MANAGEMENTOFGESTATIONALDIABETES

MELLI
TUSI
NSUB-DISTRI
CTHOSPITALWITH
LIMI
TEDRESOURCES:ACASEREPORT

I
NTRODUCTI
ON
Indones iaisr ankedoneoft hewor l
dʼstopfivewor s
taf fectednationsf
orpeopl eli
vingwi t
hdi abetesmelli
tus.Globall
y,theprevalenceofdi abetesmell
it
us( DM)was2, 8% in2000,andi t
ises t
imat edt hatt herewillbearound4, 4% in2030.Di abetesmel li
tusinpregnancyorges t
ationaldiabetesmellitus(GDM)i simpor tanthealthproblem,becauseitisassociatedwi t
hani n-
creasedr iskofcompl icat
ionofmot hersandbabi es.Thepr evalenceofGDM i nIndonesi
ais1,9%- 3,6%.InI
ndones ia,thecommonpr obl em ofGDM isoftenunderdiagnosedwhi chleadst oim-
propert r
eatment ,especi
allyinheal thcarefaci
li
tieswit
hl imi t
edr es
ources
.Womenwi thGDM andherbabi esareatgr eaterri
skofcompl icat
ionsduringpregnancyanddel ivery.Therefore,
earlydet ectionofGDM i simpor tant.
Thepr evalenceofGes t
ationalDiabet esMellit
us(GDM)i s1,9%-3,6%.I
nI ndonesi
a,thecommonpr oblem ofGDM i softenunder diagnos edwhichleadstoimpr opertreatment ,es
pecially
inheal thcaref acil
iti
eswithlimitedr esources.Womenwi thGDM andherbabi esareatgreaterri
s kofcompl i
cati
onsdur ingpregnancyanddel iver
y.Theref
ore,earlydetecti
onofGDM i s
impor tant .

Figure1.TheRoutineFollow -UpBloodGlucoseControlofTheGestationalDiabetesMellitusPatient

CASEHI
STORY
A33- year -
oldfemal epatientwi thhert hirdpregnancyand26weekspr egnancywas
diagnos edwi thGDM.Herwei ghtwas78kg,herhei ghtwas160cm,andherBMI
was30, 25kg/ m2.Shegai ned15kgofwei ghtduringhert hirdpr egnancy.Shehas
nopr i
orDM i nherf i
rstors econdpr egnancy.Herf atherdiedbecaus eofmyocar dial Bas
r
alI
api
dI
ns
ns
ul
i
ul
i
n10U &
n4U
i
nf arctionandcompl i
cationofDM t ype2.Herf ast
ingbl oodgl ucose( FBG)was128 Insulin8Uaday BasalI
nsul
in10U &
mg/ dl,andher2hourbl oodgl ucos e(2- HBG)was185mg/ dl.Ul t
ras oundexami na- rapi
dInsul
in4U

ti
onr evealedas i
nglefetuswi th1000gr amsofwei ght .Thepatientr eceivedinstr
uc-
ti
ont ochangeherl if
estyleanddi et.Aweekl ater
,herFBGwas100mg/ dland2- HBG
was145mg/ dl.At28weeks ,herFBG was110mg/ dland2- HBG was167mg/ dl.
Bas alins uli
n( l
antus)wasi nit
iatedi nher28weeks ,admi nis
ter ed8U aday.At30
weeks ,herbl oodglucosewasuncont rolled,herFBGwas155mg/ dland2- HBGwas
206mg/ dl.Bas ali
nsuli
nwasadmi nist
er ed10Uandr apidactingi nsulin(li
spro)4U
bef oremeal .At32weeks ,herFBGwas105mg. dland2- HBGwas154mg/ dl,andthe
wei ghtoff etuswas2000gr ams .

Table1.ComparisonforDiagnosticThresholdforGestationalDiabetesMellitus(GDM)
CASEMANAGEMENT
Thispatientwasdi agnos edwi t
hGDM,bas edonPERKENI ,wi t
h2- HBG was
185 g/dland FBG was128 mg/ dl.Atfirst
,t hi
spat ientwass uggested t
o
changeherdi etandlif
estyl
ef oroneweekt oc ontrolherbloodglucose.Two
weekslat er,herFBG was110mg/ dland2- HBG was167mg/ dlands hewas
administeredbybas alins
ulin8Uperday .At30weeks ,herbloodglucosewas
uncontrolled,herFBGwas155mg/ dland2- HBGwas206mg/ dl
.Basalins
uli
n
wasadmi nist
ered10Uandr apidac t
inginsulin(l
ispro)4Ubef oremeal.At32
weeks,herFBG was105mg. dland2- HBG was154mg/ dl
.Thispatientwas
suggestedwi throutinefoll
owedupt ocont rolherbloodgluc os
e.

