CHAPTER I

PREFACE

Gestational diabetes mellitus (GDM), which is defined as diabetes diagnosed in the

second and third trimesters of pregnancy has emerged as a global public health concern. (1,2) It
has been associated with short-term and long-term adverse health outcomes for both mothers
and their newborns. Women with GDM are known to have decreased quality of life and
increased risks of caesarean section, gestational hypertension, preeclampsia, and type 2
diabetes. In babies, GDM has been found to be associated with macrosomia or larger than
normal gestational-aged infants, neonatal hypoglycemia, and type 2 diabetes mellitus later in
life. As such, it is important to understand the burden of GDM in various parts of the world to
provide country-specific information to help inform on policy and planning.
Gestational diabetes mellitus affects between 2% and 5% of pregnant women.1 In the
United States, 5 to 6 percent of pregnancies—almost 250,000 women—are affected annually
by various forms of gestational diabetes. Worldwide, its prevalence differs according to race,
ethnicity, age, and body composition and by screening and diagnostic criteria.
Worldwide there are many guidelines with recommendations for appropriate
management strategies for GDM once lifestyle modifications have been instituted and failed
to achieve control. The efficacy and particularly the safety of other treatment modalities for
GDM has been the source of much debate in recent years. Currently, available evidence
indicates that GDM presents a significant risk factor for development of type II diabetes
(T2D) and cardiovascular disease in women. Children whose mothers had diabetes during
pregnancy are at increased risk of having obesity and T2D at a young age. Future research
will be needed to address how to determine whether better glucose control during pregnancy
would prevent long-term consequences for both women and their children. 1

1
 CHAPTER II
CASE REPORT

IDENTITY
Name : Mrs. X
Age : 39 years old
MR No. :
Adress : Padang
Date : July 3rd 2018

HISTORY TAKING
A 39 years old patient was admitted to the Ward Room of Dr. M. Djamil Central General
Hospital on July 3rd 2018 at 15 pm referred from Policlinic Dr. M. Djamil General Hospital
with diagnosed G3P2A0L1 37-38 weeks of term of Pregnancy + once Previous Caesarean
Section + Gestasional diabetes + Transverse Lie Persentation

Present illness history

• Previously, 2 months ago patient went to public health and found that her urinary
glucose was +++. And from the glucose blood check, there was found fasting glucose
was 168 mg/dl and 2 hours (OGTT) was 249 mg/dl. And then she reffered to dr. M.
Djamil Central Hospital for antenatal care.
• Pelvic pain to the groin was (-)
• Bloody show from the vagina (-)
• There was no fluid leakage from the vagina
• Massive bleeding from the vagina (-)
• Amenorrhea since 9 months ago.
• First date of last menstrual period : 9-10-2017
• Estimation date of delivery : 16-7-2018
• Fetal movement was felt since 5 months ago
• No complain of nausea and vomiting neither during early pregnancy or during late
pregnancy.
• Prenatal care : she controlled her pregnancy regularly to public health at 4,6, and 8
month of pregnancy. She controlled to obstetrician at 8 and 9 months of pregnancy.

2
 • Menstruation history: Menarche at 13 years old, regular cycle, for 5 to 7 days each
cycle with the amount of 2-3 times pad change/day without menstrual pain

Previous illness history :

• There was no previous history of heart, lung, liver, kidney, hypertension and allergy.
• She diagnosed with diabetes mellitus from second pregnancy, but didn’t got treatment.
She never recheck her blood sugar level after that. At 8 months of her third pregnancy
she diagnosed again with gestasional diabetes and got insulin 3x6 IU (before meal) until
right now.

Family Illness History:

• There was no history of hereditary disease, contagious and physicological illness in the
family

Occupation, Socioeconomics, Psychiatry, and Habitual History:

• History of Pregnancy/Abortion/delivery:
1. 2012,male, 4300 gram, term pregnancy, spontaneous, hospital, obstetrician, death
2. 2015,male, 4500 gram,term pregnancy, TPPCS due to breech presentation and
macrosomia, Hospital, obstetrician, alive
3. Present
• History of family planning : (-)
• History of immunization : (-)
• History of formal education : Senior high school
• Occupation : House wife
• History of habit : Smoking (-), Alcohol (-), Drug abuse (-)

General Record:

General appearrance :Moderate

Conciousness : Composmentis cooperative
Body Height : 155 cm
Body Weight : 66 kg
(before pregnant : 60 kg, BMI : 25kg/m2)
Nutrisional status : Good

3
Blood pressure : 120/80 mmHg
Heart rate : 80 x/m
Respiratory rate : 20 x/m
Body Temperature : 37⁰ C

Eyes : Conjunctiva anemic (-), sclera icteric (-)

Neck : JVP 5-2 cmH2O, thyroid gland no enlarge
Chest : H/L normal
Abdoment : OR
Genitalia : OR
Extremity : Oedem -/-, Physiological Reflex +/+,Pathological Reflex -/-

Obstetric record
Abdomen
I: Enlarge laterally , median line
hyperpigmentation (+), striae gravidarum (+), sicatric (+) Pfannenstiel
Pa :
L1 : Uterine fundal palpable between xyphoideus processus and umbilical, felt empty
L2 : Hard round mass was palpable at the right side, soft nodular mass was palpable at the
left side.
L3 : Empty
L4 : (-)
uterine contraction : (-)
Au : FHS (+) 150-160 bpm
Genitalia : I : V/U were normal VB (-)

