Diabetes Mellitus

Gestasional
BISUK PARNINGOTAN SEDLI

ENDOCRINE METABOLIC & DIABETES DIVISION

INTERNAL MEDICINE DEPARTMENT
PROF. DR. R.D. KANDOU GENERAL HOSPITAL
MEDICAL FACULTY OF SAM RATULANGI UNIVERSITY
 INTRODUCTION

Gestational diabetes Any degree of dysglycaemia that occurs for the

mellitus (GDM) first time or is first detected during pregnancy

● The most common medical disorders of pregnancy

● Affecting up to 18% of all pregnancies
● Parallel to the rise in obesity and type 2 diabetes
● Overall population attributable factor of overweight/obesity to GDM is
46.4%  ~50% of GDM cases are potentially preventable
In 2014, the estimated number of obese or overweight pregnant women was
nearly 40 million

Lee KW, et al (2018); Mahajan A, et al (2019)

 DM DEFINITION
Gestasiona
l
(DMG)
GDM is defined as
● Diabetes that is diagnosed during the 2nd or
Definition
3rd trimester of pregnancy and that is not
Any glucose clearly pregestational
intolerance with
the onset or first Pregestational diabetes
recognition during ● Exists before pregnancy and can be either
pregnancy type 1 or type 2

Lewis H, et al (2018); Akhalya K (2019)

 EPIDEMIOLOG
Y
GDM affects 9–25% of
pregnancies worldwide
The rates of GDM
fluctuates depending on
study populations and
diagnostic criteria

In Indonesia: • >150,000 cases of DMG

• Prevalence of DMG: 1.9-3.6% cases
• Newborn macrosomia due to DMG (BW > 4000 g): 6,4% cases

Alejandro EU, et al (2020); McIntyre HD, et al (2019); Venugopal S, Joewono HT, and Lestari P (2018)
 ETIOLOGY AND RISK
Modifiable factors FACTORS
Non-modifiable factors
• High pre-pregnant BMI (≥ 25kg m2) • Advanced maternal age
• Poor dietary quality • Personal history of GDM or
• Sedentary lifestyle prediabetes
• Vitamin D deficiency • Family history of diabetes
• PCOS • Ethnicity (Asian, Hispanic, Native
American and African American)
• High total bile acid in the first trimester
• Maternal history of low birth weight
• Metabolic syndrome
• Low stature
• Preeclampsia
• Twin pregnancy
• Cigarette smoking
• Genetic susceptibility
• Socioeconomic and Geographic Risk
Factors

Alejandro EU, et al (2020); Chiefari E, Arcidiacono B, Foti D, and Brunetti A (2017); McIntyre HD, et al (2019); Venugopal S, Joewono HT, and Lestari P (2018)
 PATOPHYSIOLOGY

Chiefari E, Arcidiacono B, Foti D, and Brunetti A (2017)

 PATOPHYSIOLOGY

Insulin requirements
physiologically increase Pancreatic β-cell mass
during pregnancy ↑

Failure of the β-cell

expansion + ↑
inadequate rise in
Insulin needs ↑ : insulin secretion
Retailers
• ↑ maternal caloric intake
• ↑ maternal weight
• Presence of the placental
hormones (placental GH,
placental lactogen)
DMG
• ↑ prolactin and GH
production

Lende M and Rijhsinghani A (2020)

PATOPHYSIOLOGY

Changes in insulin sensitivity during

pregnancy in normoglycaemic women and
women with GDM

Insulin sensitivity–secretion
relationships in
normoglycaemic women and
women with GDM

McIntyre HD, et al (2019)

 PATOPHYSIOLOGY

Organs involved in the pathophysiology of GDM

Plows J (2018)
 SCREENING
Guideline Recommendations for
Early Pregnancy Diabetes
Mellitus Screening Population

Johns, et al (2018)
Johns, et al (2018)
 SCREENING
Low risk when all of the following criteria :
• Including ethnic groups with a low prevalence of DMG
•
Diagnostic test recommendation
History of DM in first degree relatives (-)
• Age < 25 years old (OGTT):
• Normal weight before birth not required
• History of impaired glucose metabolism (-)
• Bad obstetric history (-)

