3/21/2016

Purnamasari

Journal of the ASEAN Federation of Endocrine Societies,Vol 28, No 1 (2013)

DOI:http://dx.doi.org/10.15605/jafes.028.01.02

IndonesianClinicalPracticeGuidelinesforDiabetesinPregnancy
DyahPurnamasari,1SarwonoWaspadji,1JohnMFAdam,2AhmadRudijanto,3DickyTahapary 1
onbehalfoftheIndonesianSocietyofEndocrinology(ISE)
1DivisionofEndocinologyandMetabolism,DepartmentofInternalMedicine,FacultyofMedicine,Universityof

Indonesia,CiptoMangunkusumoHospital,Jakarta,Indonesia
2DepartmentofInternalMedicine,JauryJusufPuteraHospital,Makasar,Indonesia
3DepartmentofInternalMedicine,FacultyofMedicine,BrawijayaUniversity,Malang,Indonesia

Corresponding Author
DyahPurnamasari,MD
Division of Endocrinology and Metabolism, Department of Internal Medicine, Faculty of Medicine
UniversityofIndonesia,CiptoMangunkusumoNationalHospital,JalanSalemba6,CentralJakarta,
DKIJakarta,Indonesia
Tel.No.:.+62213100075,+62213907703
FaxNo.:+62213928658,+62213928659
Email:dyah_p_irawan@yahoo.com
eISSN2308118x
PrintedinthePhilippines
Copyright2014bytheJAFES
ReceivedApril25,2013.AcceptedMay17,2013.

Abstract
DiabetesMellitus(DM)inpregnancyhasseriousimpactonbothmotherandbabyifnotoptimally
managed. The Indonesian Task Force on Reproductive Diseases determined that diabetes in
pregnancyrepresentsapriorityareainneedofupdatedevidencebasedpracticeguidelines.Theaim
of the guidelines is to provide the best evidencebased recommendations for diagnostic evaluation
andmanagementofdiabetesinpregnancy.Thefollowingarticlesummarizestheguidelines.
Keywords:diabetes,pregnancy,clinicalpracticeguidelines,Indonesia

INTRODUCTION
InIndonesia,theprevalenceofGDM(accordingtoOSullivansdiagnosticcriteria)was1.9to3.6%.
In a cohort study, as many as 4060 % of this group will progress to type 2 diabetes (T2DM) or
impaired glucose tolerance (IGT). In one prospective study in Makassar among 46 women with
GDM, the incidence of T2DM and impaired glucose tolerance (IGT) after 6 years of delivery were
56.6%.1Consideringtheseriousmorbidityandmortalityforbothmotherandbaby,thereshouldbe
aneffectivescreeningmethodforpregnantwomenwhowerenotpreviouslyknowntohaveDM.
TheIndonesianClinicalPracticeGuidelinesforDiabetesinPregnancyisaprojectoftheIndonesian
TaskForceonReproductiveDiseases,whichisacollaborationofIndonesianendocrinologistscaring
for pregnant women with diabetes. The objective of this project is to develop clinical practice
guidelinesonthescreening,diagnosisandmanagementofdiabetesinpregnancywhichreflectthe
current best evidence on optimal medical practice and incorporate local data into the
recommendations. It is not the intention of these guidelines to replace clinical judgment and
individualdecisionmaking.Eachrecommendationshouldbeevaluatedinlightoftheseelementsin
ordertodeliveringoptimalpatientcare.

Summary of the Methods for Guidelines Development

The guidelines were developed by the Indonesian Task Force on Reproductive Diseases. The Task
Force reviewed available literatures on diabetes in pregnancy. The Task Force was able to obtain
valuablefeedbackandsuggestionstoincludeadditionalevidencefromtheliteratureandtoconsider
alternative interpretation of data. The participants contributed to and influenced the form of the
final guidelines, making it a comprehensive report from various geographical origins and medical
disciplines.