Laboratory Finding

PARAMETER RESULT REFERENCE VALUE

Hemoglobin 13,7 9,5-15

Leucocyte 8.500/mm3 5.900 – 16.900

Hematocrit 40% 28 – 40

4
Trombocyte 238.000/mm3 150.000 – 400.000

APTT 33,0 22,6 – 37,8

PT 9,6 9,5 – 12,9

GDS 129 < 200

Calcium 8,8 8,1 – 10,4

Natrium 138 136-145

Kalium 4,1 3,5-5,1

Cloride 110 97-111

total bilirubin 0,4 mg/dl 0,3 - 1

direct bilirubin 0,2 mg/dl <0,20

indirect bilirubin 0,2 g/dl <0,60

Total Protein 6,5 mg/dL 6-7

Albumin 3,9 g/dL 3,5 – 5,2

Globulin 2,6 g/dl 0

SGOT 13 u/l 0 – 31

SGPT 5 u/l 0 – 34

Ureum 11 mg/dl 10 – 50

Creatinin 0,4 mg/dl 0,6 – 1,1

Urinalis :
Protein : -
Glucose : +++
Leucocyte : 6-7
Eritrocyte : 1-2

5
Cardiotocograph :

• Baseline : 135 dpm

• Variabilitas : 5-15 dpm
• Aceleration : (+)
• Deseleration : (-)
• Contraction : (-)
Impression : Category 1

Ultrasonography :

6
Interpretation :
• Fetal alive, singleton, intrauterine transverse lie right head, dorso superior
• Fetal movement activity was good
• Biometry :
BPD : 91 mm FL : 70,4 mm
AC : 392 mm EFW : 4187 gram
Placenta was implanted at posterior corpus grade II-III
A/ term pregnancy according to biometry,
fetal alive singleton, transverse lie, head right, dorso superior

Diagnose :
• G3P2A0L1 38-39 weeks of term pregnancy + previous CS + gestasional diabetes
• Fetal Alive Singleton Intra Uterine Transverse Lie Right Head, Dorso Superior

Management :
 Control GA,VS,HIS,FHS, Vaginal bleeding
 Informed consent
 Antibiotics ( skint Test ) pre op
 Consult to internist
 Cross match PRC 2 unit
 Consult anesthesi and perinatology department
 Report opperating room
Plan : TPPCS elective

Consult to internist :
A/ G3P2A0L1 37-38 weeks of term pregnancy + diabetes gestasional
P/
Operational risk tolerance
– Metabolic risk : moderate
– Pulmonary risk : mild
– Cardiovascular : Goldman stage class I complication
– Hematologic : Stable
• Insulin protocol pre op
• if blood sugar level > 200 : bolus 6 IU

7
 • if < 200 : (-)
• 1 hour before operation :
• 4 UI insulin
• IVFD D5% 8 hours/kolf
• Insulin protocol post op
• Sliding scale / 4 hours
• <200 : (-)
• 200-250 : insulin 8 UI, SK
• 250-300 : insulin 12 UI, SK
• 300-350 : insulin 16 UI, SK
• > 350 : insulin 20 UI, SK

At July 4th 2018 – 09.30

CCS + TP was performed
A female baby was born
Weight: 4000 gram
Height: 50 cm
Apgar score: 7/8
Placenta was born with mild traction with size 17x16x3 cm and weight 500 gr. Umbilical cord
was 60 cm length, paracentral insertion.
Found a mass size pingpong ball on uterine corpus that push the endometrium size 6x5x4 cm.
Impression : uterine myoma
Blood loss during surgery 250 cc

A/ P3A0H2 post CCS due to once previous caesarean section + transverse lie + gestasional
diabetes + pomeroy tubectomy + intramural uterine myom, puerperium day 1
Both Mother – Child were in care

P/
• Control GA, VS, uterine contraction, Vaginal bleeding
• IVFD RL 500 cc + Oxy 1 amp : metergyn 1 amp  28 gtt/min
• Inj. Ceftriaxon 2x1 gr (iv)
• Pronalges supp
• Sliding scale sugar blood check

8
Sliding scale /4 hours

Time Sugar blood level Insulin

14.00 145 (-)

18.00 160 (-)

9
 22.00 156 (-)

02.00 167 (-)

06.00 181 (-)

FOLLOW UP 5/7/18 (07.00 WIB)

S/ Fever (-) , vaginal Bleeding (-)

O/Gen Conc BP HR RR T
Mdrt CM 110/70 86 20 af
• Eyes : Conjunctiva was not anemic -/-, Sclera was not icteric -/-
• Abdomen : uterine fundal was palpated 3 Fingers Below
Umbilical, contraction was (+)
• Genitalia :V/U normal,
Vaginal bleeding (-)

A/ P3A0H2 post CCS due to once previous caesarean section + transverse lie + gestasional
diabetes + pomeroy tubectomy + intramural uterine myom, puerperium day-2
Both Mother – Child were in care

P/ Control GA, VS, uterine Contraction, VB,

• Inj.Ceftriaxon 2 x 1 (IV)
• Mefenamic acid 3 x 500 mg
• Vit C 3 x 1
• S.F 1 x 1
R/ Check random plasma glucose at 18.00

10
 Time Sugar blood level Insulin

10.00 201 8 UI, SK

14.00 190 (-)

18.00 126

FOLLOW UP 6/7/18 (07.00 WIB)

S/ Fever (-) , vaginal Bleeding (-)

O/Gen Conc BP HR RR T
Mdrt CM 110/70 86 20 af
• Eyes : Conjunctiva was not anemic -/-, Sclera was not icteric -/-
• Abdomen : uterine fundal was palpated 3 Fingers Below
Umbilical, contraction was (+)
Wound was good, no pus or blood
• Genitalia :V/U normal,
Vaginal bleeding (-)

A/ P3A0H2 post CCS due to once previous caesarean section + transverse lie + gestasional
diabetes + pomeroy tubectomy + intramural uterine myom, puerperium day-3
Both Mother – Child were in care

P/ Control GA, VS, uterine Contraction, VB,

• Cefixim 2x200 mg
• Mefenamic acid 3 x 500 mg
• Vit C 3 x 1
• S.F 1 x 1
• Insulin 3x6 IU (before meal)
R/ Outpatient