DI
SCUSSI
ON Notes:

Diagnos ticc riteri

af orGDM havec hangedovert hedec adesac cordi ngt os ever al
ADA=Amer icanDiabetesAs
soc
iati
on;ACOG=Amer i
canCongr
essofObs t
etr
ici
ansandGynecol
ogist
s;IADPSG=
Int
ernat
ionalAssoc
iati
onoftheDiabet
esandPr
egnancySt
udyGroups;PERKENI=PerkumpulanEndokri
nologiI
n-
studiesaboutr is
kofadver sepr egnanc yout comesi n women wi t
h hyper gl ycemi a. donesi
a;WHO =Wor ldHealt
hOrganiz
ati
on.

Wor ldHeal thOr ganization( WHO)hasc hangedt hec riteriat hreet imess inc e1999. Figur
e2.Algor
ithm f
orTher
apyi
nGes
tat
ionalDi
abet
esMel
li
tus
Thehyper glycemi aand adver sepr egnanc yout comess tudy( HAPO)demons trated (GDM) ,bas
edonPERKENI
thatt her iskofadver semat er nal,f etal,andneonat alout c omesc ont inuous lyi ncreas e
asaf unc t i
onofmat ernalgl ycemi aat24−28weeks ,evenwi thinr angespr evious ly
cons i
der ed nor malf orpr egnanc y.Af terr eviewi ng t her es ultsoft heHAPO s t
udy ,
manyi nt ernat ionaldi abet ess tudygr oups ,includi ngt heI nt ernat ionalAs soc i
at i
onof
Diabet esandPr egnanc ySt udyGr oupsandADAhaveadopt edt he75gor algl ucos e
toleranc et es t(OGTT)at24−28weeksasas creeni nganddi agnos t
ict estanddef ined
new c ut -offval uesf orGDM di agnos is.Bas edonPERKENIi n2014,c r i
ter iaofGDM i s
if2-HBGi s7. 8( 140)orges tationalwomenwi t
hi mpai redgl uc os etoler anc e.Theear ly
detec ti
onofGDM i simpor tantt opr eventc ompl icationandadver sepr egnanc yout -
comes .PERKENIs ugges t
st odos c reeni ngt estsi nal lpregnantwomenat26- 28weeks
ofges tat ioni ft hef i
rsteval uat ioni snor mal .
Int hisc as e,GDM wasdi agnos edat26weekswi thFBG was128mg/ dl ,andher
2-HBGwas185mg/ dl.Thispat ientwass ugges tedt oc hangeherl i
festyl eanddi et,be-
causeal lwomenwi thGDM s houl dr ec ei
venut r i
tionalc ouns elingandt her apyt oac -
compl i
s ht heirbl oodgl uc os egoal ,es pec iallywomenwi thover wei ghtorobes ity.Two
weeksl ater ,
s her eceivedi ns ulinbec aus eherbl oodgl uc osewasnotc ont rol l
ed. I
ns uli
n
isthef i
rs trec ommendat iont herapyf orGDM bec aus eor aldi abet ict her apyagenti s
notr ec ommended.Or aldi abet ict her apyhass omeadver seef fectstof etusbec aus eit CONCL
USI
ON
canpenet ratet obl oodpl ac entalbar rier. Theearl
ydetec t
ionofGes tati
onalDiabetesMel li
tus(GDM)i simportanttoprevent
Themos ti mpor t
antt hi ngi nGDM i srout ine- follow up,anddoc torandpat i
ent thecompli
cationoradver s
emat ernal,f
etal,andneonat aloutcomeswhi chisrel
ated
needt owor kt oget hert or eac ht hebl oodgl ucos egoal .Int hisc ase,thec ompl ianc eof tohyper
glycaemi a.Althoughi nhealt
hcaref aci
li
tieswithlimi
tedresources,t
heGDM
patienti sgr eat ,shef oll
owst hei ns truc ti
onf rom i nter nistandherobs tetrician.The canbeproperlytreatedi ftheobstet
rici
an,t heinterni
st,andthepatientwork
fetalwei ghtwasopt i
mal ,wasnots howi ngt hes ignofmac r osomi a. toget
hertocont r
olbl oodgl ucos
e.

DI
SCL
OSURE
Thisc
asereportwaswr i
ttenindependent ly;nocompanyori ns
tit
uti
onsupport
editfi
-
nanci
all
y.Authorsdecl
arednoi nherentc onfl
ict
sofinter
est.
REFERENCES FUNDI NGS
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cCr i
ter
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ereportrecei
vednos pecifi
cgr antfrom anyfundingagencyori
nst
itut
ioni
n
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