants, pills,
condoms, diaphragms, etc. to reduce the number of unplanned pregnancies.

Contraception in pre-gestational diabetes (diabetes mellitus type 1 and type 2).

1. Pill Combination
- low-dose birth control pills to patients without vasculopathy
- not be given to smokers and hypertension
2. The progesterone pill allowed in patients with vasculopathy
3. The IUD has no effect on glucose control and vasculopathy

18
 4. Sterilization is recommended in patients with severe vasculopathy.
Target blood sugar before pregnancy to be achieved: Before meals: 60-119 mg
/ dl; 1 hour after meals: 100-149 mg / dl.

Detection and evaluation of congenital abnormalities of the fetus: 5

1. Examination of HbA1C mother trimester 1 to determine the blood glucose

regulation last 3 months.
2. Inspection AFP at the age of 16 weeks pregnant to estimate the possibility of
congenital abnormalities of the fetus.
3. Ultrasound at 13-14 weeks to detect Anencephaly
4. ultrasound at 18-20 weeks to examinations of fetal cardiac structures
including the large blood vessels to detect possible congenital heart kelaianan.
 Antenatal 6
Women with type 1 or 2 diabetes who are pregnant will experience changes in
blood sugar levels. Pregnancy can make the symptoms of hypoglycemia difficult to
detect.

Target blood sugar in pregnant women with type 1 or 2 diabetes during

pregnancy are:

 Before lunch, dinner, before bed: 60- 99 mg / dl (3.3 to 5.4 mmol / L)

 Before breakfast: <95 mg / dL
 1 hour after the meal: <140 mg / dL
 2 hours after a meal: <120 mg / dL
 Average levels: 100 mg / dL
 HbA1C <6.0%
Blood sugar (capillaries) is checked on the advice of the treating physician, to
do as much as 8 times a day, including before, after meals (1 hour after and 2 hours
after), fasting, and before bed. The results of written examination and matched with the
target to be achieved. Make a schedule of eating and physical activity.

Target blood pressure during pregnancy:

 Systolic: 110-129 mmHg

 Diastolic: 65-79 mmHg
Insulin and oral anti-diabetic
19
 Insulin is the first choice therapy to control blood sugar levels during
pregnancy, this is because the most effective insulin to control blood sugar and
do not cross the placenta so it is safe for the fetus. Insulin can be used with a
syringe, insulin pen, or insulin pump. All three are safe for pregnant women.

If a woman who is suffering from diabetes type 1 are pregnant, the

pregnancy will affect insulin therapy planning. During pregnancy, the body will
need more insulin, especially the last three months of pregnancy. Increased
insulin requirements caused by a hormone produced by the placenta. The
placenta produces hormones that help the fetus to grow, at the same time, these
hormones block the action of insulin mother, as a result, insulin therapy should
be added.

If a woman with type 2 diabetes, treatment planning is needed before

pregnancy. If the woman is taking anti-diabetic oral medication to control their
blood sugar before pregnancy, then during pregnancy, the woman may no longer
consume her oral anti-diabetic, anti-diabetic drug for oral use in pregnancy has
not been established safe. Oral anti-diabetic therapy will be replaced with insulin
therapy. Oral anti-diabetic therapy will also decrease the effectiveness due to
insulin resistance during pregnancy.

Due to various reasons, the American Diabetes Association does not

recommend the use of oral anti-diabetic. But the use of anti-diabetic oral
medications are more commonly used to control blood sugar is not controlled
with diet and exercise in individuals outside of pregnancy.