SummaryofRecommendations
Definitions
Ingeneral,diabetesinpregnancycanbedividedintotwogroups:1)DMwhohadbeenpreviously
known and subsequently became pregnant (Pregestational Diabetes Mellitus) and 2) Newly
identifieddiabetesduringpregnancy(GestationalDiabetesMellitus/GDM).2

Epidemiology
GDMprevalencevariesineachregiondependingtothediagnosticandexaminationstandardsused,
but in general it is reported that GDM occurs in 35 % of normalpregnancies.3 Ethnicity was an
independentfactoraffectingtheincidenceofGDM.AlthoughAsianwomensBodyMassIndex(BMI)
isloweringeneral,theyaremoresusceptibletoGDMthantheirCaucasiancounterparts.4

Clinical signs and symptoms

Thesignsandsymptomsofdiabetesinpregnancyarenotspecific.5,6

Screening and diagnosis of diabetes in pregnancy

Pregestational diabetes

http://aseanendocrinejournal.org/index.php/JAFES/rt/printerFriendly/44/467

1/5

3/21/2016

Pregestational diabetes

Purnamasari

Forpregnantwomenwhohavebeendiagnosedwithdiabetesbeforepregnancy,itisnotnecessary
todoscreeningtests.6

Gestational diabetes
TheIndonesianSocietyofEndocrinology(PERKENI)suggeststodoscreeningtestsinallpregnant
womenatbaselineandreevaluateat2628weeksofgestationifthefirstevaluationisnormal.If
thescreeningisonlyperformedamonghighriskgroups,thenaround31%ofpregnantwomenwith
GDMwouldhavebeenmissed.1,2
PERKENIusestheWHOOGTTmethod(oralglucosetolerancetestusing75gofanhydrousglucose)
for measuring fasting plasma glucose and subsequent blood glucose concentration 2 hours after
glucoseadministration,toestablishdysglycemia(DMandIGT).TheimplementationoftheOGTTis
notdifferentfromtheOGTTforthegeneralpopulation(asstatedinPERKENIDMConsensus2011),
asfollows:7
Three days before the examination, no change in diet (with enough carbohydrates) and and in
theirusualnormalphysicalactivities.
Fastingforatleasteighthours(startingatnight)beforethetest,plainwaterisstillallowed
Samplingforfastingbloodglucoseconcentration
Drink75gramsofanhydrousglucosein250mLwaterwithin5minutes.
Fastingforthenexttwohours
Examinebloodglucoseconcentrationtwohoursafterglucoseload
Duringtheexamination,subjectshouldremainseatedandnotallowedtosmoke
TheresultsofOralGlucoseToleranceTestisdividedintothree:7
2hourbloodglucose<140mg/dL>>normal
2hourbloodglucose140199mg/dL>>impairedglucosetolerance
2hourbloodglucose200mg/dL>>DM
Particularlyforpregnantwomen,impairedglucosetolerancegroupshouldbemanagedasDM.

Waspadjiconductedastudytodeterminemeanbloodglucoseconcentrationsinnormalpregnancy.
NormalmaternalglycoHbconcentrationdoesnotchangesignificantlyovergestationalage,although
thereisatendencyforittodecreasewithgestationalage(Waspadjietal.)Meanconcentrationof
fastingglucoseamongnormalpregnantwomenissignificantlylower,whilemeanconcentrationof
2hour post meal glucose is significantly higher during the 3rd trimester of pregnancy, in
comparisontononpregnantwomen.8
Based on that study, the blood glucose target in pregnancy should be lower that that of non
pregnantwomen.
ClickheretodownloadTable1
Table1.Meanbloodglucoseconcentrationsofnormalpregnantwomen 8

Ultrasonography (USG)
USGshouldbeperfomedinordertodeterminethegrowthofthefetus.BasedonUSGresult,the
obstretician and endocrinologist can evaluate the treatment impact to the mother and baby and
afterthat,theycanadjustthenexttreatmentplan,particularlythebloodglucosetarget.9

Management
Management of diabetes in pregnancy should be implemented as an integrated approach by a
specialistininternalmedicine,obstetricsgynecology,nutritionistsandpediatricians.Thepurposeof
managementistoreducebothmaternalandperinatalmorbidityandmortality.Themanagementof
diabetesinpregnancyincludemealplanningandphysicalactivity,educationandinsulintherapyif
themealplanningcannotachievethetargettedbloodglucosecontrol.1,2,3

Pregestational diabetes
Among pregestational diabetes, there is no recommendation for continuing the oral hypoglycemic
agent. In pregnant women with T2DM previously controlled withdiet,bloodglucosemonitoringis
necessarytodetectifdietplanningisnolongeradequatetocontrolbloodglucose,thereafterinsulin
therapy is needed. While in pregnant women with T2DM controlled with oral hypoglycemic drugs,
the treatment regimen should be changed from oral hypoglygemic drugs to insulin. Those who
already receive insulin therapy will require insulin dose adjustment, especially after the second
trimesteronwardsconsideringincreasingincidenceofinsulinresistanceintheperiod.4

