CRITICAL APPRAISAL
“Perbandingan Skrining Tes Toleransi Glukosa Oral dengan Puasa dan Tanpa Puasa pada
Diabetes Melitus Gestasional”
Disusun Oleh:
KELOMPOK B-11
Dosen Pembimbing:
NPM : (110-2014-213)
Skenario
Ibu, 25 tahun G1P0A0 hamil 24 bulan mengeluh merasa sering lemas, mudah lelah. Terkadang
juga disertai kesemutan. Dalam 2 minggu ini penglihatan kabur. Didapatkan kenaikan berat
badan dari 60 kg menjadi 68 kg dalam 1 bulan. Tekanan darah 130/80 mm Hg, nadi 78x/menit,
pernapasan 22x/menit. GDS 140 mg/dl. Karena tidak ada gejala klasik dan GDS 140 mg/dl
dokter mengarahkan untuk melakukan pemeriksaan lebih lanjut yaitu tes toleransi glukosa oral
(TTGO) Lalu, ibu tersebut menanyakan apakah boleh jika tidak berpuasa sebelum tes karena ibu
tersebut beralasan tidak mau berpuasa pada saat hamil.
Apakah TTGO dengan berpuasa lebih baik dalam menskrining diabetes mellitus gestasional
dibandingkan TTGO dengan tidak berpuasa?
PICO
Type of Question :
Diagnosis
Type of Study :
Cross-sectional study
Kata Kunci :
Gestational diabetes mellitus AND oral glucose tolerance test AND fasting AND non fasting
Pemilihan Situs : http://www.ncbi.nlm.nih.gov/pubmed/
Limitasi: 5 tahun
Hasil Pencarian : 2
”Comparison of screening for gestasional diabetes mellitus by oral glucose tolerance tests done
in the non-fasting (random) and fasting states.”
Pendahuluan
There is no consensus regarding optimal standard for diagnosis of gestational diabetes mellitus
(GDM). In this study, use of 75 g glucose load in non-fasting state [Diabetes in Pregnancy Study
Group of India (DIPSI) criteria] as a diagnostic test for GDM in pregnant women was compared
with different oral glucose tolerance tests (OGTTs).
Metoda
This prospective study included 936 pregnant women, who underwent plasma glucose evaluation
two hours after the challenge of 75 g glucose load irrespective of the timing of last meal (DIPSI
criteria for GDM). After three days, standard 75 g OGTT was done in all women irrespective of
previous plasma glucose value. Accuracy of the first result was compared to OGTT using cut-
offs as per the World Health Organization (WHO) and International Association of Diabetes and
Pregnancy Study Groups (IADPSG) criteria for the diagnosis of GDM.
Hasil
Of the total 936 pregnant women, 73 (7.8%) patients had plasma glucose value ≥140 mg/dl when
measured two hours after glucose load. When comparing with the WHO and IADPSG criteria,
the sensitivity values were 65.1 and 74.1 per cent, respectively, and the corresponding specificity
values were 96.3 and 96.9 per cent, respectively. On comparing with the WHO OGTT, only 41
of the 73 (56.2%) were true positives, whereas when IADPSG criteria were used, true positives
were 46 (63%). False negative cases were also present when classified by the WHO and
IADPSG criteria though in lesser numbers than false positives. The positive predictive values
(PPVs) for the WHO and IADPSG criteria were 56.1 and 63 per cent, respectively, and their
corresponding negative predictive values were 97.7 and 97.9 per cent, respectively.
Kesimpulan
Our findings showed that when 75 g glucose load in non-fasting state was used as a diagnostic
test for GDM, almost one quarter of patients with GDM escaped diagnosis as sensitivity values
were low. On the other hand, some GDM cases were falsely labelled as normal as this test did
not account for cases of fasting hyperglycaemia. In addition, comparison with other OGTTs
showed low PPVs. Hence, use of DIPSI criteria for diagnosing GDM must be reconsidered till
further validation.
I. APAKAH HASIL DALAM ARTIKEL INI VALID?
A. Petunjuk Primer
1. Adakah perbandingan yang dilakukan secara independent dan blind terhadap suatu
standar rujukan?
Ada, dilakukan secara independent dan blind.
2. Apakah sampel pasien mencakup seluruh spektrum yang sesuai dengan setting praktek
klinis dimana uji diagnostik tersebut akan diaplikasikan?
Ya, sampel pasien mencakup seluruh spectrum yang sesuai.
B. Petunjuk sekunder
1. Apakah hasil tes yang sedang dievaluasi mempengaruhi keputusan untuk menjalankan
standar rujukan?
Ya. Awalnya diIndia menggunakan OGTT tanpa puasa sesuai dengan DIPSI (Diabetes in
Pregnancy India) dan menjadi Guidelines oleh Menteri Kesehatan dan Kesejahteraan
Keluarga. Namun ADA (American Diabetes Assocoation) merekomendasikan WHO
OGTT dan IADPSG OGTT untuk mendiagnosis Diabetes Melitus Gestasional.
Setelah dilakukan penelitian dibandingkan DIPSI dengan WHO dan DIPSI dengan
IADPSG didapatkan hasil non-fasting DIPSI test mempunyai sensitifitas dan PPV yang
rendah.
2. Apakah metoda untuk melaksanakan tes tersebut dideskripsikan cukup rinci untuk dapat
dilakukan replikasi?
Ya, metoda dilakukan cukup rinci dan dapat direplikasi.
a 41
Sensitivitas = = =0,56 X 100 %=56 %
a+c 41+32
d 841
Spesifisitas = = =0,97 X 100 %=97 %
b+d 22+841
a
a+ c 0,56
LR positif = = =18,67
b 1−(0,97)
b+ d
c
a+ c 1−(0,56)
LR negatif = = =0,45
d 0,97
b+ d
a 41
Positive Predictive Value (PPV) = = =0,65 X 100%= 65%
a+b 41+ 22
d 841
Negative Predictive Value (NPV) = = =0,96 X 100%=96%
c+ d 32+841
a+c 41+ 32
Pretest Probablity (PP) = = =0,07 X 100=7%
a+b+ c+ d 41+ 22+ 32+ 841
b) IADPSG OGTT
a 46
Sensitivitas = = =0,63 X 100 %=63 %
a+c 46+ 27
d 845
Spesifisitas = = =0,98 X 100 %=98 %
b+d 18+845
a
a+ c 0,63
LR positif = = =31,5
b 1−(0,98)
b+ d
c
a+ c 1−(0,63)
LR negatif = = =0,37
d 0,98
b+ d
a 46
Positive Predictive Value (PPV) = = =0,71 X 100%=71%
a+b 46+18
d 845
Negative Predictive Value (NPV) = = =0,89 X 100 %=89 %
c+ d 27+ 845
a+c 46+27 11
Pretest Probablity (PP) = = = =0,07X100%=7%
a+b+ c+ d 46+18+27+ 845 106