Insulin therapy:

1) Multiple insulin injection

 Prandial insulin (regular / insulin lispro) is supplied with current eating
 Basal insulin (Neutral Protamine Hagedorn / NPH) given before
breakfast (2/3 dose) and bedtime (1/3 dose)
2) Continuous subcutaneous Insulin Infusion (Insulin pump)
 Regular / Insulin lispro is given as a continuous basal rate and bolus in
patients with high compliance

20
Insulin preparations that can be used is 7,8,9

Figure 7. The preparation of insulin and category in pregnancy

Food

During pregnancy, the physician and nutrition specialist will adjust your
diet so blood sugar level is too low or too high. The most important in the
regulation of the diet is to improve the quality of food compared to the amount
of food alone. Good food is food that helps keep blood sugar stable while
providing the nutrients for the growing fetus.

Many pregnant women think that the food consumed 2 servings should
include individual, this is not true, because pregnant women should only
increase by approximately 300 calories per day. If at the beginning of pregnancy,
weight loss has been excessive, then the weight must be reduced in consultation
with a specialist in nutrition.

21
 If pre-pregnancy weight is normal then the women during pregnancy
weight gain is good is at 11.25 to 15.75 kg. If the women's weight before
pregnancy is less then the weight gain to be achieved for 12.6 to 18 kg. If the
women's weight before pregnancy are overweight, weight gain during
pregnancy is of 6,75- 11:25. And when the women's weight before pregnancy
are obese then the weight gain to be achieved is 4,95- 9 kg.

Diets are recommended:

Plans: 3 meals and 3 snacks
Calories: 30-35 kcal / kg normal body weight
Total: 2000-2400 kcal / day
Composition: 40-50% carbohydrate, high-fiber complex and 20% protein, 30-
40% fat (saturated fatty acids / saturated <10%).

Guidelines for the use of insulin and carbohydrate intake

- 1 unit of rapid-acting insulin will lower blood glucose 30 mg / dL

- 10 g carbohydrate will raise blood glucose of 30 mg / dL (1 unit of rapid-
acting insulin given at the intake of carbohydrates 10 g)
Physical activity

Physical activity is the key to successful treatment of diabetes. Excessive

physical activity is not recommended, because it can cause varicose veins, leg
cramps, fatigue, and konstipasti. For pregnant women who suffer from diabetes,
physical activity, especially after meals can help muscles use the glucose in the
blood, and helps keep blood sugar levels stable. However, if there are conditions
such as high blood pressure, kelaianan eye, kidney, and heart disease, a history
of vascular disease, and nerve damage, then physical activity to be performed
should be consulted first.

In general, physical activity is good for pregnant women are walking,

light aerobics, swimming and water aerobics. Physical activity should be
avoided during pregnancy are: physical activity is a risk of falling, injury to the
abdomen, physical activity that causes high pressure on the stomach, bounding
and diving.

22
 Fetal monitoring.
Antenatal fetal wellbeing monitoring to prevent fetal death
1. Fetal Biophysical Profile.
2. ultrasound to monitor fetal growth (macrosomia / PJT)
3. Amniocentesis when necessary, to estimate fetal lung maturation when
planned for elective section before 39 weeks.

 When Labor 10
Grouping the risk of pregnancy with diabetes is aimed toward the risk of
fetal death in utero.
1) Patients with uncontrolled blood glucose levels with diet alone allowed to give
birth to the term. When up to 40 weeks of labor has not occurred then begin
monitoring fetal well-being 2 times a week.
2) Patients with Hypertension In Pregnancy previous fetal wellbeing monitoring
should be done 2 times a week from the age of 32 weeks pregnant
3) Estimated birth weight clinical and ultrasound examination performed to detect
any signs of macrosomia. To reduce fetal abnormalities as a result of birth
trauma are encouraged to consider elective SC
4) Gestational Diabetes Mellitus Patients with deep insulin therapy along with diet
to control blood glucose levels planned program of monitoring / evaluation of
fetal antenatal (antepartum fetal surveillance)
5) Intensive care to detect and treat hypoglycemia, hypocalcemia and
hyperbilirubinemia in neonates.
Intrapartum glucose regulation

1. check blood glucose levels (capillary) every hour and keep always below 110
mg / dL.
2. The Glucose control during labor (see table)
Insulin (IU / h) Glucose (g / h)
latent phase 1 5
The active phase - 10
Figure 8. glucose control during the first stage in patients with DMpG

 Period after childbirth and lactation 11

23
 Women with type 2 diabetes who have given birth to return to consume such
therapy before pregnancy to maintain blood sugar levels. Therapy may be modified
during lactation.