11
 CHAPTER III
GESTATIONAL DIABETES MELLITUS

2.1. Definition

The word gestational implies that diabetes is induced by pregnancy—ostensibly

because of exaggerated physiological changes in glucose metabolism.3 Gestational diabetes
mellitus (GDM) is defined as any degree of glucose intolerance with onset or first recognition
during pregnancy. (American College of Obstetricians and Gynecologists, 2013). This
definition applies whether or not insulin is used for treatment and undoubtedly includes some
women with previously unrecognized overt diabetes.3
Gestational diabetes mellitus affects between 2% and 5% of pregnant women.1 In the
United States, 5 to 6 percent of pregnancies—almost 250,000 women—are affected annually
by various forms of gestational diabetes. Worldwide, its prevalence differs according to race,
ethnicity, age, and body composition and by screening and diagnostic criteria.3 Use of the term
gestational diabetes has been encouraged to communicate the need for increased surveillance
and to stimulate women to seek further testing postpartum. The most important perinatal
correlate is excessive fetal growth, which may result in both maternal and fetal birth trauma.
The likelihood of fetal death with appropriately treated gestational diabetes is not different
from that in the general population. Importantly, more than half of women with gestational
diabetes ultimately develop overt diabetes in the ensuing 20 years.3

2.2. Pathogenesis

During early pregnancy, glucose tolerance is normal or slightly improved and

peripheral (muscle) sensitivity to insulin and hepatic basal glucose production is normal. These
could be caused by the increased maternal estrogen and progesterone in early pregnancy which
increase and promote pancreatic ß-cell hyperplasia (Expansion of beta-cell mass in response to
pregnancy) causing an increased insulin release. This explains the rapid increase in insulin
level in early pregnancy, in response to insulin resistance. In the second and third trimester, the
continuous increase in the feto-placental factors will decrease maternal insulin sensitivity, and
this will stimulate mother cells to use sources of fuels (energy) other than glucose as free fatty
acids, and this will increase supply of glucose to the fetus. In the normal physiological

12
conditions, the fetal blood glucose is 10-20% less than maternal blood glucose allowing the
transport of glucose in the placenta to the fetal blood by the process of simple diffusion and
facilitated transport. Therefore, glucose is the main fuel required by the developing fetus,
whether as a source of energy for cellular metabolism or to provide energy for the synthesis of
protein, lipids, and glycogen. 5

Picture 1. Gestational Diabetes Insulin Requirements During Pregnancy 1

During pregnancy, the insulin resistance of the whole body is increased to about three
times the resistance in the non-pregnant state.5 Insulin resistance during pregnancy stems from
a variety of factors, including alterations in growth hormone and cortisol secretion (insulin
antagonists), human placental lactogen secretion (which is produced by the placenta and affects
fatty acids and glucose metabolism, promotes lipolysis, and decreases glucose uptake), and
insulinase secretion (which is produced by the placenta and facilitates metabolism of insulin).
In addition, estrogen and progesterone also contribute to a disruption of the glucose insulin
balance.1 In general, the resistance to insulin can be characterized as pre-receptor (insulin
antibodies) as in autoimmune diseases, receptor (decreased number of receptors on the cell
surface) as in obesity, or post-receptor (defects in the intracellular insulin signaling pathway).
In pregnancy, the decreased insulin sensitivity is best characterized by a post-receptor defect
resulting in the decreased ability of insulin to bring about SLC2A4 (GLUT4) mobilization from
the interior of the cell to the cell surface. This could be due to increase in the plasma levels of
one or more of the pregnancy-associated hormones. Although, pregnancy is associated with
increase in the beta-cell mass and increase in insulin level throughout pregnancy but certain

13
pregnant women are unable to up-regulate insulin production relative to the degree of insulin
resistance, and consequently become hyperglycemic, developing gestational diabetes.5

2.3. Risk Factor

Several risk factors are associated with the development of GDM. The most common
risk factors include1
a. History of macrosomia (birth weight > 4000 g)
b. Being a member of an ethnic group with a higher rate of type II diabetes (as
mentioned above)
c. Polycystic ovarian syndrome
d. Essential hypertension or pregnancy-related hypertension, history of spontaneous
abortions and unexplained stillbirths, strong family history of diabetes (especially
in first-degree relatives)
e. Obesity (pregnancy weight > 110% of ideal body weight or body mass index [BMI]
> 30)
f. Age older than 25 years
g. Persistent glucosuria
h. History of GDM in a previous pregnancy.

2.4. Screening and Diagnosis of GDM

There is debate regarding the preferred screening protocol for GDM.4 Despite more
than 40 years of research, there is still no agreement regarding optimal gestational diabetes
screening.3 Some experts recommend universal screening because not all women who develop
GDM have risk factors. The ADA policy states that screening may be omitted in low-risk
women. A woman is considered low risk if all of the following factors are present: age younger
than 25 years; BMI less than 25 before pregnancy; not of Hispanic, African American,
American Indian, South or East Asian, or Pacific Islander descent; no first-degree relative with
DM; no history of abnormal glucose tolerance; and no history of poor obstetric outcome. The
American College of Obstetricians and Gynecologists (ACOG) practice bulletin states that
universal screening is the most sensitive and more practical approach, but it notes that low-risk
women may be excluded from screening per the ADA recommendation. The United States
Preventive Services Task Force on Preventive Health Care concluded that there is not enough
evidence to support or deny universal screening for GDM.4

14
 Screening and diagnosis of GDM may consist of either a one- or a two-step approach.4
The difficulty in achieving consensus is underscored by the controversy following publication
of the single-step approach espoused by the IADPSG Consensus Panel (2010). This strategy
was greatly influenced by results of the Hypoglycemia and Pregnancy Outcomes (HAPO)
Study described later. Although the ADA adopted this new scheme, the American College of
Obstetricians and Gynecologists (2013) declined to endorse the single 75-gram oral glucose
tolerance test. Instead, the College continues to recommend a two-step approach to screen and
diagnose gestational diabetes. Similarly, the NIH Consensus Development Conference in 2013
concluded that evidence is insufficient to adopt a one-step approach.3

