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ALT test

ALT test

What is ALT test

ALT is short for alanine aminotransferase is also called SGPT (Serum Glutamic-Pyruvic Transaminase) or GPT (Glutamic-Pyruvic Transaminase) or alanine transaminase, which is an enzyme found mostly in the cells of the liver and kidney. Much smaller amounts of ALT are also found in the heart and muscles. ALT blood test measures the level of ALT (alanine aminotransferase) in the blood. Normal ALT are less than 36U/L [7 to 55 units per liter (U/L)]. This result is typical for adult men. Normal results vary from laboratory to laboratory and might be slightly different for women and children (neonate < 50 U/L).

The function of ALT (alanine aminotransferase) is to convert alanine, an amino acid found in proteins, into pyruvate, an important intermediate in cellular energy production. In healthy individuals, ALT levels in the blood are low. When the liver is damaged, ALT is released into the blood, usually before more obvious signs of liver damage occur, such as jaundice. This makes ALT (alanine aminotransferase) a useful test for early detection of liver damage.

A number of conditions can cause damage to liver cells, resulting in an increase in ALT. The ALT (alanine aminotransferase) test is most useful in detecting damage due to hepatitis or as a result of drugs or other substances that are toxic to the liver. ALT (alanine aminotransferase) is more specific for hepatocellular damage than is AST (aspartate aminotransferase) or LD (lactate dehydrogenase) and remains elevated for longer, due to its longer half-life.

ALT is commonly tested in conjunction with aspartate aminotransferase (AST), another liver enzyme, as part of a liver panel. Both ALT and AST levels usually rise whenever the liver is being damaged, although ALT is more specific for the liver and, in some cases, may be the only one of the two to be increased. An AST/ALT ratio may be calculated to aid in distinguishing between different causes and severity of liver injury and to help distinguish liver injury from damage to heart or muscles. The AST/ALT ratio is typically > 1 in alcoholic liver disease and AST/ALT < 1 in non-alcoholic liver disease.

ALT may be elevated in skeletal muscle disease but the degree of elevation is much less than for AST (aspartate aminotransferase) and CK (creatine kinase).

The Liver

Your liver is the largest organ inside your body, weighing about 1.4 kg (3 pounds) in an average adult. Your liver is a vital organ located in the upper right-hand side of the abdominal cavity, just inferior to the diaphragm in the right superior part of the abdominal cavity and under your right ribs just beneath your right lung – filling much of the right hypochondriac and epigastric regions and extending into the left hypochondriac region.

Your liver is partially surrounded by the ribs, and extends from the level of the fifth intercostal space to the lower margin of the right rib cage, which protects this highly vascular organ from blows that could rupture it. Your liver is shaped like a wedge, the wide base of which faces right and the narrow apex of which lies just inferior to the level of the left nipple. The reddish-brown liver is well supplied with blood vessels.

Your liver is involved in many important functions in the body. Your liver helps to process your body’s nutrients, manufactures bile to help digest fats, produces many important proteins such as blood clotting factors, and breaks down potentially toxic substances into harmless ones that the body can use or excrete.

Figure 1. Location of the human liver

liver

Figure 2. Liver lobule

liver hepatic lobules

Footnote: (a) Cross section of a hepatic lobule. (b) Enlarged longitudinal section of a hepatic lobule. (c) Light micrograph of hepatic lobules in cross section.

Liver functions

Amazingly versatile, your liver performs over 500 functions. Its digestive function is to produce bile, a green alkaline liquid that is stored in the gallbladder and secreted into the duodenum. Bile salts emulsify fats in the small intestine; that is, they break up fatty nutrients into tiny particles, just as dish detergent breaks up a pool of fat drippings in a roasting pan. These smaller particles are more accessible to digestive enzymes from the pancreas. The liver also performs many metabolic functions and you cannot live without your liver:

  • Picks up glucose from nutrient-rich blood returning from the alimentary canal and stores this carbohydrate as glycogen for subsequent use by the body.
  • Processes fats and amino acids and stores certain vitamins.
  • Detoxifies many poisons and drugs in the blood.
  • Makes the blood proteins.
  • It breaks down and stores many of the nutrients absorbed from the intestine that your body needs to function. Some nutrients must be changed (metabolized) in the liver before they can be used for energy or to build and repair body tissues.
  • It makes most of the clotting factors that keep you from bleeding too much when you are cut or injured.
  • It secretes bile into the intestines to help absorb nutrients (especially fats).
  • It breaks down alcohol, drugs, and toxic wastes in the blood, which then pass from the body through urine and stool.

Almost all of these functions are carried out by a type of cell called a hepatocyte or simply a liver cell.

The liver carries on many important metabolic activities. The liver plays a key role in carbohydrate metabolism by helping maintain concentration of blood glucose within the normal range. Liver cells responding to the hormone insulin lower the blood glucose level by polymerizing glucose to glycogen. Liver cells responding to the hormone glucagon raise the blood glucose level by breaking down glycogen to glucose or by converting noncarbohydrates into glucose.

The liver’s effects on lipid metabolism include oxidizing (breaking down) fatty acids at an especially high rate; synthesizing lipoproteins, phospholipids, and cholesterol; and converting excess portions of carbohydrate molecules into fat molecules. The blood transports fats synthesized in the liver to adipose tissue for storage.

Other liver functions concern protein metabolism. They include deaminating amino acids; forming urea; synthesizing plasma proteins such as clotting factors; and converting certain amino acids into other amino acids.

The liver also stores many substances, including glycogen, iron, and vitamins A, D, and B12. In addition, macrophages in the liver help destroy damaged red blood cells and phagocytize foreign antigens. The liver also removes toxic substances such as alcohol and certain drugs from blood (detoxification).

Table 1. Major Functions of the Liver

General FunctionSpecific Function
Carbohydrate metabolismPolymerizes glucose to glycogen; breaks down glycogen to glucose; converts noncarbohydrates to glucose
Lipid metabolismOxidizes fatty acids; synthesizes lipoproteins, phospholipids, and cholesterol; converts excess portions of carbohydrate molecules into fats
Protein metabolismDeaminates amino acids; forms urea; synthesizes plasma proteins; converts certain amino acids into other amino acids
StorageStores glycogen, iron, and vitamin A, vitamin D and vitamin B12
Blood filteringRemoves damaged red blood cells and foreign substances by phagocytosis
DetoxificationRemoves toxins from blood
SecretionProduces and secretes bile

The Bile

Bile is a yellowish-green liquid continuously secreted from hepatic cells. In addition to water, bile contains bile salts, bile pigments (bilirubin and biliverdin), cholesterol, and electrolytes. Of these, bile salts are the most abundant and are the only bile components that have a digestive function.

Bile pigments are breakdown products of hemoglobin from red blood cells and are normally secreted in the bile.

Jaundice, a yellowing of the skin and mucous membranes due to accumulation of bile pigment, has several causes. In obstructive jaundice bile ducts are blocked, perhaps by gallstones or tumors. In hepatocellular jaundice the liver is diseased, as in cirrhosis or hepatitis. In hemolytic jaundice red blood cells are destroyed too rapidly, as happens with an incompatible blood transfusion or a blood infection.

Regulation of Bile Release

Normally bile does not enter the duodenum until cholecystokinin stimulates the gallbladder to contract. The intestinal mucosa releases this hormone in response to proteins and fats in the small intestine. The hepatopancreatic sphincter usually remains contracted until a peristaltic wave in the duodenal wall approaches it. Then the sphincter relaxes, and bile is squirted into the duodenum.

Functions of Bile Salts

Bile salts aid digestive enzymes. Bile salts affect fat globules (clumped molecules of fats) much like a soap or detergent would affect them. That is, bile salts break fat globules into smaller droplets that are more soluble in water. This action, called emulsification, greatly increases the total surface area of the fatty substance. The resulting fat droplets disperse in water. Fat-splitting enzymes (lipases) can then digest the fat molecules more effectively. Bile salts also enhance absorption of fatty acids, cholesterol, and the fat-soluble vitamins A, D, E, and K.

Low levels of bile salts result in poor lipid absorption and vitamin deficiencies.

What does ALT mean in a blood test

The alanine aminotransferase (ALT) test is typically used to detect liver injury. It is often ordered in conjunction with aspartate aminotransferase (AST) as part of a liver panel or comprehensive metabolic panel (CMP) to screen for and/or help diagnose liver disease.

ALT is an enzyme found mostly in the cells of the liver and kidney. When the liver is damaged, ALT is released into the blood. This makes ALT a useful test for early detection of liver damage.

AST and ALT are considered to be two of the most important tests to detect liver injury, although ALT is more specific to the liver than is AST. Sometimes AST is compared directly to ALT and an AST/ALT ratio is calculated. This ratio may be used to distinguish between different causes of liver damage and to help recognize heart or muscle injury.

ALT values are often compared to the results of other tests such as alkaline phosphatase (ALP), total protein, and bilirubin to help determine which form of liver disease is present.

ALT is often used to monitor the treatment of persons who have liver disease, to see if the treatment is working, and may be ordered either by itself or along with other tests for this purpose.

When is ALT test ordered?

ALT may be ordered as part of a comprehensive metabolic panel when a person has a routine health examination.

A healthcare practitioner usually orders an ALT test (and several others) to evaluate a person who has signs and symptoms of a liver disorder. Some of these signs and symptoms may include:

  • Weakness, fatigue
  • Loss of appetite
  • Nausea, vomiting
  • Abdominal swelling and/or pain
  • Jaundice
  • Dark urine, light-colored stool
  • Itching (pruritus)

ALT may also be ordered, either by itself or with other tests, for people who are at an increased risk for liver disease since many people with mild liver damage will have no signs or symptoms. Even without other symptoms, ALT will be increased with mild liver damage. Some examples include:

  • Persons who have a history of known or possible exposure to hepatitis viruses
  • Those who are heavy drinkers
  • Individuals whose families have a history of liver disease
  • Persons who take drugs that might damage the liver
  • Persons who are overweight and/or have diabetes

When ALT is used to monitor the treatment of people who have liver disease, it may be ordered on a regular basis during the course of treatment to determine whether the therapy is effective.

Alt test range

ALT blood test normal range: Normal ALT are less than 36U/L [7 to 55 units per liter (U/L)]. This result is typical for adult men. Normal results vary from laboratory to laboratory and might be slightly different for women and children (neonate < 50 U/L).

A low level of ALT in the blood is expected and is normal.

ALT blood test high

Liver disease is the most common reason for higher than normal levels of ALT.

A shot or injection of medicine into the muscle tissue, or strenuous exercise, may increase ALT levels. And many drugs may raise ALT levels by causing liver damage in a very small percentage of patients taking the drug. This is true of both prescription drugs and some “natural” health products. Be sure to tell your healthcare provider about all of the drugs and/or health supplements you are taking.

Very high levels of ALT (more than 10 times normal) are usually due to acute hepatitis, sometimes due to a viral infection. In acute hepatitis, ALT levels usually stay high for about 1-2 months but can take as long as 3-6 months to return to normal. Levels of ALT may also be markedly elevated (sometimes over 100 times normal) as a result of exposure to drugs or other substances that are toxic to the liver or in conditions that cause decreased blood flow (ischemia) to the liver.

ALT levels are usually not as high in chronic hepatitis, often less than 4 times normal. In this case, ALT levels often vary between normal and slightly increased, so the test may be ordered frequently to see if there is a pattern. Other causes of moderate increases in ALT include obstruction of bile ducts, cirrhosis (usually the result of chronic hepatitis or bile duct obstruction), heart damage, alcohol abuse, and with tumors in the liver.

ALT is often performed together with a test for AST or as part of a liver panel. For more about ALT results in relation to other liver tests, see the Liver Panel article.

In most types of liver diseases, the ALT level is higher than AST and the AST/ALT ratio will be low (less than 1). There are a few exceptions; the AST/ALT ratio is usually greater than 1 in alcoholic hepatitis, cirrhosis, and with heart or muscle injury and may be greater than 1 for a day or two after onset of acute hepatitis.

What conditions other than liver problems can cause increased ALT?

ALT is more specific for the liver than AST and so is much less affected by conditions affecting other parts of the body. Nevertheless, injury to organs other than the liver, such as the heart and skeletal muscle, can cause elevations of ALT. For example, small increases may be seen with skeletal muscle damage or heart attacks.

What other tests may be performed to help determine the cause of liver damage?

After a thorough physical exam and evaluation of a person’s medical history, there are several other tests that may be performed as follow up depending on what is suspected to be the cause of liver damage. Some of these include:

  • Tests for hepatitis A, hepatitis B, and hepatitis C
  • Testing for exposure to drugs and other substances toxic to the liver (see Drug Abuse Testing and Emergency and Overdose Drug Testing)
  • Ethanol level
  • Copper and ceruloplasmin for Wilson disease
  • Iron tests and genetic tests for hereditary hemochromatosis

A liver biopsy may be performed to help determine the cause of liver injury and to evaluate the extent of liver damage.

How is the sample collected for testing?

A blood sample is drawn from a vein in the arm.

Is any test preparation needed to ensure the quality of the sample?

No test preparation is needed.

Hepatic-related causes of high ALT

Viral hepatitis (mainly hepatitis B virus [HBV] and hepatitis C virus [HCV] infections)

Viral hepatitis infection is the leading or secondary cause of ALT elevation in populations worldwide 1. ALT activity is an indicator of liver injury in patients with acute and chronic viral hepatitis 2.

With respect to hepatitis B virus (HBV) infection, ALT elevation is often observed in the process of the cytolytic immune response (acute phase) and the following ineffective HBV clearance (chronic phase) 3. Liaw et al 3 have described a fluctuation in ALT activity during the process of HBV infection. ALT activity is a crucial reference indicator in treatment selection and the evaluation of prognosis in patients infected with HBV 3. Nevertheless, controversy exists and Lai et al 45 reported significant fibrosis and inflammation in 37% of patients infected with HBV and persistently normal ALT levels 4. Unlike hepatitis B virus (HBV) infections, the ALT level is less meaningful for diagnosis and prognosis of hepatitis C virus (HCV) treatment. More patients infected with hepatitis C virus (HCV) progress to chronic hepatitis with persistent hepatocyte injury 2. Greater than 6 in 10 of common hepatitis C virus (HCV) carriers have normal ALT levels or mildly elevated ALT levels (< 2 times the upper limit of normal) with rare hepatic histologic lesions confirmed by liver biopsy 5. Recently, Ruhl et al 6 suggested that lowering the upper limit of normal of the ALT level (29 IU/L for men and 22 IU/L for women) was the best cut-off value to identify hepatitis C virus (HCV) infectors in the US population with a high prevalence of hepatitis C virus (HCV) infection. Otherwise, the HCV RNA titer is closely linked to the ALT elevation. Cathy et al 7 reported that approximately 68% of patients with positive HCV-RNA levels have ALT elevations in asymptomatic blood donors who tested positive for antibodies to the HCV (anti-HCV).

Alcohol intake

Excessive alcohol intake is another cause of ALT elevation in the general population. In an Italian population, 45.6% of altered liver tests have been attributed to excessive alcohol intake (≥28 g/day) 35, while in a US national population survey, excessive alcohol (>1 time/day) is a crucial cause of ALT elevation, second only to hepatitis C virus (HCV) infection 1, however, alcohol intake might be a time-and dose-dependent covariate that influences ALT activity. Short-term and light alcohol consumption was not shown to induce significant ALT elevation in adults 8, however, ethnicity differences exist regarding the biological consequences of alcohol abuse 9. In a UK study based on alcohol abusers from different areas worldwide, adults from South Asia were shown to be more susceptible to alcohol-related liver damage and the ALT levels were higher than in European alcohol abusers 10. Indeed, the effect of mild alcohol intake on ALT activity can be distinguished from binge drinking. Moderate alcohol intake does not contribute to significant ALT elevation, especially in a normal weight population, due to its potential effect on improvement of insulin sensitivity 11.

Some medications

Pratt et al 12 listed the medications that might cause ALT elevations. A randomized controlled trial indicated that the estimated odds ratios of ALT elevation in active treatment groups (including acetaminophen, paracetamol, hydromorphone+acetaminophen, morphine+acetaminophen, and oxycodone+acetaminophen) were 2.57-3.08 compared to the placebo group involving 343 healthy participants, even at the recommended dose 13. Another commonly used medication, statins, also causes mild ALT elevation 14. The mechanism underlying statin-associated ALT elevation is still unclear. Some scholars have suggested that the ALT elevation in statin users is attributed to cholesterol reduction in hepatocytes and co-morbid conditions, rather than liver damage or dysfunction 15. Therefore, the long-term medications should be carefully considered when faced with an unexplained ALT elevation. Pratt et al 16 also indicated that cessation of drug treatment is the best way to confirm the relationship between a drug and ALT elevation.

Coffee consumption

Of note, coffee intake might be a protective factor against ALT elevation. In NHANES III, there was a 50% and 70% decrease in ALT elevation amongst participants who consumed >2 cups of coffee/day or ≥373 mg of caffeine, respectively, compared to participants who did not consume coffee 17. Lee et al 18 attributed the protective effects of caffeine to antioxidant activity.

Non-alcoholic fatty liver disease (NAFLD)

NAFLD is a spectrum of clinical and pathologic changes, from fatty liver alone to steatohepatitis 19. Non-alcoholic fatty liver disease (NAFLD) is common in asymptomatic patients, and the prevalence ranges from 10 to 24% worldwide 20. Considered as a manifestation of the metabolic syndrome in liver 21, NAFLD has been strongly associated with ALT activity in previous studies 22. Non-alcoholic fatty liver disease (NAFLD) is the common cause of unexplained mild ALT elevation 23. NAFLD in asymptomatic patients is often serendipitously detected by liver biochemistry testing during routine health check-ups 24. Similar to the increasing prevalence of obesity 25, NAFLD is increasing and becoming a major health burden 26. In spite of the non-linear correlation between the degree of ALT elevation and the histologic severity of NAFLD 27, a mild ALT elevation is largely attributed to NAFLD. When faced with an unexplained ALT elevation (without viral hepatitis or a history of excessive alcohol intake), NAFLD should be considered in the differential diagnosis.

Autoimmune hepatitis

Autoimmune hepatitis is a less common liver disease than NAFLD 28, and the mechanism underlying autoimmune hepatitis is still unknown 29. ALT elevation is an available auxiliary measurement in the diagnosis of autoimmune hepatitis 30.

Moreover, ALT activity is a crucial indicator in detecting the effect of immunosuppressive treatment, prognosis, and long-term survival in patients with autoimmune hepatitis. In a study based on 84 Japanese autoimmune hepatitis patients, a persistently low ALT level (≤40 U/l) was the threshold value that was associated with improved prognosis 31. Another study also showed an association between persistent ALT elevation and poor survival in 69 autoimmune hepatitis patients 32. ALT is considered to be a crucial non-invasive marker of inflammation in patients with autoimmune hepatitis 33.

Non-hepatic cause of high ALT

Metabolic covariates

Except for apparent causes, such as viral hepatitis, alcohol intake, and some medications, the so-called unexplained causes of ALT elevation in some previous studies have mainly been attributed to metabolic syndrome 34. Similar to the pandemic of obesity 35, metabolic syndrome presents as a series of metabolic disorders, including glucose intolerance, central obesity, dyslipidaemia, and hypertension, has caused worldwide concern in the most recent decades.

Compared to the obvious cause of ALT elevation referred above, ALT elevation caused by metabolic syndrome is mild and neglected. In a cross-sectional study, the ALT level in metabolic syndrome patients, as defined by the National Cholesterol Education Programme Adult Treatment Panel III (NCEP-ATP-III) criteria, was approximately 30% higher than participants without metabolic syndrome in a male population from south China 36. This impact of metabolic syndrome on ALT elevation, however, is progressive and cumulative with a linear trend 37. Even within upper limit of normal values, which did not consider the impact of metabolic syndrome and are higher than the updated values, the increasing prevalence of metabolic syndrome is still correlated with the increasing ALT level in the general population. In a community-based Korean population, the odds ratios for metabolic syndrome in the highest quintiles of ALT were 7.1-fold higher than the reference quintile in men and 2.1-fold higher in women 38. All of the enrolled participants were selected within the upper limit of normal values (the upper limit of normal value is 30 U/l for males and 19 U/l for females) 38. Another Korean national health survey also showed a significantly increased prevalence of metabolic syndrome components, as defined by NCEP-ATP-III criteria, in the subgroup with high-normal ALT levels 39. With respect to the lipoproteins, ALT was shown to be stably and significantly associated with intermediate-density lipoprotein (IDL) and apolipoprotein B (ApoB) after adjusting various covariates in different models 40. These associations were commonly attributed to the stable and independent effects of insulin resistance and fatty liver disease in subjects with ALT elevations 41.

In addition, the impact of metabolic syndrome components on ALT activities varies to some extent. These distinguishing effects emerged after logistic regression using all of the metabolic syndrome components as covariates. The impact of the individual metabolic syndrome components on ALT elevation was disproportionate 42. The body mass index (BMI) and waist circumstance, representing the central obesity component of metabolic syndrome, were more closely linked to the ALT elevation 43, although, the underlying mechanism has not been elucidated. The possible explanation is that obesity, especially abdominal fat, is potentially involved in the visceral adipose deposition that causes hepatotoxic fatty acids 44. In a US national population-based study 45, BMI lost significance when evaluating the association between obesity and ALT abnormities after adjusting for leptin, insulin, and triglyceride concentrations, rather than the waist circumstance, which was representative of the visceral adipose deposition, indicating that BMI might be an intrinsic association between obesity and ALT abnormalities. Another viewpoint was that the obesity-ALT elevation association was modulated by insulin resistance. In a national health survey from a Korean adolescent population, the prevalence of insulin resistance status was positively correlated with the degree of obesity 46. The odds ratio of obesity-induced ALT elevation was significantly decreased after adjusting the homeostasis model as an index of insulin resistance status 47. Despite the ill-defined intrinsic mechanism, central obesity is the crucial metabolic syndrome component that most influences the ALT level in general population.

Celiac disease and muscle injury

Chronic ALT elevation is also found in several non-hepatic disorders, such as celiac disease and muscle injury 48. The intrinsic mechanism between celiac disease is not known. Approximately 40-57% of patients with celiac disease have abnormal liver tests 49. Celiac disease patients with elevated ALT levels should be treated with gluten-free diet; doing so will restore ALT levels to normal in 75-95% of patients within 6 months 49. It is well known that ALT elevation is often observed in patients with muscle necrosis 50 and the ALT elevation without evidence of liver disease should be considered due to muscle injury 48. Otherwise, the increased creatine kinaseand lactate dehydrogenase activities that occurred following muscle injury should be assayed to identify the cause of ALT elevation 51.

Hemochromatosis

As an ethnic specific disease mainly occurring in individuals of Nordic descent, hemochromatosis is a less common cause of ALT elevation. HFE gene mutations are the major cause of hereditary hemochromatosis, and iron overload is the main cause of hepatic injury. Measurements of serum ferritin, total iron-binding capacity, and the HEF mutation test can help diagnose hemochromatosis 52. Liver biopsy might be necessary if the aforementioned tests are negative in patients highly suspected to have hemochromatosis to evaluate the status of liver injury from iron overload.

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  35. James PT. Obesity: the worldwide epidemic. Clinics in dermatology. 2004;22(4):276–280.[]
  36. Liu Z, Hu Y, Yang X, Tan A, Gao Y, Qin X, Liang Y, Mo Z, Peng T. Combinative analysis of factors influence serum alanine aminotransferase activity in adult male population from southern China. Clinical biochemistry. 2012;45(18):1683–1688 https://www.ncbi.nlm.nih.gov/pubmed/22975640[]
  37. Yun JE, Kim SY, Kang H-C, Lee SJ, Kimm H, Jee SH. Alanine aminotransferase is associated with metabolic syndrome independently of insulin resistance. Circulation journal: official journal of the Japanese Circulation Society. 2010;75(4):964–969. https://www.jstage.jst.go.jp/article/circj/75/4/75_CJ-10-0465/_pdf/-char/en[]
  38. Jeong S, Nam H, Rhee J, Shin J, Kim J, Cho K. Metabolic syndrome and ALT: a community study in adult Koreans. International journal of obesity. 2004;28(8):1033–1038.[][]
  39. Suh S-Y, Choi S-E, Ahn H-Y, Yang H-M, Kim Y-I, Sung N-J. The association between normal alanine aminotransferase levels and the metabolic syndrome: 2005 Korean National Health and Nutrition Examination Survey. Metabolism. 2009;58(12):1731–1736.[]
  40. Lorenzo C, Hanley A, Rewers M, Haffner S. The association of alanine aminotransferase within the normal and mildly elevated range with lipoproteins and apolipoproteins: the Insulin Resistance Atherosclerosis Study. Diabetologia. 2013;56(4):746–757 https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3615715/[]
  41. Yun JE, Kim SY, Kang H-C, Lee SJ, Kimm H, Jee SH. Alanine aminotransferase is associated with metabolic syndrome independently of insulin resistance. Circulation journal: official journal of the Japanese Circulation Society. 2010;75(4):964–969.[]
  42. Liu Z, Hu Y, Yang X, Tan A, Gao Y, Qin X, Liang Y, Mo Z, Peng T. Combinative analysis of factors influence serum alanine aminotransferase activity in adult male population from southern China. Clinical biochemistry. 2012;45(18):1683–1688[]
  43. Clark JM, Brancati FL, Diehl AM. The prevalence and etiology of elevated aminotransferase levels in the United States. The American journal of gastroenterology. 2003;98(5):960–967.[]
  44. Falck-Ytter Y, Younossi ZM, Marchesini G, McCullough AJ. Clinical features and natural history of nonalcoholic steatosis syndromes. In: Seminars in liver disease: 2001; 2001. pp. 15–22.[]
  45. Ruhl CE, Everhart JE. Determinants of the association of overweight with elevated serum alanine aminotransferase activity in the United States. GASTROENTEROLOGY-BALTIMORE THEN PHILADELPHIA- 2003;124(1):71–79.[]
  46. Park SH, Heo NY, Park JH, Kim TO, Yang SY, Moon YS, Kim CH, Suk KT, Kim DJ, Lee HY. Obesity, insulin resistance, and the risk of an elevated alanine aminotransferase activity in the Korean adolescent population. Journal of Pediatric Endocrinology and Metabolism. 2012;25(9-10):945–949.[]
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  50. Janssen G, Kuipers H, Willems G, Does R, Janssen M, Geurten P. Plasma activity of muscle enzymes: quantification of skeletal muscle damage and relationship with metabolic variables. International journal of sports medicine. 1989;10(S 3):S160–S168.[]
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Procedures

HIDA scan

HIDA scan

What is a HIDA scan

HIDA scan is also known as hepatobiliary hydroxy iminodiacetic acid (HIDA) scan, cholescintigraphy or hepatobiliary scan or hepatobiliary scintigraphy, is an imaging procedure that uses radiotracers to assess the anatomy and function of the biliary system (and the liver indirectly). HIDA scan is used to diagnose problems of the liver, gallbladder and bile ducts. Currently, HIDA scan is most commonly performed with Tc99m-iminodiacetic acid analogues. During a HIDA scan, a radioactive tracer is injected into a vein in your arm. The tracer travels through your bloodstream to your liver, where the bile-producing cells (hepatocytes) take it up. The tracer then travels with the bile into your gallbladder and through your bile ducts to your small intestine. A nuclear medicine scanner (gamma camera) tracks the flow of the tracer from your liver into your gallbladder and small intestine and creates computer images.

