Diabetes Mellitus DIAGNOSIS AND TREATMENT

 Diabetes is detected by measuring the amount of glucose in the blood after an individual has fasted (abstained from food) for about eight hours. In some cases, physicians diagnose diabetes by administering an oral glucose tolerance test, which measures glucose levels before and after a specific amount of sugar has been ingested. 

 Once diabetes is diagnosed, treatment consists of controlling the amount of glucose in the blood and preventing complications. Depending on the type of diabetes, this can be accomplished through regular physical exercise, a carefully controlled diet, and medication. Individuals with Type 1 diabetes must receive insulin, often two to four times a day, to provide the body with the hormone it does not produce. Insulin cannot be taken orally, because it is destroyed in the digestive system. 

Consequently, insulin-dependent diabetics have historically injected the drug using a hypodermic needle or a beeper-sized pump connected to a needle inserted under the skin. In 2006 the United States Food and Drug Administration approved a form of insulin that can be inhaled and then is absorbed by blood in the lungs. The amount of insulin needed varies from person to person and may be influenced by factors such as a person’s level of physical activity, diet, and the presence of other health disorders. 

Typically, individuals with Type 1 diabetes use a meter several times a day to measure the level of glucose in a drop of their blood obtained by pricking a fingertip. They can then adjust the dosage of insulin, physical exercise, or food intake to maintain the blood sugar at a normal level. People with Type 1 diabetes must carefully control their diets by distributing meals and snacks throughout the day so as not to overwhelm the ability of the insulin supply to help cells absorb glucose. They also need to eat foods that contain complex sugars, which break down slowly and cause a slower rise in blood sugar levels. Although most persons with Type 1 diabetes strive to lower the amount of glucose in their blood, levels that are too low can also cause health problems. For example, if a person with Type 1 diabetes takes too much insulin, it can produce low blood sugar levels. This may result in hypoglycemia, a condition characterized by shakiness, confusion, and anxiety. 

A person who develops hypoglycemia can combat symptoms by ingesting glucose tablets or by consuming foods with high sugar content, such as fruit juices or hard candy. In order to control insulin levels, people with Type 1 diabetes must monitor their glucose levels several times a day. In 1983 a group of 1,441 Type 1 diabetics aged 13 to 39 began participating in the Diabetes Control and Complications Trial (DCCT), the largest scientific study of diabetes treatment ever undertaken. The DCCT studied the potential for reducing diabetes-related complications, such as nerve or kidney disease or eye disorders, by having patients closely monitor their blood sugar levels four to six times a day, maintaining the levels as close to normal as possible. The results of the study, reported in 1993, showed a 50 to 75 percent reduction of diabetic complications in people who aggressively monitored and controlled their glucose levels. Although the study was performed on people with Type 1 diabetes, researchers believe that close monitoring of blood sugar levels would also benefit people with Type 2 diabetes. For persons with Type 2 diabetes, treatment begins with diet control, exercise, and weight reduction, although over time this treatment may not be adequate. 

People with Type 2 diabetes typically work with nutritionists to formulate a diet plan that regulates blood sugar levels so that they do not rise too swiftly after a meal. A recommended meal is usually low in fat (30 percent or less of total calories), provides moderate protein (10 to 20 percent of total calories), and contains a variety of carbohydrates, such as beans, vegetables, and grains. Regular exercise helps body cells absorb glucose—even ten minutes of exercise a day can be effective. Diet control and exercise may also play a role in weight reduction, which appears to partially reverse the body’s inability to use insulin. For some people with Type 2 diabetes, diet, exercise, and weight reduction alone may work initially, but eventually this regimen does not help control high blood sugar levels. In these cases, oral medication may be prescribed. 

If oral medications are ineffective, a person with Type 2 diabetes may need insulin doses or a combination of oral medication and insulin. About 50 percent of individuals with Type 2 diabetes require oral medications, 40 percent require insulin or a combination of insulin and oral medications, and 10 percent use diet and exercise alone.

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Abortion methods

Induced abortions are performed using drugs or surgery. The safest and most appropriate method is determined by the age of the fetus, which is calculated from the beginning of the pregnant woman’s last menstrual period. Most pregnancies last an average of 39 to 40 weeks. This period is divided into three stages known as trimesters.

The first trimester consists of the first 13 weeks, the second trimester spans weeks 14 to 28, and the third trimester lasts from the 29th week to birth. Abortions in the first trimester of pregnancy are easier and safer to perform while abortions in the second and third trimesters require more complicated procedures and pose greater risks to a woman’s health. In the United States, a pregnant woman’s risk of death from a first-term abortion is less than 1 in 100,000. The risk increases by about 30 percent with each week of pregnancy after 12 weeks.

