Drug noxae as indications for pregnancy interruption]

Factors are discussed which are important in determining whether use of a substance with a known or suspected teratogenic effect can be considered an indication for induced abortion. In some cases, the fetal membranes can compensate for damage done during embryonic development. Not only the type of substance is important; the teratogenic effect of various compounds is dose-dependent. A risk of spontaneous fetal abnormality is present in every pregnancy; no substance is known which causes such abnormalities in 100% of the cases. In order to determine whether a substance actually has teratogenic effects, an epidemiological study must be very large. A list of several commonly prescribed substances and the risk of teratogenic effects associated with them is presented. Use of teratogenic substances can be considered as an indication for abortion only if the dosage, the length of use, the stage of pregnancy in which the substance is taken, the psychological status of the mother, and other factors are considered. The mother should decide for herself if the risk of a fetal abnormality is acceptable to her.     

Psychiatric indications for pregnancy interruption]

The granting of abortions according to the psychiatric indication (PI) in West Germany is discussed. The PI is sharply differentiated from the emergency indication, which is of a social nature. These 2 indications merge in the case of psycho-social considerations. Possible psychological complications of the abortion operation itself should be considered in deciding whether an abortion should be granted, and a waiting period of at least a day should be allowed for both patient and physician before a definite decision is made. The indication for sterilization in conjunction with the abortion operation and the possibility of continuing therapy for those whose abortions are not granted are additional considerations or the decision on the suitability of the PI for a particular patient. The evaluation of suicidal tendencies is important for the psychological evaluation of abortion seekers. In general, cases of endogenous depression do not constitute a indication for abortion, while reactive depression may lead to depressive decompensation in a patient who has an unwanted pregnancy. The prognosis in such cases is especially hard to determine in younger patients. Character neuroses and alcoholism or similar diseases complicate the psychiatrical determination. In cases of schizophrenia and oligophrenia with good prognoses, abortion is not usually indicated. Most applications for abortion which are denied under the PI are of social character and belong under the emergency indication, e.g. serious physical illness of the mother, other handicapped family members, young, unwed mothers. These principles are illustrated with sample cases.     

Legal prerequisites for pregnancy interruption due to medical, eugenic and social indications]

The provisions of the revised West German abortion law of June 21, 1976 are explained. Abortion is permitted under a sociomedical indication, which consists of 4 "sub-indications": medical, eugenic, criminological, and social. The abortion candidate must give her documented informed consent to the operation after a personal consultation with the physician, and in general should be advised of those complications which minors, the extent of the minor's capacity for informed consent should be established and the approval of the legal guardians should be obtained. The legal guardian cannot, however, force the minor to have an abortion or carry the pregnancy to term. If sterilization is to be performed in conjunction with abortion, the necessary indication must exist and the required informed consent must be obtained. The abortion candidate must also be informed of available aid to pregnant women, mothers, and children at least 3 days before the operation, except in the case of the medical indication. In 1977 the social indication accounted for 50.5%; medical 43% (10% psychiatric), eugenic 5%, and criminological .2%. The incidence of abortion under the social indication was on the increase and under the medical indication on the decrease. Abortions must be performed in approved medical facilities. No medical personnel can be forced to perform an abortion, except in cases of extreme danger to the mother.     

Diabetes mellitus and pregnancy

Summary The following points are important for the care of the diabetic gravida: at the beginning of pregnancy, accurate adjustment of the metabolic situation (possibly during hospitalization), current medical and obstetrical checks, hospitalization about eight weeks before the expected term of delivery and, if need be, premature childbirth. According to the conditions of each individual case, spontaneous delivery or cesarean section may be indicated. The as yet unsatisfactory percentage of infant mortality and deformities in the offspring of diabetic mothers can only be improved by optimal care, i.e. the best possible metabolic control, if feasible already at the time of conception. Apart from the cooperation of the diabetic patient herself, close collaboration of obstetrician, physician, pediatrician and anesthesiologist, which is possible in well equipped specialized departments, are an essential condition for optimal results.

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Zusammenfassung Für die Betreuung schwangerer Diabetikerinnen sind folgende Gesichtspunkte wichtig: zu Beginn der Schwangerschaft Neueinstellung des Diabetes mellitus (zumeist stationär), laufende internistische und geburtshilfliche Kontrollen, vorzeitige stationäre Aufnahme etwa acht Wochen vor dem errechneten Entbindungstermin und gegebenenfalls auch frühzeitige Entbindung. Je nach Lage des Falles kommen Spontangeburt oder Sectio caesarea in Betracht. Der noch immer unbefriedigend hohe Prozentsatz kindlicher Mortalität sowie die Mißbildungsrate bei den Kindern diabetischer Mütter können nur durch optimale Betreuung, d.h. gute Stoffwechselführung, wenn möglich schon zum Zeitpunkt der Konzeption, verbessert werden. Unerläßliche Voraussetzung ist neben der Kooperation der graviden Diabetikerin die enge Zusammenarbeit zwischen Geburtshelfer, Internist, Pädiater und Anaesthesist, wie es in gut ausgerüsteten Spezialabteilungen möglich ist.