Most of the time, HIDA scan is done only if a person has sudden pain that may be from gallbladder disease or gallstones. For this reason, some people may need urgent treatment based on the test results.

HIDA scan is combined with other imaging (such as CT or ultrasound). After the gallbladder scan, the person may be prepared for surgery, if needed.

Indications for HIDA scan

  • The HIDA scan should be done when ultrasound is not diagnostic and when there is a clinical diagnosis of acute cholecystitis.
  • Usually, HIDA scans are ordered for patients who are suspected of having an obstruction in the biliary tract, most commonly those who are thought to have a stone blocking the cystic duct leading out of the gallbladder.
  • Such a scenario is consistent with acute cholecystitis, which often requires surgical removal of the gallbladder.
  • In cholecystitis, HIDA will appear in the bile ducts, but it will not enter the cystic duct or the gallbladder — a finding that indicates obstruction.
  • If the HIDA enters the bile ducts but does not enter the small intestine, then an obstruction of the bile duct (usually due to stones or cancer) is suspected.

In a healthy person, HIDA will pass through the bile ducts and into the cystic duct to enter the gallbladder.

Limitation of HIDA scan

HIDA scans can be falsely positive when the gallbladder is not filling in the absence of cholecystitis. These situations include severe liver disease, patients on total parenteral nutrition, hyperbilirubinemia, inadequate fasting, and alcohol and opiate abuse.

In the presence of cystic duct obstruction the gallbladder does not fill with isotope.

Reasons for HIDA scan

A HIDA scan is most often done to evaluate your gallbladder. It’s also used to look at the bile-excreting function of your liver and to track the flow of bile from your liver into your small intestine. A HIDA scan is often used with X-ray and ultrasound.

A HIDA scan might help in the diagnosis of several diseases and conditions, such as:

  • Gallbladder inflammation (cholecystitis)
  • Bile duct obstruction
  • Congenital abnormalities in the bile ducts, such as biliary atresia
  • Postoperative complications, such as bile leaks and fistulas
  • Assessment of liver transplant

Your doctor might use a HIDA scan as part of a test to measure the rate at which bile is released from your gallbladder (gallbladder ejection fraction).

HIDA scan can be used for evaluation of:

  • Acute cholecystitis
    • most common use is to confirm acute cholecystitis after an equivocal ultrasound study
    • if the tracer does not enter the gallbladder after a sufficient length of time, then this is compatible with obstruction of the cystic duct
  • Chronic cholecystitis
    • diagnosed if an adequate % of bile mixed with radiotracer does not exit the gallbladder after administration of CCK
  • Biliary atresia in neonates
  • Bile leak
    • if tracer spreads outside the biliary system, it provides direct evidence of a biliary leak
  • Biliary obstruction
    • tracer dose is held up before it can progress into the duodenum
  • Confirmation of biliary dilatation
    • may be useful in imaging choledochal cysts

With the exception of biliary atresia (and possibly chronic cholecystitis), cholescintigraphy is rarely a first line imaging modality but is often used as a problem-solving tool.

HIDA scan side effects

A HIDA scan carries only a few risks. They include:

  • Allergic reaction to medications containing radioactive tracers used for the scan
  • Bruising at the injection site
  • Radiation exposure, which is small. The amount of radiation is small (less than that of a regular x-ray). It is almost all gone from the body within 1 or 2 days. Your risk from radiation may increase if you have a lot of scans.
  • There is a small risk to pregnant or nursing mothers. Unless it is absolutely necessary, HIDA scan will be delayed until you are no longer pregnant or nursing.

Tell your doctor if there’s a chance you could be pregnant or if you’re breast-feeding. In most cases, nuclear medicine tests, such as the HIDA scan, aren’t performed in pregnant women because of potential harm to the fetus.

Is a HIDA scan painful?

No. There is normally no pain during the scan. You will feel a sharp prick from the needle when the tracer is injected into the vein. You might feel pressure or a cold sensation while the radioactive tracer is injected into the vein in your arm. The site may be sore after the injection.

How long does a HIDA scan take?

Images will be taken every 5 to 15 minutes. Most of the time, the HIDA scan test takes about 1 hour, but it can take up to 4 hours.

Liver anatomy

A fibrous capsule encloses the liver, and ligaments divide the organ into a large right lobe and a smaller left lobe (Figure 2).

The liver also has two minor lobes, the quadrate lobe and the caudate lobe. Each lobe is separated into many tiny hepatic lobules, the liver’s functional units (Figure 3). A lobule consists of many hepatic cells radiating outward from a central vein. Blood-filled channels called hepatic sinusoids separate platelike groups of these cells from each other. Blood from the digestive tract, carried in the hepatic portal vein, brings newly absorbed nutrients into the sinusoids and nourishes the hepatic cells.

Large phagocytic macrophages called Kupffer cells are fixed to the inner linings of the hepatic sinusoids. They remove bacteria or other foreign particles that enter the blood through the intestinal wall, and are brought to the liver via the hepatic portal vein. Blood passes from these sinusoids into the central veins of the hepatic lobules and exits the liver via the hepatic veins.

Within the hepatic lobules are many fine bile canaliculi, which carry secretions from hepatic cells to bile ductules. The ductules of neighboring lobules converge to ultimately form the hepatic ducts. These ducts merge, in turn, to form the common hepatic duct.

Figure 1. Location of the human liver

liver

Figure 2. Liver anatomy

Liver anatomy

Figure 3. Liver lobule

liver hepatic lobules

Note: (a) Cross section of a hepatic lobule. (b) Enlarged longitudinal section of a hepatic lobule. (c) Light micrograph of hepatic lobules in cross section.

Figure 4. Gallbladder location

gallbladder location

Figure 5. Gallbladder anatomy

gallbladder anatomy

Figure 6. The common bile duct is closely associated with the pancreatic duct and the duodenum

bile duct and pancreatic duct opening into the duodenum

HIDA scan Results

To make a diagnosis, your doctor will consider your signs and symptoms and other test results with the results of your HIDA scan.

Results of a HIDA scan include:

  • Normal. The radioactive tracer moved freely with the bile from your liver into your gallbladder and small intestine. A normal result means that the gallbladder is visualized within 1 hour of the injection and the tracer is in the small intestine.
  • Slow movement of radioactive tracer. Slow movement of the tracer might indicate a blockage or obstruction, or a problem in liver function.
  • No radioactive tracer seen in the gallbladder (gallbladder not visualized). Inability to see the radioactive tracer in your gallbladder might indicate acute inflammation (acute cholecystitis). If the gallbladder is not visualized within 4 hours after the injection it indicates that there is either cholecystitis or cystic duct obstruction. HIDA scan for acute cholecystitis has a sensitivity of 97%, Specificity of 94%.
  • Abnormally low gallbladder ejection fraction. The amount of tracer leaving your gallbladder is low after you’ve been given a drug to make it empty, which might indicate chronic inflammation (chronic cholecystitis).
  • Radioactive tracer detected in other areas. Radioactive tracer found outside of your biliary system might indicate a leak.
  • Tracer not visualized in intestines means common bile duct obstruction. If the radioactive tracer moves through bile ducts very slowly, this may indicate a blockage or obstruction. Or it may indicate a problem in liver.

Figure 7. Normal HIDA scanNormal HIDA scanFootnotes: Normal HIDA scan performed with 200 mBq of Tc-99m DISIDA given IV and 30 minutes of imaging.

  • Uniform radiotracer activity throughout the liver
  • Prompt excretion into the bile ducts
  • Radioactivity tracer activity seen in the gallbladder after 10 min
  • Ongoing accumulation of radiotracer over the 30 min study.
  • Acute cholecystitis and/or cystic duct obstruction can effectively be excluded since there is radiotracer activity in the gallbladder after 10 min and ongoing accumulation over the 30 min study

Figure 8. Normal HIDA scan

Normal HIDA scan

Footnotes: Normal HIDA scan performed with 75 MBq of Tc-99m DISIDA given intravenously, with imaging commenced at 1 hr and an oral fat-rich meal given to stimulate gallbladder contraction. Radiotracer activity in the gallbladder is measured over time as the gallbladder empties through the cystic duct, allowing gallbladder function to be assessed. A normal gallbladder ejection fraction under this protocol is > 33%.

What Abnormal HIDA scan Results Mean

Abnormal HIDA scan results may be due to:

  • Abnormal anatomy of the bile system (biliary anomalies)
  • Bile duct obstruction
  • Bile leaks or abnormal ducts
  • Cancer of the hepatobiliary system
  • Gallbladder infection (cholecystitis)
  • Gallstones
  • Infection of the gallbladder, ducts, or liver
  • Liver disease
  • Transplant rejection (after liver transplant)

Figure 9. HIDA scan of a patient with biliary atresia

HIDA scan of a patient with biliary atresia

Figure 10. HIDA scan of a patient with acute acalculous cholecystitis – the gallbladder area which doesn’t light up with the radio-tracer.

HIDA scan of a patient with acute acalculous cholecystitis

Figure 11. HIDA scan of a patient with gallbladder agenesis

HIDA scan of a patient with gallbladder agenesis

Figure 12. HIDA scan of a patient with bile leak

HIDA scan of a patient with bile leak

Footnotes: (a) Magnetic resonance cholangiopancreatography and (b) HIDA scan images depicting normal hepatobiliary pathway with unidentified site of leak. (a) Coronal magnetic resonance cholangiopancreatography image of the hepatobiliary system showing fluid collection in the subhepatic region (white arrow), gall bladder with pericholecystic fluid (black arrow) and duodenal cap (arrow head). (b) HIDA scan showing some leak in the subhepatic region (large black arrow) with normal hepatobiliary pathway (small black arrow)

Figure 13. HIDA scan of a patient with gallbladder dysfunction

HIDA scan of a patient with gallbladder dysfunction

Footnotes: This cholescintigraphy (HIDA) scan was performed with 75 MBq of Tc-99m given IV, with imaging commenced at 1 hr and an oral fat-rich meal given to stimulate gallbladder contraction. Radiotracer activity in the gallbladder is measured over time as the gallbladder empties through the cystic duct, assessing gallbladder function. A normal gallbladder ejection fraction under this protocol is > 33%. The patient in this case proceeded to cholecystectomy. Histopathology revealed patchy, light chronic inflammation with Rokitansky-Aschoff sinus formation.

HIDA scan prep

How you prepare

Food and medications

Your doctor is likely to ask you:

  • To fast for 4 hours before your HIDA scan. You might be allowed to drink clear liquids.
  • About medications and supplements you take.

Clothing and personal items

You might be asked to:

  • Change into a hospital gown
  • Leave jewelry and other metal accessories at home or remove them before the procedure

HIDA scan procedure

Your health care team will position you on a table, usually on your back, and inject the radioactive tracer into a vein in your arm. You might feel pressure or a cold sensation while the radioactive tracer is injected. In some cases, you may be given a medicine during this test to see how well your gallbladder squeezes (contracts). The medicine may be injected into the vein.

If the provider cannot see the gallbladder after certain amount of time, you may get an intravenous injection of the drug sincalide (Kinevac), which makes your gallbladder contract and empty. Morphine is another drug sometimes given during a HIDA scan, this can help the radionuclide get into the gallbladder and makes the gallbladder easier to visualize. The morphine may cause you to feel tired after the exam. Otherwise, you may be asked to drink a high-density drink like Boost which will help your gallbladder contract.

A gamma camera is positioned over your abdomen to take pictures of the tracer as it moves through your body. The scanner detects the rays being emitted from the tracer. A computer displays images of where the tracer is found in the organs. Images will be taken every 5 to 15 minutes. This process takes about an hour, during which you’ll need to remain still.

Tell your team if you become uncomfortable. You might be able to lessen the discomfort by taking deep breaths.

On a computer, the radiologist will watch the progress of the radioactive tracer through your body. In some cases, you might need additional imaging within 24 hours if original images aren’t satisfactory.

After the HIDA scan procedure

In most cases, you can go about your day after your scan. The small amount of radioactive tracer will lose its reactivity or pass through your urine and stool over the next day or two. Drink plenty of water to help flush it out of your system.

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Procedures

Dilation and curettage

dilatation-and-curettage

What is a D&C

D&C also called dilation and curettage, is a surgical procedure in which the cervix (lower, narrow part of the uterus) is opened (dilated) and a thin instrument is inserted into the uterus so that the uterine lining (endometrium) can be scraped with a curette (spoon-shaped instrument) to remove abnormal tissues. This instrument (curette) is used to remove tissue from the inside of the uterus (curettage). Curettes used in a D&C can be sharp or use suction.

D&C refers to opening of the cervix (dilatation) followed by removal of tissue from inside the uterus (curettage). The D&C procedure is used to diagnose and treat many conditions that affect the uterus, such as abnormal bleeding, bleeding after menopause or if you have abnormal endometrial cells. A small sample of the tissue is sent to a laboratory for testing, allowing a pathologist to identify conditions such as polyps or uterine cancer.

Other related procedures used for diagnosing and treating the endometrium include endometrial ablation, hysteroscopy, in which a slender device is used to view the inside of the uterus and hysterectomy.

A D&C can also be used to remove all the contents from inside your womb, for example after a miscarriage or abortion (to prevent heavy bleeding), to remove remnants of the placenta after childbirth, or to remove polyps. A sample of tissue from inside the uterus can be viewed under a microscope to tell whether any cells are abnormal.

How to prepare for the D&C procedure

Your doctor will ask you a series of questions before a D&C. Make sure you tell them if you are pregnant or might be pregnant, or if you have a history of bleeding or allergies. You should follow any instructions on drinking and eating.

Sometimes your doctor may start dilating your cervix a few hours before the procedure, either with a medication called misoprostol (Cytotec) — given orally or vaginally — to soften the cervix or with a small rod called a laminaria, which is inserted into the cervix and left in place for a while.

Contact your doctor if you experience any of the following after a D&C:

  • Bleeding that’s heavy enough that you need to change pads every hour
  • Fever
  • Cramps lasting more than 48 hours
  • Pain that gets worse instead of better
  • Foul-smelling discharge from the vagina

How long does a D&C take?

The D&C procedure normally takes 5 to 10 minutes, but you will need to wait in recovery for a few hours afterwards.

How long do you bleed after a D&C?

You might have light bleeding for 10 to 14 days, which may become heavier when you do physical activity such as lifting. Use sanitary pads and not tampons. Your next period may also be heavier than usual.

You should see your doctor 1 to 2 weeks after the D&C procedure, but call them earlier if you experience:

  • bleeding after menopause (you need to change the pad every hour)
  • fever
  • cramps for more than 48 hours
  • worsening pain
  • a foul-smelling discharge from the vagina

Pregnancy after D&C

Up to 20% of pregnancies result in spontaneous abortion 1. Dilation and curettage (D&C) has been the traditional treatment throughout most of the 20th and 21st centuries 2.

Review of the literature regarding the effect of induced abortion on late pregnancy outcomes yields conflicting results 3. Some studies have suggested that dilation and curettage may predispose to negative future pregnancy outcomes, including higher rates of spontaneous abortion, incompetent cervix, preterm labor, preterm rupture of membranes, early neonatal death, and ectopic pregnancy 4. Multiple dilation and curettage procedures have even been associated with first trimester bleeding, abnormal presentations, placenta abruption, fetal distress, low birth weight, short gestation, and major malformations in subsequent pregnancies 5. The World Health Organization (WHO) in 1979 reported that second trimester spontaneous pregnancy loss was more common in women who had a history of induced abortion compared to primigravid women 6. Other studies concluded that second trimester dilation and evacuation (D&E) was not a risk factor for midtrimester pregnancy loss or spontaneous preterm birth 6. Overall, few studies are available pertaining to the effect of dilation and curettage on future pregnancy outcome, and it is questionable whether existing studies accounted for all confounding variables, including differences in medical history and demographics.

Expectant management has been shown to be successful in 82%–96% of women. Medical management is considered safe and effective, with success rates as high as 95% 7.

The current study 3 suggests that dilation and curettage may predispose to postpartum hemorrhage. It is important to consider the effects of surgical management for miscarriage on future pregnancy outcomes.

Other studies have also described an increase in abnormal bleeding during pregnancy following a D&C. In a study performed by Harlap and Davies in 1975, women with a history of induced abortion reported an increased frequency of first trimester bleeding compared to women with no prior abortions 8. Linn et al. observed an increase in first trimester bleeding in women with a history of one induced abortion, and an increase in first and third trimester bleeding and placental abruption in women with a history of two or more induced abortions 5. It is known that endomyometrial injury is frequent following D&C; in a study performed by Beuker et al. 9 in 2005, myometrium was observed microscopically among products of conception in 44% and 35% of termination and miscarriage tissues, respectively. Levin et al. 10 proposed that curettage itself may increase the risk of subsequent pregnancy loss, and that multiple induced abortions may somehow impair implantation or placentation. This study also suggests that uterine curettage may predispose to abnormal bleeding following delivery.

This study 3 does not demonstrate that cervical dilation during D&C predisposes to cervical insufficiency as previously described. Patients with a history of both dilation and curettage had no increase in poor pregnancy outcomes over patients who underwent curettage alone without mechanical dilation 3. The incidence of cervical incompetence was similar to that reported when patients with preexisting disease were excluded 11. Patients with an incompetent cervix may be at higher risk of requiring a D&C in a subsequent pregnancy secondary to retained placenta or incomplete abortion, which could explain the high incidence of cervical incompetence in this cohort. Other studies have suggested that rigid mechanical dilation, especially above 9 mm, may cause significant cervical trauma. Further research on this topic should be performed to determine at what point dilation becomes significant.

It is important to consider the effects of surgical management for missed and incomplete abortion on future pregnancy outcomes when managing patients. Nonsurgical management is an effective and safe alternative that carries a lower incidence of both short- and medium-term complications in randomized controlled trials 12. A more conservative approach may also decrease healthcare costs due to a reduction in the number of surgical procedures 12. Patient satisfaction should also be considered, and women have expressed high acceptance and satisfaction with conservative management 12. At the least, women should be given the opportunity to choose a treatment option after being informed of all the risks and alternatives. If surgical management is chosen, premedication with cytotec, or preoperative placement of laminaria, could reduce mechanical injury to the cervix and should be considered.

Uterus anatomy

The uterus is a hollow, muscular organ shaped somewhat like an inverted pear. The uterus receives the embryo that develops from an oocyte fertilized in the uterine tube, and sustains its development.

In its nonpregnant, adult state, the uterus is about 7 centimeters long, 5 centimeters wide (at its broadest point), and 2.5 centimeters in diameter. The size of the uterus changes greatly during pregnancy and it is somewhat larger in women who have been pregnant. The uterus is located medially in the anterior part of the pelvic cavity, superior to the vagina, and usually bends forward over the urinary bladder (see Figure 3).

The upper two-thirds or body (corpus), of the uterus has a domeshaped top called the fundus (see Figure 1). The uterine tubes (also called Fallopian tubes) connect at the upper lateral edges of the uterus. The lower third of the uterus is called the cervix. This tubular part extends downward into the upper part of the vagina. The cervix surrounds the opening called the cervical orifice, through which the uterus opens to the vagina.

The uterine wall is thick and has three layers (Figure 1). The endometrium, the inner mucosal layer, is covered with columnar epithelium and contains abundant tubular glands (Figure 3). The myometrium, a thick, middle, muscular layer, consists largely of bundles of smooth muscle cells. During the monthly female menstrual cycles and during pregnancy, the endometrium and myometrium change extensively. The perimetrium consists of an outer serosal layer, which covers the body of the uterus and part of the cervix.

Figure 1. Uterus anatomy

uterus

Figure 2. Uterus location

uterus anatomy

The menstrual cycle

With each menstrual cycle, the endometrium (Figure 3 below) prepares itself to nourish a fetus, as increased levels of estrogen and progesterone help to thicken its walls. If implantation of the fertilized egg does not occur, the lining of the endometrium, coupled with blood and mucus from the vagina and cervix (the lower, narrow part of the uterus located between the bladder and the rectum), make up the menstrual flow (also called menses) that leaves the body through the vagina. After menopause, menstruation stops and a woman should not have any bleeding.

Figure 3. Endometrium of the uterus and its blood supply

endometrium of the uterus and its blood supplyFigure 4. Dilation and curettagedilation and curettage

dilatation-and-curettage

Reasons for D&C procedure

A D&C may be used as a diagnostic or therapeutic procedure for abnormal bleeding. A D&C may be performed to determine the cause of abnormal or excessive uterine bleeding, to detect cancer, or as part of infertility (inability to become pregnant) investigation.

Causes of abnormal bleeding include the presence of abnormal tissues, such as fibroid tumors (benign tumors that develop in the uterus, also called myomas) polyps, or cancer of the endometrium or uterus. Tissues obtained from the D&C can be examined under a microscope. Abnormal uterine bleeding may also be due a hormone imbalance or disorder (particularly estrogen and progesterone) especially in women approaching menopause or after menopause.

A suction D&C uses suction to remove uterine contents. A suction D&C may be used following a miscarriage to remove the fetus and other tissues if they have not all been naturally passed. Infection or heavy bleeding can occur if these tissues are not completely removed.

Occasionally following childbirth, small pieces of the placenta (afterbirth) remain adhered to the endometrium and are not passed. This can cause bleeding or infection. A D&C may be used to remove these fragments so that the endometrium can heal properly.

There may be other reasons for your doctor to recommend a D&C.

D&C to diagnose a condition

Your doctor might recommend a type of D&C called endometrial sampling to diagnose a condition if:

  • You have abnormal uterine bleeding
  • You experience bleeding after menopause
  • Your doctor discovers abnormal endometrial cells during a routine test for cervical cancer

To perform the test, your doctor collects a tissue sample from the lining of your uterus (endometrium) and sends the sample to a lab for testing. The test can check for:

  • Endometrial hyperplasia — a precancerous condition in which the uterine lining becomes too thick
  • Uterine polyps
  • Uterine cancer

D&C to treat a condition

When performing a therapeutic D&C, your doctor removes the contents from inside your uterus, not just a small tissue sample. Your doctor may do this to:

  • Clear out tissues that remain in the uterus after a miscarriage or abortion to prevent infection or heavy bleeding
  • Remove a molar pregnancy, in which a tumor forms instead of a normal pregnancy
  • Treat excessive bleeding after delivery by clearing out any placenta that remains in the uterus
  • Remove cervical or uterine polyps, which are usually noncancerous (benign)

Your doctor may perform the D&C along with another procedure called a hysteroscopy. During a hysteroscopy, your doctor inserts a slim instrument with a light and camera on the end into your vagina, through your cervix and up into your uterus.

Your doctor then views the lining of your uterus on a screen, noting any areas that look abnormal, making sure there aren’t any polyps and taking tissue samples as needed. During a hysteroscopy, your doctor can also remove uterine polyps and fibroid tumors.

D&C complications

As with any surgical procedure, complications may occur. Dilation and curettage is usually very safe, and complications are rare. However, there are risks. Some possible complications of a D&C may include, but are not limited to, the following:

  • Heavy bleeding
  • Infection. Infection after a D&C is possible, but rare.
  • Perforation of the uterine wall or bowel. Perforation of the uterus occurs when a surgical instrument pokes a hole in the uterus. This happens more often in women who were recently pregnant and in women who have gone through menopause. Most perforations heal on their own. However, if a blood vessel or other organ is damaged, a second procedure may be necessary to repair it.
  • Damage to the cervix. If the cervix is torn during the D&C, your doctor can apply pressure or medicine to stop the bleeding, or can close the wound with stitches (sutures).
  • A reaction to the anaesthetic
  • Adhesions (scar tissue) may develop inside the uterus, leading to infertility or changes to your menstruation – known as Asherman syndrome, this is very rare and can often be treated with surgery

Patients who are allergic to or sensitive to medications, iodine, or latex should notify their doctor.

If you are pregnant or suspect that you may be pregnant, you should notify your health care provider.

There may be other risks depending on your specific medical condition. Be sure to discuss any concerns with your doctor prior to the procedure.

A vaginal, cervical, or pelvic infection may interfere with a D&C.

Before the D&C procedure

  • Your doctor will explain the D&C procedure to you and offer you the opportunity to ask any questions that you might have about the procedure.
  • You will be asked to sign a consent form that gives your permission to do the procedure. Read the form carefully and ask questions if something is not clear.

In addition to a complete medical history, your doctor may perform a complete physical examination to ensure you are in good health before undergoing the procedure. You may undergo blood tests or other diagnostic tests.

If your D&C procedure requires general, spinal, or epidural anesthesia, you will be asked to fast for eight hours before the procedure, generally after midnight. If your procedure is to be done under local anesthesia, your doctor will give you instructions about fasting.

  • If you are pregnant or suspect that you are pregnant, you should notify your health care provider. He or she may recommend a pregnancy test prior to the procedure.
  • Notify your doctor if you are sensitive to or are allergic to any medications, iodine, latex, tape, and anesthetic agents (local and general).
  • Notify your doctor of all medications (prescribed and over-the-counter) and herbal supplements that you are taking.
  • Notify your doctor if you have a history of bleeding disorders or if you are taking any anticoagulant (blood-thinning) medications, aspirin, or other medications that affect blood clotting. It may be necessary for you to stop these medications prior to the procedure.

If a sedative is given before the procedure, you will need someone to drive you home afterwards.

  • Arrange for someone to help you get home because you may be drowsy after the anesthesia wears off.
  • Clear your schedule to allow enough time for the procedure and recovery afterward. You’ll likely spend a few hours in recovery after the procedure.

You may want to bring a sanitary napkin to wear home after the procedure.

Based on your medical condition, your doctor may request other specific preparation.

In some cases, your doctor may start the process of dilating your cervix a few hours or even a day before the procedure. This helps your cervix open gradually and is usually done when your cervix needs to be dilated more than in a standard D&C, such as during pregnancy terminations or with certain types of hysteroscopy.

To promote dilation, your doctor uses a medication called misoprostol (Cytotec) — given orally or vaginally — to soften the cervix or inserts a slender rod made of laminaria into your cervix. The laminaria gradually expands by absorbing the fluid in your cervix, causing your cervix to open.

During the D&C procedure

A D&C may be performed in a doctor’s office, on an outpatient basis, or as part of your stay in a hospital. Procedures may vary depending on your condition and your doctor’s practices.