The recommended two-step approach begins with either universal or risk-based

selective screening using a 50-g, 1-hour oral glucose challenge test. Universal screening is also
acceptable. Gabbe and associates (2004) surveyed practicing obstetricians and reported that 96
percent used universal screening. Screening should be performed between 24 and 28 weeks’
gestation in those women not known to have glucose intolerance earlier in pregnancy. This 50-
g screening test is followed by a diagnostic 100-g, 3-hour oral glucose tolerance test (OGTT)
if screening results meet or exceed a predetermined plasma glucose concentration.3

Picture 2. Screening and Diagnostic Criteria for Gestational Diabetes Mellitus3

15
From Fifth International Workshop-Conference on Gestational Diabetes, there are
recommended screening strategy based on risk assessment for detecting gestational diabetes
(GDM). GDM risk assessment should be ascertained at the prenatal visit. The category :

1. Low risk

Blood glucose testing not routinely required if all the following are present :

a. Member of ethnic group with a low prevalence of GDM no known diabetes in

first-degree relatives
b. Age <25 years
c. Weight normal before pregnancy
d. Weight normal at birth
e. No history of abnormal glucose metabolism
f. No history of abnormal glucose metabolism
g. No history of poor obstetrical outcome
2. Average risk

Perform blood glucose testing at 24 to 28 weeks using either :

Two-step procedure : 50-g oral glucose challenge test (GCT), followed by a diagnostic
100-g OGTT for those meeting the threshold value in the GCT

One-step procedure : diagnostic 100-g OGTT performed on all subjects

3. High risk

Perform blood glucose testing as soon as feasible, using the procedures described
above, if one or more of these are present:

• Severe obesity
• Strong family of type 2 diabetes
• Previous history of GDM, impaired glucose metabolis, or glucosuria

If GDM is not diagnosed, blood glucose testing should be repeated at 24 to 28 weeks’s

gestation or at any time symptoms or signs suggest hyperglicemia

16
 For the 50-g screen, the plasma glucose level is measured 1 hour after a 50-g oral
glucose load without regard to the time of day or time of last meal. In a recent review, the
pooled sensitivity for a threshold of 140 mg/dL ranged from 74 to 83 percent depending on
100-g thresholds used for diagnosis (van Leeuwen, 2012). Sensitivity estimates for a 50-g
screen threshold of 135 mg/dL improved only slightly to 78 to 85 percent. Importantly,
specificity dropped from a range of 72 to 85 percent for 140 mg/dL to 65 to 81 percent for a
threshold of 135 mg/dL. That said, the American College of Obstetricians and Gynecologists
(2013) recommends using either 135 or 140 mg/dL as the 50-g screen threshold. At Parkland
Hospital, we continue to use 140 mg/dL.

Justification for screening and treatment of women with gestational diabetes was
strengthened by the study by Crowther and coworkers (2005). They assigned 1000 women with
gestational diabetes between 24 and 34 weeks’ gestation to receive dietary advice with blood
glucose monitoring plus insulin therapy—the intervention group—or to undergo routine
prenatal care. Women were diagnosed as having gestational diabetes if their blood glucose was
< 100 mg/dL after an overnight fast and was between 140 and 198 mg/dL 2 hours after
ingesting a 75-g glucose solution. Women in the intervention group had a significantly reduced
risk of a composite adverse outcome that included perinatal death, shoulder dystocia, fetal bone
fracture, and fetal nerve palsy. Macrosomia defined by birthweight ≥ 4000 g complicated 10
percent of deliveries in the intervention group compared with 21 percent in the routine prenatal
care group. Cesarean delivery rates were almost identical in the two study groups.

Slightly different results were reported by the Maternal-Fetal Medicine Units Network
randomized trial of 958 women (Landon, 2009). Dietary counseling plus glucose monitoring
was compared with standard obstetrical care in women with mild gestational diabetes to reduce
perinatal morbidity rates. Mild gestational diabetes was identified in women with fasting
glucose levels < 95 mg/dL. They reported no differences in rates of composite morbidity that
included stillbirth; neonatal hypoglycemia, hyperinsulinemia, and hyperbilirubinemia; and
birth trauma. Importantly, secondary analyses demonstrated a 50-percent reduction in
macrosomia, fewer cesarean deliveries, and a significant decrease in shoulder dystocia rates—
1.5 versus 4 percent—in treated versus control women.

Based largely on these two studies, the U.S. Preventive Services Task Force (2013)
now recommends universal screening in low-risk women after 24 weeks’ gestation. However,
the Task Force concluded that evidence is insufficient to assess the balance of benefits versus

17
harms of screening before 24 weeks. From the foregoing, there obviously is not international
agreement as to the optimal glucose tolerance test to identify gestational diabetes. The World
Health Organization (1998) and now the American Diabetes Association (2013) recommend
the 75-g 2-hour oral glucose tolerance test. In the United States, however, the 100-g, 3-hour
OGTT test performed after an overnight fast is recommended by the American College of
Obstetricians and Gynecologists (2013).