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Resumen En la asistencia ed la gestante diabética son importantes las siguientes precauciones: al inicio de la gestación, regulaciónex novo de la situación metabólica (posiblemente con hospitalización de la gestante), controles médicos y obstétricos periódicos, hospitalización precoz (8 semanas aproximadamente antese de la prevista conclusión de la gestación) y, en caso de necesidad, parto prematuro. Según la situación del caso se dará la preferencia al parto espontáneo y al corte cesáreo. El porcentaje, insatisfactorio todavía, de mortalidad infantil y de malformaciones entre los nacidos de madres diabéticas, se puede mejorar sólo por medio de la más esmerada asistencia, es decir: de una regulación metabólica lo más satisfactoria posible, actuada ya desde el momento de la concepción. Otra condición indispensable para alcanzar los mejores resultados es la estrecha colaboración entre el obstétrico, el internista, el pediatra y el anestesista, cosa posible en los repartos especializados bien equipados.

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Résumé Pour l'assistance à la femme enceinte diabétique, les points suivants sont importants au début de la grossesse: régularisationex novo de la situation métabolique (éventuellement avec hospitalisation), contrôles internes et obstétriques périodiques, hospitalisation précoce quelque 8 semaines avant le terme prévu de la grossesse et, en cas de nécessité, accouchement prématuré. Selon la situation du cas, on donnera la priorité à l'accouchement spontané et à la césarienne. Le pourcentage encore insatisfaisant de mortalité des enfants et de malformations parmi les enfants nés de mères diabétiques ne peut être amélioré que grâce à une assistance optimale, c'est-à-dire une régularisation métabolique plus satisfaisante, à réaliser dès la conception. A côté de la coopération de la patiente, la condition préalable pour atteindre des résultats optimaux est une collaboration étroite entre obstétricien, spécialiste de médecine interne, pédiatre et anesthésiste, laquelle n'est possible que dans des ensembles hospitaliers bien équipés et spécialisés.

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Riassunto Per l'assistenza della gestante diabetica sono importanti i seguenti punti: all'inizio della gravidanza, regolazioneex novo della situazione metabolica (possibilmente in regime di ricovero ospedaliero), controlli internistici ed ostetrici periodici, ospedalizzazione precoce circa 8 settimane prima del termine previsto della gravidanza e, in caso di necessità, parto prematuro. A seconda della situazione del caso, si darà la preferenza al parto spontaneo o al taglio cesareo. La percentuale ancora insoddisfacente di mortalità infantile e di malformazioni tra i nati da madri diabetiche può essere migliorata soltanto per mezzo di un'assistenza ottimale, cioè di una regolazione metabolica il più possibile soddisfacente, da attuarsi già al momento del concepimento. Condizione indispensabile per il raggiungimento di risultati ottimali è, oltre alla cooperazione della paziente stessa, la stretta collaborazione tra ostetrico, internista, pediatra ed anestesista, quale risulta possibile in reparti specializzati bene attrezzati.

     

Diabetes mellitus and liver diseases

Diabetes mellitus is a independent risk factor for the hepatitis C and for the hepatocellular carcinoma. Fatty liver is a obviously finding in patients with type 2 diabetes. It can develop steatofibrosis, steatohepatitis or liver cirrhosis. Steatohepatitis may be affected with weight reduction, metformin, rosiglitazon, or orlistat.     

糖尿病与心血管疾病

由于生活方式变化和人口老龄化,我国患糖尿病人数在明显增加。Framingham研究随访20年,糖尿病患者患冠心病危险增加2~4倍,且常是多支病变,介入治疗预后差。不典型心绞痛,无痛性心肌梗死(心梗)和非Q波心梗多见。OASIS研究糖尿病患者不稳定心绞痛及非Q波心梗死亡率增加57%。Haffn     

糖尿病皮肤病变

精尿病患者皮肤受累非常普遍,其皮肤损害表现多种多样,主要包括与糖尿病有父的皮肤病变、皮肤感染、精尿病并发症的皮肤病变及糖尿病治疗的皮肤反应.糖尿病皮肤病变的发病机制尚不清楚.治疗的关键是控制血糖,使血糖达标,针对不同的病因及皮损表现采取相应的处理.     

Diabetes and pregnancy]

The presence of insulin-dependent or non insulin-dependent diabetes mellitus in pregnant women has been associated with an adverse effect on the maternal an fetal outcomes of pregnancy. The incidence of obstetrical and diabetic complications is increased, and a continuum has been observed between maternal blood glucose levels and perinatal outcome. The incidence of congenital malformations, macrosomia and prematurity is increased in offspring of diabetic mothers. Programming and intensive collaborative follow-up improve the outcome of such pregnancies. Gestational diabetes mellitus is an heterogenous condition defined as carbohydrate intolerance of variable severity with onset or first recognition during pregnancy. Short term complications are mainly represented by fetal macrosomia and high cesarean section rate. Women with a history of gestational diabetes mellitus are at increased risk of future diabetes, predominantly type 2. Obesity and type 2 diabetes are increased among their children.