Gestational diabetes
Ingeneral,themanagementofGDMissimilartothemanagementofDM,exceptfortheuseoforal
hypoglycemic drugs. Until now, the use of oral hypoglycemic drugs in gestational diabetes is not
recommended.1,5,6,10,11Someexpertsdonotabsolutelyprohibittheuseoforalhypoglycemicdrugs
onGDMforremoteareaswithlessfacilitiesandnoinsulinavailable.6,12

Target control of diabetes in pregnancy

Target glycemic control in pregnant women with diabetes are in accordance with Gestational
DiabetesMellitusConsensusfromPERKENI,whichare:1

http://aseanendocrinejournal.org/index.php/JAFES/rt/printerFriendly/44/467

2/5

3/21/2016

Purnamasari

Fastingbloodglucose:95mg/dL
2hourspostprandialbloodglucose:120mg/dL
TheuseofHbA1cformonitoringandcontroltargetsisnotrecommendedgiventheweaknessofthe
relationship between HbA1c with risk of macrosomia incidence and negative impact on other
pregnancy.5,6 However, examination of HbA1c during the first trimester of pregnancy may predict
theIGTandDMinthenexttwotrimesters.13
Incidence of macrosomia can be prevented by performing ultrasonography (USG) periodically to
assess the fetal abdominal circumference. The combination of maternal glycemic control and the
results of an ultrasound examination can guide clinicians in monitoring and determining the
mother'sbloodglucosetargets.Forexample,iftheresultsofthefetalabdominalcircumferenceisin
thenormalrangethenitisnotnecessarytodostrictmonitoring.Conversely,ifthefetalabdominal
circumferenceisbeyondthenormallimitthentheglucosetargetshouldbelower.6,9
a.MedicalNutritionTherapyandPhysicalActivity
The goal is to achieve normoglycemia and ensure the growth and optimal fetal development.1 In
normal pregnancy, the expected weight gain during pregnancy varies, which is influenced by pre
pregnancy weight. The Institute of Medicine recommends weight gain of around 7 kg in obese
women(BMI30kg/m2)andweightgainofupto18kginwomenwhowereunderweight(BMI
<18.5kg/m2)beforepregnancy.Theweightgainrecommendationsduringpregnancybasedonpre
pregnancyBMIare:3,14

A study by Mangunkusumo on 26 women with GDM reported that in all of the women, blood
glucoseconcentrationcanbecontrolledwithmealplanning.Thisshowstheroleofmealplanningis
veryimportantinthecontrolofbloodglucose.15
Pregnant women with GDM should receive nutritional counseling. In general, the calculation of
caloricrequirementsforpregnantwomenwithdiabeteswereasfollows:16,17
3540kcal/kgdesirablebodyweightforunderweight
3034kcal/kgfornormalweight
2325kcal/kgforoverweightsubjects
Forobesewomen(BMI>30kg/m2),a3033%calorierestriction(to25kcal/kgactualweightper
day) has been shown to reduce hyperglycemia and plasma triglycerides with no increase in
ketonuria.
Composition settings and allocation of meal portion has no difference with nonpregnant diabetic,
withproteinintake11,5gram/kgBW.1
ItisrecommendedthatallwomenwithGDMdophysicalactivityfor30minutesaday.Walkingand
arm exercise when seated for 10 minutes after each meal will be quite helpful. The American
Diabetes Association recommends starting or continuing a program of moderate exercise without
medical or obstetrical contraindications (vaginal bleeding, faintness, decreased fetal activity,
generalized edema, low back paint). Recommended forms of exercise include walking, stationary
bicycling,lowimpactaerobics,andswimming1,18
ClickheretodownloadFigure1
Figure1.AlgorithmofTherapyinGDM