Tabel 1. Fifth International Workshop Conference on Gestational Diabetes : Diagnosis

Criteria of Gestational Diabetes by Oral Glucose Tolerance Testing4

ACOG has adopted the NIDDK / ADA guidance on screening for diabetes and
prediabetes which takes in to account not only previous pregnancy history but also risk factors
associated with type 2 diabetes. Screen early in pregnancy if:

Patient is overweight with BMI of 25 (23 in Asian Americans), and one of the following:

 Physical inactivity

 Known impaired glucose metabolism

 Previous pregnancy history of:

o GDM

o Macrosomia (≥ 4000 g)

o Stillbirth

18
  Hypertension (140/90 mm Hg or being treated for hypertension)

 HDL cholesterol ≤ 35 mg/dl (0.90 mmol/L)

 Fasting triglyceride ≥ 250 mg/dL (2.82 mmol/L)

 PCOS, acanthosis nigricans, nonalcoholic steatohepatitis, morbid obesity and other

conditions associated with insulin resistance

 Hgb A1C ≥ 5.7%, impaired glucose tolerance or impaired fasting glucose

 Cardiovascular disease

 Family history of diabetes – 1st degree relative (parent or sibling)

 Ethnicity of African American, American Indian, Asian American, Hispanic, Latina,

or Pacific Islander

2.5. Management of Gestational Diabetes

2.5.1. Non Pharmacologic Management

2.5.1.1. Nutritional Therapy

Medical nutrition therapy is the cornerstone of treatment for GDM. Dietary

intervention, in combination with insulin therapy as needed, reduces the risk of LGA infants,
fetal macrosomia, preeclampsia, and serious perinatal complications. All women with GDM
should receive dietary counseling at the time of diagnosis, preferably provided by a registered
dietitian or nutritionist experienced in GDM management. The goals of dietary modification
in GDM are to attain the desired level of glycemic control; provide adequate weight gain, which
contributes to maternal and fetal well-being; and prevent the development of ketosis.4

Suggested weight gain during pregnancy for patients with GDM varies according to the
pre-pregnancy BMI. The ADA recommends a weight gain of 6.8–11.3 kg (15–25 lb) for over-
weight women and 4.5–9.1 kg (10–20 lb) for women with obesity (ADA 2016b), and the
Endocrine Society suggests similar gestational weight gain, as outlined in the Institute of
Medicine (IOM) revised guidelines for weight gain during pregnancy.

Medical nutrition therapy for women with GDM should emphasize distribution of
calories, with a focus on restriction of carbohydrates. The ACOG guidelines recommend a
caloric distribution of 33%–40% carbohydrates, 20% protein, and 40% fat (ACOG 2013).
Strong evidence for the optimal proportion of carbohydrates in GDM is lacking, and the

19
Endocrine Society suggests a slightly less restrictive carbohydrate intake of 35%–45% of total
calories. Other sources recommend a minimum intake of 175 g of carbohydrates per day,
although this is greater than the recommended daily carbohydrate consumption (130 g) for
nonpregnant women (Blumer 2013; ADA 2008; IOM 2002). Regardless of the strategy used
to determine initial carbohydrate intake in GDM, adjustment of carbohydrate consumption
should be ongoing and based on clinical measures such as blood glucose concentrations, ketone
concentrations, and weight gain. A typical daily meal plan for women with GDM includes
three small to moderate-sized meals and two to four snacks, one of which should be at bedtime
to prevent the development of ketosis overnight (ADA 2008).

2.5.1.2. Physical Activity

Together with medical nutrition therapy, physical activity is a key component in initial
GDM management. Physical activity improves insulin sensitivity and reduces both fasting and
postprandial glucose concentrations in patients with diabetes. The ADA, ACOG, and
Endocrine Society guidelines recommend a program of moderate exercise consisting of 30
minutes most days of the week for women with GDM who have no medical or obstetric
contraindications to physical activity (ACOG 2013). Examples of moderate exercise include
brisk walking, recumbent bicycling, or 10 minutes of seated arm exercises after each meal.

2.5.2. Pharmacologic Management

With appropriate lifestyle modification, 70%–85% of women with GDM can achieve
adequate glucose control.4 Drug therapy should be considered when medical nutrition therapy
and moderate physical activity fail to achieve glucose goals within 1–2 weeks. Little consensus
exists regarding the threshold glucose values that should trigger initiation of drug therapy. A
systematic review and meta-analysis found no evidence to support that maternal and infant
outcomes were affected by the glucose concentration at initiation of drug therapy for GDM.

2.5.2.1. Insulin

It is accepted that insulin is effective in the management of GDM and is supported as a

first-line option by many guidelines.7 However, as noted in the literature reviewed here, there
continues to be controversy over the safety of insulin analogs. One 2013 review of the use of
insulin analogs in GDM actually concluded that additional safety data are needed despite being

20
clinically effective and did not recommend the use of rapid-acting insulins in GDM solely
based on their pharmacokinetic profile. A second review article, including pregnant patients
with pregestational diabetes and GDM, analyzed the efficacy and safety of insulin analogs. The
authors of this review argue that because lispro, aspart, glargine, and detemir did not differ in
fetal outcomes in patients with type 1 diabetes that are well-controlled on their current regimen,
even if it is regular insulin/NPH, there is no reason to switch. However, in patients with
increased incidence of hypoglycemia, changing to detemir may offer an advantage of improved
fasting blood glucose levels without increasing hypoglycemia. This review in particular notes
that the authors believe the evidence to be lacking to utilize long-acting analogs for patients
with GDM due to their lack of propensity to experience hypoglycemia.7 For women with
marked hyperglycemia, several daily injections provide optimal glucose control. A typical
starting dose of insulin is 0.7–1 unit/kg/day , administered in divided doses (ACOG 2013; Hone
2010). Higher insulin doses may be required in women with obesity or multiple gestation
pregnancies.4

Analyzing all of the available evidence regarding efficacy and safety, it seems
reasonable to select any of the insulins (regular, NPH, or one of the analogs) for patients with
GDM who need insulin therapy. Cost concerns may direct providers to select regular or NPH
while the convenience of mealtime administration may direct providers to one of the rapid-
acting analogs. Additionally, the long-acting insulin analogs can provide consistent control of
blood glucose, which could be an advantage in patients in whom hypoglycemia is a concern.
Ease of delivery of many of the insulins in pen formulation now may also assist patients with
the transition to insulin. However, as evidence regarding the safety of the various insulin
products continues to be published, providers and patients will have additional data to consider
as they decide which insulin product to utilize.

