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Supervisor:
dr. Gioseffi Purnawarman, SpOG
By:
Dede Satria Sabarudin (406171004)
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
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
3
table of contents
Chapter I Introduction
a. Background ......................................................................................................... 5
b. Epidemiology................................................. .................................................. ..... 7
Chapter II Discussion
Conclusion ............................................................................................................................. 34
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.
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
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).
9
Pathophysiology DM pragestasi equal to the pathophysiology of diabetes mellitus type 1 or 2.
Hyperglycemia and consequently when perikonsepsi cause organ growth
10
cardiovascular diseases. Likewise, macrosomia babies will be easier developing
diabetes and obesity later. 3
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:
During postpartum:
- puerperal sepsis
- reduced lactation
- Increased morbidity maternal or
Effect on the fetus:
d. diagnosis
Pregnant women
Glucose 50 Gram
OGTT - 3 hours
Normal
100 grams of
glucose
Normal DMG
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.
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%
Pregnant women
Glucose 50 Gram
OGTT - 2hours
Normal
75 grams of glucose
Normal DMG
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.
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.
Insulin therapy:
20
Insulin preparations that can be used is 7,8,9
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.
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
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.
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.
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
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.
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
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.
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
32
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33
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