The type of anesthesia will depend on the specific procedure being performed and your medical history. Some D&C procedures may be performed while you are asleep under general anesthesia, or while you are awake under spinal or epidural anesthesia or with a local anaesthetic, where just the area around your cervix is numb. If spinal or epidural anesthesia is used, you will have no feeling from your waist down. The anesthesiologist will continuously monitor your heart rate, blood pressure, breathing, and blood oxygen level during the surgery.

Once you can’t feel anything, your doctor will insert an instrument called a speculum into your vagina so they can see your cervix. They will slowly dilate the cervix using a series of thicker and thicker rods. They will then remove the rods and insert an instrument called a curette to scrape away the lining of the uterus. This can also be done with suction.

The D&C procedure normally takes 5 to 10 minutes, but you will need to wait in recovery for a few hours afterwards.

Generally, a D&C follows this process:

  • You will be asked to remove clothing and be given a gown to wear.
  • You will be instructed to empty your bladder.
  • You lie on your back on an operating or examination table, with your feet and legs supported as for a pelvic examination.
  • An intravenous (IV) line may be started in your arm or hand.
  • A urinary catheter may be inserted.
  • Your doctor will insert an instrument called a speculum into your vagina to spread the walls of the vagina apart to expose the cervix.
  • Your cervix may be cleansed with an antiseptic solution.
  • For local anesthesia, the doctor may numb the area using a small needle to inject medication.
  • If general or regional anesthesia is used, the anesthesiologist will continuously monitor your heart rate, blood pressure, breathing, and blood oxygen level during surgery.
  • A type of forceps, called a tenaculum, may be used to hold the cervix steady for the procedure.
  • The inside of the cervical canal may be scraped with a small curette if the cervical tissue needs to be examined.
  • A thin, rod-like instrument, called a uterine sound, may be inserted through the cervical opening to determine the length of the uterus. If you have local anesthesia, this may cause some cramping. The sound will then be removed.
  • The cervix will be dilated by inserting a series of thin rods. Each rod will be larger in diameter than the previous one. This process will gradually enlarge the opening of the cervix so that the curette (spoon-shaped instrument) can be inserted.
  • The curette will be inserted through the cervical opening into the uterus and the sharp spoon-shaped edges will be passed across the lining of the uterus to scrape away the tissues. In some cases, suction may be used to remove tissues. If you have local anesthesia, this may cause cramping.
  • The instruments will be removed.

Any tissues collected with the procedure will be sent to the lab for examination. Pregnancy tissues (called products of conception) may be sent to the lab for culture or testing for genetic or chromosomal abnormalities.

What to expect after a D&C

The recovery process will vary depending on the type of procedure performed and type of anesthesia that was administered.

If you received regional or general anesthesia, you will be taken to the recovery room for observation. If you had general anesthesia, you may become nauseated or vomit, or you might have a sore throat if a tube was placed in your windpipe to help you breathe. With general anesthesia or light sedation, you may also feel drowsy for several hours.

Once your blood pressure, pulse, and breathing are stable and you are alert, you will be taken to your hospital room or discharged to your home. If this procedure was performed on an outpatient basis, you should plan to have another person drive you home.

After a D&C using local anesthesia, you may rest for about two hours before going home.

You may want to wear a sanitary pad for bleeding. It is normal to have some spotting or light vaginal bleeding for a few days after the procedure.

You may experience cramping for the first few days after a D&C.

Normal side effects of a D&C may last a few days and include:

  • Mild cramping
  • Spotting or light bleeding

For discomfort from cramping, your doctor may suggest taking ibuprofen (Advil, Motrin IB, others) or another medication.

You should be able to resume your normal activities within a day or two.

You may be instructed not to douche, use tampons, or have intercourse for two to three days after a D&C, or for a period of time recommended by your doctor.

Wait to put anything in your vagina until your cervix returns to normal to prevent bacteria from entering your uterus, possibly causing an infection.

You may also have other restrictions on your activity, including no strenuous activity or heavy lifting.

Because a D&C removes the lining of the uterus, the lining must build back up. Your next menstrual period may begin earlier or later than usual.

You may resume your normal diet unless your doctor advises you differently.

Take a pain reliever for cramping or soreness as recommended by your doctor. Aspirin or certain other pain medications may increase the chance of bleeding. Be sure to take only recommended medications.

Your doctor will advise you on when to return for further treatment or care.

Notify your doctor if you have any of the following:

  • Heavy bleeding
  • Foul-smelling drainage from your vagina
  • Fever and/or chills
  • Severe abdominal pain

Your doctor may give you additional or alternate instructions after the procedure, depending on your particular situation.

D&C recovery

It will take you a while to recover if you have had a general anaesthetic, and you should have someone with you when you go home. You should also not drive, operate machinery or drink alcohol for at least 24 hours after the procedure. You can get back to normal activities in a day or two.

You might feel some cramping and discomfort after a D&C, which you can control with paracetamol and with a heat pack. You might have light bleeding for 10 to 14 days, which may become heavier when you do physical activity such as lifting. Use sanitary pads and not tampons. Your next period may also be heavier than usual.

You should see your doctor 1 to 2 weeks after the D&C procedure, but call them earlier if you experience:

  • bleeding after menopause (you need to change the pad every hour)
  • fever
  • cramps for more than 48 hours
  • worsening pain
  • a foul-smelling discharge from the vagina

D&C recovery time

Normal side effects of a D&C may last a few days and include:

  • Mild cramping
  • Spotting or light bleeding

For discomfort from cramping, your doctor may suggest taking ibuprofen (Advil, Motrin IB, others) or another medication.

How many days rest after D&C?

You should be able to resume your normal activities within a day or two.

You may be instructed not to douche, use tampons, or have intercourse for two to three days after a D&C, or for a period of time recommended by your doctor.

Wait to put anything in your vagina until your cervix returns to normal to prevent bacteria from entering your uterus, possibly causing an infection.

You may also have other restrictions on your activity, including no strenuous activity or heavy lifting.

  1. Management of spontaneous abortion. Griebel CP, Halvorsen J, Golemon TB, Day AA. Am Fam Physician. 2005 Oct 1; 72(7):1243-50. https://www.aafp.org/afp/2005/1001/p1243.html[]
  2. A comparison of medical management with misoprostol and surgical management for early pregnancy failure. Zhang J, Gilles JM, Barnhart K, Creinin MD, Westhoff C, Frederick MM, National Institute of Child Health Human Development (NICHD) Management of Early Pregnancy Failure Trial. N Engl J Med. 2005 Aug 25; 353(8):761-9. https://www.nejm.org/doi/10.1056/NEJMoa044064[]
  3. Lohmann-Bigelow J, Longo SA, Jiang X, Robichaux AG. Does Dilation and Curettage Affect Future Pregnancy Outcomes? The Ochsner Journal. 2007;7(4):173-176. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3096409/[][][][]
  4. Madore C., Hawes W. E., Many F., et al. A study on the effects of induced abortion on subsequent pregnancy outcome. Am J Obstet Gynecol. 1981;139:516–521 https://www.ncbi.nlm.nih.gov/pubmed/7468718[]
  5. Linn S., Schoenbaum S. C., Monson R. R., et al. The relationship between induced abortion and outcome of subsequent pregnancies. Am J Obstet Gynecol. 1983;146:136–140. https://www.ncbi.nlm.nih.gov/pubmed/6682630[][]
  6. Kalish R. B., Chasen S. T., Rosenzweig L. B., et al. Impact of midtrimester dilation and evacuation on subsequent pregnancy outcome. Am J Obstet Gynecol. 2002;187:882–885 https://www.ncbi.nlm.nih.gov/pubmed/12388969[][]
  7. Nanda K., Peloggia A., Grimes D., et al. The Cochrane Library, Issue 2, 2007. Oxford: Update Software; Expectant care versus surgical treatment for miscarriage[]
  8. Harlap S., Davies A. M. Late sequelae of induced abortion: complications and outcome of pregnancy and labor. Am J Epidemiol. 1975;102:217–224 https://www.ncbi.nlm.nih.gov/pubmed/1163527[]
  9. Beuker J. M., Erwich J. J., Khong T. Y. Is endomyometrial injury during termination of pregnancy or curettage following miscarriage the precursor to placenta accreta? J Clin Pathol. 2005;58:273–275. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1770603/[]
  10. Levin A. A., Schoenbaum S. C., Monson R. R., et al. Association of induced abortion with subsequent pregnancy loss. JAMA. 1980;243:2495–2499 https://www.ncbi.nlm.nih.gov/pubmed/7382035[]
  11. Vyas N. A., Vink J. S., Ghidini A., et al. Risk factors for cervical insufficiency after term delivery. Am J Obstet Gynecol. 2006;195:787–791 https://www.ncbi.nlm.nih.gov/pubmed/16949413[]
  12. Tam W. H., Tsui M. H. Y., Lok I. H., et al. Long-term reproductive outcome subsequent to medical versus surgical treatment for miscarriage. Hum Reprod. 2005;20:3355–3359[][][]
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Procedures

Homocysteine

Homocysteine test

What is homocysteine

Homocysteine is a sulfhydryl (sulfur) containing amino acid, which is an intermediate product in the normal biosynthesis of the amino acids methionine and cysteine that is typically present in very small amounts in all cells of your body 1. Homocysteine is an amino acid produced via demethylation of dietary methionine, which is abundant in animal protein 2. Vitamin B6 (Pyridoxine), Folic acid (vitamin B9), Riboflavin, and Vitamin B12 (Cyanocobalamin) are all required for methionine metabolism, and deficiency of each of these vitamins result in elevated plasma homocysteine. That is because your body normally converts homocysteine into other products quickly. Since vitamin B6 (pyridoxine), vitamin B12 (cyanocobalamin) and folate (vitamin B9) are necessary to metabolize homocysteine, increased levels of the homocysteine amino acid may be a sign of deficiency in those vitamins. Elevations in plasma homocysteine are commonly found as a result of vitamin deficiencies, polymorphisms of enzymes of methionine metabolism, and renal disease. Homocysteine test determines the level of homocysteine in the blood and/or urine. A polymorphism of methylenetetrahydrofolate reductase (C-to-T substitution at nucleotide 677), which is quite common in most populations with a homozygosity rate of 10-15 %, is associated with moderate hyperhomocysteinemia, especially in the context of marginal folate intake. Plasma homocysteine is inversely related to plasma creatinine in patients with renal disease. This is due to an impairment in homocysteine removal in renal disease. The role of these factors, and of modifiable lifestyle factors, in affecting methionine metabolism and in determining plasma homocysteine levels.

Note that homocysteine blood level is a more sensitive test for folate and vitamin B12 deficiency than folate and vitamin B12 levels. A normal homocysteine blood level excludes significant folate and vitamin B12 deficiency, though homocysteine blood level has limited specificity because elevations occur in other inherited and acquired disorders.

Homocysteine is present in plasma in four different forms: around 1% circulates as free thiol, 70–80% remains disulphide-bound to plasma proteins, mainly albumin and 20–30% combines with itself to form the dimer homocysteine or with other thiols 3. Homocysteine is a key determinant of the methylation cycle 4. It is methylated to methionine, which undergoes S-adenosylation and forms S-adenosylmethionine (SAM) 4. S- adenosylmethionine is the principal methyl donor for all methylation reactions in cells 4. Condensation of methionine with ATP, leads to the formation of SAM (S- Adenosylmethionine) 5. The methyl group attached to the tertiary sulphur of S-adenosylmethionine can be transferred and therefore can cause methylation of other substances. This methylation is accompanied by energy loss, so this reaction is irreversible. The demethyation reaction leads to the formation of SAH (S- adenosylhomocysteine) 5. S- adenosylhomocysteine is a thioether (a sulfur bonded to two alkyl or aryl groups) analogous to methionine. The S-adenosylmethionine-to-S- adenosylhomocysteine ratio defines the methylation potential of a cell 4. Hydrolysis of SAH leads to the formation of homocysteine and adenosine 5. This homocysteine can be used in one of two ways:

  • In case of methionine deficiency, homocysteine can be re-methylated to form methionine 5. The enzyme N5, N10-methylenetetrahydrofolate reductase converts homocysteine to methionine 1.
  • In presence of sufficient methionine, homocysteine is instead used to produce cysteine 5. Cystathionine-β-synthase is an enzyme (with pyridoxine (vitamin B6) as an essential cofactor) that converts homocysteine to cysteine 1. Homocysteine is synthesized from the essential amino acid methionine, therefore cysteine is not an essential amino acid as long as sufficient methionine is available 5.

Figure 1. Homocysteine

Homocysteine

Figure 2. Homocysteine metabolism

Homocysteine metabolism

Homocysteine is an independent cardiovascular disease risk factor modifiable by nutrition and possibly exercise. Elevated homocysteine may be related to a higher risk for coronary heart disease, stroke, peripheral vascular disease (fatty deposits in peripheral arteries), and hardening of the arteries (atherosclerosis). Several mechanisms have been proposed for how homocysteine leads to cardiovascular disease risk, including damaging blood vessel walls and supporting the formation of inappropriate blood clots, but direct links haven not been confirmed. There are also several studies that indicate no benefit or lowering of cardiovascular disease risk with folic acid and B vitamin supplements. So far, the American Heart Association does not consider it a major risk factor for heart disease.

Homocysteine was first identified as an important biological compound in 1932 and linked with human disease in 1962 when elevated urinary homocysteine levels were found in children with mental retardation. This condition, called homocysteinuria (homocystinuria), was later associated with premature occlusive cardiovascular disease, even in children. Homocystinuria also called cystathionine beta synthase deficiency is a rare inherited condition that can also greatly increase homocysteine in the blood and urine. In homocystinuria, one of several different genes is altered, leading to a dysfunctional enzyme that does not allow the normal breakdown of the precursor to homocysteine, called methionine. Methionine is one of the eleven essential amino acids that must come from your diet because the body cannot produce it. Without the proper enzyme to break them down, homocysteine and methionine begin to build up in the body. Babies with this condition will appear normal at birth but within a few years begin to develop signs such as a dislocated lens in the eye, a long slender build, long thin fingers, skeletal abnormalities, osteoporosis, and a greatly increased risk of thromboembolism and of atherosclerosis that can lead to premature cardiovascular disease. The buildup of homocysteine in the arteries may also cause intellectual disability, mental illness, slightly low IQ, behavioral disorders, and seizures. Some of those may be alleviated if the condition is detected early, which is why all states screen newborns for homocystinuria.

Although homocysteine concentration in plasma is only about 10 micromolar (μM), even moderate hyperhomocysteinemia is associated with increased incidence of cardiovascular disease and Alzheimer’s disease. These observations led to research investigating the relationship of elevated homocysteine levels and cardiovascular disease in a wide variety of populations including middle age and elderly men and women with and without traditional risk factors for cardiovascular disease 6, 7. Moreover, homocysteine is found to be associated with cystathionine beta-synthase deficiency, cystathioninuria, methylenetetrahydrofolate reductase deficiency, and sulfite oxidase deficiency, which are inborn errors of metabolism.

The homocysteine and the nervous system

In the last decade, epidemiological observations have pointed towards a plausible association between hyperhomocysteinemia and CNS neurodegenerative disorders. Several studies demonstrated that homocysteine is capable of triggering neuronal damage via oxidative stress, DNA damage and activation of pro-apoptotic factors in cell cultures or animal models 8. In an experiment, SH-SY5Y neuroblastoma cells were modified to act as neuronal cells, by incubating them with retinoic acid, which induced their differentiation towards a neuronal-like phenotype 8. This was followed by incubation with/without D,L-homocysteine in a concentration range from 20 μM to 80 μM 8. The exposure to homocysteine induced a time and concentration dependent reduction of cell viability in comparison with controls. The highest cytotoxicity was portrayed by 80 μM homocysteine which produced 80% of cell death after 5 days of incubation 8. A significant reduction of cell viability to 35% was also observed after 5 days of incubation with 40 μM homocysteine. Cell exposure to homocysteine for a period of 3 days did not induce any significant change in Reactive Oxygen Species (ROS) levels, but incubation with homocysteine for 5 days resulted in a 4.4-fold increase in ROS production 8. Homocysteine notably triggered significant levels of genotoxic stress which was indicated by the assessment of DNA fragmentation by Comet assay. But the levels of genotoxic stress was significant only after a longer time of exposure, as shown by the number of Comet positive cells, which was significantly increased only after 5 days of incubation with homocysteine 8. Bax and Bcl-2 mRNA levels in cells showed an increase by two-fold and 14-fold, respectively, in the case of 5 days exposure to homocysteine 8. A time-dependent effect of homocysteine was also evident. The mRNA levels for the cyclins D1, E1, and A1 were increased by two-fold, six-fold, and five-fold, respectively, in cells exposed to homocysteine for 3 days, but the mRNA levels in case of cyclin B1 were not affected in the 3 day period 8. The mRNA levels of all cyclins returned to the basal levels after 5 days of incubation with homocysteine. A decrease in both mRNA and protein level, of p21, another key protein regulator of DNA damage induced cell death, was noted after 3 days of incubation with homocysteine, followed by a dramatic p21 up-regulation and protein synthesis at 5 days . Further down the timeline, a significant upregulation of p16 was observed, concomitantly with the reduction by 35% of phosphorylated pRB 8. These proteins are check-point regulators of G1-S phase progression through the inhibition of cyclin D-cdk4 complex and the direct binding and sequestration of the transcription factor E2F, respectively 8. Therefore, this indicates the arrest of cell cycle at G1 phase 8. The results suggest that prolonged exposure to mildly elevated homocysteine concentrations triggers oxidative and genotoxic stress in neuronal-like cells 8.

The effect of homocysteine on the brain

By adulthood, the folate related enzymes involved in purine and pyrimidine synthesis, decline almost tenfold. Hence, this leads us to believe that the provision of methyl groups for S-adenosylmethionine and methylation reactions coupled with recycling of homocysteine through methionine synthase may be dominant function of adult brain folate metabolism 9. The brain has a limited capacity for homocysteine metabolism. Folate plays an important role in the brain so a crucial mechanism is in play to protect the brain from folate deficiency. The level of 5 tetrahydrofolate in the cerebrospinal fluid is 3 times that of the plasma level and there exists an active process to maintain it 9. Methionine synthase is the only enzyme in the brain (neural tissue) that is capable of converting homocysteine to methionine. Cobalamin is a cofactor (hence essential) 9.

The brain tissue utilizes three mechanisms to maintain a low level of homocysteine 9:

  1. Efficient recycling through cobalamin dependent methionine synthase (given an adequate supply of cobalamine and folate),
  2. Catabolism through cystathione beta synthase to cystathione a non-noxious product,
  3. Export to external circulation 9.

In the brain and elsewhere disruption of homocysteine metabolism may result from nutritional imbalance, genetic defects or as a result of drug therapy 9.

The direct effect of homocysteine on the nervous system

The action of homocysteine as a neurotransmitter: homocysteine and its related compounds may have a role as an excitatory agonist on the NMDA subtype of glutamate receptors and recent evidence also points to the involvement of NMDA modulatory sites 9. It has also been shown that homocysteine, besides acting as a partial agonist at glutamate receptors also acts as a partial antagonist of glycine co-agonist site of the NMDA receptor 9. In the presence of normal glycine levels and normal physiological conditions homocysteine does not cause toxicity below millimolar concentrations. However in case of a head trauma or stroke, there is an elevation in glycine levels in which instance the neurotoxic effect of homocysteine as an agonist outweighs its neuroprotective antagonist effect. This may cause neuronal damage via calcium ion influx or free radical generation 9.

One evaluative experiment to discover the direct effect of homocysteine on the central nervous system involved local application of homocysteine by two different methods of drug delivery to the central nervous system of rats- pressure ejection and ionophoresis 10. Extracellular recordings were taken from neurons of cerebral cortex, cerebellum and midbrain. The recordings after either method of administration portrayed a dose-dependent increase in neuronal activity by D, L-homocysteine and L-glutamate in 67% of cells tested with both drugs. The similarity in the dose required of D,L-homocysteine and L-Glutamate, points out that D,L-homocysteine seems to be as potent as the latter. This data indicates that homocysteine seems to have an excitatory action on neurons, and this finding may account for neurological symptoms associated with disorders of amino acid metabolism 10. Some studies also suggest that elevated homocysteine levels may be associated with alterations in mental health such as cognitive impairment, dementia, depression, Alzheimer’s and Parkinson’s disease 9.

Homocysteine levels

Normal homocysteine levels: <5 μmol/L (less than 5 μmol/L)

Total concentration of homocysteine in plasma of healthy humans (fasting) is low and its level is between 5.0 and 15.0 μmol/L when assessed with the use of HPLC, or 5.0-12.0 μmol/l when immunoassay methods are used 11.

Elevated homocysteine levels

The definition of hyperhomocysteinemia differs between studies 1. Hyperhomocysteinemia is defined as a medical condition characterized by an abnormally high level (above 15 μmol/L) of homocysteine in the blood 12.

  • 5-15 μmol/L (Mild elevation)
  • 15-30 μmol/L (Moderate elevation) 3
  • 30-100 μmol/L (Intermediate elevation) 3
  • >100 μmol/L (Severe elevation) 3

What does abnormal homocysteine test result mean?

In cases of suspected malnutrition or vitamin B12 or folate deficiency, homocysteine levels may be elevated. If an individual does not get enough B vitamins and/or folate through diet or supplements, then the body may not be able to convert homocysteine to forms that can be used by the body. In this case, the level of homocysteine in the blood can increase.

Studies from the mid- to late-1990s suggested that people who have elevated homocysteine levels have a much greater risk of heart attack or stroke than those with average levels. Investigating the link between high homocysteine levels and heart disease remains an active area of research. At present, however, the use of homocysteine levels for risk assessment of cardiovascular disease, peripheral vascular disease, and stroke is uncertain given that several trials investigating folic acid and B vitamin supplementation indicate no benefit or lowering of cardiovascular disease risk.

Additionally, a 2012 study of multiple datasets, including 50,000 people with coronary heart disease, called the potential for a cause-and-effect relationship between homocysteine levels and heart disease into question. The American Heart Association does acknowledge the relationship between homocysteine levels and heart attack/stroke survival rates but doesn’t consider elevated homocysteine a major risk factor for cardiovascular disease.

While the American Heart Association does not recommend widespread use of folic acid and B vitamins to reduce risk of heart attack and stroke, it does promote a balanced, healthy diet and advise health practitioners to consider overall risk factors and diet in managing cardiovascular disease.

In newborn testing, greatly increased concentrations of homocysteine in the urine and blood mean that it is likely that an infant has homocystinuria and indicates the need for further testing to confirm the cause of the increase.

When test results suggest homocystinuria, liver or skin biopsy samples are sometimes tested to determine whether the enzyme cystathionine beta synthase is present. The absence of this enzyme is the most common cause of homocystinuria. Genetic tests may be ordered to test for one or more of the most common gene mutations. If someone has a strong family history of early atherosclerosis or a family member has been diagnosed with homocystinuria, then that person should be tested for the gene mutation that was found in the family member.

Could any medications I may be taking have an effect on my homocysteine level?

Yes. There are numerous drugs that may either increase or decrease the amount of homocysteine in your body. You should always keep your healthcare provider and pharmacist aware of any medications, traditional or herbal, that you are taking since they may affect the test results. Azaribine, carbamazepine, methotrexate, nitrous oxide, and phenytoin can all cause increased levels of homocysteine. Oral contraceptives can also affect the metabolism of homocysteine.

Possible causes of elevated homocysteine levels

There are two types of hyperhomocysteinemia: (1) the rare but severe forms are due to major genetic mutations of the enzymes implicated in homocysteine metabolism; (2) the more common forms cause moderately elevated homocysteine levels related to a pathogenesis such as genetic and environmental factors 1.

  • Genetic disorders
  • Consider vitamin B6 (Pyridoxine), Folic acid (vitamin B9) and Vitamin B12 (Cyanocobalamin) deficiencies
  • Renal disease
  • Smoking

Homocysteine levels can increase with age, when a person smokes, and with the use of drugs such as carbamazepine, methotrexate, and phenytoin. Homocysteine levels are lower in women than in men. Women’s concentrations increase after menopause, possibly due to decreased estrogen production.

Hyperhomocysteinemia may arise from genetic defects of enzymes involved in homocysteine metabolism. The enzymes involved can be 5, 10-methylene tetrahydrofolate reductase, methionine synthase, and cystathionine-β-synthase 13. The most common one that is detected worldwide and has a high incidence in different populations, is single nucleotide polymorphisms of 5,10-methylene tetrahydrofolate reductase which has been associated with mild (13–24 μM) and moderate (25–60 μM) hyperhomocysteinemia 13. Hankey et al. 14 stated that the most common enzyme defect associated with moderately raised total homocysteine is a point mutation (C-to-T substitution at nucleotide 677) in the coding region of the gene for MTHFR, which is associated with a thermo labile MTHFR variant that has about half-normal activity 14. The most common of the genetic causes of severe hyperhomocysteinemia and classic homocystinuria (congenital homocystinuria) is believed to be homozygous deficiency of CβS (cystathionine-β-synthase) which results in an increase of up to 40-fold in fasting total homocysteine. Other rarer causes of severe hyperhomocysteinemia are considered to be homozygous deficiency of MTHFR, deficiency of methionine synthase, and impaired activity of methionine synthase due to genetic disorders of vitamin B12 metabolism 14.

Hyperhomocysteinemia can also arise from nutritional deficiencies of folate, vitamin B6, and vitamin B12 13. Blood levels of folate, vitamin B12 and to a lesser extent, vitamin B6 are related inversely to total homocysteine; therefore a person with a nutritional deficiency that leads to low blood concentrations of the aforementioned is at increased risk of hyperhomocysteinemia 13. Several diseases such as renal and thyroid dysfunction, cancer, psoriasis, and diabetes as well as various drugs, alcohol, tobacco, coffee, older age and menopause, are believed to be associated with moderately elevated homocysteine concentrations 15. A rise in serum creatinine also leads to a rise in fasting total homocysteine 14. The major route of homocysteine clearance from plasma is the kidney, and the rise is due to defective metabolism of homocysteine by the kidney 14. Total homocysteine levels are found to be considerably higher in patients with chronic renal disease than the moderately raised concentrations commonly found in patients with atherothrombotic vascular disease, and this may be the probable cause that contributes to the high incidence of vascular complications in patients with chronic renal failure 14. Plasma homocysteine concentrations can be increased by various drugs and diseases that interfere with folate, vitamin B6, and B12 metabolism, hence an abnormal homocysteine concentration may have a probable use as a diagnostic aid for some of these conditions 14.