Table 2. Suggested Starting Dose of Insulin in Gestational Diabetes (ACOG, 2013)

21
2.5.2.2. Metformin

Because many women with GDM have mild hyperglycemia, treatment with oral
medications such as metformin is also an acceptable option when medical nutrition therapy
and exercise fail to control glucose adequately. Metformin improves peripheral insulin
sensitivity and is not known to cause weight gain or hypoglycemia when used alone. In
addition, metformin has been used in patients with polycystic ovary syndrome to increase
ovulation and enhance fertility, and it may be continued until the end of the first trimester in
an attempt to reduce the rate of spontaneous abortion.4 Metformin crosses the placenta, and
initially, there was concern about using metformin in pregnancy when a small retrospective
cohort study of 118 patients found an increased incidence of preeclampsia and perinatal loss
with metformin compared with with sulfonylureas or insulin.

Recommendations for the role of metformin in GDM treatment differ, according to the
various guidelines. The ACOG guidelines recommend metformin as an appropriate first-line
therapy for GDM management, and the NICE guideline also supports metformin as initial
therapy in women with GDM and a fasting glucose below 7 mmol/L (126 mg/dL) at diagnosis
(NICE 2015; ACOG 2013). In contrast, the Endocrine Society suggests metformin as an
alternative in women who refuse or have contraindications to insulin or glyburide. The
rationale for this recommendation includes the higher failure rate of metformin and the
unknown long-term safety pro le in offspring of women treated with metformin. The ADA
recommends insulin as a first-line agent and proposes metformin as an acceptable alternative
if glucose control is sucient (ADA 2016b). The ADA cites the slightly higher risk of
prematurity and unknown long-term effects on offspring as concerns with metformin use in
GDM.

2.5.2.3. Glyburide

Glyburide has been extensively studied for GDM managment. Glyburide is the only
sulfonylurea that crosses the placenta to a minimal extent, likely because of high protein
binding. Depending on the manufacturer, glyburide is rated as FDA pregnancy risk category B
or C. Management of GDM is an off-label use of glyburide. When used in GDM treatment, the
initial glyburide dose is typically 2.5–5 mg once daily in the morning. The dose is titrated
according to glucose readings to a maximum of 20 mg daily, usually given in two divided doses
(ACOG 2013). For best eficacy, glyburide should be administered 30–60 minutes before meals,

22
and the drug’s activity should be carefully balanced with meals and snacks to minimize the risk
of hypoglycaemia.

The ADA continues to endorse insulin as a first-line agent for GDM management,
stating that glyburide may be inferior to insulin and metforamin because of the increased risk
of macrosomia and neonatal hypoglycemia (ADA 2016b). The NICE guideline recommends
consideration of glibenclamide (glyburide) in women intolerant of metformin therapy or those
with poor glycemic control on metformin alone who refuse insulin therapy (NICE 2015). In
contrast, ACOG supports glyburide as a suitable first-line treatment for GDM, and the
Endocrine Society recommends glyburide as an acceptable alternative to insulin therapy,
although these recommendations were made before the more recent glyburide safety data
(ACOG 2013; Blumer 2013). Women with GDM who are initiated on glyburide should be
counseled about the potential increased risk of macrosomia and neonatal hypoglycemia, as well
as the risk of maternal hypoglycemia and strategies for managing hypoglycemia with this
agent. In addition, they should be informed that glyburide crosses the placenta in trace amounts,
and long-term safety data are lacking.

2.5.3. Antenatal Management

Antenatal care :
a. Fetal monitoring

 Poor control on medication without co-morbidities: 32 weeks

o Begin earlier if other co-morbidities are present

 Well controlled on diet: no consensus

o Start > 32 weeks – can be based on local practice

o Include amniotic fluid volume assessment due to risk of polyhydramios

b. Maternal monitoring :

ACOG and ADA recommend the following target levels to reduce risk of macrosomia

 Fasting or preprandial blood glucose values < 95 mg/dL

 Postprandial blood glucose values < 140 mg/dL at 1 hour and < 120 mg/dL at 2
hours

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 Review weekly but may alter based on degree of glucose control.

2.5.3.1. Fetal Assessment

The need for other management strategies often depends on the severity of maternal
hyperglycemia and the ease of glucose control. The ACOG guidelines recommend antenatal
testing for poor glycemic control because these pregnancies have a higher likelihood of
complications such as stillbirth (ACOG 2013). Specific guidelines detailing the type and timing
of antenatal assessments in women with GDM are not available, and ACOG recommends that
antenatal testing be conducted in accordance with local standards of practice (ACOG 2013).
Many experts recommend that antenatal testing begin at 32 weeks’ gestation. Typical testing
might include once- or twice-weekly fetal non-stress tests (NSTs) or modified biophysical pro
les. The NST poses no harm to the fetus and involves the mother wearing one belt to measure
fetal heart rate and another to monitor contractions over 20–30 minutes. A normal NST is
“reactive,” showing that the fetal heart rate accelerates during times of movement. A modified
biophysical profile includes the NST, together with an assessment of amniotic fluid volume by
ultrasonography. The modified biophysical profie is considered normal if the NST is reactive
and there is at least one adequate pocket of amniotic fluid more than 2 cm deep.4

Ultrasonography is another fetal assessment that can be used to identify the risk of
macrosomia. Many obstetricians use ultrasonography at 36–39 weeks’ gestation to assess fetal
growth. However, ultrasonography is not a highly sensitive or specific method for identifying
LGA infants, and clinical examination may be comparable. The ACOG guidelines recommend
that clinicians assess fetal size late in the third trimester using either ultrasonography or clinical
examination. In the future, as ultrasound technology continues to advance, ultrasonography
may have a more de ned role in the fetal assessment of women with GDM.