b.OralHypoglycemicDrugTherapy
Studies that previously have been done still have pros and cons to the use of oral hypoglycemic
drugsinpregnancy.Sofar,glibenclamideandmetforminhavebeenstudiedseveraltimesfortheir
useinpregnancy.Considerationoftheuseoforalhypoglycemicdrugsiswhetherthedrugpasses
throughtheplacentalbarrierandifso,whetheritwillcauseadverseeffectonthefetus.1923
A study from the Department of Obstetrics and Gynecology, Faculty of Medicine, University of
Indonesia,reportedtheeffectsofmetformincomparedtodietinpregnantwomenwithgestational
age2430weeksdiagnosedwithGDM.GDMcharacteristicsofthestudyarelikelyolderage(>31
years),multiparous,obese,haveaclosefamilyhistoryofDM,hasahistoryofGDMandhistoryof
previousmacrosomicbaby.Theuseofmetformincomparedwithstandardtherapy,dietaryplanning
infirst2weeks,hasnosignificantdifferenceincontrollingbloodglucoseinthe2nd,4thand6th
weeks.Themostcommonfetalcomplication is hypoglycemia (31.7 %) in addition to macrosomia

http://aseanendocrinejournal.org/index.php/JAFES/rt/printerFriendly/44/467

3/5

3/21/2016

Purnamasari
24

(26.8%)andlargeforgestationalage.

Sofartherehasbeennorecommendationontheuseofmetforminandglibenclamideinpregnancy.
The evidence is limited and we still need further research and monitoring to detect possible long
termsideeffectsinbabies.
c.InsulinTherapy
So far, human insulins are the safest insulin among pregnant women with diabetes who cannot
achievebloodglucosecontrolbymealplanning.Theuseofinsulinanaloguesisstillcontroversialand
no study had recommended the use of insulin analogues in pregnancy. Consideration for not
recommending insulin analogues in pregnancy includes its amino acid structure that is different
from human insulin. The difference in the structure of this amino acid resulted in a difference of
affinitybetweeninsulinanaloguesandhumaninsulintotheinsulinreceptorandIGF1receptors.
Given the concept that HPL (whose concentration peaks in the third trimester of pregnancy) is
throughIGF1receptor,thestrongaffinitybetweeninsulinanaloguesandIGF1receptorisfeared
todisruptthehormonesandoutcomeofpregnancy.25
AccordingtoGDMconsensus,characteristicsandfastingbloodglucose2hourspostprandialcanbe
aguideintheselectionofinsulinregimen,whichcanbeseeninTable5below:1
ClickheretodownloadTable5
Table5.Routeofadministrationofinsulinbytheglucoseconcentration 7

Monitoring in women with gestational diabetes after delivery

After delivery monitoring covers all aspects related to the risk of incident diabetes and other
metabolicabnormalitiesassociatedwithinsulinresistance.Duringthisperiod,thephysicianshould
considerseveralfactors:1)impairedglucosemetabolismandriskofcardiovasculardisease(CVD),2)
the process of breastfeeding, 3) appropriate use of contraception, and 4) type 2 diabetes
prevention.6
Examination of blood glucose should be routinely performed before women leave the hospital as
earlymonitoring.Examinationoffastingbloodglucose126mg/dLorbloodglucose2hourspost
prandial200mg/dLconfirmthediagnosisofDM.Iftheresultisnormal,subsequentmonitoring
canbedoneatcontrol (approximately 612 weeks postpartum or postparturition) by performing
anoralglucosetolerancetest.Consideringthatthephysiologicalconditions of insulin resistance is
expectedtohavefullyrecoveredoneyearaftergivingbirth,thenthisperiodisalsorecommended
formonitoring.Iftheresultsremainnormal,subsequentmonitoringcanbecarriedouteverythree
yearsbydoingOGTT.Inthehighriskgroup,monitoringcanbedonemorefrequently.6,10
GDM women who have given birth are still advised to undergo dietary planning with or without
drugs to maintain optimal glycemic control and adequate nutrition status in order to continue
breastfeeding their babies. Human insulin, glibenclamide and glipizide are safe for breastfeeding.
Studiesofmetforminuseinlactatingwomenislimited.Metforminisalsoexcretedviahumanbreast
milk, but did not result in a negative impact on the baby. However, they require large studies to
provethesafetyofmetformininbreastfeedingwomen.6

Prognosis
Diabetesinpregnancywhichisnotoptimallymanagedwillcausemorbidityinmothersandbabies.
Short term effects on the fetus are risk of macrosomia, congenital anomalies or low birth
weight.1,5,6,10,11,32 Incidence of macrosomia in GDM with poor glycemic control was 40%.
Macrosomiaincreasestheriskofdystociaduringlaborandasphyxia.Increasedriskofmacrosomiais
associated with blood glucose concentrations after meal instead of the average blood glucose
concentration in a single day. Long term effects on the mother include the risk of developing
impairedglucosetoleranceandtype2diabetes.Whilethebabymayhaveanincreasedriskoflater
obesity and IGT. Therefore, adequate glycemic control during pregnancy is important to prevent
complicationsinthemotherandbaby.5,6,11

Authors Disclosure
Thisreviewwaswrittenindependentlynocompanyorinstitutionsupporteditfinancially.Authors
declarednoinherentconflictsofinterest.