Women with a history of gestational diabetes should do blood sugar tests for
assuring their blood sugar levels have returned to normal. Women with a history of
gestational diabetes also have the possibility of developing type 2 diabetes later in
life so that he must always be checked out every 1-3 years.

Duration of breastfeeding is good for women with diabetes, but with

breastfeeding, blood sugar levels are difficult to predict. To avoid blood sugar levels
that are too low during lactation, here are some ways you can do:

- Consumption of snack before breastfeeding

- Sufficient fluid intake (mineral water or decaffeinated beverages)
- Keep your blood sugar levels enough before breastfeeding
Breastfeeding can also help women who have given birth to return to lose
weight. During breastfeeding is very important for nursing mothers to get enough
fluids, protein, vitamins, and minerals. 12

f. Gestational diabetes mellitus

Gestational diabetes mellitus (GDM) is defined as glucose intolerance that
begins or newly discovered during pregnancy. It did not rule out the possibility that
glucose intolerance may have occurred prior to pregnancy. After she gave birth, DMG
situation will often return to normal glucose regulation. 13

The incidence
Varies between 2-5%

Risk factor
low risk
a. Age <25 years
b. Normal weight before pregnancy
c. There is no family history / parents DM
d. No history of abnormal glucose tolerance

24
e. No history of poor obstetric
f. Instead of the ethnic group with a high prevalence of diabetes

high risk
a. Age> 30 years
b. obesity
c. Polycystic ovary syndrome
d. Pregnancy ago there glucose intolerance
e. Pregnancy ago with a large baby (> 4000g)
f. History of fetal death in utero of unknown
g. Families with type 2 diabetes (first-degree relatives)
h. An ethnic group with a high prevalence of diabetes among others: Hispanic, African,
Native American and South East Asian.

Skirining and Diagnosis, 14.15

Screening is done only in pregnant women at high risk for diabetes mellitus
(ADA). The grounds because the Indonesian included ethnic group of Southeast Asia
(South East Asian) then we adopt a universal screening (ACOG), which is performed
for every pregnant woman began the first visit (trimester 1) to screen for DM Pragestasi
(DMpG), if negative repeated at 24-28 weeks of pregnancy to screen for gestational
diabetes mellitus (GDM).
Recommended screening and diagnosis is one step (One Step Approach by
WHO), namely with the OGTT (Oral Glucose Tolerance Test), to give 75 g glucose
load anhidrus after fasting for 8-14 hours.
When a negative result is repeated in a manner similar examination at the age of
24-28 weeks pregnant.

complications
1. Mother:
- DM settled until after delivery (type 2 diabetes).
- Preeclampsia
- Polyhydramnios
2. Fetal and Neonatal:
- Macrosomia and birth trauma
25
- Hypoglycemia, hypocalcemia and neonatal hyperbilirubinemia
- Long-term baby is developing future diabetes disease, cardiovascular, obesity (Barker
Hypothesis). 16