2.5.3.2. Obstetric Considerations

Given the potential risks of pregnancies complicated by GDM, timing and route of
delivery are important considerations. Unlike in preexisting diabetes, well-controlled trials that
examine the optimal timing of delivery in GDM are not available, and evidence-based
recommendations cannot therefore be made. The ACOG guidelines suggest that expectant
management should be practiced in women with GDM controlled with diet or drug therapy and
recommend against delivery before 39 weeks’ gestation (ACOG 2013). If glycemic control is

24
poor or other maternal or fetal complications are present, an earlier delivery can be considered.
The NICE guideline offers a similar recommendation, suggesting that women with GDM
should be advised to give birth before the end of the 40th week of gestation, and elective
delivery before this time can be considered in the presence of maternal or fetal complications
(NICE 2015). In clinical practice, many obstetricians offer induction of labor for women with
GDM at 39–40 weeks’ gestation, or at the estimated date of delivery (40 weeks). Because the
risk of shoulder dystocia is higher in pregnancies complicated by diabetes, ACOG also suggests
that women with GDM with a predicted fetal weight of 4500 g or more be counseled about
cesarean delivery as an option to reduce the incidence of birth trauma (ACOG 2013).

2.5.4. Intrapartum Management

Maternal hyperglycemia during labor and delivery can contribute to the risk of neonatal
hypoglycemia (Blumer 2013). Thus, prevention of neonatal hypoglycemia is a primary goal of
intrapartum glucose management. Hypoglycemia in the mother should be avoided if a long-
acting insulin is used during labor. Of note, insulin requirements are usually decreased during
labor because the woman is typically fasting, and the work of labor requires energy
expenditure. Therefore, for women with GDM managed with insulin, it may be reasonable to
omit the dose of long-acting insulin or give only one-half of the usual dose on the day of
delivery.4

Both the Endocrine Society and NICE guidelines recommend a target plasma glucose
concentration of 72–126 mg/dL during labor and delivery, whereas ACOG recommends a tar-
get of 70–110 mg/dL (ACOG 2005). Plasma glucose values should be monitored every 1–2
hours, and intravenous dextrose or insulin infusion should be administered as needed to
maintain intrapartum glucose concentrations in the desired range (Blumer 2013). Women with
diet-controlled GDM are unlikely to require intrapartum administration of insulin. Glucose
concentrations in most women with GDM return to near-normal concentrations shortly after
delivery, and glucose-lowering therapies should be discontinued immediately after birth (NICE
2015).

25
2.5.5. Postpartum Management

Within 24–72 hours of delivery and before returning to community care, women should
have a glucose assessment (fasting plasma glucose or self-monitored glucose) to exclude
ongoing hyperglycemia (NICE 2015; Blumer 2013). Because women with a history of GDM
are at a greater risk of developing prediabetes or type 2 diabetes, most guidelines recommend
screening at 6–12 weeks postpartum using the one-step approach (2-hour 75-g OGTT)
previously described.(3,4) The NICE guideline differs, advocating screening with fasting blood
glucose rather than the 2-hour 75-g OGTT, and advises against the routine use of the OGTT
(NICE 2015). ACOG suggest screening woman who had GDM between 4 and 12 weeks
of postpartum for diabetes and pre-diabetes.

After the initial postpartum screening, some sources recommend continued use of the
2-hour 75-g OGTT, whereas others, such as the ADA, indicate that A1C, fasting glucose, or
the 2-hour 75-g OGTT may be used. Nonpregnant thresholds should be used when doing
postpartum screening. Screening should be repeated every 1–3 years and continued life-long.
The frequency of screening may depend on other risk factors for GDM or plans for subsequent
pregnancies (ADA 2016b). Patients with identified glucose intolerance should be referred for
treatment.

Table 3. Fifth International Workshop-Conference : Metabolic assessments recommended

after Pregnancy with Gestational Diabetes3

26
Picture 3. Management of Gestational Diabetes Mellitus 8

27
 CHAPTER IV
DISCUSSION

This case report discusses a 39 years old patient was admitted to the Ward Room of D
r. M. Djamil Central General Hospital on July 3rd 2018 at 15 pm referred from Policlinic Dr.
M. Djamil General Hospital with diagnosed G3P2A0L1 37-38 weeks of term of Pregnancy +
once Previous Caesarean Section + Gestasional diabetes + Transverse Lie Persentation. As a g
uide to the discussion on target academically comprehensive scientific then we will discusss s
ome of the reference questions are as follows :
1. Whether the diagnose of this patient was right ?
2. Whether the management of this patient was appropriate ?
3. What is the screening of the patient was right ?
4. What is the cause of transverse lie in this patient ?

1. Whether the diagnose of this patient was right ?

Discussion based on the question are :
Know by anamnese this patient was a multiparous, haven’t had menstrual since 9
months ago. On physical examination,. Abdomen was enlarge equal to term pregnancy, fundus
uteri was felt empty and cicatric (+). Hard round mass was palpable at the right side, soft
nodular mass was palpable at the left side. From abdominal palpation we can describe that the
baby was tranverese lie. From the ultrasound examination, confirmed by biometry, placenta
grading that this patiuent have reached term pregnancy. Estimated fetal weight is 4100 gram.
IADPSG Consensus Panel recommended the diagnosis of GDM with one-step
approach. By perform a 75-g OGTT, which constitutes obtaining a fasting plasma glucose,
administering glucose, and making additional plasma glucose assessments 1 and 2 hr later.
Diagnosis of GDM is made if one or more of the plasma glucose values meet or exceed the
following thresholds :
Fasting : 92 mg/dl
1 hr 180 mg/dl
2 hr 153 mg/dl
At this patient, previously, 2 months ago patient went to public health and found that
her urinary glucose was +++. And from the glucose blood check, there was found fasting
glucose was 168 mg/dl and 2 hours (OGTT) was 249 mg/dl. She refered to Dr. M. Djamil

28
General Hospital for antenatal care and controlled for her diabetes. From internist, she
diagnosed with gestational diabetes melllitus and got insulin 3x6 IU (before meal) until
delivery. She diagnosed with diabetes mellitus from second pregnancy, but didn’t got
treatment. She never recheck her blood sugar level after that.
Based on anamneses, physical and assisted examination, the diagnosis was correct, a
G3P2A0L1 38-39 weeks of term pregnancy previous CS + gestasional diabetes. Fetal Alive
Singleton Intra Uterine Transverse Lie Right Head, Dorso Superior.