References
1. Konsensus Diagnosis dan Penatalaksanaan Diabetes Melitus Gestasional. Perkumpulan
EndokrinologiIndonesia,1997.
2. Waspadji S. Diabetes mellitus pada kehamilan. Dalam: Markum, HMS. Sudoyo AW, Effendy S,
SetiatiS,GaniRA,AlwiI.NaskahlengkapPertemuanIlmiahTahunanIlmuPenyakitDalam1997.
BagianIlmuPenyakitDalamFKUI/RSUPNdr.CiptoMangunkusumo,Jakarta,1997.
3.BenHaroushA,YogevY,HodM.Epidemiologyofgestationaldiabetesmelitusanditsassociation
withtype2diabetes.DiabetMed.200421:10313.
4. Retnakaran R, Hanley AJG, Connely PW, Sermer M, Zinman B. Ethnicity modifies the effect of
obesity on insulin resistance in pregnancy: A comparison of Asian, South Asian and Caucasian
women.JClinEndocrinolMetab.200691:937.
5. Hod M, Yogey Y. Goals of metabolic management of gestational diabetes. Diabetes Care. 2007
30(suppl2):S1807.
6.MetzgerBE,BuchananTA,OrganizingCommittee.SummaryandrecommendationsoftheFifth

http://aseanendocrinejournal.org/index.php/JAFES/rt/printerFriendly/44/467

4/5

3/21/2016

Purnamasari

International WorkshopConference on Gestational Diabetes Mellitus. Diabetes Care. 2007