17.18 antenatal care

1. DMG case treatment program implemented in multi-disciplinary consisting of the
Department of Obstetrics, Internal Medicine, Nutrition, Neonatal and Anesthesia.
2. Antenatal care, visits every 2 weeks until the age of 36 weeks pregnant then 1 week
until term (when blood glucose levels are well controlled).
3. Target blood glucose levels as normal as possible with fasting glucose = 95 mg / dL
and 2 hours pp = 140 mg / dL were achieved with diet, exercise and insulin. Approach
with dietary adjustments aimed at reducing maternal serum glucose concentrations, by
limiting carbohydrate intake to 40% - 50% of total calories, protein 20%, fat 30% - 40%
(less than 10% saturated), high-fiber meal.
4.Kenaikan weight during pregnancy operated only from 11 to 12.5 kg. Nutrition and
food regulatory program that is recommended by the American Diabetes Association
(American Diabetes Association) is the provision of adequate calories and nutrients to
meet the needs of pregnancies and reduce maternal hyperglycemia. The daily calories
needed for women with normal body weight during the second half of pregnancy is 30
kcal per kg body weight is normal. When the body mass index (Body Mass Index) of
over 30 kg per m2, it is recommended low-calorie intake to 30-33% (about 25 Kilo
Calories per kg). This diet will prevent ketonemia.
5. Regular exercise will improve blood sugar control in pregnant women with
gestational diabetes mellitus although its effect on perinatal outcome is unclear.
6. OAD is not recommended because it can penetrate the placental barrier, it is feared
teratogenicity and further stimulate the beta cells of Langerhans in the fetus. OAD that
may be considered are metformin and sulfonylurea. The incidence of macrosomia be
lowered by administration of insulin to achieve blood sugar concentration praprandial
less than 80 mg / dl (4.4 mmol / l)
Oral anti-diabetic drug that may be used is glyburide or metformin. Metformin
considered after insulin or glyburide. 7.8.9

26
 Figure 8. Drug oral anti diabetic and the category in pregnancy
Antepartum management of women with GDM is aimed at: 19
 Doing management of the third trimester of pregnancy in a bid to prevent
stillbirths or asphyxia, as well as minimizing the incidence of maternal and fetal
morbidity due to childbirth.

27
  Regularly monitor fetal growth and continuous (eg by ultrasound) to determine
the development and growth of the fetus so that it can be determined when and
how the proper delivery.
 Estimating maturity (maturity) of the fetal lungs (eg amniocentesis) if there is a
plan termination (cesarean section) at 39 weeks gestation.
 Recommended antenatal checks performed since age 32 to 40 weeks gestation.
Antenatal checks carried out on pregnant women with uncontrolled blood sugar
levels, which received insulin treatment, or suffering from hypertension. It is
advisable to conduct the examination nonstress test, biophysical profile, or
modification of the biophysical profile as nonstress inspection test and amniotic
fluid index.

Care during childbirth 16, 17

1. For patients whose glucose levels under control with diet alone allowed to give birth
to the term. When up to 40 weeks of labor has not occurred then begin monitoring fetal
well-being 2 times a week. Decision to conduct early delivery (at 38 weeks gestation)
by way of induction of labor or cesarean section performed on the consideration of the
risk of perinatal mortality or perinatal morbidity associated with macrosomia, shoulder
dystocia, fetal distress, and respiratory distress syndrome. In pregnant women with
GDM who received insulin treatment, there is no benefit in delaying childbirth
performed 38-39 weeks gestation because of deliveries performed at 38-39 weeks of
pregnancy, can reduce the likelihood of macrosomia.
2. Estimated birth weight clinical and ultrasound examination performed to detect any
signs of macrosomia. To reduce fetal abnormalities due to birth trauma SC encouraged
to consider effective on Estimated fetal weight = 4500 g. Management of pregnant
women with GDM at 38 weeks gestation with induction of labor mendaat insulin
treatment, is associated with weight loss efforts fetuses above 4000 g or above the 90th
percentile.
3. Patients with deep DMG insulin therapy along with diet to control glucose levels
planned program monitoring / evaluation of antenatal fetus (fetal surveillance
anterpartum) as DMpG.
4. Treatment incentive to detect and treat hypoglycemia, hypocalcemia and
hyperbilirubinemia in neonates.