There has been an indication towards a significant correlation between hyperhomocysteinemia and cardiovascular disease and its complications such as heart attacks and strokes 16. It is believed that hyperhomocysteinemia leads to endothelial cell damage, reduction in the flexibility of vessels, and alters the process of haemostasis 16. Hyperhomocysteinemia may lead to an enhancement of the adverse effects of risk factors like hypertension, smoking, lipid and lipoprotein metabolism, as well as promotion of the development of inflammation 16. The prevalence of hyperhomocysteinemia may vary significantly between populations, and most likely depend on age, diet, and genetic background as well 15. Increasing age, male sex, smoking, coffee consumption, high blood pressure, unfavourable lipid profile, high creatinine and faulty diet are some of the factors associated with increased homocysteine levels 17. On the other hand, physical activity, moderate alcohol consumption, good folate and vitamin B12 status are associated with lower homocysteine levels. Vegetarians may be at a higher risk of hyperhomocysteinemia due to low plasma B12 levels but the difference is likely to be insignificant 17.

Management Options

  • Consider vitamin supplements in those with genetic hyperhomocysteinemia
    • Nutrients involved in the metabolism of homocysteine include folate, vitamin B12, vitamin B6, riboflavin, and choline. Although supplementation with folate, vitamin B6, and vitamin B12 successfully lowers homocysteine concentration in the blood, no significant effect on cardiovascular disease risk has been demonstrated. There is some evidence that riboflavin supplementation may lower homocysteine and blood pressure in individuals with a certain genetic predisposition. The consumption of folic acid supplements or cereals that are fortified with folic acid and to a lesser extent vitamin B6 and vitamin B-12, can lower blood homocysteine levels and may be beneficial in people with even mild genetic hyperhomocysteinemia.
  • Manage other cardiovascular risk factors including obesity, exercise, diabetes, hypertension, cholesterol and cigarette smoking

Homocysteine test

The homocysteine test may be used a few different ways:

  • A health practitioner may order a homocysteine test to determine if a person has a vitamin B12 or folate deficiency. The homocysteine concentration may be elevated before B12 and folate tests are abnormal. Some health practitioners may recommend homocysteine testing in malnourished individuals, the elderly, who often absorb less vitamin B12 from their diet, and individuals with poor nutrition, such as drug or alcohol addicts.
  • Homocysteine may be ordered as part of a screen for people at high risk for heart attack or stroke. It may be useful in someone who has a family history of coronary artery disease but no other known risk factors, such as smoking, high blood pressure, or obesity. However, the exact role that homocysteine plays in the progression of cardiovascular disease has not been established, so the utility of the screening test continues to be questioned. Routine screening, such as that done for total cholesterol, has not been recommended.
  • Tests for both a urine and blood homocysteine may be used to help diagnose homocystinuria if a health practitioner suspects that an infant or child may have this inherited disorder. In the U.S., all babies are routinely tested for excess methionine, a sign of homocystinuria, as part of their newborn screening. If a baby’s test is positive, then urine and blood homocysteine tests are often performed to confirm the findings.

When is homocysteine test ordered?

Homocysteine test may be ordered when a health practitioner suspects that a person may have a vitamin B12 and/or folate deficiency. Signs and symptoms are initially subtle and nonspecific. People with an early deficiency may be diagnosed before they experience any overt symptoms. Other affected people may experience a variety of mild to severe symptoms that can include:

  • Diarrhea
  • Dizziness
  • Fatigue, weakness
  • Loss of appetite
  • Paleness
  • Rapid heart rate
  • Shortness of breath
  • Sore tongue and mouth
  • Tingling, numbness, and/or burning in the feet, hands, arms, and legs (with B12 deficiency)

Homocysteine testing may be ordered as part of assessing a person’s risk of cardiovascular disease, depending on the individual’s age and other risk factors. It may also be ordered following a heart attack or stroke to help guide treatment.

Homocysteine test is may be ordered when newborn screening detects an elevated level of methionine or if an infant or child has signs and symptoms of homocystinuria. Babies with this condition will appear normal at birth, but if not treated, they will, within a few years, begin to develop signs such as a dislocated lens in the eye, a long slender build, long thin fingers, and skeletal abnormalities.

Vitamin B12 and folate deficiencies

Vitamin B12 and folate deficiencies are a lack of these two B complex vitamins that the body needs for several important functions. They are required to make normal red blood cells (RBCs), repair tissues and cells, synthesize DNA (the genetic material in cells). B12 is also important for normal nerve cell function. B12 and folate (also known as folic acid or vitamin B9) are nutrients that cannot be produced in the body and must be supplied by the diet. The body stores 3 to 6 years worth of B12 and about a 3 months’ supply of folate in the liver. So a B12 and/or folate deficiency reflects a chronic shortage of one or both of these vitamins.

In the U.S., B12 and folate deficiencies are not common in healthy adults because the body can store sufficient amounts and most adults eat enough foods or take supplements that contain these vitamins to meet their daily requirements. There are, however, people at risk of deficiency, such as the elderly, people with intestinal problems that prevent them from absorbing enough of the vitamins, heavy alcohol drinkers, and pregnant women, who need increased amounts of these vitamins.

B12 and folate deficiencies and their associated signs and symptoms can take months to years to manifest in adults. Infants and children will show signs of deficiency more rapidly because they have not yet had time to store sufficient amounts.

Over time, a deficiency in either B12 or folate can lead to macrocytic anemia, a condition in which red blood cells are enlarged. This production of fewer but larger red blood cells decreases the blood’s ability to carry oxygen. People with anemia may be weak, light-headed, and short of breath. Megaloblastic anemia, a type of macrocytic anemia, is characterized by the production of fewer but larger red blood cells in addition to some cellular changes in the bone marrow. Other laboratory findings associated with megaloblastic anemia include decreased white blood cell (WBC) count and platelet count.

A deficiency in B12 can also result in varying degrees of neuropathy or nerve damage that can cause tingling and numbness in the person’s hands and feet. In severe cases, mental changes that range from confusion and irritability to dementia may occur.

Pregnant women need increased folate for proper fetal development because of the added stress of rapidly growing fetal cells. A folate deficiency during pregnancy, especially in the early weeks when a woman might not know she is pregnant, may lead to premature birth and neural tube birth defects  such as spina bifida in the child. To help prevent neural tube birth defects, the Food and Drug Administration mandated increased folate supplementation of grain products a number of years ago, which led to about a 50% decrease in neural tube defects in the U.S. Even so, it can be difficult sometimes to get enough folate from foods, so it is recommended that all women who may become pregnant take 400 micrograms of folate every day.

Figure 3. Folate-rich food sources

Folate-rich food sources

Figure 4. Vitamin B12 rich food sources

Vitamin B12 rich food sources

Vitamin B12 and folate deficiencies signs and symptoms

The initial signs and symptoms associated with B12 and folate deficiencies may be subtle and nonspecific. They may be related to the resulting megaloblastic anemia, nerve damage, and/or gastrointestinal changes. People with an early deficiency may be diagnosed before they experience any noticeable symptoms. Other affected people may experience a variety of mild to severe signs and symptoms that can include:

  • Diarrhea
  • Dizziness
  • Fatigue, muscle weakness
  • Loss of appetite
  • Pale skin
  • Rapid heart rate, irregular heartbeats
  • Shortness of breath
  • Sore tongue and mouth
  • Tingling, numbness, and/or burning in the feet, hands, arms, and legs (with B12 deficiency)
  • Confusion or forgetfulness
  • Paranoia

Vitamin B12 and folate deficiencies causes

There are a variety of causes of B12 and/or folate deficiencies. They include:

Insufficient dietary intake

B12 is found in animal products such as red meat, fish, poultry, milk, and eggs. Folate, also called folic acid or vitamin B9, is found in leafy green vegetables, citrus fruits, dry beans, yeast, and fortified cereals.

The human body stores several years’ worth of B12 in the liver. Since a variety of foods consumed by Americans contain B12, a dietary deficiency of this vitamin is extremely rare in the U.S. It may be seen, for example, in people with generally poor nutrition or malnutrition, in vegans who do not consume any animal products, including milk and eggs, and in breastfed infants of vegans. In adults, dietary deficiencies do not usually cause symptoms until stores of the vitamins within the body have been depleted. Deficiencies in children and infants, however, show up fairly quickly since they have not had time to store as much of the vitamins as adults.

Folate deficiency used to be a common, but in 1997 the U.S. government mandated supplementation of cereals, breads, and other grain products with folic acid. Because folate is stored in tissue in smaller quantities than B12, folate must be consumed more regularly than B12.

Malabsorption

Both B12 and folate deficiencies may be seen in people who have conditions that interfere with absorption of the vitamins in the small intestine. Vitamin B12 absorption occurs in a series of steps. B12 is normally released from food by stomach acid and then, in the small intestine, is bound to intrinsic factor (IF), a protein made by parietal cells in the stomach. This B12-IF complex is then absorbed by the small intestine, bound by carrier proteins (transcobalamins), and enters the circulation. If a disease or condition interferes with any of these steps, then B12 absorption is impaired.

Some examples of these conditions include:

  • Pernicious anemia is the most common cause of B12 deficiency. A protein called intrinsic factor, made by parietal cells that line the stomach, is needed for B12 absorption. In pernicious anemia, inflammation damages the parietal cells, leading to little or no intrinsic factor, thus preventing the intestines from absorbing B12. With insufficient B12, the body produces enlarged but fewer RBCs. Because of the larger than normal RBCs, this is often referred to as megaloblastic or macrocytic anemia.
  • Celiac disease
  • Inflammatory bowel disease, including Crohns disease and ulcerative colitis
  • Bacterial overgrowth or the presence of parasites in the intestines
  • Reduced stomach acid production; stomach acid is necessary to separate B12 from the protein in food. This is the most common cause of B12 deficiency in the elderly and in individuals on drugs that suppress gastric acid production.
  • Surgery that removes part of the stomach (and the parietal cells) or the intestines may greatly reduce absorption of nutrients. This is a concern that is considered when gastric by-pass procedures are performed.
  • Chronic pancreatitis

Increased need

All pregnant women need increased amounts of folate for proper fetal development. If a woman has a folate deficiency prior to pregnancy, it will be intensified during the pregnancy and may lead to premature birth and neural tube defects in the child. It is recommended that women with any chance of becoming pregnant take folic acid supplements because neural tube defects can develop in the first few weeks of pregnancy, before many women realize they are pregnant.

People with cancer that has spread (metastasized) or with a chronic hemolytic anemia such as due to sickle cell disease have an increased need for folate.

Other causes:

  • Heavy alcohol drinking and chronic alcoholism can cause B12 and/or folate deficiency through a combination of poor nutrition and a decrease in the amount of B12 released from dietary proteins.
  • Some drugs can cause B12 deficiency. For example, the diabetes drug metformin prevents B12 from being absorbed, while omeprazole (an acid reflux drug also known as Prilosec) reduces gastric acids and prevents B12 release from food.
  • Anti-seizure medications such as phenytoin can decrease folate by blocking folate absorption.
  • Methotrexate, an anti-cancer drug, affects body metabolism and use of folate.

Vitamin B12 and folate deficiencies diagnosis

Laboratory testing is used to detect a vitamin deficiency, determine its severity, establish it as the underlying cause of someone’s symptoms, and to monitor the effectiveness of treatment. The anemia and large red blood cells (RBCs) associated with a vitamin B12 or folate deficiency are often initially detected during a routine complete blood count (CBC). Additional laboratory testing is performed as follow up to identify the specific deficiency.

Laboratory Tests

To diagnose or monitor B12 and folate deficiencies:

  • B12 blood level. If low, a deficiency is indicated, but it does not identify the cause. A low level of intrinsic factor may be a cause, for example. This test also may be ordered to monitor the effectiveness of treatment.
  • Folate level. Either serum or RBC folate levels may be tested; if either is low, it indicates a deficiency. The tests may also be ordered to monitor the effectiveness of treatment. Pregnant women may be given this test at prenatal checkups.
  • Complete blood count (CBC). This group of tests is ordered routinely to evaluate the health of blood cells. It determines the number of cell types and can give an indication of the physical characteristics of some of the cells. With both B12 and folate deficiencies, the amount of hemoglobin and the red blood cell count may be low and the RBCs are abnormally large (macrocytic or megaloblastic), resulting in an anemia. White blood cells and platelets also may be decreased.
  • Methylmalonic acid (MMA). This test may be ordered to help detect mild or early B12 deficiency.
  • Homocysteine. This test is seldom ordered but may be elevated in both B12 and folate deficiency.

To help determine the cause of a B12 deficiency:

  • Intrinsic factor antibody. The antibody prevents intrinsic factor from carrying out its function, that is, to carry vitamin B12 and allow B12 to be absorbed at a specific segment of the small intestine.
  • Parietal cell antibody. An antibody against the parietal cells that produce intrinsic factor. This antibody can disrupt the production of intrinsic factor and is present in a large percentage of those with pernicious anemia, but it may also be seen in other autoimmune disorders.
  • Gastrin. A hormone that regulates the production of acid in the stomach during the digestive process. Increased gastrin is sometimes seen in pernicious anemia.
  • Schilling test. Once frequently ordered to confirm a diagnosis of pernicious anemia, this test is generally no longer available.

Vitamin B12 and folate deficiencies treatment

Treatment for B12 and folate deficiencies frequently involves supplementation, which may be long-term or lifetime, depending on the underlying cause. People who lack intrinsic factor or have conditions causing general malabsorption require injections of B12. Folate is given as an oral supplement.

It is generally recommended that all women contemplating having a child or who may become pregnant take folic acid supplements to ensure that they have a sufficient store for normal fetal development and to prevent neural tube defects.

Individuals deficient in both B12 and folate will require replenishment of both. If someone with a B12 deficiency only takes folic acid supplements, the macrocytic anemia may be resolved but the underlying neuropathy caused by the B12 deficiency will persist. Appropriate treatment should resolve symptoms but may not reverse all of the nerve damage.

Homocystinuria

Homocystinuria is an inherited disorder in which the body is unable to process certain building blocks of proteins (amino acids) properly. There are multiple forms of homocystinuria, which are distinguished by their signs and symptoms and genetic cause. The most common form of homocystinuria is characterized by nearsightedness (myopia), dislocation of the lens at the front of the eye, an increased risk of abnormal blood clotting, and brittle bones that are prone to fracture (osteoporosis) or other skeletal abnormalities. Some affected individuals also have developmental delay and learning problems.

Less common forms of homocystinuria can cause intellectual disability, failure to grow and gain weight at the expected rate (failure to thrive), seizures, problems with movement, and a blood disorder called megaloblastic anemia. Megaloblastic anemia occurs when a person has a low number of red blood cells (anemia), and the remaining red blood cells are larger than normal (megaloblastic).

The signs and symptoms of homocystinuria typically develop within the first year of life, although some mildly affected people may not develop features until later in childhood or adulthood.

The most common form of homocystinuria affects at least 1 in 200,000 to 335,000 people worldwide. The disorder appears to be more common in some countries, such as Ireland (1 in 65,000), Germany (1 in 17,800), Norway (1 in 6,400), and Qatar (1 in 1,800). The rarer forms of homocystinuria each have a small number of cases reported in the scientific literature.

Homocystinuria Causes

Homocystinuria is inherited in families as an autosomal recessive trait. This means that the child must inherit a non-working copy of the gene from each parent to be seriously affected. Most often, the parents of an individual with an autosomal recessive condition each carry one copy of the mutated gene, but do not show signs and symptoms of the condition.

Although people who carry one mutated copy and one normal copy of the CBS gene do not have homocystinuria, they are more likely than people without a CBS mutation to have shortages (deficiencies) of vitamin B12 and folic acid.

Homocystinuria has several features in common with Marfan syndrome, including skeletal and eye changes.

Homocystinuria Genetic Changes

Mutations in the CBS, MTHFR, MTR, MTRR, and MMADHC genes cause homocystinuria. The CBS gene provides instructions for making an enzyme called cystathionine beta-synthase. This enzyme acts in a chemical pathway and is responsible for using vitamin B6 to convert building block of proteins (amino acid) called homocysteine and serine to a molecule called cytathionine. Another enzyme then converts cystathionine to the amino acid cysteine, which is used to build proteins or is broken down and excreted in urine. Additionally, other amino acids, including methionine, are produced in this pathway.

Mutations in the CBS gene cause the most common form of homocystinuria. The CBS gene provides instructions for producing an enzyme called cystathionine beta-synthase. This enzyme acts in a chemical pathway and is responsible for converting the amino acid homocysteine to a molecule called cystathionine. As a result of this pathway, other amino acids, including methionine, are produced. Mutations in the CBS gene disrupt the function of cystathionine beta-synthase, preventing homocysteine from being used properly. As a result, this amino acid and toxic byproducts substances build up in the blood. Some of the excess homocysteine is excreted in urine.

Rarely, homocystinuria can be caused by mutations in several other genes. The enzymes made by the MTHFR, MTR, MTRR, and MMADHC genes play roles in converting homocysteine to methionine. Mutations in any of these genes prevent the enzymes from functioning properly, which leads to a buildup of homocysteine in the body. Researchers have not determined how excess homocysteine and related compounds lead to the signs and symptoms of homocystinuria.

Homocystinuria Prevention

Genetic counseling is recommended for people with a family history of homocystinuria who want to have children. Prenatal diagnosis of homocystinuria is available. This involves culturing amniotic cells or chorionic villi to test for cystathionine synthase (the enzyme that is missing in homocystinuria).

If there are known gene defect in the parents or family, samples from chorionic villus sampling (CVS) or amniocentesis can be used to test for these defects.

Homocystinuria Signs and Symptoms

Newborn infants appear healthy. Early symptoms, if present, are not obvious.

Symptoms may occur as mildly delayed development or failure to thrive. Increasing visual problems may lead to diagnosis of this condition.

The health care provider may notice that the child is tall and thin.

Other signs include:

  • Curved spine (scoliosis)
  • Deformity of the chest
  • Dislocated lens of the eye

If there is poor or double vision, an eye doctor (ophthalmologist) will perform a dilated eye exam to look for dislocation of the lens or nearsightedness.

There may be a history of blood clots. Intellectual disability or mental illness is also possible.

Other symptoms include:

  • Chest deformities (pectus carinatum, pectus excavatum)
  • Flush across the cheeks
  • High arches of the feet
  • Intellectual disability
  • Knock knees
  • Long limbs
  • Mental disorders
  • Nearsightedness
  • Spidery fingers (arachnodactyly)
  • Tall, thin build

Possible Complications

Most serious complications result from blood clots. These episodes can be life threatening.

Dislocated lenses of the eyes can seriously damage vision. Lens replacement surgery may be needed.

Intellectual disability is a serious consequence of the disease. But, it can be reduced if diagnosed early.

Homocystinuria Diagnosis

Exams and Tests

Tests that may be ordered include any of the following:

  • Amino acid screen of blood and urine
  • Genetic testing
  • Liver biopsy and enzyme assay
  • Skeletal x-ray
  • Skin biopsy with a fibroblast culture
  • Standard ophthalmic exam

Homocystinuria Treatment

There is no cure for homocystinuria. About half of people with the disease respond to vitamin B6 (also known as pyridoxine).

Those who do respond will need to take vitamin B6 (pyridoxine), B9 (folate), and B12 supplements for the rest of their lives. Those who do not respond will need to eat a low-methionine diet. Most will need to be treated with trimethylglycine (a medicine also known as betaine).

Neither a low-methionine diet nor medicine will improve existing intellectual disability. Medicine and diet should be closely supervised by a doctor who has experience treating homocystinuria.

Figure 6. Pyridoxine vitamin B6 rich food sources

Pyridoxine vitamin B6 rich food sources

Homocystinuria Outlook (Prognosis)

Although no cure exists for homocystinuria, vitamin B therapy can help about half of people affected by the condition.

If the diagnosis is made in childhood, starting a low-methionine diet quickly may prevent some intellectual disability and other complications of the disease. For this reason, some states screen for homocystinuria in all newborns.

People whose blood homocysteine levels continue to rise are at increased risk for blood clots. Clots can cause serious medical problems and shorten lifespan.

  1. Homocysteine as a risk factor for cardiovascular disease: should we (still) worry about? Faeh D, Chiolero A, Paccaud F. Swiss Med Wkly. 2006 Dec 2; 136(47-48):745-56. https://www.ncbi.nlm.nih.gov/pubmed/17225194/[][][][][]
  2. Venes D, Clarence WT. In: Taber’s Cyclopedic Medical Dictionary. 21. Venes D, editor. Philadelphia: F.A. Davis; 2005. p. 1089.[]
  3. Homocysteine and vascular disease. Hankey GJ, Eikelboom JW. Lancet. 1999 Jul 31; 354(9176):407-13. https://www.ncbi.nlm.nih.gov/pubmed/10437885/[][][][]
  4. Epigenetic modifications: basic mechanisms and role in cardiovascular disease (2013 Grover Conference series). Loscalzo J, Handy DE. Pulm Circ. 2014 Jun; 4(2):169-74. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4070783/[][][][]
  5. Harvey RA, Ferrier DR. In: Lippincott’s Illustrated Reviews, Biochemistry. 5. Rhyner S, editor. Philadelphia: Wolters Kluwer Health; 2011. pp. 264–5.[][][][][][]
  6. Exercise, nutrition, and homocysteine. Int J Sport Nutr Exerc Metab. 2006 Aug;16(4):341-61. https://www.ncbi.nlm.nih.gov/pubmed/17136938[]
  7. Homocysteine and cardiovascular disease: interactions between nutrition, genetics and lifestyle. Can J Appl Physiol. 2004 Dec;29(6):773-80. https://www.ncbi.nlm.nih.gov/pubmed/15630149[]
  8. Curro M, Gugliandolo A, Gangemi C, Risitano R, Ientile R, Caccamo D. Toxic effects of mildly elevated homocysteine concentrations in neuronal-like cells. Neurochem Res. 2014;39:1485–95. doi: 10.1007/s11064-014-1338-7. https://www.ncbi.nlm.nih.gov/pubmed/24867323[][][][][][][][][][][][]
  9. Carmel R, Jacobsen DW. In: Homocysteine in health and disease. Carmel R, Jacobsen DW, editors. Cambridge: Cambridge UP; 2001. pp. 183–93.[][][][][][][][][][]
  10. The effect of local application of homocysteine on neuronal activity in the central nervous system of the rat. Wuerthele SE, Yasuda RP, Freed WJ, Hoffer BJ. Life Sci. 1982 Dec 13; 31(24):2683-91. https://www.ncbi.nlm.nih.gov/pubmed/6130457/[][]
  11. [Hyperhomocysteinemia in patients with cardiovascular disease]. Baszczuk A, Kopczyński Z. Postepy Hig Med Dosw (Online). 2014 Jan 2; 68():579-89. https://www.ncbi.nlm.nih.gov/pubmed/24864108/[]
  12. Influence of folic acid on plasma homocysteine levels &amp; arterial endothelial function in patients with unstable angina. Guo H, Chi J, Xing Y, Wang P. Indian J Med Res. 2009 Mar; 129(3):279-84. https://www.ncbi.nlm.nih.gov/pubmed/19491420/[]
  13. Curro M, Gugliandolo A, Gangemi C, Risitano R, Ientile R, Caccamo D. Toxic effects of mildly elevated homocysteine concentrations in neuronal-like cells. Neurochem Res. 2014;39:1485–95. doi: 10.1007/s11064-014-1338-7 https://www.ncbi.nlm.nih.gov/pubmed/24867323[][][][]
  14. Hankey GJ, Eikelboom JW. Homocysteine and vascular disease. Lancet. 1999;354:407–13. doi: 10.1016/S0140-6736(98)11058-9. https://www.ncbi.nlm.nih.gov/pubmed/10437885[][][][][][][]
  15. Faeh D, Chiolero A, Paccaud F. Homocysteine as a risk factor for cardiovascular disease: should we (still) worry about it? Swiss Med Wkly. 2006;136:745–56 https://www.ncbi.nlm.nih.gov/pubmed/17225194[][]
  16. Baszczuk A, Kopczynski Z. Hyperhomocysteinemia in patients with cardiovascular disease [Abstract] Postepy Hig Med Dosw. 2014;68:579. doi: 10.5604/17322693.1102340 https://www.ncbi.nlm.nih.gov/pubmed/24864108[][][]
  17. Shenov V, Mehendale V, Prabhu K, Shetty R, Rao P. Correlation of serum homocysteine levels with the severity of coronary artery disease. Ind J Clin Biochem. 2014;29(3):339–44. doi: 10.1007/s12291-013-0373-5 https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4062675/[][]
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Procedures

Amniotic fluid

amniotic fluid

What is amniotic fluid

Amniotic fluid is is a clear, slightly yellowish liquid that surrounds, protects and nourishes a growing baby in the uterus during pregnancy. Amniotic fluid allows a fetus to move relatively freely within the uterus, keeps the umbilical cord from being compressed, and helps maintain a stable temperature. Amniotic fluid is contained within the amniotic sac and is normally a clear to pale yellow liquid that contains proteins, nutrients, hormones, fetal cells, fetal urine and antibodies.

Amniotic fluid begins forming one to two weeks after conception and increases in volume until there is about a quart (800 mL) at 36 weeks of pregnancy. Amniotic fluid is absorbed and continually renewed. The amniotic fluid constantly moves (circulates) as the baby swallows and “inhales” the fluid, and then releases it.

The fetus swallows and inhales amniotic fluid and releases it as urine. The amount of amniotic fluid increases over time and is constantly being absorbed and renewed. During this circulation process, cells from various parts of the fetus’s body slough off into the fluid, and chemicals produced by the fetus are present as well. This is why samples of the amniotic fluid can be tested to evaluate fetal health. Several laboratory tests may be performed on the amniotic fluid to help identify various conditions and diseases.

Amniocentesis is the removal of a small amount of fluid (about an ounce) from the sac that surrounds a developing fetus using a needle and syringe. Before the procedure, ultrasound is used to find the position of the fetus in the womb and is continuously used throughout the procedure to ensure that the needle remains safely away from the baby. Prior to inserting the needle, the skin on the mother’s abdomen is cleaned and sometimes a local anesthetic is applied to the surface of the skin or injected into the skin.

During the procedure, the needle is carefully inserted through the walls of the abdomen and the uterus so that it just enters the thin-walled sac of amniotic fluid that surrounds the developing fetus. A small amount of amniotic fluid is discarded to ensure that no maternal contamination is present within the needle, and then the fluid is drawn up into the syringe and sent to a laboratory for analysis. Depending on the specific tests being performed, results may be available within a few days to up to 4 weeks or, in the case of fetal lung maturity testing, within a few hours.

There is a slight risk with amniocentesis that the needle inserted into the amniotic sac might puncture the baby, cause a small amount of amniotic fluid leakage following the procedure, cause a uterine infection, or, in rare cases, cause a miscarriage. The risk for a miscarriage associated with this procedure is considered to be 1/300 to 1/500, which is much lower than a woman’s risk (at any age) to have a baby with a chromosomal abnormality.