30(suppl2):251S60S.
7. Konsensus diagnosis dan penatalaksanaan diabetes melitus di Indonesia. Perkumpulan
EndokrinologiIndonesia,Jakarta2006.
8.WaspadjiS,NapitupuluB,HasanuddinF,Supartondo.Kadarglukosadarahpuasa,sesudahmakan
dankadarglikoHbpadawanitahamilnondiabetesmelitus.Dalam:TjokroprawiroA,SukahatyaM,
Suhadi B, Sutjahjo A, Tandra H, Buku naskah lengkap. Kongres nasional II Perkumpulan
EndokrinologiIndonesia.Surabaya1989.
9.KjosSL,SchaeferGrafUM,Modifiedtherapyforgestationaldiabetesusinghighriskandlowrisk
fetal abdominal circumference growth to select strict versus relaxed maternal glycemic target.
DiabetesCare.200730(suppl2):S2005.
10.KjosSL,BuchananTA.GestationalDiabetesMellitus.NEnglJMed.1999341:174956.
11.BenHaroushA,YogevY,HodM.Epidemiologyofgestationaldiabetesmelitusanditsassociation
withtype2diabetes.DiabetMed.200421:10313.
12. Jovanovic L. Point: Oral hypoglycaemic agents should not be used to treat diabetic pregnant
women.Editorials.DiabetesCare.200730:29769.
13. Committee on Nutritional Status During Pregnancy and Lactation, Institute of Medicine.
NutritionDuringPregnancy:PartI:WeightGain,PartII:NutrientSupplements.NationalAcademy
Press,Washington,DC,1990.
14. Bloomgarden ZT. Gestational Diabetes Mellitus and Obesity. Diabetes Care. 2010 33(5). E60
e65.
15.Chamim.Penatalaksanaandiabetesdalamkehamilan.Tesis.BagianObstetri&GinekologiFKUI/
RSCMJakarta1995.
16. Reader DM. Medical nutrition therapy and lifestyle interventions. Diabetes Care. 2007 30:
S188S193.
17.SnyderJ,GrayDonaldK.KoskiKG.Predictorsofinfantbirthweightingestationaldiabetes.AmJ
ClinNutr.199459:14091414.
18. Harris GD, White RS. Diabetes management and exercise in pregnant patients with diabetes.
ClinicalDiabetes.200523(4):1658.
19. Balaji V, Madhuri BS, Ashalatha S, Sheela S, Suresh S, Seshiah V. A1c in gestational diabetes
melitusinAsianIndianwomen.DiabetesCare.200730:18657.
20.KahnBF,DaviesJK,LynchAM,ReynoldsRM,BarbourLA,Predictorsofglyburidefailureinthe
treatmentofgestationaldiabetes.ObstetGynecol.2006107:13039.
21. Langer O, Conway DL, Berkus MD, Xenakis EM, Gonzales O. A comparison of glyburide and
insulininwomenwithgestationaldiabetesmelitus.NEnglJMed.2000343:11348.
22.MooreTR.Glyburideforthetreatmentofgestationaldiabetes.Acriticalappraisal.DiabetesCare.
200730(suppl2):s20913.
23.HoFL,LiewCH,CunananEC,LeeKO,Oralhypoglycaemicagentsfordiabetesinpregnancy.An
appraisal of the current evidence for oral antidiabetic drug use in pregnancy. Ann Acad Med
Singapore.2007366728.
24.RowanJA,HagueWM,GaoW,BattinMR,MooreP.Metforminversusinsulinforthetreatmentof
gestationaldiabetes.NEnglJMed.2008358:200315.
25. Wendyansyah. Perbandingan pengendalian gula darah dan luaran kehamilan pasien diabetes
mellitus gestasional pada pemberian metformin dengan metode standar. Tesis. Program Studi
ObstetridanGinekologiProgramPendidikanDokterSpesialisI.FKUIRSCMJakarta2005.
26. Jovanovic L, Pettitt DJ. Treatment with insulin and its analogs in pregnancies complicated by
diabetes.DiabetesCare.200730(suppl2)S2204.
27.PantaloneKM,FaimanC,OlanskyL.Insulinglargineuseduringpregnancy.EndocrinePractice.
201117(No.3).
28.deValkHW,VisserGHA.Insulinduringpregnancy,labour,anddelivery.BestPractice&Research
ClinicalObstetricsandGynaecology.201125:6576.
29. Negrato CA, Rafacho A, Negrato G, Teixeira MF, Araujo CAR, et al. Glargine vs NPH insulin
therapy in pregnancies complicated by diabetes: Anobservational cohort study. Diabetes Research
andClinicalPractice.201089:4651.
30.LeperqJ,LinJ,HallGC,WangE,DaiMP,etal.MetaAnalysisofmaternalandneonataloutcomes
associated with the use of insulin glargine versus NPH insulin during pregnancy. Obstetrics and
GynecologyInternational.doi:10.1155/2012/649070.
31.CianniGD,VolpeL,GhioA,LencioniC,CuccuruI,BenziL,etal.Maternalmetaboliccontroland
perinataloutcomeinwomenwithgestationaldiabetesmelitustreatedwithlisprooraspartinsulin.
Comparisonwithregularinsulin.Letters.DiabetesCare.200730:e11.
32.PettittDJ,OspinaP,HowardC,ZisserH,JovanovicL.Efficacy,safetyandlackofimmunogenicity
ofinsulinaspartcomparedwithregularhumaninsulinforwomenwithgestationaldiabetesmellitus.
DiabetMed.200724:112935.
33.CrowtherCA,HillerJE,MossJR,McPheeAJ,JeffriesWS,RobinsonJS,etal.Effectoftreatment
gestationaldiabetesmellitusonpregnancyoutcome.NEnglJMed.2005352247786.

Disclaimer
ArticlesandanyothermaterialpublishedintheJAFESrepresenttheworkoftheauthor(s)andshouldnotbeconstruedtoreflecttheopinionsoftheEditorsor
thePublisher.
Authorsarerequiredtoaccomplish,signandsubmitscannedcopiesoftheJAFESDeclarationthatthearticlerepresentsoriginalmaterialthatisnotbeing
consideredforpublicationorhasnotbeenpublishedoracceptedforpublicationelsewhere.
Consentforms,asappropriate,havebeensecuredforthepublicationofinformationaboutpatientsotherwise,authorsdeclaredthatallmeanshavebeen
exhaustedforsecuringsuchconsent.
Theauthorshavesigneddisclosuresthattherearenofinancialorotherrelationshipsthatmightleadtoaconflictofinterest.Allauthorsarerequiredtosubmit
AuthorshipCertificationsthatthemanuscripthasbeenreadandapprovedbyallauthors,andthattherequirementsforauthorshiphavebeenmetbyeach
author.

http://aseanendocrinejournal.org/index.php/JAFES/rt/printerFriendly/44/467

5/5