2. Whether the management of this patient was appropriate ?

This patient pregnancy was planned to be terminated by caesarean section due to

previous CS, transverse lie, and macrosemia (>4000 gram). Since antenatal care, she got insulin
3x6 IU (before meal). But the management pre partum was not optimal. According to ADA
algoritm target blood glucose is .

 Fasting ≤90 mg/dL (5.0 mmol/L)

 1-hr postprandial ≤130-140 mg/dL (7.2-7.8 mmol/L)
 2-hr postprandial ≤120 mg/dL (6.7 mmol/L

In this patient, no fasting or OOGT blood glucose check, to get target blood glucose with
insulin dose 3x6 IU. So we cannot get conclusion that the target was reached.

Management intra partum was correct to prevent neonatal hypoglycemia. From ACOG
recommends intravenous dextrose or insulin infusion should be administered as needed to
maintain intrapartum glucose concentrations. Glucose concentrations in most women with
GDM return to near-normal concentrations shortly after delivery, and glucose-lowering
therapies should be discontinued immediately after birth.

3. What is the screening of the patient was right ?

From Fifth International Workshop-Conference on Gestational Diabetes, there are

recommended screening strategy based on risk assessment for detecting gestational diabetes
(GDM). GDM risk assessment should be ascertained at the prenatal visit. The category :

29
 1. Low risk

Blood glucose testing not routinely required if all the following are present :

o Member of ethnic group with a low prevalence of GDM no known diabetes in

first-degree relatives
o Age <25 years
o Weight normal before pregnancy
o Weight normal at birth
o No history of abnormal glucose metabolism
o No history of abnormal glucose metabolism
o No history of poor obstetrical outcome

2. Average risk

Perform blood glucose testing at 24 to 28 weeks using either :

Two-step procedure : 50-g oral glucose challenge test (GCT), followed by a diagnostic
100-g OGTT for those meeting the threshold value in the GCT

One-step procedure : diagnostic 100-g OGTT performed on all subjects

3. High risk

Perform blood glucose testing as soon as feasible, using the procedures described
above, if one or more of these are present:

• Severe obesity
• Strong family of type 2 diabetes
• Previous history of GDM, impaired glucose metabolis, or glucosuria

The screening of the patient was incorrect. From anamnese we got that she screening
at 8 months of pregnancy (30 weeks of pregnancy). The patient is high risk category because
of her history of GDM on previous pregnancy and macrosemia. So this patient should be
screened as soon as feasible (first trimester of pregnancy).

30
4. Whether the management post partum (follow up) of this patient was appropriate ?

Women with a history of GDM are at a greater risk of developing prediabetes or type
2 diabetes, most guidelines recommend screening at 6–12 weeks postpartum using the one-
step approach (2-hour 75-g OGTT). Within 24–72 hours of delivery and before returning to
community care, women should have a glucose assessment (fasting plasma glucose or self-
monitored glucose) to exclude ongoing hyperglycemia. After the initial postpartum screening,
some sources recommend continued use of the 2-hour 75-g OGTT, whereas others, such as the
ADA, indicate that A1C, fasting glucose, or the 2-hour 75-g OGTT may be used. Nonpregnant
thresholds should be used when doing postpartum screening. Screening should be repeated
every 1–3 years and continued life-long. The frequency of screening may depend on other risk
factors for GDM or plans for subsequent pregnancies. Patients with identified glucose
intolerance should be referred for treatment. On this patient, management post partum was
correct, 24-72 hours of delivery, random plasma glucose was checked and no sign of ongoing
hyperglycemia.

Newborn babies of GDM mothers when there has been poor diabetic control in
pregnancy will often struggle with their own blood sugar levels after birth. This is due to the
baby overproducing their own insulin whilst growing in the uterus to help process the excess
sugars passed from the mothers bloodstream. These babies may have high insulin levels
persisting in the first few days after birth which can result in hypoglycaemia as they are no
longer receiving excess sugar from the mothers bloodstream and they may struggle to regulate
their own insulin production to normal levels. From NICE guidelines, recommends preventing
and asseing neonatal hypoglycaemia women with diabetes should feed their babies as soon as
possible after birth (within 30 minutes) and then at frequent intervals (every 2–3 hours) until
feeding maintains pre-feed capillary plasma glucose levels at a minimum of 2.0 mmol/litre. In
this baby, random glucose checked after delivery was 33, and got intravenous dextrose for 24
hours.

5. What is the cause of transverse lie ?

From intraop, found that there is a myom uterine. It can be cause of transverse lie on
this case.

31
 CHAPTER V
SUMMARY

1. the diagnose of this patient was correct, a G3P2A0L1 38-39 weeks of term pregnancy
previous CS + gestasional diabetes. Fetal Alive Singleton Intra Uterine Transverse Lie
Right Head, Dorso Superior. But, from the examination (physical and ultrasound), cannot
found the myom uterine.
2. The management on this case was correct by doing the caesarean section was the best
choice for this patient. The management pre partum was not optimal because no fasting or
OOGT blood glucose check before delivery.
3. The screening of the patient was incorrect. From anamnese we got that she screening at 8
months of pregnancy (30 weeks of pregnancy). The patient is high risk category because
of her history of GDM on previous pregnancy and macrosemia. So this patient should be
screened as soon as feasible (first trimester of pregnancy).
4. The management of post partum in this patient screening at 6–12 weeks postpartum using
the one-step approach (2-hour 75-g OGTT).
5. From intraop, found that there is a myom uterine. It can be cause of transverse lie on this
case.

32
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3. Cunningham. McGraw-Hill Education. Gestational Diabetes. 2014. P: 2376-2388
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