Recently, advances in testing technology and improved prenatal screening options, specifically non-invasive prenatal screening, has led to a decrease in the use of diagnostic tests such as amniocentesis. Non-invasive prenatal screening screens a blood sample from a pregnant woman for fragments of cell-free DNA (cfDNA) produced by the placenta. It typically screens for certain chromosomal abnormalities, including Down syndrome (trisomy 21), Edwards syndrome (trisomy 18), and Patau syndrome (trisomy 13), and it can be performed as early as the 10th week of pregnancy. However, at this time, “invasive” diagnostic tests such as amniocentesis and chorionic villus sampling (CVS) are still needed to confirm the results of a positive prenatal screening test or to test for conditions not covered by the screening test.

Figure 1. Amniotic fluid

amniotic fluid

Figure 2. Amniocentesis

amniocentesis

How does amniotic fluid keep your baby healthy?

During pregnancy, your uterus is filled with amniotic fluid. Here’s what the fluid does:

  • Cushions and protects your baby from injury by cushioning sudden blows or movements
  • Keeps a steady temperature around your baby, protecting from heat loss
  • Helps your baby’s lungs grow and develop because your baby breathes in the fluid
  • Helps your baby’s digestive system develop because your baby swallows the fluid
  • Helps your baby’s muscles and bones develop because your baby can move around in the fluid
  • Keeps the umbilical cord (the cord that carries food and oxygen from the placenta to your baby) from being squeezed
  • The amniotic fluid helps the developing baby to move in the womb, which allows for proper bone growth.

The amniotic sac (bag) inside the uterus holds your growing baby. It is filled with amniotic fluid. This sac forms about 12 days after getting pregnant.

In the early weeks of pregnancy, the amniotic fluid is mostly water that comes from your body. After about 20 weeks of pregnancy, your baby’s urine makes up most of the fluid. Amniotic fluid also contains nutrients, hormones (chemicals made by the body) and antibodies (cells in the body that fight off infection).

Amniotic fluid levels

The amount of amniotic fluid increases until about 36 weeks of pregnancy. At that time, it makes up about 1 quart (averages 800 mL). After that, the amount of amniotic fluid usually begins to decrease. About 600 mL of amniotic fluid surrounds the baby at full term (40 weeks gestation).

Amniotic fluid volume undergoes characteristic changes with gestation. It progressively rises.

  • 10 weeks gestation it is about 10 to 20 mL
  • at 16 weeks gestation ~250 mL
  • at 33 weeks gestation ~800 mL
  • at 38-39 weeks reaches a plateau of ~1000 mL
  • finally decreases at 40 weeks to ~600-800 mL

Amniotic fluid rate of change

At 8 weeks the amniotic fluid volume increases by ~10 mL/week, at 13 weeks the amniotic fluid volume increases by 25 mL/week and reaches a maximum rate of 60 mL/week at 21 weeks gestation. The weekly volume increment then decreases and reaches zero at about 33 weeks of gestation at which point the mean amniotic fluid volume reaches its peak. After term the amniotic fluid volume declines at a rate of ~8% per week. During the first half of pregnancy, amniotic fluid volume is closely correlated with fetal weight. The ratio of amniotic fluid to fetal volume increases until about 36 weeks gestation and then appears to decline.

Sometimes you can have too little or too much amniotic fluid. Too little fluid is called oligohydramnios. Too much fluid is called polyhydramnios. Either one can cause problems for a pregnant woman and her baby. Even with these conditions, though, most babies are born healthy.

Abnormal amounts of amniotic fluid may cause your health care provider to watch your pregnancy more carefully. Removing a sample of the fluid through amniocentesis can provide information about the sex, health, and development of the fetus.

What does amniotic fluid look like?

Normal amniotic fluid is clear or tinted yellow.

Amniotic fluid that looks green or brown usually means that the baby has passed his first bowel movement (meconium) while in the womb. (Usually, the baby has his first bowel movement after birth.)

If the baby passes meconium in the womb, it can get into his lungs through the amniotic fluid. This can cause serious breathing problems, called meconium aspiration syndrome, especially if the amniotic fluid is thick.

Some babies with meconium in the amniotic fluid may need treatment right away after birth to prevent breathing problems. Babies who appear healthy at birth may not need treatment, even if the amniotic fluid has meconium.

Amniotic fluid test

Amniotic fluid analysis involves a variety of tests that can be performed to evaluate the health of a fetus.

Amniotic fluid analysis may be used for several different purposes and the specific testing that is done depends on the reason for testing. The following list includes some of the more common ways that this analysis may be used for prenatal diagnosis:

To detect chromosomal abnormalities or genetic disorders

The American College of Obstetricians and Gynecologists recommends that all pregnant women should be given the option of having amniocentesis performed to detect chromosome abnormalities. A healthcare practitioner can help a pregnant woman weigh the pros and cons.

  • Chromosome analysis—performed as either a cytogenetics test that can also be called karyotyping or as a chromosomal microarray analysis. Both methods detect chromosome abnormalities associated with a variety of chromosome disorders. The testing evaluates the 22 paired chromosomes and the sex chromosomes (X, Y) in cells from the sample of amniotic fluid and can be used to diagnose a variety of disorders, including:
    • Down syndrome (Trisomy 21), caused by an extra chromosome 21 in all or most cells of the body
    • Edwards syndrome (Trisomy 18), caused by an extra chromosome 18
    • Patau syndrome (Trisomy 13), caused by an extra chromosome 13
    • Klinefelter syndrome, the most common sex chromosome abnormality in males; caused by an extra X chromosome
    • Turner syndrome, caused by missing one X chromosome in females
    • Due to the nature of this type of testing, chromosome analysis can also definitively determine the sex of a fetus.
  • Genetic testing, also called molecular testing, evaluates fetal DNA to look for specific gene mutations that are associated with specific genetic disorders. Molecular testing may be offered because of a family history of a specific inherited disorder or because of specific fetal ultrasound abnormalities that are known to have a genetic cause.

To detect open neural tube defects, such as spina bifida or anencephaly, or open abdominal wall defects

For example:

  • AFP (alpha-fetoprotein) is elevated in amniotic fluid with neural tube defects.
  • Acetylcholinesterase is increased with neural tube defects and other anatomic abnormalities.

To detect Rh and other blood type incompatibilities

When a mother has been previously exposed through prior pregnancies or blood transfusions to “foreign” red blood cells (RBCs), she may develop antibodies to the proteins present on the outer layer of the foreign red cells (antigens). If the antigens are present on the red blood cells of the fetus (inherited from the father), then the mother’s red blood cell antibodies can cross the placenta and bind to and destroy the fetus’s red blood cells, causing hemolytic anemia. An affected fetus can develop hemolytic disease of the newborn. One of the most commonly encountered incompatibilities are due to ABO and Rh group differences, but there are many other blood types that may also cause this problem.

Typically, if a fetus has been tested and is known to have Rh or blood type incompatibility with the mother, the fetus is monitored non-invasively using imaging scans. However, if the fetus shows signs that a blood transfusion is needed, then tests for bilirubin (also known as delta OD450) may be performed to help evaluate the severity of the hemolytic anemia. This is an invasive test and is not performed routinely. Bilirubin is an orange-yellow pigment, a waste product primarily produced by the normal breakdown of heme. Heme is a component of hemoglobin, which is found in red blood cells (RBCs).

To detect fetal infections

There are a few tests that can be performed on amniotic fluid to detect infections that are passed from mother to baby during pregnancy (congenital infections). Some of these infections may have serious consequences for the developing fetus. A few examples include tests for:

  • TORCH: toxoplasmosis, rubella, cytomegalovirus (CMV), herpes simplex virus (HSV)
  • Parvovirus B19
  • Cultures for bacterial infections

To evaluate fetal lung maturity

Recent guidelines from American College of Obstetricians and Gynecologists no longer recommends routine use of fetal lung maturity in clinical decision-making. However, testing to evaluate fetal lung maturity may be performed in select situations, for example, if a woman is very unsure of her dates and is at an increased risk for premature delivery or there is a sudden medical need for a preterm delivery. Various substances are measured in amniotic fluid (lamellar body count, phosphatidylglycerol, lecithin/sphingomyelin (L/S) ratio). The goal of the testing is to determine the risk of a life-threatening condition called neonatal respiratory distress syndrome.

When is amniotic fluid test ordered?

Genetic amniotic fluid analysis may be offered as part of second trimester prenatal testing and is performed primarily between 15 and 20 weeks of pregnancy. In particular, testing is recommended when:

  • A woman has an abnormality on a first trimester Down syndrome screen, non-invasive prenatal screening (NIPS) using cell-free DNA, or second trimester maternal serum screen
  • A woman had a previous child or pregnancy with a chromosomal abnormality or genetic disorder
  • A parent has an inherited disorder or both parents have a known gene for an inherited disorder
  • An abnormality has been detected on a fetal ultrasound

Testing may be ordered to monitor bilirubin levels when there is a known Rh or blood type incompatibility between the fetus and mother and monitoring of the fetus indicates a blood transfusion may be needed.

An amniotic fluid analysis may be performed in late pregnancy to diagnose a fetal infection.

Fetal lung maturity amniotic fluid testing may be ordered woman is unsure of her dates and is at an increased risk for premature delivery or there is a sudden medical need for a preterm delivery.

What does amniotic fluid test result mean?

Genetic tests, chromosome analysis and testing for neural tube defects

Because these results can be complex, women should discuss their test results not only with their healthcare practitioner but also ideally with someone who has expertise in genetics, such as a genetic counselor or maternal-fetal medicine specialist.

If a chromosomal abnormality or a genetic disorder is detected by diagnostic testing, then the baby likely will have the associated condition. However, many chromosomal disorders have a range of severity, and simply knowing a diagnosis does not help predict the condition’s severity or prognosis. It should also be noted that not every genetic disorder or chromosomal abnormality will be detected with this testing.

If an increased alpha fetoprotein (AFP) suggests an abnormality, such as an open neural tube defect or abdominal wall defect, then additional testing and imaging may be performed to determine the severity of the condition and the best course of action.

Rh or other blood type incompatibility

Increasing bilirubin levels in the amniotic fluid in the case of fetal-maternal blood type incompatibility indicate increasing destruction of red blood cells and the likelihood that the fetus will have hemolytic disease of the newborn, requiring treatment before or after birth, depending on the severity.

Fetal infections

Results of cultures of the amniotic fluid as well as tests for various viruses will indicate whether an infection is present.

Fetal lung maturity

Although rarely used these days, if testing indicates that the a fetus’s lungs have not yet matured, then a healthcare practitioner may take measures to attempt delaying delivery, use medications to promote lung maturity, or when necessary to begin treating the baby immediately after birth.

Maternal or fetal blood contamination and stool from the fetus (meconium) in the amniotic fluid can affect some chemical test results.

An alternative to amniotic fluid analysis for chromosomal analysis and genetic testing is chorionic villus sampling (CVS), which can be performed earlier, between 10 and 12 weeks of pregnancy. This first trimester procedure collects a small placenta tissue sample at the site of implantation and carries about the same risks as amniocentesis when performed by an experienced practitioner. CVS cannot, however, detect neural tube defects or abdominal wall defects, and occasionally may provide a chromosomal result that is representative of the placenta, but not the fetus (confined placental mosaicism).

Can disorders detected through amniotic fluid analysis be prevented?

  • Genetic and chromosomal abnormalities cannot be prevented, only diagnosed.
  • The risk for open neural tube birth defects can be minimized by a woman getting plenty of folic acid prior to and during pregnancy.
  • The number of women with Rh sensitization has greatly decreased since injections of Rh immune globulin to prevent the formation of Rh antibodies became routine in prenatal and postnatal care.

Should every pregnant woman have amniotic fluid analysis?

This is a highly personal decision, and one best made by a woman and her healthcare provider working together. The American College of Obstetricians and Gynecologists recommends that all pregnant women be given the option of having amniocentesis performed. Although the associated risk is low, it must be weighed against the desire for information that would be gained by testing. Speaking with a genetic counselor may also be helpful in learning more about the various types of testing available and what to expect from the information that can be learned through them.

Low amniotic fluid

Too little amniotic fluid is also called oligohydramnios, which is described as decreased amniotic fluid volume relative to gestational age. Too little amniotic fluid (oligohydramnios) occurs in approximately 11% of all pregnancies. Too little amniotic fluid (oligohydramnios) can happen at any time during pregnancy, but it’s most common in the last trimester (last 3 months). It happens in about 12 out of 100 (12 percent) women whose pregnancies last about 2 weeks past their due dates. This is because the amount of amniotic fluid usually decreases by that time.

Low amniotic fluid is most commonly caused by leaking of amniotic fluid due to a tear in the amniotic sac (premature rupture of the membranes), but it can also be caused by an abnormality of the fetal kidneys and/or urinary tract. If the fetal kidneys are not functioning normally, they will not produce enough urine to replace what the fetus swallows, and if there is a blockage of the urinary tract, it can prevent the urine from cycling back out to the amniotic fluid sac. Pregnancies affected by oligohydramnios are at higher risk for adverse fetal outcomes and should be monitored with care.

If you notice that you are leaking fluid from your vagina, tell your health care provider. It may be a sign of oligohydramnios. Your provider watches out for other signs, such as if you’re not gaining enough weight or if the baby isn’t growing as fast as he should.

Your health care provider uses ultrasound to measure the amount of amniotic fluid.

There are two ways to measure the amniotic fluid: amniotic fluid index (AFI) and maximum vertical pocket (MPV).

The amniotic fluid index (AFI) checks how deep the amniotic fluid is in four areas of your uterus. These amounts are then added up. If your amniotic fluid index (AFI) is less than 5 centimeters, you have oligohydramnios.

The normal range for amniotic fluid volumes varies with gestational age. Typical values include:

  • Amniotic fluid index (AFI) between 8-18 cm is considered normal; median AFI level is ~14 cm from week 20 to week 35, after which the amniotic fluid volume begins to reduce
  • Amniotic fluid index (AFI) <5 cm is considered as oligohydramnios
    value changes with age: the 5th percentile for gestational ages is most often taken as the cutoff value, and this around an AFI of 7 cm for second and third trimester pregnancies; and AFI of 5 cm is two standard deviations from the mean
  • Amniotic fluid index (AFI) >20-24 cm is considered as polyhydramnios

Amniotic fluid index (AFI) has been known to play significant role in obstetric management 1. AFI is calculated by adding the depth in centimeters of the largest vertical pocket in each of four equal uterine quadrants 2. Amniotic fluid index (AFI) less than or equal to 5 cm is defined as oligohydramnios 3. A borderline AFI has been defined as an AFI of 5.1 cm to 8 cm 3. The incidence of an AFI of 5.1 to 8 cm compared with a normal AFI (8.1 cm to 18 cm) in different studies varied from 6% to 44%, with the overall rate being 12% 4.

The maximum vertical pocket (MPV) measures the deepest area of your uterus to check the amniotic fluid level. If your MPV is less than 2 centimeters, you have oligohydramnios.

The deepest (maximal) vertical pocket (MPV) depth is considered a reliable method for assessing amniotic fluid volume on ultrasound 5. It is performed by assessing a pocket of maximal depth of amniotic fluid which is free of umbilical cord and fetal parts.

The usually accepted maximum vertical pocket (MPV) values are:

  • <2 cm: indicative of oligohydramnios
  • 2-8 cm: normal but should be taken in the context of subjective volume
  • >8 cm: indicative of polyhydramnios (although some centers particularly in Australia, New Zealand and the United Kingdom use a cut off of >10 cm)

Ask your health provider if you have questions about these measurements.

Figure 3. Amniotic fluid index (AFI is normal = 10.67 cm)

Amniotic fluid index

What problems can low amniotic fluid cause?

If oligohydramnios happens in the first 2 trimesters (first 6 months) of pregnancy, it is more likely to cause serious problems than if it happens in the last trimester. These problems can be:

  • Birth defects – Problems with a baby’s body that are present at birth
  • Miscarriage – When a baby dies in the womb before 20 weeks of pregnancy
  • Premature birth – Birth before 37 weeks of pregnancy
  • Stillbirth – When a baby dies in the womb after 20 weeks of pregnancy

If oligohydramnios happens in the third trimester of pregnancy, it can cause:

  • The baby to grow slowly
  • Problems during labor and birth, such as the umbilical cord being squeezed. The umbilical cord carries food and oxygen from the placenta to the baby. If it’s squeezed, the baby doesn’t get enough food and oxygen.
  • A greater chance of needing a cesarean section (when your baby is born through a cut the doctor makes in your belly and uterus)

Low amniotic fluid causes

The causes of oligohydramnios are many and sometimes the causes of oligohydramnios are not known.

Some known causes of low amniotic fluid can be simplified by using the mnemonic DRIPPC:

D: demise and drugs: e.g. prostaglandin inhibitors (indomethacin) or medicine to treat high blood pressure – If you have high blood pressure, talk to your provider before getting pregnant to make sure your blood pressure is under control.

R: renal abnormalities (from decreased urine output)

  • renal agenesis
  • renal dysplasia
  • posterior urethral valves
  • polycystic kidneys
  • multicystic dysplastic kidney
  • urethral atresia

I: IUGR (intra-uterine growth restriction): 80% may occur from decreased renal perfusion due to sparing effect

P: premature rupture of membranes

  • premature rupture of membranes (PROM): when the amniotic sac breaks after 37 weeks of pregnancy but before labor starts. Estimated incidence is at 10% of pregnancies at term
  • preterm premature rupture of membranes (PPROM): refers to rupture of membranes prior to 37 weeks of gestation. Estimated incidence is at 0.7%-2.0% of preterm pregnancies.

P: Post-term pregnancy – A pregnancy that goes 2 or more weeks past the due date. A full-term pregnancy is one that lasts 39 to 41 weeks.

C: chromosomal anomalies (especially if other anomalies are found)

  • trisomy 18
  • trisomy 13
  • triploidy

How is low amniotic fluid treated?

If you have a healthy pregnancy and get oligohydramnios near the end of your pregnancy, you probably don’t need treatment. Your provider may want to see you more often. She may want to do ultrasounds weekly or more often to check the amount of amniotic fluid.

Sometimes amnioinfusion can help prevent problems in the baby. Amnioinfusion is when the provider puts a saline solution (salty water) into the uterus through your cervix (the opening to the uterus that sits at the top of your vagina). This treatment can help prevent some problems, such as the umbilical cord being squeezed. If the umbilical cord is squeezed, the baby doesn’t get enough food and oxygen.

If the fluid gets too low or if your baby is having trouble staying healthy, your provider may recommend starting labor early to help prevent problems during labor and birth. However, with regular prenatal care, chances are that your baby will be born healthy.

What can you do if you have low amniotic fluid?

Drinking lots of water may help increase the amount of amniotic fluid. Your provider may recommend less physical activity or going on bed rest.

Leaking amniotic fluid

Premature rupture of membranes (PROM) refers to a rupture of the amniotic sac and chorion (membranes) occurring prior to the onset of uterine contractions. When this occurs prior to 37 weeks it is then termed a pre-term premature rupture of membranes (PPROM). By this definition, premature rupture of membranes (PROM) is classified as a rupture of membranes between 37 weeks and full term.

Prolonged rupture of membranes refers to a rupture of membranes lasting longer than 18-24 hours (i.e. between time of rupture and time of delivery) 6. This situation can occur in either the term or pre-term newborns where in the latter case it is also termed prolonged preterm rupture of membranes.

Leaking amniotic fluid signs and symptoms

  • Slow leak or gushing of fluid from the vagina
  • Wetness in underwear

Sometimes women mistake the leaking of amniotic fluid for urine, especially when it leaks slowly. If you notice any symptoms or think your membranes may have ruptured call your primary health care provider immediately.

You’ll be offered:

  • antibiotics to take for a maximum of 10 days, or until labor starts – whichever is sooner
  • tests for infection, which may include blood and urine tests

Pre-term premature rupture of membranes (PPROM) doesn’t definitely mean you’re going into labor. You may be able to go home if there’s no infection and you don’t go into labor within 48 hours. If you go home, you’ll be advised to tell your midwife immediately if:

  • your temperature is raised (a raised temperature is usually over 37.5 °C (99.5 °F) but check with your midwife – they may need you to call before it gets to 37.5 °C). You should take your temperature every four hours when you’re awake
  • any fluid coming from your vagina (called vaginal loss) is colored or smelly
  • you bleed from your vagina
  • your baby’s movements slow down or stop

Complications of premature rupture of membranes

  • increased risk of neonatal sepsis
  • increased risk of chorioamnionitis: an infection of the chorion and amnion during pregnancy
  • pulmonary hypoplasia can develop when there is very long-standing rupture of membranes causing persistent oligohydramnios
  • increased risk of cerebral palsy 7

Clinical presentation of chorionamnionitis

Clinically, chorionamnionitis can present with the following maternal signs and symptoms 8:

  • fever
  • abdominal pain / uterine tenderness
  • raised white blood cell count (> 15 000 cells/mm3)
  • purulent or foul vaginal discharge
  • tachycardia

Pathology

Chorioamnionitis most frequently occurs due to an ascending bacterial infection from the lower genital tract (vagina and cervix) in the setting of prolonged rupture of membranes (PROM) 8. Other less common causes include introduction of an infection through invasive procedures such as amniocentesis and chorionic villus sampling 8.

Risk factors of ruptured membranes include

  • Premature birth
  • Infection
  • Bleeding
  • Early labor and preterm delivery
  • Compression of the umbilical called (umbilical cord prolapse)
  • Placental abruption

Premature labor and birth

Premature labor is labor that happens before the 37th week of pregnancy. About 8 out of 100 babies will be born prematurely.

If you think your labor might be starting and you’re less than 37 weeks pregnant, call your midwife or hospital straight away. They’ll need to check you and your baby to find out whether you’re in labor, and discuss your care choices with you.

They’ll offer checks, tests and monitoring to find out whether:

  • your waters have broken
  • you’re in labor
  • you have an infection

These may include a vaginal examination, blood test, urine test and cardiotocography to record contractions and the baby’s heartbeat.

If you’re in premature labor

The midwife or doctor may offer:

  • medicine to try to slow down or stop your labor (tocolysis)
  • corticosteroid injections, which can help your baby’s lungs

Slowing down labor or stopping it isn’t appropriate in all circumstances – your midwife or doctor can discuss your situation with you. They will consider:

  • how many weeks pregnant you are
  • whether it might be safer for the baby to be born – for example, if you have an infection or you’re bleeding
  • local neonatal (newborn) care facilities and whether you might need to be moved to another hospital
  • your wishes

Corticosteroid injections can help your baby’s lungs get ready for breathing if they’re born prematurely. There are two injections, given 12 hours apart – your midwife or doctor will discuss the benefits and risks with you.

Corticosteroids probably won’t be offered after 36 weeks as your baby’s lungs are likely to be ready for breathing on their own.

If you’re in premature labor and you’re between 24 and 29 weeks pregnant you should be offered magnesium sulphate. This can help protect your baby’s brain development. You may also be offered it if you’re in labor between 30 and 34 weeks. This is to protect your baby against problems linked to being born too soon, such as cerebral palsy.

What are the risks to my baby of being born early?

Babies born before full term (before 37 weeks) are vulnerable to problems associated with being born premature. The earlier in the pregnancy a baby is born, the more vulnerable they are.

Babies are considered ‘viable’ at 24 weeks of pregnancy – this means it’s possible for them to survive being born at this stage.

Babies born this early need special care in a hospital with specialist facilities for premature babies. This is called a neonatal unit. They may have health and development problems because they haven’t fully developed in the womb.

If your baby is likely to be delivered early, you should be admitted to a hospital with a neonatal unit.

Not all hospitals have facilities for the care of very premature babies, so it may be necessary to transfer you and your baby to another unit, ideally before delivery (if time permits) or immediately afterwards.

Too much amniotic fluid

Too much amniotic fluid is also called polyhydramnios, which is the medical term for excessive accumulation of amniotic fluid — the fluid that surrounds the baby in the uterus during pregnancy. Too much amniotic fluid or polyhydramnios occurs in about 1 to 2 percent of pregnancies and while it typically is not associated with significant issues, it if is severe, it can affect the mother by causing shortness of breath, preterm labor, or severe post-delivery bleeding.

Most cases of too much amniotic fluid (polyhydramnios) are mild and result from a gradual buildup of amniotic fluid during the second half of pregnancy. Severe polyhydramnios may cause shortness of breath, preterm labor, or other signs and symptoms. In some cases, draining of excess fluid by amniocentesis may be required.

In approximately 20% of pregnancies with polyhydramnios, a fetal abnormality is identified, such as an incompletely formed esophagus that prevents the fetus from swallowing the amniotic fluid. However, a majority of the time, the cause is not clear.

If you’re diagnosed with polyhydramnios, your health care provider will carefully monitor your pregnancy to help prevent complications. Treatment depends on the severity of the condition. Mild polyhydramnios may go away on its own. Severe polyhydramnios may require closer monitoring.

Excess amniotic fluid symptoms

Polyhydramnios symptoms result from pressure being exerted within the uterus and on nearby organs.

Mild excess amniotic fluid may cause few — if any — signs or symptoms.

Severe excess amniotic fluid may cause:

  • Shortness of breath or the inability to breathe
  • Swelling in the lower extremities and abdominal wall
  • Uterine discomfort or contractions
  • Fetal malposition, such as breech presentation

Your health care provider may also suspect polyhydramnios if your uterus is excessively enlarged and he or she has trouble feeling the baby.

Too much amniotic fluid causes

Some of the known causes of polyhydramnios include:

  • A birth defect that affects the baby’s gastrointestinal tract or central nervous system
  • Maternal diabetes
  • Twin-twin transfusion — a possible complication of identical twin pregnancies in which one twin receives too much blood and the other too little
  • A lack of red blood cells in the baby (fetal anemia)
  • Blood incompatibilities between mother and baby
  • Infection during pregnancy

Often, however, the cause of too much amniotic fluid (polyhydramnios) isn’t clear.

Too much amniotic fluid complications

Polyhydramnios is associated with:

  • Premature birth
  • Premature rupture of membranes (PROM) — when your water breaks early
  • Placental abruption — when the placenta peels away from the inner wall of the uterus before delivery
  • Umbilical cord prolapse — when the umbilical cord drops into the vagina ahead of the baby
  • Cesarean section delivery
  • Stillbirth
  • Heavy bleeding due to lack of uterine muscle tone after delivery

The earlier that polyhydramnios occurs in pregnancy and the greater the amount of excess amniotic fluid, the higher the risk of complications.

Too much amniotic fluid diagnosis

If your health care provider suspects polyhydramnios, he or she will do a fetal ultrasound. This test uses high-frequency sound waves to produce images of your baby on a monitor.

If the initial ultrasound shows evidence of polyhydramnios, your health care provider may do a more detailed ultrasound. He or she will estimate the amniotic fluid volume (AFV) by measuring the single largest, deepest pocket of fluid around your baby. An AFV value of 8 centimeters or more suggests polyhydramnios.