A Drug-Based Abortion Methods

Drug-based abortion, also known as medication abortion, typically requires that a woman take two types of drugs within the first weeks of a confirmed pregnancy. In one method, a pregnant woman first takes the drug mifepristone, also known as RU-486, which blocks progesterone, a hormone needed to maintain the pregnancy. About 48 hours later, she takes another drug called misoprostol. Misoprostol is a prostaglandin (a hormone-like chemical produced by the body) that causes contractions of the uterus, the organ in which the fetus develops. These uterine contractions expel the fetus.

Another type of drug combination that induces abortion is the use of misoprostol with methotrexate, an anticancer drug that interferes with cell division. A physician first injects a pregnant woman with methotrexate. About a week later, the woman takes a pill containing misoprostol to induce uterine contractions and expel the fetus.

These drug-based abortion methods effectively end pregnancy in approximately 96 percent of the women who take them and are most effective when performed very early in a pregnancy. These methods require no anesthesia. However, the use of drugs to induce abortion has not been widely adopted by women in the United States for a number of reasons. These drugs can cause unpleasant side effects—some women experience nausea, cramping, and bleeding. More serious complications, such as arrhythmia, edema, and pneumonia, affect the heart and lungs and may cause death. Perhaps the primary deterrent is that these drug-based abortion methods require at least two visits to a physician over a period of several days, and these methods are no cheaper than a surgical abortion.

B Surgical Abortion Methods

Legal surgical abortion, when done by a trained provider, is essentially 100 percent effective. A number of surgical methods can be used to induce abortions. To end a pregnancy before it reaches eight weeks, a doctor typically performs a preemptive abortion or an early uterine evacuation. In both procedures a narrow tube called a cannula is inserted through the cervix (the opening to the uterus) into the uterus. The cannula is attached to a suction device, such as a syringe, and the contents of the uterus, including the fetus, are extracted. Preemptive abortion uses a smaller cannula and is performed in the first four to six weeks of pregnancy. Early uterine evacuation, which uses a slightly larger cannula, is performed in the first six to eight weeks of pregnancy. Both types of abortions typically require no anesthesia and can be performed in a clinic or physician’s office. The entire procedure lasts for only several minutes. In preemptive abortions the most common complication is infection. Women who undergo early uterine evacuation may experience heavy bleeding for the first few days after the procedure.

Vacuum aspiration is a procedure used for abortions in the 6th to 14th week of pregnancy. It requires that the cervix be dilated, or enlarged, so that a cannula can be inserted into the uterus. Progressively larger, tapered instruments called dilators may be used to dilate the cervix. During the procedure, the cannula is attached to an electrically powered pump that removes the contents of the uterus. In some cases, the lining of the uterus must also be scraped with a spoonlike tool called a curette to loosen and remove tissue. This procedure is referred to as curettage. Vacuum aspiration may require local anesthesia and can be performed in a clinic or physician’s office. Minor bruising or injuries to the cervix may occur when the cannula is inserted.

Dilation and curettage (D&C), performed during the 6th to 16th week of pregnancy, involves dilating the cervix and then scraping the uterine lining with a curette to remove the contents. A D&C often requires general anesthesia and must be performed in a clinic or hospital. Possible complications include a reaction to the anesthesia and cervical injuries. Since the development of vacuum aspiration, the use of D&C has declined.

After the first 16 weeks of pregnancy, abortion becomes more difficult. One method that can be used during this period is dilation and evacuation (D&E), which requires greater dilation of the cervix than other methods. It also requires the use of suction, a large curette, and a grasping tool called a forceps to remove the fetus. D&E is a complicated procedure because of the larger size of the fetus and the thinner walls of the uterus, which stretch to accommodate a growing fetus. Bleeding in the uterus often occurs. D&E is often performed under general anesthesia in a clinic or hospital. It is typically used in the first weeks of the second trimester but can be performed up to the 24th week of pregnancy.

An induction abortion can also be performed in the second trimester, usually between the 16th and 24th week of pregnancy. In this type of abortion a small amount of amniotic fluid, the fluid that surrounds the fetus, is withdrawn and replaced with another fluid. About 24 to 48 hours later, the uterus begins to contract and the fetus is expelled. When this method was first developed, physicians used a strong saline (salt) solution to abort the fetus; today they may also use solutions containing prostaglandins or pitocin, a synthetic form of a chemical produced by the pituitary gland that induces labor. Heavy bleeding, infection, and injuries to the cervix can occur. This procedure is performed in the hospital and requires a stay of one or more days.

Abortions performed at the end of the second trimester and during the third trimester require major surgery. Two such late-term procedures include hysterotomy and intact dilation and extraction. In hysterotomy, the uterus is cut open and the fetus is removed surgically in an operation similar to a cesarean section, but a hysterotomy requires a smaller incision. Hysterotomy is major abdominal surgery performed under general anesthesia.

Intact dilation and extraction, also referred to as a partial birth abortion, consists of partially removing the fetus from the uterus through the vaginal canal, feet first, and using suction to remove the brain and spinal fluid from the skull. The skull is then collapsed to allow complete removal of the fetus from the uterus.

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