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C V BOWO PRAMONO
PENDAHULUAN
Pedersen (1954) hiperglikemia pada ibu hamil
menyebabkan makrosomia
Frienkel: asam amino rantai cabang dan asam
lemak bebas meningkatkan sekresi insulin
pada janin
Casson (UK) : DM tipe 1 yang hamil
malformasi janin (10x), lahir mati (5x),
kematian perinatal (3x)
PENDAHULUAN
Intensifikasi insulin pada ibu hamil
menurunkan kejadian malformasi janin
(DCCT) pada 680 wanita hamil dengan DM
Patogenesis hiperglikemia malformasi janin
multifaktorial : defisiensi myoinositol,
defisiensi asam arakhidonat dan peningkatan
radikal bebas
PENDAHULUAN
Komplikasi hiperglikemia pada neonatus :
Hipokalsemia
Hipoglikemia
Hiperbilirubinemia
Makrosomia
Intra uterine growth retardation
Respiratory distress syndrome
Policitemia
Hipertropic cardiomyopati
Tabel 2.
Perencanaan makan
Pemantauan gula darah mandiri
Pengaturan dosis insulin mandiri
Penanganan terhadap hipoglikemia
Aktifitas fisik yang benar
Pengelolaan stres
IMUNOGENESITAS
MITOGENESITAS
MITOGENESITAS
Tidak ada perbedaan yang bermakna antara
insulin lispro, aspart maupun reguler terhadap
kemungkinan menimbulkan retinopati
diabetik, atau memperburuk kondisi retinopati
yang sudah ada
23
glycaemic control,
hypoglycaemia and
safety1
perinatal and obstetric
pregnancy outcomes2
Main inclusion
criteria
Main exclusion
criteria
Treatment with
insulin for 12
months
Planning to
become pregnant
and HbA1c 9.0%
Pregnant with a
singleton
pregnancy of 8
12 gestational
weeks
At confirmation of
pregnancy,
Impaired
hepatic or renal
function
Uncontrolled
hypertension
Use of in vitro
fertilisation or
other medical
infertility
treatment
Previous
randomisation
in this trial
HbA1c 8.0%
1. Mathiesen et al. Diabetes Care 2012;35:20127; 2. Hod et al. J Matern Fetal Neonatal Med
2014;27:713
Main withdrawal
criteria:
Multiple pregnancies
22 further
withdrawals
25 withdrawals
152 pregnancies
160 pregnancies*
145 (91%) pregnancy outcome
7.00
7.00
6.75
6.75
HbA1c (%)
HbA1c (%)
Randomised before
pregnancy
6.50
6.25
6.00
5.75
Insulin detemir
NPH insulin
HbA1c levels
were similar
between
treatments
6.50
6.25
6.00
5.75
0
8 12 16 20 24 28 32 36
GA (weeks)
44
Adapted from1
8 12 16 20 24 28 32 36
GA (weeks)
44
Adapted from1
Insulin
detemir
NPH
insulin
Difference
[95% CI]
6.27
6.33
0.06 [0.21;0.08]
CI, confidence interval; GW, gestational week
7.00
7.00
6.50
6.50
HbA1c (%)
HbA1c (%)
Randomised before
pregnancy
6.00
5.50
5.00
4.50
5.50
5.00
0
8 12 16 20 24 28 32 36
GA (weeks)
Mean FPG,
total pregnant
population
NPH insulin
6.00
4.50
Insulin detemir
Adapted from1
8 12 16 20 24 28 32 36
GA (weeks)
Insulin
detemir
NPH
insulin
95% CI
P-value
At GW 36,
mmol/L
4.8
5.4
1.2;0.1
0.017
At GW 24,
mmol/L
5.4
6.3
1.7;0.2
0.012
Adapted from1
1,6
16 vs. 21%
of patients
11 vs. 19%
of patients
1,2
9 vs. 6%
of patients
0,8
0,4
2,0
0,0
100,0
Insulin detemir
NPH insulin
95 vs. 92%
of patients
80,0
60,0
76 vs. 80%
of patients
40,0
20,0
0,0
Overall
Daytime
Nocturnal
Based
Overall
on1
Daytime Nocturnal
Based on1
Summary (Levemir)
Insulin detemir is non-inferior to NPH insulin for HbA1c at
36 GW when given as a treatment for type 1 diabetes1
FPG was significantly lower in patients receiving insulin
detemir compared with NPH insulin at 24 and 36 GW1
Rates of major hypoglycaemia were low and similar
between groups1
Studies in pregnant women with type 2 diabetes are
ongoing
NovoRapid in Gestational
85. Mathiesen ERet al. Diabetes Care 2007; 30: 771-6. 86. Hod M, et al. Am J Obstet Gynecol 2008; 198 (2): 186.e1186.e7.
87. Pettitt Det al. Diabet Med 2007; 24: 1129-35. 88. Plank J, et al. Arch Intern Med 2005; 165: 1337-44.
NovoRapid in Pregnancy
APPROVED FOR USE IN PREGNANCY based on multicentric
randomized clinical trials
APPROVED BY EMEA (EU)
US FDA Approved: Category B
APPROVED BY BPOM
* p < 0.01
* p < 0.05
(n = 322)
1.5
1.0
NovoRapid
(mean2SEM)
0.5
HI
(mean2SEM)
0
-0.5
-1.0
Visit
VP1*
VP2
VP3
VP4
NovoRapid
HI
2.5
p=0.362
Rate
(episodes/year)
2.0
p=0.096
52% lower risk
1.0
0.5
0
24h
Nocturnal
Daytime
Perinatal Outcomes
NovoRapid
RHI
137
131
343871.5
355572.9
28 (20%)
41 (31%)
46 (34%)
52 (40%)
Summary (Novorapid)
NovoRapid treatment Safe in Mother:
52% lower risk of major nocturnal hypoglycaemia
better glycaemic control
RINGKASAN
TERIMA KASIH