An alternative way of measuring amniotic fluid is measuring the largest pocket in four specific parts of your uterus. The sum of these measurements is the amniotic fluid index (AFI). An AFI of 25 centimeters or more indicates polyhydramnios. Your health care provider will also use a detailed ultrasound to diagnose or rule out birth defects and other complications.

Your health care provider may offer additional testing if you have a diagnosis of polyhydramnios. Testing will be based on your risk factors, exposure to infections and prior evaluations of your baby. Additional tests may include:

Blood tests. Blood tests for infectious diseases associated with polyhydramnios may be offered.
Amniocentesis. Amniocentesis is a procedure in which a sample of amniotic fluid — which contains fetal cells and various chemicals produced by the baby — is removed from the uterus for testing. Testing may include a karyotype analysis, used to screen the baby’s chromosomes for abnormalities.

If you’re diagnosed with polyhydramnios, your health care provider will closely monitor your pregnancy. Monitoring may include the following:

Nonstress test. This test checks how your baby’s heart rate reacts when your baby moves. During the test, you’ll wear a special device on your abdomen to measure the baby’s heart rate. You may be asked to eat or drink something to make the baby active. A buzzer-like device also may be used to wake the baby and encourage movement.
Biophysical profile. This test uses an ultrasound to provide more information about your baby’s breathing, tone and movement, as well as the volume of amniotic fluid in your uterus. It may be combined with a nonstress test.

Too much amniotic fluid treatment

Mild cases of polyhydramnios rarely require treatment and may go away on their own. Even cases that cause discomfort can usually be managed without intervention.

In other cases, treatment for an underlying condition — such as maternal diabetes — may help resolve polyhydramnios.

If you experience preterm labor, shortness of breath or abdominal pain, you may need treatment — potentially in the hospital. Treatment may include:

  • Drainage of excess amniotic fluid. Your health care provider may use amniocentesis to drain excess amniotic fluid from your uterus. This procedure carries a small risk of complications, including preterm labor, placental abruption and premature rupture of the membranes.
  • Medication. Your health care provider may prescribe the oral medication indomethacin (Indocin) to help reduce fetal urine production and amniotic fluid volume. Indomethacin isn’t recommended beyond 31 weeks of pregnancy. Due to the risk of fetal heart problems, your baby’s heart may need to be monitored with a fetal echocardiogram and Doppler ultrasound. Other side effects may include nausea, vomiting, acid reflux and inflammation of the lining of the stomach (gastritis).

After treatment, your doctor will still want to monitor your amniotic fluid level approximately every one to three weeks.

If you have mild to moderate polyhydramnios, you’ll likely be able to carry your baby to term, delivering at 39 or 40 weeks. If you have severe polyhydramnios, your health care provider will discuss the appropriate timing of delivery, to avoid complications for you and your baby.

Polyhydramnios can be a worrisome finding during pregnancy. Work with your pregnancy care provider to ensure that you and your baby receive the best possible care.

Amniotic fluid embolism

Amniotic fluid embolism is a rare but serious condition that occurs when amniotic fluid or fetal material, such as fetal cells, enters the mother’s bloodstream. Amniotic fluid embolism is most likely to occur during delivery or immediately afterward.

Amniotic fluid embolism is difficult to diagnose. If your doctor suspects you might have amniotic fluid embolism, you’ll need immediate treatment to prevent potentially life-threatening complications.

Amniotic fluid embolism signs and symptoms

Amniotic fluid embolism develops suddenly and rapidly.

Signs and symptoms of amniotic fluid embolism might include:

  • Sudden shortness of breath
  • Excess fluid in the lungs (pulmonary edema)
  • Sudden low blood pressure
  • Sudden failure of the heart to effectively pump blood (cardiovascular collapse)
  • Life-threatening problems with blood clotting (disseminated intravascular coagulopathy)
  • Altered mental status, such as anxiety
  • Chills
  • Rapid heart rate or disturbances in the rhythm of the heart rate
  • Fetal distress, such as a slow heart rate
  • Seizures
  • Coma
  • Sudden fetal heart rate abnormalities
  • Bleeding from the uterus, incision or intravenous (IV) sites

Causes of amniotic fluid embolism

Amniotic fluid embolism occurs when amniotic fluid or fetal material enters the mother’s bloodstream. Why this happens isn’t well understood. A likely cause is a breakdown in the placental barrier, such as from trauma.

When this breakdown happens, the immune system responds by releasing products that cause an inflammatory reaction, activating abnormal clotting in the mother’s lungs and blood vessels that can result in a serious blood-clotting disorder known as disseminated intravascular coagulation (DIC).

However, amniotic fluid embolisms are rare — and it’s likely that some amniotic fluid commonly enters the mother’s bloodstream during delivery without causing problems. It’s not clear why in some cases this leads to amniotic fluid embolism.

Further research on what causes amniotic fluid embolisms is needed.

Amniotic fluid embolism risk factors

Amniotic fluid embolisms are rare, which makes it difficult to identify risk factors. It’s estimated that there are between 1 and 12 cases of amniotic fluid embolism for every 100,000 deliveries.

Research suggests that several factors might be linked to an increased risk of amniotic fluid embolism, however, including:

  • Advanced maternal age. If you’re 35 or older at the time of your child’s birth, you might be at increased risk of amniotic fluid embolism.
  • Placenta problems. If there are abnormalities in your placenta — the structure that develops in your uterus during pregnancy — you might be at increased risk of amniotic fluid embolism. Abnormalities might include the placenta partially or totally covering the cervix (placenta previa) or the placenta peeling away from the inner wall of the uterus before delivery (placental abruption). These conditions can disrupt the physical barriers between you and your baby.
  • Preeclampsia. If you have preeclampsia — high blood pressure and excess protein in the urine after 20 weeks of pregnancy — you might be at increased risk of developing amniotic fluid embolism.
  • Medically induced labor. Limited research suggests that certain labor induction methods are associated with an increased risk of amniotic fluid embolism. Research on this link, however, is conflicting.
  • Operative delivery. Having a cesarean section, a forceps delivery or a vacuum extraction might increase your risk of amniotic fluid embolism. These procedures can disrupt the physical barriers between you and your baby. It’s not clear, however, whether operative deliveries are true risk factors for amniotic fluid embolisms or are used after the condition develops to ensure a rapid delivery.
  • Polyhydramnios. Having too much amniotic fluid around your baby may put you at risk of amniotic fluid embolism.

Amniotic fluid embolism complications

Amniotic fluid embolism can cause serious complications for you and your baby.

If you have amniotic fluid embolism, you’re at increased risk of:

  • Brain injury. Low blood oxygen can cause permanent, severe neurological damage or brain death.
  • Lengthy hospital stay. Women who survive an amniotic fluid embolism often require treatment in the intensive care unit and — depending on the extent of their complications — might spend weeks or months in the hospital.
  • Maternal death. The number of women who die of amniotic fluid embolism (mortality rate) is very high. The numbers vary, but as many as 20 percent of maternal deaths in developed countries may be due to amniotic fluid embolisms. However, prompt evaluation and treatment may save your life.
  • Infant death. Your baby is at risk of brain injury or death. Prompt evaluation and delivery of your baby improves survival.

Amniotic fluid embolism diagnosis

The diagnosis of amniotic fluid embolism is based on a doctor’s evaluation. A diagnosis is typically made after other conditions have been ruled out. In some cases, a diagnosis is only made after maternal death. Your health care provider might order the following lab tests during your evaluation:

  • Blood tests, including those that evaluate clotting, heart enzymes, electrolytes and blood type, as well as a complete blood count (CBC)
  • Electrocardiogram (ECG or EKG) to evaluate your heart’s rhythm
  • Pulse oximetry to check the amount of oxygen in your blood
  • Chest X-ray to look for fluid around your heart
  • Echocardiography to evaluate your heart’s function

Amniotic fluid embolism treatment

Amniotic fluid embolism requires rapid treatment to address low blood oxygen and low blood pressure.

Emergency treatments might include:

  • Catheter placement. Your health care team places a thin, hollow tube into one of your arteries (arterial catheter) to monitor your blood pressure. You’ll also have another tube placed into a vein in your chest (central venous catheter), which can be used to give fluids, medications or transfusions, as well as draw blood.
  • Oxygen. You might need to have a breathing tube inserted into your airway to help you breathe.
  • Medications. Your doctor might give you medications to improve and support your heart function. Other medications might be used to decrease the pressure caused by fluid going into your heart and lungs.
  • Transfusions. If you have uncontrollable bleeding, you’ll need transfusions of blood, blood products and replacement fluids.

If you have amniotic fluid embolism before delivering your baby, your doctor will treat you with the goal of safely delivering your baby as soon as possible. An emergency cesarean section might be needed.

Coping and support

Experiencing a life-threatening pregnancy condition can be frightening and stressful for you and your family. You and your baby might experience serious complications and require lengthy hospital stays.

Amniotic fluid embolism is a medical emergency, leaving you no time to prepare. If you’re concerned about your risk of amniotic fluid embolism, talk with your doctor. Keep in mind, however, that amniotic fluid embolisms are rare, unpredictable and unpreventable.

During this challenging time, lean on loved ones for support. Consider joining a survivors’ network. Also, work with your health care provider to determine how you can safely manage your recovery and your role as the mother of a newborn.

  1. [Maternal and perinatal outcomes in women with decreased amniotic fluid]. Souza AS, de Andrade LR, da Silva FL, Cavalcanti AN, Guerra GV. Rev Bras Ginecol Obstet. 2013 Aug; 35(8):342-8. https://www.ncbi.nlm.nih.gov/pubmed/24126352/[]
  2. Cunningham FG, Leveno KJ, Bloom SL, Spong CY, Dashe JS, Hoffman BL, et al. Amniotic fluid. Williams Obstetrics. New York: McGraw Hill Education; 2014. pp. 460–76.[]
  3. Choi SR. Borderline amniotic fluid index and perinatal outcomes in the uncomplicated term pregnancy. J Matern Fetal Neonatal Med. 2016;29(3):457–60. https://www.ncbi.nlm.nih.gov/pubmed/25626056[][]
  4. Kwon J-Y, Kwon H-S, Kim Y-H, Park Y-W. Abnormal Doppler velocimetry is related to adverse perinatal outcome for borderline amniotic fluid index during third trimester. J Obstet Gynaecol Res. 2006;32(6):545–49. https://www.ncbi.nlm.nih.gov/pubmed/17100815[]
  5. Magann EF, Chauhan SP, Doherty DA et-al. The evidence for abandoning the amniotic fluid index in favor of the single deepest pocket. Am J Perinatol. 2007;24 (9): 549-55.[]
  6. Callahan TL, Caughey AB. Blueprints Obstetrics and Gynecology. Lippincott Williams & Wilkins. (2008) ISBN:078178249X[]
  7. Azziz R. Obstetrics and gynecology, cases, questions, and answers. McGraw-Hill Professional. (2006) ISBN:0071458204[]
  8. Czikk MJ, McCarthy FP, Murphy KE. Chorioamnionitis: from pathogenesis to treatment. Clinical microbiology and infection : the official publication of the European Society of Clinical Microbiology and Infectious Diseases. 17 (9): 1304-11. https://www.clinicalmicrobiologyandinfection.com/article/S1198-743X(14)61208-8/fulltext[][][]
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Procedures

Hemodialysis

hemodialysis

What is hemodialysis

Hemodialysis is a type of dialysis which is a treatment to filter wastes and water from your blood, as your kidneys did when they were healthy. Hemodialysis is a way to artificially clean your blood if your kidneys are no longer able to cope. Hemodialysis helps control blood pressure and balance important minerals, such as potassium, sodium, and calcium, in your blood.

Hemodialysis can help you feel better and live longer, but it’s not a cure for kidney failure.

Table 1. Kidney Failure Treatment Options

TreatmentScheduleLocationAvailabilityEquipment and SuppliesTraining RequiredDietLevel of FreedomLevel of Responsibility
In-Center HemodialysisThree treatments a week for about 4 hours.Dialysis center.Available in most communities; may require travel in some rural areas.No equipment or supplies in the home.Little training required; clinic staff perform most tasks.Must limit fluids, sodium, potassium, and phosphorus.Little freedom during treatments. Greater freedom on nontreatment days.Some patients prefer to let clinic staff perform all tasks.
Home HemodialysisMore flexibility in determining your schedule of treatments.Home.More widely used as smaller and simpler machines are developed.Hemodialysis machine connected to plumbing, chair.You and a partner must attend several training sessions.Must limit fluids, sodium, potassium, and phosphorus.More freedom to set your own schedule. You’re still linked to a machine for several hours a week.You and your partner have to monitor vital signs and clean and set up equipment. Can be stressful on your partner.
Continuous Ambulatory Peritoneal dialysis (CAPD)Four to six exchanges a day, every day.Any clean environment that allows solution exchanges.Widely available.Bags of dialysis solution take up storage space.You’ll need to attend several training sessions. You may need to bring a partner.Must limit sodium and calories.You can move around, exercise, work, drive, etc., with solution in your abdomen.You must perform exchanges four to six times a day, every day.
Automated Peritoneal DialysisThree to five exchanges a night, every night, with an additional exchange begun first thing in the morning.Any clean environment that allows solution exchanges.Widely available.Cycling machine, bags of dialysis solution.You’ll need to attend several training sessions. You may need to bring a partner.Must limit sodium and calories.You’re linked to a machine during the night. You’re free from exchanges during the day.You must set up your cycler every night.
Kidney Transplant (Deceased Donor)You may wait several years before a suitable kidney is available.

After surgery, you’ll have regular checkups with your doctor.

The transplant surgery takes place in a hospital.Transplant centers are located throughout the country. However, the demand for kidneys is far greater than the supply.No equipment or supplies needed.You’ll need to learn about your medicines and when to take them.Fewer dietary restrictions.Offers the greatest amount of freedom.You must take anti-rejection medicines every day.
Kidney Transplant (Living Donor)If a friend or family member is donating, you can schedule the surgery when you’re both ready.
After surgery, you’ll have regular checkups with your doctor.
The transplant surgery takes place in a hospital.Transplant centers are located throughout the country. However, the demand for kidneys is far greater than the supply.No equipment or supplies needed.You’ll need to learn about your medicines and when to take them.Fewer dietary restrictions.Offers the greatest amount of freedom.You must take anti-rejection medicines every day.
[Source 1]

Table 2. Dialysis center and home hemodialysis comparison

Dialysis Center and Home Hemodialysis Comparison Chart
Dialysis centerHome
ScheduleThree treatments a week for about 4 hours. Monday, Wednesday, Friday; or Tuesday, Thursday, Saturday.Flexible. Three to seven short or long treatments per week at times that work best for you.
AvailabilityAvailable in most communities; may require travel in some rural areas.Becoming more widely available as smaller equipment is developed.
Machine/suppliesThe clinic has the machine and supplies.The machine and 2- to 4-weeks’ worth of supplies are in the home. You may need minor changes in your home to connect the machine to electricity and water.
TrainingThe clinic teaches about treatments, diet, liquids, medicines, lab tests, etc.You and a partner must attend 3 to 8 weeks of home hemodialysis training.
Diet and liquidsStrict limits on liquids, phosphorus, sodium, and potassium intake.Fewer limits on liquids or diet, based on the amount of hemodialysis and lab tests.
Level of freedomLess freedom on treatment days. May feel washed out and tired for hours after each treatment.More freedom because you set the treatment schedule to meet the total amount prescribed. Work and travel are much easier.
Amount of workCenter staff members do hemodialysis tasks. They can teach you to do some tasks.You and your partner must set up, run, and clean the machine; check vital signs; track the treatments and send in forms; and order supplies.
PaymentMedicare and most other health plans cover three hemodialysis treatments a week.Medicare covers three hemodialysis treatments a week and may cover more for medical reasons; other health plans may cover all hemodialysis treatments.
[Source 1]

Hemodialysis vs dialysis

Dialysis is a way to artificially clean the blood if your kidneys are no longer able to cope.

There are two main types of dialysis:

  1. Hemodialysis, in which your blood is circulated through a dialysis machine for cleaning.
  2. Peritoneal dialysis, which uses the peritoneal membrane in your abdomen (tummy) to filter blood allowing cleaning to take place inside the body.

How does hemodialysis work

During hemodialysis, your blood goes through a filter, called a dialyzer, outside your body. A dialyzer is sometimes called an “artificial kidney.”

At the start of a hemodialysis treatment, a dialysis nurse or technician places two needles into your arm. You may prefer to put in your own needles after you’re trained by your health care team. A numbing cream or spray can be used if placing the needles bothers you. Each needle is attached to a soft tube connected to the dialysis machine.

The dialysis machine pumps blood through the filter and returns the blood to your body. During the process, the dialysis machine checks your blood pressure and controls how quickly

  • blood flows through the filter
  • fluid is removed from your body

Figure 1. How hemodialysis work

how hemodialysis workFigure 2. Hemodialysis – during hemodialysis, your blood is pumped through a filter, called a dialyzer.

hemodialysis

What happens to your blood while it’s in the filter

Blood enters at one end of the filter and is forced into many, very thin, hollow fibers. As your blood passes through the hollow fibers, dialysis solution passes in the opposite direction on the outside of the fibers. Waste products from your blood move into the dialysis solution. Filtered blood remains in the hollow fibers and returns to your body.

Your nephrologist—a doctor who specializes in kidney problems—will prescribe a dialysis solution to meet your needs. The dialysis solution contains water and chemicals that are added to safely remove wastes, extra salt, and fluid from your blood.

Your doctor can adjust the balance of chemicals in the solution if:

  • your blood tests show your blood has too much or too little of certain minerals, such as potassium or calcium
  • you have problems such as low blood pressure or muscle cramps during dialysis

Figure 3. Hemodialysis filter – dialyzer (in the hemodialysis filter, your blood flows inside hollow fibers that filter out wastes and extra salt and water.)

Hemodialysis filter - dialyzer

Can hemodialysis do everything my kidneys once did?

No. Hemodialysis can replace part, but not all, of your kidney function. Dialysis will help improve your energy level, and changes you make to your diet can help you feel better. Limiting how much water and other liquid you drink and take in through foods can help keep too much fluid from building up in your body between treatments. Medicines also help you maintain your health while on dialysis.

Can dialysis cure my kidney disease?

In some cases of sudden or acute kidney failure, dialysis may only be needed for a short time until the kidneys get better. However, when chronic kidney disease progresses to kidney failure over time, your kidneys do not get better and you will need dialysis for the rest of your life unless you are able to receive a kidney transplant.

How long will each hemodialysis treatment last?

In a dialysis center, hemodialysis is usually done 3 times per week for about 4 hours at a time. People who choose to do hemodialysis at home may do dialysis treatment more frequently, 4-7 times per week for shorter hours each time.

Your doctor will give you a prescription that tells you how much treatment you need. Studies have shown that getting the right amount of dialysis improves your overall health, keeps you out of the hospital and enables you to live longer. Your dialysis care team will monitor your treatment with monthly lab tests to ensure you are getting the right amount of dialysis. One of the measures your dialysis care team may use is called urea reduction ratio (URR). Another measure is called Kt/V (pronounced kay tee over vee). Ask your dialysis care team what measure they use and what your number is. To ensure that you are getting enough dialysis:

  • your Kt/V should be at least 1.2 or
  • your urea reduction ratio (URR) should be at least 65 percent.

Will I be uncomfortable on hemodialysis?

When you begin hemodialysis, the needles put in your fistula or graft may be uncomfortable. Most patients get used to this in time. Your dialysis care team will make sure you are as comfortable as possible during your treatment. Symptoms like cramps, headaches, nausea or dizziness are not common, but if you do have any of them, ask your dialysis care team if any of the following steps could help you:

  • Slow down your fluid removal, which could increase your dialysis time.
  • Increase the amount of sodium in your dialysate.
  • Check your high blood pressure medications.
  • Adjust your dry weight, or target weight.
  • Cool the dialysate a little.
  • Use a special medication to help prevent low blood pressure during dialysis.

You can help yourself by following your diet and fluid allowances. The need to remove too much fluid during dialysis is one of the things that may make you feel uncomfortable during your treatment.

How will I pay for my dialysis?

Dialysis is expensive. However, the federal government’s Medicare program pays 80 percent of all dialysis costs for most patients. Private health insurance or state medical aid may also help with the costs. For more information on insurance please go here (https://www.kidney.org/atoz/content/insurance).

Can dialysis patients continue to work?

Yes. Many dialysis patients continue to work or return to work after they have gotten used to dialysis. If your job has a lot of physical labor (heavy lifting, digging, etc.), you may need to change your duties.

Some people continue to work full time as they begin treatment. Others switch to a part-time or flexible schedule. Some people ask for jobs that are less physically demanding.

You may need to work different hours to go to hemodialysis. Or you may need a clean, private area where you can do peritoneal dialysis.

You should feel free to talk to your employer about job changes that might make it easier for you to work. Remember, your employer probably won’t know what changes you might need if you don’t ask for them.

Your employer may not know much about kidney disease or how it may affect your abilities. There might be concerns about how much work you can do and how much time off you will need. There could also be concerns about how much your health benefits will cost the company. You may want to ask your doctor or another member of your healthcare team to talk with your employer about these. A little information about your illness, abilities, and limitations can do a lot to ease an employer’s concerns. Here are a few of the topics you and your employer may want to discuss:

  • Changing your work schedule to allow for dialysis and healthcare visits
  • Making up time taken off for medical reasons
  • Physical limitations, if any
  • What to do in case of an emergency

Employers may not know about tax credits they can get for making changes to the workplace.

The Civil Rights Act, the Rehabilitation Act, and the Americans with Disabilities Act all protect you from job discrimination. Examples of discrimination include being fired or being turned down for a job or a promotion because of an illness or condition that does not affect your ability to do your job. The Department of Labor handles complaints filed under the Rehabilitation Act.

If you work for a company with 15 or more employees, the Americans with Disabilities Act (ADA) requires your employer to make any “reasonable accommodations” that you might need in order to work. Examples include:

  • Making parking lots, bathrooms, and work areas handicapped accessible
  • Having flexible work schedules
  • Reassigning you to a less strenuous job if you request one and one is available
  • Assigning any of your non-essential tasks to other employees, at your request

The Equal Employment Opportunity Commission handles complaints under the ADA.

If you work at least 20 weeks of the year for an employer with 50 or more employees, you may qualify for the Family and Medical Leave Act (FMLA). The FMLA allows for 12 weeks of unpaid, job-protected leave for medical reasons.

If you had group health insurance coverage before the leave, it will continue under the same terms or conditions. Your employer can ask for medical certification stating that you have a serious illness, but cannot punish you for taking leave to have surgery or begin treatment. Your spouse, children, or parents may also be eligible for FMLA leave if you need them to provide you with care or transportation. The Department of Labor handles complaints under the FMLA.

Can dialysis patients travel?

Yes. Dialysis centers are located in every part of the United States and in many foreign countries.

Before you travel, you must make an appointment for dialysis treatments at another center. The staff at your center may be able to help you arrange this appointment.

Many dialysis centers have a staff member who is experienced in arranging dialysis treatments away from home (transient dialysis). Some centers will assist patients in making their own arrangements. Ask your social worker or primary nurse if there is such a person at your center.

It is important to start planning at least six to eight weeks in advance. More time should be allowed for popular vacation spots or travel during holidays. Be flexible about the dates for your trip as space in dialysis units may be limited. If you would prefer to have your treatments on specific days and at specific times, let the center know in advance. The unit may not always be able to honor your request, however, because space is limited.

You or your patient travel coordinator may need to contact more than one center in order to find a center that can provide dialysis for you. Check with the center as soon as you arrive to confirm your appointment. You may also want to visit the center and meet the staff so you will feel more comfortable. Before doing this, however, make an appointment with the social worker or nurse manager of the dialysis center you plan to visit.

What happens if I have been on dialysis and I decide to stop?

If you’ve been on dialysis and wish to stop, you’ll still receive supportive care. The dialysis social worker may be able to help you develop an end-of-life care plan before you stop dialysis.

Where can I have hemodialysis?

You can receive treatment at a dialysis center or at home. Each location has its pros and cons.

Dialysis center

Most people go to a dialysis center for treatment. At the dialysis center, health care professionals set up and help you connect to the hemodialysis machine. A team of health care workers will be available to help you. You will continue to see your doctor. Other team members may include nurses, health care technicians, a dietitian, and a social worker.

Set schedule

You’ll have a fixed time slot for your treatments, usually three times per week: Monday, Wednesday, and Friday; or Tuesday, Thursday, and Saturday. Each hemodialysis session lasts about 4 hours. When choosing a hemodialysis schedule, think about your work and child care or other caregiving duties.

Nighttime option

Some hemodialysis centers offer nighttime treatments. These treatments occur at the dialysis center 3 nights a week while you sleep, which takes longer. Getting longer overnight hemodialysis treatments means:

  • your days are free.
  • you have fewer diet changes.
  • your liquid allowance (how much liquid you can drink) is closer to normal.
  • you may have a better quality of life than with a standard hemodialysis schedule. Longer treatment sessions may reduce your symptoms.

How do I find a dialysis center?

Your doctor, nurse, or social worker can help you find a dialysis center that’s convenient for you. Under Medicare rules, you have the right to choose the dialysis center where you’ll receive treatment. You may want to use Dialysis Facility Compare (https://www.medicare.gov/DialysisFacilityCompare/), which rates all dialysis centers according to quality. Your doctor will give your medical information to the dialysis center you choose.

Most large cities have more than one dialysis center to choose from. You can visit the centers to see which one best fits your needs. For example, you can ask about a center’s rules for laptop and cellphone use, as well as for having visitors. You may want the center to be close to your home to save travel time. If you live in a rural area, the closest dialysis center may be far from your home. If you’d have a hard time getting to the dialysis center, you may want to consider home dialysis treatments such as home hemodialysis or peritoneal dialysis.

Home hemodialysis

Home hemodialysis lets you have longer or more frequent dialysis, which comes closer to replacing the work healthy kidneys do—usually three to seven times per week, and with treatment sessions that last between 2 and 10 hours. Machines for home use are small enough to sit on an end table.

If you choose to have your treatments at home, you’ll still see your doctor once per month.

Flexible schedule

You can choose a schedule that fits the way you live. You can use:

  • Standard home hemodialysis — three times a week or every other day for 3 to 5 hours
  • Short daily hemodialysis — 5 to 7 days per week for 2 to 4 hours at a time
  • Nightly home hemodialysis — three to six times per week while you sleep

Your doctor will decide how many treatments you need each week for daily or nightly home hemodialysis.