28
Postpartum care 20
1. Evaluation anticipation of carbohydrate intolerance that persist.
- Self monitoring to evaluate blood glucose profile
- At 6 weeks postpartum, OGTT performed by loading 75 g of glucose (see terms of
diagnosis DMG) was then measured blood glucose levels (plasma) when fasting and 2
hours.
- If the above OGTT showed normal levels, the evaluation after 3 years with fasting
glucose levels, regular exercise and weight loss in the obese.
2. The low-dose oral contraceptives have been reported to say no effect on the incidence
of carbohydrate intolerance.
3. Reccurrence risk for GDM around 60%.
Normal glucose Intolerance DM
Fasting (mg / dL) <100 100-125 ≥100
2 hours (mg / dL) <140 140-199 ≥140

Figure 9. The plasma glucose levels at 6 weeks postpartum DMG

4.Perempuan who have had gestational diabetes mellitus should be counseled in order
to feed the baby because breastfeeding will improve blood sugar control.

5.Harus planned to use contraception for all pregnant women suffer from diabetes, then
he is at risk of the same thing in a subsequent pregnancy. There are no restrictions on
the use of hormonal contraceptives in patients with a history of gestational diabetes
mellitus.

6. For women who are obese, having given birth should make efforts weight loss with
diet and exercise regularly in order to decrease the risk of developing diabetes.

The explanations in accordance with its values evidens 21

1. The most important of DMG treatment is diet. Calories eaten depends on the mother's
weight before pregnancy. Treatment with diet and exercise are given for two weeks, if
it fails to proceed with the administration of insulin
2. There is no standard number of times sugar levels should be checked in patients with
GDM. The goal is to determine whether the target sugar level has been reached.

29
Common target used is achieved fasting glucose levels less than 95 mg / dl and 2-hour
glucose levels after eating less than 120 mg / dl
3. Deliveries on GDM is affected by gestational age, babies, rude uncontrolled blood
sugar. Mothers with GDM are at increased risk of uncontrolled fetal lung immaturity
and respiratory distress syndrome (RDS), but GDM risk in a controlled equal to the non-
diabetic population. RDS risk becomes equal to the mother without GDM at the age of
38.5 weeks. The study by Piper, et al no RDS after 37 weeks' gestation despite fetal lung
examination results showed immaturity
4. Indications childbirth at the age of 37-38 weeks include: do not obtain adequate
control of blood sugar levels, patient noncompliance, a history of previous fetal death,
their hypertension. Women with controlled blood sugar levels, better patient compliance
and better fetal growth should wait until 40-41 weeks of spontaneous labor.
5. Macrosomia and shoulder dystocia occurs more frequently in women with diabetes
compared with the general popuasi. Most of shoulder dystocia occur in women with
diabetes with birth weight infants> 4000 grams 22,23,24

30
Figure 10. Management of labor in pregnancies DMpG and DMG 25,26,27

31
 CHAPTER III

Cover

Conclusion

Diabetes in pregnancy is impaired glucose tolerance in various levels occurring or first

detected in pregnancy or already occurred before pregnancy and persists after pregnancy.
The diagnosis of diabetes is often made for the first time in pregnancy because the patient
for the first time come to the doctor or diabetes is becoming more apparent by the pregnancy.
Diabetes showed a tendency to become more severe in pregnancy and the need for insulin
increases.
DM uncontrolled during pregnancy lead to an increased risk of miscarriage in the first
trimester, congenital abnormalities, especially heart defects and abnormalities of the central
nervous system, increased fetal death, preterm labor, pre-eclampsia, ketoacidosis,
polihidramniom, macrosomia, birth trauma, especially nerve damage brakhialis, delayed
lung maturation , respiratory distress syndrome, jaundice, hypoglycemia, hypocalcemia,
increased perinatal mortality. Long-term risks include obesity, type 2 diabetes and low IQ.
Given the risk of severe complications hence the need for early detection and appropriate
treatment for managing patients with diabetes who undergo pregnancy.
Management of multidisciplinary treatment involving medicine can improve maternal
and fetal life.

32
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