Medium risk: Recommended diagnostic test

Not included in the low or high risk group (OGTT): performed at 24-28
weeks gestation
High risk if meets two or more of the following
criteria:
• Obesity Performed at the first pregnancy
• History of DM in first degree relatives (+) examination or as soon as
• History of impaired glucose tolerance (+) possible thereafter. If the results
• History of giving birth to a macrosomic baby (+) are normal, it will be repeated at
• Ethnic groups with high prevalence (Hispanic,
American, Native American, Asian American, African
24-28 weeks of gestation
American, Pasific Islander, Asian and South Asian
PB Perkeni (2021).
 First visit for pregnancy check-up
SCREENIN
G - Evaluation of risk factors
- RBG Check

Moderate risk and • Moderate risk, RBG 140 -199 mg/dL RBG ≥ 200 mg/dL,
RBG < 140 mg/dL • High risk, RBG ≤ 199 mg/dL regardless of risk factors

Check RBG Immediately prepare for The process of diagnosing

Education
every pregnancy the DMG diagnosis type 2 DM
healthy life in check, at least
pregnancy 1x/month
Determine the most optimal Not type 2
accessible OGTT procedure
Type 2 DM
< 140 mg/dL ≥ 140 mg/dL
DM

• The selection of the OGTT method is adjusted to the

Refer to interna
optimal conditions that can be reached. Consider the
medicine or
patient's carrying capacity and available health
endocrinologist for
facilities.
management as DMH
• Perform DMG diagnostic OGTT, in the same week
• If there is a risk that the patient is difficult to reach
again, then the OGTT is carried out immediately after
screening
 DIAGNOSIS

Age Pregnancy Fasting Blood Glucose Level (mg/dL)

< 92 92-125 ≥ 126

< 24 weeks Continue OGTT Continue OGTT The OGTT was not
with a solution of with a solution of continued, but
75 g glucose 75 g glucose continued to the
≥ 24 weeks Continue OGTT OGTT does not diagnostic pathway
with a solution of need to be for type 2 DM
75 g glucose continued. The
diagnosis of DMG
can be made

PB Perkeni (2021).
Standard OGTT OGTT examination of venous blood glucose with fasting
The diagnostic value of GDM is:
FBG ≥ 92 mg/dL ; or
I hour BG ≥ 180 mg/dL ; or
2 hour BG ≥ 153 mg/dL

1st Alternative: If a venous blood glucose test cannot be performed, a capillary blood glucose test is
performed.
Fasting capillary blood glucose OGTT examination, the diagnostic value of GDM is:
FBG ≥ 95 mg/dL ; or
I hour BG ≥ 191 mg/dL ; or
2 hour BG ≥ 162 mg/dL
2nd Alternative: If the patient is unable to fast, then the 75 gram glucose solution is still administered
without fasting.
OGTT examination without fasting, the diagnostic value of GDM is:
Using venous blood: I hour BG ≥ 180 mg/dL ; or
2 hour BG ≥ 153 mg/dL

Using capillary blood: I hour BG ≥ 191 mg/dL ; or

2 hour BG ≥ 162 mg/dL
The diagnosis of gestational diabetes mellitus (GDM) can be made if:

Gestational age:
≥ 24 weeks: there is at least 1 DMG diagnostic value on the OGTT performed
< 24 weeks: there is at least 2 DMG diagnostic value on the OGTT performed
 THERAPY

● Medical Nutrition & Physical Activity is 1st line

therapy
● 1st line therapy must be achieved in 2-4 weeks
● Pharmacological Therapy if target unmet using
Insulin and/or Metformin
NUTRITION
Contoh diet wanita hamil dengan DM
Physical Activity
 COMPLICATIONS

McIntyre, et al (2019); Szmuilowicz, E.D., Josefson, J.L., and Metzger, B.E. (2019)
 CONCLUSION

• Gestational diabetes mellitus (GDM) is not only associated with adverse

effects on pregnancy, but also associated with adverse long term health
effects on mother and child.
• Women with GDM are at increased risk of developing pre-eclampsia and an
increased need for cesarean section.
• Required identification and screening of women at risk of GDM allows early
health monitoring and intervention.
Thank you