More dialysis filters your blood more thoroughly

Compared with a standard hemodialysis schedule, daily or nightly home hemodialysis will let you:

  • eat and drink more normally
  • take fewer blood pressure medicines

Healthy kidneys work 24 hours a day, 7 days a week. Getting more hemodialysis feels more like having healthy kidneys and lowers your chances for problems that are common with a standard hemodialysis schedule, such as:

  • painful muscle cramps from removing too much fluid too quickly
  • high blood pressure, which can cause a headache or, in rare cases, a stroke
  • low blood pressure, which can make you faint, feel sick to your stomach, or be more likely to fall
  • high phosphate levels, which can weaken bones and make your skin itch

Better quality of life

Standard hemodialysis can make you feel tired or washed out for several hours after each treatment. People who have switched from standard hemodialysis to longer or more frequent hemodialysis report they feel better, with more energy, less nausea, and better sleep. They also may report a better quality of life 2.

Training for home hemodialysis

Most dialysis centers require that you have a trained partner in your home during hemodialysis treatments, so you must ask a family member or friend to go through the training with you. The clinic’s home-training nurse will teach you important safety skills.

During training, you and your care partner will learn to:

  • set up the machine
  • take steps to prevent infection
  • place needles into the vascular access
  • respond to any alarms from the machine
  • check your weight, temperature, blood pressure, and pulse
  • record treatment details for the clinic
  • clean the machine
  • throw out used supplies safely
  • track used supplies and order new ones

Training may take 4½ to 6 hours, 5 days a week, for 3 to 8 weeks. If you already know how to place the needles into your access, training may take less time.

The home-training nurse will make sure that you and your partner feel confident and may visit your home to help with your first at-home treatment. In addition to providing training and a hemodialysis machine that stays in your home, the dialysis center also provides 24-hour support if you have a question or problem. Some programs also monitor treatments over the internet.

Hemodialysis procedure

Dialysis is a complex treatment that takes time to understand.

Take care of the blood vessels in your arms

It’s important for you to protect the veins in your arm prior to starting dialysis. If you have kidney disease, remind health care providers to draw blood and insert IV lines only in veins below your wrist; for example, ask them to use a vein in the back of your hand. If an arm vein is damaged by an IV line or by repeated blood draws, that vein may not be able to be used for dialysis.

Vascular access surgery

One important step before starting hemodialysis treatment is having minor surgery to create a vascular access. Your vascular access will be your lifeline through which you’ll connect to the dialyzer. Dialysis moves blood through the filter at a high rate. Blood flow is very strong. The machine withdraws and returns almost a pint of blood to your body every minute. The access will be the place on your body where you insert needles to allow your blood to flow from and return to your body at a high rate during dialysis.

Three types of vascular access exist

  1. an arteriovenous (AV) fistula
  2. an arteriovenous (AV) graft
  3. a catheter

Work closely with your nephrologist and vascular surgeon—a surgeon who works with blood vessels—to make sure the access is in place in plenty of time. Healing may take several months. The goal is for your access to be ready for use when you are ready for dialysis.

Arteriovenous fistula

The best type of long-term access is an arteriovenous fistula. A surgeon connects an artery to a vein, usually in your arm, to create an arteriovenous fistula. An artery is a blood vessel that carries blood away from your heart. A vein is a blood vessel that carries blood back toward your heart. When the surgeon connects an artery to a vein, the vein grows wider and thicker, making it easier to place the needles for dialysis. The arteriovenous fistula also has a large diameter that allows your blood to flow out and back into your body quickly. The goal is to allow high blood flow so that the largest amount of blood can pass through the dialyzer.

The arteriovenous fistula is considered the best option because it:

  • provides highest blood flow for dialysis
  • is less likely to become infected or clot
  • lasts longer

Most people can go home after outpatient surgery. You will get local anesthesia to numb the area where the vascular surgeon creates the arteriovenous fistula. Depending on your situation, you may get general anesthesia and not be awake during the procedure.

The preferred location for placing an arteriovenous fistula for the first time is distally at the radius, thus making it possible to place a second fistula proximally if the first one failed to mature. The order of preference for creating an arteriovenous fistula 3:

  • Distal Radio-Cephalic (Distal radial artery to cephalic vein)
  • Proximal Radio-Cephalic (Proximal radial artery to cephalic vein)
  • Brachio-Cephalic (Brachial artery to Cephalic vein)
  • Brachio-Basilic (Brachial artery to Basilic vein)

Figure 4. Arteriovenous fistula for dialysis

Arteriovenous graft

If problems with your veins prevent you from having an arteriovenous fistula, you may need an arteriovenous graft instead. To create an arteriovenous graft, your surgeon uses a man-made tube to connect an artery to a vein. You can use an arteriovenous graft for dialysis soon after surgery. However, you’re more likely to have problems with infection and blood clots. Repeated blood clots can block the flow of blood through the graft and make it hard or impossible to have dialysis.

Catheter for temporary access

If your kidney disease has progressed quickly, or you have not had a vascular access placed before you need dialysis, you may need a venous catheter—a small, soft tube inserted into a vein in your neck, chest, or leg near the groin—as a temporary access. A nephrologist or an interventional radiologist—a doctor who uses medical imaging equipment to perform surgery—places the venous catheter while you’re in a hospital or at an outpatient clinic. You’ll receive local anesthesia and medicine to keep you calm and relaxed during the procedure.

What changes will I have to make when I start hemodialysis?

You have to adjust your life to build your hemodialysis treatment sessions into your routine. If you have in-center dialysis, you may need to rest after each treatment. Adjusting to the effects of kidney failure and the time you spend on hemodialysis can be hard. You may need to make changes in your work or home life, giving up some activities and responsibilities. Accepting these changes can be hard on you and your family. A mental health counselor or social worker can answer your questions and help you cope .

You will have to change what you eat and drink. Your health care team may adjust the medicines that you take.

Take care of your hemodialysis access

Your hemodialysis access is your lifeline. You will need to protect your access. Wash the area around your access with soap and warm water every day. Check the area for signs of infection, such as warmth or redness. When blood is flowing through your access and your access is working well, you can feel a vibration over the area. Let your dialysis center know if you can’t feel the vibration.

Sometimes, even when you are very careful, your access may clot or become infected.

Clots can form inside the opening of the catheter or form on the outside of the catheter and block the opening. This can cause blood to flow at a slower rate than the rate your doctor ordered. If the blood flow rate remains low for more than one dialysis treatment, the catheter should be checked and treated the same day. Early treatment may prevent the clot from totally blocking the catheter. It is important to restore the recommended blood flow rate and treat clots that are forming so that your catheter continues to work well and you get the amount of dialysis you need.

Infection can also occur even with a good blood flow rate. It is important to follow your catheter care instructions, exactly as you were taught, in order to avoid infection. You should know the following signs and symptoms of a catheter infection and report them to your doctor or dialysis team right away, so you can get the proper treatment as quickly as possible. The signs and symptoms of an infection include:

  • Fever
  • Chills
  • Drainage from the catheter exit site
  • Redness or tenderness around the catheter exit site
    General feeling of weakness and illness

Treatment depends on the type of infection but may include:

  • An ointment applied directly to the infected area if it is an exit site infection.
  • Antibiotic medication if there is drainage from the exit site.
  • An intravenous IV antibiotic (a solution containing an antibiotic that is administered directly into a vein) if the infection has spread to the blood.

Make changes to what you eat and drink

If you’re on hemodialysis, you may need to limit:

  • sodium in foods and drinks.
  • high-phosphorus foods.
  • the amount of liquid you drink, including liquid found in foods. Fluid builds up in your body between hemodialysis treatments.

You may also need to:

  • add protein to your diet because hemodialysis removes protein
  • choose foods with the right amount of potassium
  • take vitamins made for people with kidney failure
  • find healthy ways to add calories to your diet because you may not have a good appetite

Eating the right foods can help you feel better when you’re on hemodialysis. Talk with your dialysis center’s dietitian to find a hemodialysis meal plan that works for you.

Points to remember

  • Your choices about what to eat and drink while on hemodialysis can make a difference in how you feel and can make your treatments work better.
  • Between dialysis treatment sessions, wastes can build up in your blood and make you sick. You can reduce waste buildup by controlling what you eat and drink.
  • It helps to limit or avoid foods and beverages that have lots of:
    • potassium
    • phosphorus
    • sodium—for example, vegetable juice and sports drinks
  • You may feel better if you keep track of and limit how much liquid you eat and drink.
  • Hemodialysis removes extra fluid from your body. However, hemodialysis can remove only so much fluid at a time safely. If you come to your hemodialysis with too much fluid in your body, your treatment may make you feel ill. You may get muscle cramps or have a sudden drop in blood pressure that causes you to feel dizzy or sick to your stomach.
  • Potassium levels can rise between hemodialysis sessions and affect your heartbeat. Eating too much potassium can be dangerous to your heart and may even cause death.
  • Too much phosphorus in your blood pulls calcium from your bones. Losing calcium may make your bones weak and likely to break.
  • Renal dietitians encourage most people on hemodialysis to eat high-quality protein because it produces less waste for removal during dialysis. High-quality
  • protein comes from meat, poultry, fish, and eggs.
  • Sodium is a part of salt. Sodium is found in many canned, packaged, frozen, and fast foods. Sodium is also found in many condiments, seasonings, and meats. Too much sodium makes you thirsty, which makes you drink more liquid.
  • Everyone’s calorie needs are different. You might need to cut down on calories if you are overweight, or you might need to find ways to add calories to your diet if you are losing weight without trying.
    You may not get enough vitamins and minerals in your diet because you have to avoid so many foods. Your health care provider may prescribe a vitamin and mineral supplement designed specifically for people with kidney failure. For safety reasons, talk with your health care provider before using probiotics, dietary supplements, or any other medicine together with or in place of the treatment your health care provider prescribes.

How will I know if my hemodialysis is working?

You’ll know your hemodialysis treatments are working by how you feel. Your energy level may increase and you may have a better appetite. Hemodialysis reduces salt and fluid buildup, so you should have less shortness of breath and swelling as well.

To make the most of your hemodialysis treatment, keep to your ideal “dry weight.” Your ideal dry weight is your weight when you don’t have extra fluid in your body. If you’re careful about the sodium in your diet and the hemodialysis is working, you should be able to reach your ideal dry weight at the end of every hemodialysis treatment. When hemodialysis treatments are working and you keep to your ideal dry weight, your blood pressure should be well controlled.

In addition, blood tests can show how well your hemodialysis treatments are working. Once a month, whether you’re on home or dialysis center hemodialysis, your dialysis center will test your blood.

To see whether hemodialysis is removing enough urea, the dialysis clinic should periodically—normally once a month—test your blood to measure the hemodialysis adequacy. Blood is sampled at the start of hemodialysis and at the end. The levels of urea in the two blood samples are then compared. Two methods are generally used to assess dialysis adequacy, URR (urea reduction ratio) and Kt/V.

What is the urea reduction ratio (URR)?

URR stands for urea reduction ratio, meaning the reduction in urea as a result of dialysis. The urea reduction ratio is one measure of how effectively a dialysis treatment removed waste products from the body and is commonly expressed as a percentage.

Example: If the initial, or predialysis, urea level was 50 milligrams per deciliter (mg/dL) and the postdialysis urea level was 15 mg/dL, the amount of urea removed was 35 mg/dL.

  • 50 mg/dL – 15 mg/dL = 35 mg/dL

The amount of urea removed (35 mg/dL) is expressed as a percentage of the predialysis urea level (50 mg/dL).

  • 35/50 = 70/100 = 70%

Although no fixed percentage can be said to represent an adequate dialysis, patients generally live longer and have fewer hospitalizations if the urea reduction ratio is at least 60 percent. As a result, some experts recommend a minimum urea reduction ratio of 65 percent.

The urea reduction ratio is usually measured only once every 12 to 14 treatments, which is once a month. The urea reduction ratio may vary considerably from treatment to treatment. Therefore, a single value below 65 percent should not be of great concern, but a patient’s average urea reduction ratio should exceed 65 percent.

What is the Kt/V?

Kt/V is another way of measuring dialysis adequacy. In this measurement,

  • K stands for the dialyzer clearance, the rate at which blood passes through the dialyzer, expressed in milliliters per minute (mL/min)
  • t stands for time
  • Kt, the top part of the fraction, is clearance multiplied by time, representing the volume of fluid completely cleared of urea during a single treatment
  • V, the bottom part of the fraction, is the volume of water a patient’s body contains

Example: If the dialyzer’s clearance is 300 mL/min and a dialysis session lasts for 180 minutes (3 hours), Kt will be 300 mL/min multiplied by 180 minutes. The result comes to 54,000 mL, or 54 liters.

  • Kt = 300 mL/min multiplied by 180 minutes
  • Kt = 54,000 mL = 54 liters

The body is about 60 percent water by weight. If a patient weighs 70 kilograms (kg), or 154 pounds (lbs), V will be 42 liters.

  • V = 70 kg multiplied by .60 = 42 liters

So the ratio—K multiplied by t to V, or Kt/V—compares the amount of fluid that passes through the dialyzer with the amount of fluid in the patient’s body. The Kt/V for this patient would be 1.3.

  • Kt/V = 54/42 = 1.3

How Does the Kt/V Compare with the urea reduction ratio?

The Kt/V is mathematically related to the urea reduction ratio and is in fact derived from it, except that the Kt/V also takes into account two additional factors:

  • urea generated by the body during dialysis
  • extra urea removed during dialysis along with excess fluid

The Kt/V is more accurate than the urea reduction ratio in measuring how much urea is removed during dialysis, primarily because the Kt/V also considers the amount of urea removed with excess fluid. Consider two patients with the same urea reduction ratio and the same postdialysis weight, one with a weight loss of 1 kg—about 2.2 lbs—during the treatment and the other with a weight loss of 3 kg-about 6.6 lbs. The patient who loses 3 kg will have a higher Kt/V, even though both have the same urea reduction ratio.

The fact that a patient who loses more weight during dialysis will have a higher Kt/V does not mean it is better to gain more water weight between dialysis sessions so more fluid has to be removed, because the extra fluid puts a strain on the heart and circulation. However, patients who lose more weight during dialysis will have a higher Kt/V for the same level of urea reduction ratio.

On average, a Kt/V of 1.2 is roughly equivalent to a urea reduction ratio of about 63 percent. Thus, another standard of adequate dialysis is a minimum Kt/V of 1.2. The Kidney Disease Outcomes Quality Initiative group has adopted the Kt/V of 1.2 as the standard for dialysis adequacy 4. Like the urea reduction ratio, the Kt/V may vary considerably from treatment to treatment because of measurement error and other factors. So while a single low value is not always of concern, the average Kt/V should be at least 1.2. In some patients with large fluid losses during dialysis, the Kt/V can be greater than 1.2 with a urea reduction ratio slightly below 65 percent—in the range of 58 to 65 percent. In such cases, the Kidney Disease Outcomes Quality Initiative guidelines consider the Kt/V to be the primary measure of adequacy.

Is a urea reduction ratio of 65 percent or a Kt/V of 1.2 good enough?

These dialysis adequacy guidelines were determined on the basis of studies in large groups of patients. These studies generally showed that patients with lower Kt/V and urea reduction ratio numbers had more health problems and a greater risk of death. However, the HEMO study showed that a Kt/V greater than 1.2 did not result in improved outcomes.

If a patient’s Kt/V is always above 1.2 and the urea reduction ratio is close to 65 percent, then the patient’s treatment is meeting adequacy guidelines. The patient’s urea reduction ratio may be a few points below 65 if the person has large fluid losses during dialysis.

What can patients do to improve their Kt/V?

If a patient’s average Kt/V—usually the average of three measurements—is consistently below 1.2, the patient and the nephrologist need to discuss ways to improve it. Since the V value is fixed, Kt/V can be improved either by increasing K or t.

Increase Blood Flow through the Dialyzer

Increasing K depends primarily on the rate of blood flow through the dialyzer. No matter how good a dialyzer is, how well it works depends primarily on moving blood through it. In many patients, a good rate is difficult to achieve because of vascular access problems.

If a patient’s blood flow rate is good, further improvements in clearance can be obtained by using a big dialyzer or, in some cases, by increasing the flow rate for dialysis solution from the usual 500 mL/min to 600 or 800 mL/min. A good flow rate for adult patients is 350 mL/min and higher. A few centers are even using two dialyzers at the same time to increase K in larger than average patients.

However, the rate of blood flow through the dialyzer is key, and a good vascular access is crucial to make sure a patient is getting good clearance.

Increase Time on Dialysis

The other way to improve the Kt in Kt/V is to increase t by dialyzing for a longer period. For example, if the Kt/V is 0.9 and the goal is 1.2, then 1.2/0.9 = 1.33, so 1.33 times more Kt is needed. If K is not changed, this means the length of the session needs to increase by 33 percent. If the inadequate sessions lasted 3 hours, they should be increased to 4 hours.

Identify and Eliminate Circulation Problems

If during any given month a patient’s Kt/V is extremely low, the measurement should be repeated, unless a reason for the low Kt/V is obvious. Obvious reasons include treatment interruption, problems with blood or solution flow, and a problem in sampling either the pre- or postdialysis blood. If no reason for the sudden drop is apparent, then a problem with needle placement, like accidental needle reversal, or with the vascular access, such as recirculation, should be suspected.

Hemodialysis complications

You could have a problem with your vascular access, which is the most common reason someone on hemodialysis needs to go to the hospital. Any type of vascular access may:

  • become infected
  • have poor blood flow or blockage from a blood clot or scar

These problems can keep your treatments from working. You may need to have more procedures to replace or repair your access for it to work properly.

Sudden changes in your body’s water and chemical balance during treatment can cause additional problems, such as:

  • muscle cramps.
  • a sudden drop in blood pressure, called hypotension. Hypotension can make you feel weak, dizzy, or sick to your stomach.

Your doctor can change your dialysis solution to help avoid these problems. The longer and more frequent treatments of home hemodialysis are less likely to cause muscle cramps or rapid changes in blood pressure than standard in-center dialysis.

You can lose blood if a needle comes out of your access or a tube comes out of the dialyzer. To prevent blood loss, dialysis machines have a blood leak detector that sets off an alarm. If this problem occurs at the clinic, a nurse or technician will be on hand to act. If you’re using home dialysis, your training will prepare you and your partner to fix the problem.

You may need a few months to adjust to hemodialysis. Always report problems to your health care team, who often can treat side effects quickly and easily. You can avoid many side effects by following an eating plan you develop with your dietitian, limiting liquid intake, and taking your medicines as directed.

Peritoneal dialysis vs hemodialysis

When kidneys fail, waste products such as urea and creatinine build up in the blood. One way to remove these wastes is a process called peritoneal dialysis. Peritoneal dialysis is a treatment for kidney failure that uses the lining of your abdomen, or belly, to filter your blood inside your body. The walls of the abdominal cavity are lined with a membrane called the peritoneum. During peritoneal dialysis, a mixture of dextrose (sugar), salt, and other minerals dissolved in water, called dialysis solution, is placed in a person’s abdominal cavity through a catheter. The body’s peritoneal membrane enclosing the digestive organs allows waste products and extra body fluid to pass from the blood into the dialysis solution. These wastes then leave the body when the used solution is drained from the abdomen. Each cycle of draining and refilling is called an exchange. The time the solution remains in the abdomen between exchanges is called the dwell time. During this dwell time, some of the dextrose in the solution crosses the membrane and is absorbed by the body.

A few weeks before you start peritoneal dialysis, a surgeon places a soft tube, called a catheter, in your belly.

When you start treatment, dialysis solution—water with salt and other additives—flows from a bag through the catheter into your belly. When the bag is empty, you disconnect it and place a cap on your catheter so you can move around and do your normal activities. While the dialysis solution is inside your belly, it absorbs wastes and extra fluid from your body.

After a few hours, the solution and the wastes are drained out of your belly into the empty bag. You can throw away the used solution in a toilet or tub. Then, you start over with a fresh bag of dialysis solution. When the solution is fresh, it absorbs wastes quickly. As time passes, filtering slows. For this reason, you need to repeat the process of emptying the used solution and refilling your belly with fresh solution four to six times every day. This process is called an exchange.

You can do your exchanges during the day, or at night using a machine that pumps the fluid in and out. For the best results, it is important that you perform all of your exchanges as prescribed. Dialysis can help you feel better and live longer, but it is not a cure for kidney failure.

Figure 5. Peritoneal dialysis

Peritoneal dialysis

How will I feel when the dialysis solution is inside my belly?

You may feel the same as usual, or you may feel full or bloated. Your belly may enlarge a little. Some people need a larger size of clothing. You shouldn’t feel any pain. Most people look and feel normal despite a belly full of solution.

Types of peritoneal dialysis

You can choose the type of peritoneal dialysis that best fits your life:

  • continuous ambulatory peritoneal dialysis (CAPD)
  • automated peritoneal dialysis

The main differences between the two types of peritoneal dialysis are:

  • the schedule of exchanges
  • one uses a machine and the other is done by hand

If one type of peritoneal dialysis doesn’t suit you, talk with your doctor about trying the other type.

Continuous ambulatory peritoneal dialysis

Continuous ambulatory peritoneal dialysis (CAPD) doesn’t use a machine. You do the exchanges during the day by hand.

You can do exchanges by hand in any clean, well-lit place. Each exchange takes about 30 to 40 minutes. During an exchange, you can read, talk, watch television, or sleep. With continuous ambulatory peritoneal dialysis (CAPD), you keep the solution in your belly for 4 to 6 hours or more. The time that the dialysis solution is in your belly is called the dwell time. Usually, you change the solution at least four times a day and sleep with solution in your belly at night. You do not have to wake up at night to do an exchange.

Automated peritoneal dialysis

With automated peritoneal dialysis, a machine called a cycler fills and empties your belly three to five times during the night while you sleep. In the morning, you begin the day with fresh solution in your belly. You may leave this solution in your belly all day or do one exchange in the middle of the afternoon without the machine. People sometimes call this treatment continuous cycler-assisted peritoneal dialysis (CCPD).

Figure 6. Automated peritoneal dialysis

automated peritoneal dialysis

Where can I do peritoneal dialysis?

You can do both continuous ambulatory peritoneal dialysis (CAPD) and automated peritoneal dialysis in any clean, private place, including at home, at work, or when traveling.

Before you travel, you can have the manufacturer ship the supplies to where you’re going so they’ll be there when you get there. If you use automated peritoneal dialysis, you’ll have to carry your machine with you or plan to do exchanges by hand while you’re away from home.

How do I prepare for peritoneal dialysis?

Surgery to put in your catheter

Before your first treatment, you will have surgery to place a catheter into your belly. Planning your catheter placement at least 3 weeks before your first exchange can improve treatment success.

Although you can use the catheter for dialysis as soon as it’s in place, the catheter tends to work better when you have 10 to 20 days to heal before starting a full schedule of exchanges.

Your surgeon will make a small cut, often below and a little to the side of your belly button, and then guide the catheter through the slit into your peritoneal cavity. You’ll receive general or local anesthesia , and you may need to stay overnight in the hospital. However, most people can go home after the procedure.

You’ll learn to care for the skin around the catheter, called the exit site, as part of your dialysis training.

Peritoneal dialysis training

After training, most people can perform both types of peritoneal dialysis on their own. You’ll work with a dialysis nurse for 1 to 2 weeks to learn how to do exchanges and avoid infections. Most people bring a family member or friend to training. With a trained friend or family member, you’ll be prepared in case you have a sick day and need help with exchanges.

If you choose automated peritoneal dialysis, you’ll learn how to:

  • prepare the cycler
  • connect the bags of dialysis solution
  • place the drain tube

If you choose automated peritoneal dialysis, you also need to learn how to do exchanges by hand in case of a power failure or if you need an exchange during the day in addition to nighttime automated peritoneal dialysis.

How do you perform a peritoneal dialysis?

You’ll need the following supplies:

  • transfer set
  • dialysis solution
  • supplies to keep your exit site clean

If you choose automated peritoneal dialysis you’ll need a cycler.

Your health care team will provide everything you need to begin peritoneal dialysis and help you arrange to have supplies such as dialysis solution and surgical masks delivered to your home, usually once a month. Careful hand washing before and wearing a surgical mask over your nose and mouth while you connect your catheter to the transfer set can help prevent infection.

Use a transfer set to connect your catheter to the dialysis solution

A transfer set is tubing that you use to connect your catheter to the bag of dialysis solution. When you first get your catheter, the section of tube that sticks out from your skin will have a secure cap on the end to prevent infection. A connector under the cap will attach to any type of transfer set.

Between exchanges, you can keep your catheter and transfer set hidden inside your clothing. At the beginning of an exchange, you’ll remove the disposable cap from the transfer set and connect the set to a tube that branches like the letter Y. One branch of the Y-tube connects to the drain bag, while the other connects to the bag of fresh dialysis solution.

Figure 7. How to connect your catheter to the transfer set to do your peritoneal dialysis

how to connect your catheter to the transfer set to do your peritoneal dialysis

Use dialysis solution as prescribed

Dialysis solution comes in 1.5-, 2-, 2.5-, or 3-liter bags. Solutions contain a sugar called dextrose or a compound called icodextrin and minerals to pull the wastes and extra fluid from your blood into your belly. Different solutions have different strengths of dextrose or icodextrin. Your doctor will prescribe a formula that fits your needs.

You’ll need a clean space to store your bags of solution and other supplies.

Doing a peritoneal dialysis by hand

  • After you wash your hands and put on your surgical mask, drain the used dialysis solution from your belly into the drain bag. Near the end of the drain, you may feel a mild tugging sensation that tells you most of the fluid is gone. Close the transfer set.
  • Warm each bag of solution to body temperature before use. You can use an electric blanket, or let the bag sit in a tub of warm water. Most solution bags come in a protective outer wrapper, and you can warm them in a microwave. Don’t microwave a bag of solution after you have removed it from its wrapper.
  • Hang the new bag of solution on a pole and connect it to the tubing.
  • Remove air from the tubes—allow a small amount of fresh, warm solution to flow directly from the new bag of solution into the drain bag.
  • Clamp the tube that goes to the drain bag.
  • Open or reconnect the transfer set, and refill your belly with fresh dialysis solution from the hanging bag.

Using a cycler for automated peritoneal dialysis exchanges

In automated peritoneal dialysis, you use a machine called a cycler to fill and drain your belly. You can program the cycler to give you different amounts of dialysis solution at different times.

Each evening, you set up the machine to do three to five exchanges for you. You connect three to five bags of dialysis solution to tubing that goes into the cycler—one bag of solution for each exchange. The machine may have a special tube to connect the bag for the last exchange of the night.

At the times you set, the cycler:

  • releases a clamp and allows used solution to drain out of your belly into the drain line
  • warms the fresh dialysis solution before it enters your body
  • releases a clamp to allow body-temperature solution to flow into your belly

A fluid meter in the cycler measures and records how much solution the cycler removes. Some cyclers compare the amount that was put in with the amount that drains out. This feature lets you and your doctor know if the treatment is removing enough fluid from your body.

Some cyclers allow you to use a long drain line that drains directly into your toilet or bathtub. Others have a disposal container.

What changes will I have to make when I start peritoneal dialysis?

Daily routine

Your schedule will change as you work your dialysis exchanges into your routine. If you do continuous ambulatory peritoneal dialysis (CAPD) during the day, you have some control over when you do the exchanges. However, you’ll still need to stop your normal activities and take about 30 minutes to perform an exchange. If you do automated peritoneal dialysis, you’ll have to set up your cycler every night.

Physical activity

You may need to limit some physical activities when your belly is full of dialysis solution. You may still be active and play sports, but you should discuss your activities with your health care team.

Make changes to what you eat and drink

If you’re on peritoneal dialysis, you may need to limit:

  • sodium
  • phosphorus
  • calories in your eating plan

You may also need to:

  • watch how much liquid you drink and eat. Your dietitian will help you determine how much liquid you need to consume each day.
  • add protein to your diet because peritoneal dialysis removes protein.
  • choose foods with the right amount of potassium.
  • take supplements made for people with kidney failure.

Eating the right foods can help you feel better while you’re on peritoneal dialysis. Talk with your dialysis center’s dietitian to find a meal plan that works for you.

Medicines

Your doctor may make changes to the medicines you take.

Coping

Adjusting to the effects of kidney failure and the time you spend on dialysis can be hard for both you and your family. You may:

  • have less energy
  • need to give up some activities and duties at work or at home

A counselor or social worker can answer your questions and help you cope .

Take care of your exit site, supplies, and catheter to prevent infections

Your health care team will show you how to keep your catheter clean to prevent infections. Here are some general rules:

  • Store your supplies in a cool, clean, dry place.
  • Inspect each bag of solution for signs of contamination, such as cloudiness, before you use it.
  • Find a clean, dry, well-lit space to perform your exchanges.
  • Wash your hands every time you need to handle your catheter.
  • Clean your skin where your catheter enters your body every day, as instructed by your health care team.
  • Wear a surgical mask when performing exchanges.

Peritoneal dialysis possible side effects and complications

Possible complications from peritoneal dialysis include infection, hernia, and weight gain.

Infection

One of the most serious problems related to peritoneal dialysis is infection. You can get an infection of the skin around your catheter exit site or you can develop peritonitis, an infection in the fluid in your belly. Bacteria can enter your body through your catheter as you connect or disconnect it from the bags.

  • Seek immediate care if you have signs of infection

Signs of an exit site infection include redness, pus, swelling or bulging, and tenderness or pain at the exit site. Health care professionals treat infections at the exit site with antibiotics.

Peritonitis may cause:

  • pain in the abdomen
  • fever
  • nausea or vomiting
  • redness or pain around your catheter
  • unusual color or cloudiness in used dialysis solution
  • the catheter cuff to push out from your body—the cuff is the part of the catheter that holds it in place

Health care professionals treat peritonitis with antibiotics. Antibiotics are added to the dialysis solution that you can usually take at home. Quick treatment may prevent additional problems.

Hernia

A hernia is an area of weakness in your abdominal muscle.

Peritoneal dialysis increases your risk for a hernia for a couple of reasons. First, you have an opening in your muscle for your catheter. Second, the weight of the dialysis solution within your belly puts pressure on your muscle. Hernias can occur near your belly button, near the exit site, or in your groin. If you have a swelling or new lump in your groin or belly, talk with your health care professional.

Weight gain from fluid and dextrose (glucose)

The longer the dialysis solution remains in your belly, the more dextrose (glucose) your body will absorb from the dialysis solution. This can cause weight gain over time.

Limit weight gain

With continuous ambulatory peritoneal dialysis (CAPD), you might have a problem with the long overnight dwell time. If your body absorbs too much fluid and dextrose overnight, you may be able to use a cycler to exchange your solution once while you sleep. This extra exchange will shorten your dwell time, keep your body from absorbing too much fluid and dextrose, and filter more wastes and extra fluid from your body.

With automated peritoneal dialysis, you may absorb too much solution during the daytime exchange, which has a long dwell time. You may need an extra exchange in the midafternoon to keep your body from absorbing too much solution and to remove more wastes and extra fluid from your body.

Your dietitian can provide helpful guidance to reduce weight gain.

How will you know if your peritoneal dialysis is working?

To find out if your peritoneal dialysis exchanges are removing enough wastes from your body, you’ll have a blood test and collect used dialysis solution once a month. If you’re still urinating, you may need to collect urine.

These tests help your doctor prescribe a dialysis schedule and dose to meet your health needs. If your dialysis schedule isn’t removing enough wastes or your body is absorbing too much dextrose, your doctor will make adjustments.

Many factors affect how much waste and extra fluid are removed from the blood. Some factors—such as the patient’s size and the permeability, or speed of diffusion, of the peritoneum—cannot be controlled. Dialysis solution comes in 1.5-, 2-, 2.5-, or 3-liter bags for manual exchanges and 5- or 6-liter bags for automated exchanges. The dialysis dose can be increased by using a larger fill volume, but only within the limits of the person’s abdominal capacity. Everyone’s peritoneum filters wastes at a different rate. In some people, the peritoneum does not allow wastes to enter the dialysis solution efficiently enough to make peritoneal dialysis feasible.

Other factors that determine how efficiently a person’s blood is filtered can be controlled. Controllable factors include the number of daily exchanges and the dwell times. When fresh solution is first placed in the abdomen, it draws in wastes rapidly. As wastes fill the solution, it cleans the blood less efficiently. For example, a patient may perform one exchange with a 6-hour dwell time, during which the solution pulls in nearly as much urea as it can hold. But in the second half of that dwell time, urea is being removed from the blood very slowly. If the patient performed two exchanges with 3-hour dwell times instead, the amount of urea removed would be substantially greater than that removed in one 6-hour dwell time.

Another way to increase the amount of fluid and waste drawn into the peritoneal cavity is to use dialysis solution with a higher concentration of dextrose. Dialysis solution comes in 1.5 percent, 2.5 percent, and 4.25 percent dextrose (glucose) concentrations. A higher dextrose concentration moves fluid and more wastes into the abdominal cavity, increasing both early and long-dwell exchange efficiency. Eventually, however, the body absorbs dextrose from the solution. As the concentration of dextrose in the body comes closer to that in the solution, dialysis becomes less effective, and fluid is slowly absorbed from the abdominal cavity.

Testing for efficiency of peritoneal dialysis

The tests to see whether the exchanges are removing enough urea are especially important during the first weeks of dialysis, when the health care team needs to determine whether the patient is receiving an adequate amount, or dose, of dialysis.

The peritoneal equilibration test—often called the PET—measures how much dextrose has been absorbed from a bag of infused dialysis solution and how much urea and creatinine have entered into the solution during a 4-hour dwell. The peritoneal transport rate varies from person to person. People who have a high rate of transport absorb dextrose from the dialysis solution quickly, and they should be given a dialysis schedule that avoids exchanges with a long dwell time because they tend to absorb too much dextrose and dialysis solution from such exchanges.

In the clearance test, samples of used solution drained over a 24-hour period are collected, and a blood sample is obtained during the day when the solution is collected. The amount of urea in the solution is compared with the amount in the blood to see how effective the current peritoneal dialysis schedule is in clearing the blood of urea. If the patient has more than a few ounces of urine output per day, the urine should also be collected during this period to measure its urea concentration.

From the used solution, urine, and blood measurements, one can compute a urea clearance, called Kt/V, and a creatinine clearance rate—normalized to body surface area. The residual clearance of the kidneys is also considered. Based on these measurements, one can determine whether the peritoneal dialysis dose is adequate.

If the laboratory results show that the dialysis schedule is not removing enough urea and creatinine, the doctor may change the prescription by:

  • increasing the number of exchanges per day for patients treated with continuous ambulatory peritoneal dialysis (CAPD) or per night for patients treated with continuous cycler-assisted peritoneal dialysis (CCPD)
  • increasing the volume—amount of solution in the bag—of each exchange in continuous ambulatory peritoneal dialysis (CAPD)
  • adding an extra, automated middle-of-the-night exchange to the continuous ambulatory peritoneal dialysis (CAPD) schedule
  • adding an extra middle-of-the-day exchange to the continuous ambulatory peritoneal dialysis (CAPD) schedule
  • using a dialysis solution with a higher dextrose concentration

Compliance

One of the big problems with peritoneal dialysis is that patients sometimes do not perform all of the exchanges recommended by their medical team. They either skip exchanges or sometimes skip entire treatment days when using continuous cycler-assisted peritoneal dialysis (CCPD). Skipping peritoneal dialysis treatments has been shown to increase the risk of hospitalization and death.

Residual Kidney Function

Normally the peritoneal dialysis prescription factors in the amount of residual kidney function. Residual function typically falls, although slowly, over the months or even years of treatment with peritoneal dialysis. This means that, more often than not, the number of peritoneal dialysis exchanges prescribed, or the volume of exchanges, needs to be increased as residual function falls.

Your doctor should determine your dose of peritoneal dialysis on the basis of practice guidelines published by the National Kidney Foundation’s Kidney Disease Outcomes Quality Initiative. Your health care provider should work closely with you to ensure that the proper peritoneal dialysis dose is administered. To maximize your health and prolong your life, you should follow instructions carefully to get the most out of your dialysis exchanges.

Hemodialysis diet

The renal dietitian at your dialysis center will help you plan a diet for your special needs.

Use this as a guide only until your dietitian prepares a personalized meal plan for you. You will need to:

  • Eat more high protein foods.
  • Eat less high salt, high potassium, and high phosphorus foods.
  • Learn how much fluid you can safely drink (including coffee, tea, and water).

You will need to carefully plan your meals and keep track of the amount of liquids you eat and drink. It helps to limit or avoid foods and beverages that have lots of:

  • potassium
  • phosphorus
  • sodium—for example, vegetable juice and sports drinks

Why is it important to keep track of how much liquid you eat and drink?

You may feel better if you keep track of and limit how much liquid you eat and drink. Excess fluid can build up in your body and may cause:

  • swelling and weight gain between dialysis sessions
  • changes in your blood pressure
  • your heart to work harder, which can lead to serious heart trouble
  • a buildup of fluid in your lungs, making it hard for you to breathe

Hemodialysis removes extra fluid from your body. However, hemodialysis can remove only so much fluid at a time safely. If you come to your hemodialysis with too much fluid in your body, your treatment may make you feel ill. You may get muscle cramps or have a sudden drop in blood pressure that causes you to feel dizzy or sick to your stomach.

Your health care provider can help you figure out how much liquid is right for you.

One way to limit how much liquid you have is to limit the salt in the foods you eat. Salt makes you thirsty, so you drink more. Avoid salty foods such as chips and pretzels.

Your renal dietitian will give you other tips to help you limit how much liquid you consume while making sure you don’t feel too thirsty.

What foods count as liquid and why?

Foods that are liquid at room temperature, such as soup, contain water. Gelatin, pudding, ice cream, and other foods that include a lot of liquid in the recipe also count. Most fruits and vegetables contain water, such as melons, grapes, apples, oranges, tomatoes, lettuce, and celery. When you count up how much liquid you have in a day, be sure to count these foods.

What is my dry weight?

Your dry weight is your weight after a hemodialysis session has removed all extra fluid from your body. Controlling your liquid intake helps you stay at your proper dry weight. If you let too much fluid build up between sessions, it is harder to achieve your dry weight. Your health care provider can help you figure out what dry weight is right for you.

My dry weight goal: _____________.

Why you need to be on a special hemodialysis diet?

Because your kidneys are not able to get rid of enough waste products and fluids from your blood and your body now has special needs, you will need to limit fluids and change your intake of certain foods in your diet. How well you feel will depend on:

  • eating the right kind and amounts of food from your diet
  • having the hemodialysis treatments your doctor orders for you
  • taking the medications your doctor orders for you.

Your diet is very important to your care. It is important that you have the right amount of protein, calories, fluids, vitamins and minerals each day. Your dietitian will help you plan your meals to make sure you get the proper balance.

Is there anything else I should know?

The following important tips can be helpful with your diet:

  • Fresh or plain frozen vegetables contain no added salt. Drain all the cooking fluid before serving.
  • Canned fruits usually contain less potassium than fresh fruits. Drain all the fluid before serving.
  • Non-dairy creamers are low in phosphorus and can be used in place of milk.
  • Labels on food packages will give you information about some of the ingredients that may not be allowed in your diet. Learn to read these labels.
  • To help you avoid salt, many herbs and spices can be used to make your diet more interesting. Check with your dietitian for a list of these.

What if I have high cholesterol?

Changing your diet may help lower the cholesterol level in your blood. Your dietitian will talk with you about the kinds of fat and animal foods you eat. Also, your doctor may decide you need a special medication to reduce the cholesterol in your blood.

What if I have diabetes?

In some cases, you may need to make only a few changes in your diet to fit your needs as a kidney patient. For example, some of the free foods you have been using may need to be limited on your kidney diet. Your dietitian will help develop a meal plan especially for you.

What you need to know about potassium

Healthy kidneys keep the right amount of potassium in your blood to keep your heart beating at a steady pace. Potassium levels can rise between hemodialysis sessions and affect your heartbeat. Eating too much potassium can be dangerous to your heart and may even cause death.

To control potassium levels, limit potassium-rich foods such as avocados, bananas, kiwis, and dried fruit. Choose fruits and vegetables that are lower in potassium. Have very small portions of foods that are higher in potassium, such as one or two cherry tomatoes on a salad or a few raisins in your oatmeal.

You can remove some of the potassium from potatoes by dicing or shredding them and then boiling them in a full pot of water.

Your renal dietitian will give you more specific information about the potassium content of foods.

What you need to know about phosphorus

Too much phosphorus in your blood pulls calcium from your bones. Losing calcium may make your bones weak and likely to break. Also, too much phosphorus may make your skin itch. Limiting phosphorus can be hard because foods that contain phosphorus, such as meat and milk, also contain the protein you need. You should be careful to eat enough protein; however, not so much that you get too much phosphorus. Processed and packaged foods contain especially high levels of phosphorus. You can also find phosphorus naturally in foods such as poultry, fish, nuts, peanut butter, beans, cola, tea, and dairy products. Usually, people on hemodialysis should only have a 1/2 cup of milk per day. Your renal dietitian will give you more specific information about phosphorus.

You may need to take a phosphate binder such as sevelamer (Renvela), calcium acetate (PhosLo), lanthanum carbonate (Fosrenol), or calcium carbonate to control the phosphorus in your blood between hemodialysis sessions. These medicines act like plastic bags with zip tops. The phosphorus binder “seals” the phosphorus from food and moves it out through stool so the phosphorous does not enter the bloodstream.

What you need to know about protein

Renal dietitians encourage most people on hemodialysis to eat high-quality protein because it produces less waste for removal during dialysis. High-quality protein comes from meat, poultry, fish, and eggs. Avoid processed meats such as hot dogs and canned chili, which have high amounts of sodium and phosphorus.

What you need to know about sodium

Sodium is a part of salt. Sodium is found in many canned, packaged, frozen, and fast foods. Sodium is also found in many condiments, seasonings, and meats. Too much sodium makes you thirsty, which makes you drink more liquid.

  • Use less salt and eat fewer salty foods: this may help to control blood pressure and reduce weight gains between dialysis sessions.
  • Use herbs, spices, and low-salt flavor enhancers in place of salt.
  • Avoid salt substitutes made with potassium.

Try to eat fresh, naturally low-sodium foods. Look for products labeled “low sodium,” especially in canned and frozen foods.

Do not use salt substitutes because they contain potassium. Talk with your renal dietitian about spices you can use to flavor your food. Your renal dietitian can help you find spice blends without sodium or potassium.

What you need to know about calories

All foods contain calories, and you need calories for energy. Many people on hemodialysis do not have a good appetite and do not get enough calories. If you find you do not feel like eating, talk with your renal dietitian to find healthy ways to add calories to your diet. Vegetable oils—such as olive oil, canola oil, and safflower oil—are good sources of calories and are the healthiest way to add fat to your diet if you need to gain weight. Use them generously on breads, rice, and noodles only if your renal dietitian tells you to add calories to your diet.

Butter and margarines are rich in calories; however, they are mainly saturated fat. Saturated fats and trans fats can clog your arteries. Use them less often. Soft margarine that comes in a tub is better than stick margarine. Choose a soft margarine with less saturated and trans fats.

Talk with your renal dietitian about the types and amounts of fat you need in your diet. Everyone will have different needs that a renal dietitian can help address.

Hard candy, sugar, honey, jam, and jelly provide calories and energy without fat or adding other things that your body does not need. If you have diabetes, be careful about eating sweets and talk with your renal dietitian before adding sweets to your food plan.

Should you take vitamin and mineral supplements?

You may not get enough vitamins and minerals in your diet because you have to avoid so many foods. Hemodialysis also removes some vitamins from your body. Your health care provider may prescribe a vitamin and mineral supplement designed specifically for people with kidney failure.

Warning: Do not take nutritional supplements you can buy over the counter. These supplements may contain vitamins or minerals that are harmful to you. For safety reasons, talk with your health care provider before using probiotics, dietary supplements, or any other medicine together with or in place of the treatment your health care provider prescribes.

Meat and Protein

People on dialysis need to eat more protein. Protein can help maintain blood protein levels and improve health. Eat a high protein food (meat, fish, poultry, fresh pork, or eggs) at every meal, or about 8-10 ounces of high protein foods everyday.

3 ounce = the size of a deck of cards, a medium pork chop, a ¼ pound hamburger patty, ½ chicken breast, a medium fish fillet.

1 ounce = 1 egg or ¼-cup egg substitute, ¼-cup tuna, ¼-cup ricotta cheese, 1 slice of low sodium lunchmeat.

Note: Even though peanut butter, nuts, seeds, dried beans, peas, and lentils have protein, these foods are generally not recommended because they are high in both potassium and phosphorus.

Grains/Cereals/Bread

Unless you need to limit your calorie intake for weight loss and/or manage carbohydrate intake for blood sugar control, you may eat, as you desire from this food group. Grains, cereals, and breads are a good source of calories. Most people need 6 -11 servings from this group each day.

Avoid “whole grain” and “high fiber” foods (like whole wheat bread, bran cereal and brown rice) to help you limit your intake of phosphorus. By limiting dairy–based foods you protect your bones and blood vessels.

Amounts equal to one serving:

  • 1 slice bread (white, rye, or sourdough)
  • ½ English muffin
  • ½ bagel
  • ½ hamburger bun
  • ½ hot dog bun
  • 1 6-inch tortilla
  • ½ cup cooked pasta
  • ½ cup cooked white rice
  • ½ cup cooked cereal (like cream of wheat)
  • 1 cup cold cereal (like corn flakes or crispy rice)
  • 4 unsalted crackers
  • 1½ cups unsalted popcorn
  • 10 vanilla wafers

Milk/Yogurt/Cheese

Limit your intake of milk, yogurt, and cheese to ½-cup milk or ½-cup yogurt or 1-ounce cheese per day. Most dairy foods are very high in phosphorus.

The phosphorus content is the same for all types of milk – skim, low fat, and whole! If you do eat any high-phosphorus foods, take a phosphate binder with that meal.

Dairy foods “low” in phosphorus (ask your dietitian about the serving size that is right for you):

  • Butter and tub margarine
  • Cream cheese
  • Heavy cream
  • Ricotta cheese
  • Brie cheese
  • Non-dairy whipped topping
  • Sherbet

If you have or are at risk for heart disease, some of the high fat foods listed above may not be good choices for you.

Certain brands of non-dairy creams and “milk” (such as rice milk) are low in phosphorus and potassium. Ask your dietitian for details.

Fruit/Juice

All fruits have some potassium, but certain fruits have more than others and should be limited or totally avoided. Limiting potassium protects your heart.

Always AVOID star fruit (carambola).

  • Eat 2-3 servings of low potassium fruits each day.
  • One serving = ½-cup or 1 small fruit or 4 ounces of juice.

Limit or avoid:

  • Oranges and orange juice
  • Kiwis
  • Nectarines
  • Prunes and prune juice
  • Raisins and dried fruit
  • Bananas
  • Melons (cantaloupe and honeydew)

Choose:

  • Apple (1)
  • Berries (½ cup)
  • Cherries (10)
  • Fruit cocktail, drained (½ cup)
  • Grapes (15)
  • Peach (1 small fresh or canned, drained)
  • Pear, fresh or canned, drained (1 halve)
  • Pineapple (½ cup canned, drained)
  • Plums (1-2)
  • Tangerine (1)
  • Watermelon (1 small wedge)

Drinks:

  • Apple cider
  • Cranberry juice cocktail
  • Grape juice
  • Lemonade

Vegetables and Salads

All vegetables have some potassium, but certain vegetables have more than others and should be limited or totally avoided. Limiting potassium intake protects your heart.

Eat 2-3 servings of low-potassium vegetables each day. One serving = ½-cup.

Choose:

  • Broccoli (raw or cooked from frozen)
  • Cabbage
  • Carrots
  • Cauliflower
  • Celery
  • Cucumber
  • Eggplant
  • Garlic
  • Green and Wax beans (“string beans”)
  • Lettuce-all types (1 cup)
  • Onion
  • Peppers-all types and colors
  • Radishes
  • Watercress
  • Zucchini and Yellow squash

Limit or avoid:

  • Potatoes (including French Fries, potato chips and sweet potatoes)
  • Tomatoes and tomato sauce
  • Winter squash
  • Pumpkin
  • Asparagus (cooked)
  • Avocado
  • Beets
  • Beet greens
  • Cooked spinach
  • Parsnips and rutabaga

Dessert

Depending on your calorie needs, your dietitian may recommend high-calorie deserts. Pies, cookies, sherbet, and cakes are good choices (but limit dairy-based desserts and those made with chocolate, nuts, and bananas). If you are a diabetic, discuss low carbohydrate dessert choices with your dietitian.

Sample Menu

This meal plan provides 2150 Calories, 91 grams protein, 2300 mg sodium, 1800 mg (46 mEq) potassium, 950 mg phosphorus. 38 ounces of oral fluid.

Breakfast

  • Cranberry Juice, 4 ounces
  • Eggs (2) or ½-cup egg substitute
  • Toasted white bread, 2 slices, with Butter or tub margarine or fruit spread
  • Coffee, 6 ounces

Lunch

  • Tuna salad sandwich made with 3 ounces tuna on a hard roll with lettuce and mayonnaise.
  • (Other good choices for sandwiches include egg and chicken salad, lean roast beef, low salt ham and turkey breast.)
  • Coleslaw, ½-cup
  • Pretzels (low salt)
  • Canned and drained peaches, ½-cup
  • Ginger Ale, 8 ounces

Cola drinks are high in phosphorus. Choose ginger ale or lemon-lime beverages instead.

Dinner

  • Hamburger patty, 4 ounces on a bun with 1-2 teaspoons ketchup
  • Salad (1 cup): lettuce, cucumber, radishes, peppers, with olive oil and vinegar dressing
  • Lemonade, 8 ounces

Aim for at least 2-3 “fish” meals each week. Many fish are rich in heart-healthy “omega-3” fats. Tuna and salmon (rinsed or canned without salt) and shellfish are excellent heart healthy protein choices.

Snack/Dessert

  • Milk, 4 ounces
  • Slice of apple pie

How will I know if I am eating right to keep me healthy?

Because you are on dialysis, you have some very special needs. Eating well helps you stay healthy. Eating poorly can increase your risk of illness. Your dietitian will talk with you about how well you are eating.

Some questions you might be asked:

  • Have you noticed a change in the kind or amount of food you eat each day?
  • Have you had any problems eating your usual or recommended diet?
  • Have you lost weight without trying?
  • Have you noticed any changes in your strength or ability to take care of yourself?

Your dietitian or nurse might look at the fat and muscle stores in your face, hands, arms, shoulders, and legs. Your dialysis care team will look for changes in your blood level of proteins, and especially one called albumin. A change in this protein can mean that you are losing body protein.

Some special blood tests that are done each month are called Kt/V or urea reduction ratio. These tests help your doctor decide if you are getting enough dialysis. Getting the right amount of dialysis is important to help you feel your best.

A change in your fat and muscle stores or any of these blood tests could be a sign that you are not getting enough dialysis. Along with the Kt/V, these tests provide information about your intake of protein or your protein equivalent of nitrogen appearance. Using the protein equivalent of nitrogen appearance, your albumin and any changes in your appetite, your dietitian will determine if you are eating enough of the right foods. The right amount of dialysis is needed to make sure you are able to enjoy your food while keeping you healthy.

  1. Kidney Failure Treatment Options – Comparison Chart. https://www.niddk.nih.gov/health-information/kidney-disease/kidney-failure/choosing-treatment/comparison-chart[][]
  2. Hall YN, Larive B, Painter P, et al. Effects of six versus three times per week hemodialysis on physical performance, health, and functioning: Frequent Hemodialysis Network (FHN) randomized trials. Clinical Journal of the American Society of Nephrology. 2012;7(5):782–794.[]
  3. McCann M, Einarsdottir H, Van Waeleghem JP, Murphy F, Sedgewick J. Vascular access management 1: an overview. J Ren Care. (2008);34: 77–84. doi: 10.1111/j.1755-6686.2008.00022.x https://www.ncbi.nlm.nih.gov/pubmed/18498572[]
  4. National Kidney Foundation: K/DOQI clinical practice guidelines for hemodialysis adequacy, 2000. American Journal of Kidney Disease. 2001;37(suppl 1):S7-S64.[]
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Procedures

Cesarean section

cesarean section

What is cesarean section

A cesarean section, or C-section, is an operation to deliver your baby through a cut made in your abdomen and womb (uterus). The cut is usually made across your abdomen, just below your bikini line. A cesarean is a major operation that carries a number of risks, so it’s usually only done if it’s the safest option for you and your baby. After the baby is removed from the womb, the uterus and abdomen are closed with stitches that later dissolve 1.

In the United States, almost one in three women has their babies this way. Cesarean section is now the most common surgery performed in the United States, with over 1 million women delivered by cesarean every year 2. The cesarean delivery rate rose from 5% in 1970 to 31.9% in 2016 3. Though there are continuing efforts to reduce the rate of cesarean sections, experts do not anticipate a significant drop for at least a decade or two 4. While it confers risks of both immediate and long-term complications, for some women, cesarean delivery can be the safest or even the only way to deliver a healthy newborn.

Some C-sections are planned, but many are done when unexpected problems happen during delivery. Reasons for a C-section may include:

  • Health problems in the mother
  • The mother carrying more than one baby
  • The size or position of the baby
  • The baby’s health is in danger
  • Labor is not moving along as it should

The cesarean section surgery is relatively safe for mother and baby. Still, it is major surgery and carries risks. It also takes longer to recover from a C-section than from vaginal birth. It can raise the risk of having difficulties with future pregnancies. Some women may have problems attempting a vaginal birth later. Still, many women are able to have a vaginal birth after cesarean section.

Most cesareans are carried out under spinal or epidural anaesthetic. This mean you’ll be awake, but the lower part of your body is numbed so you won’t feel any pain.

During the cesarean section procedure:

  • a screen is placed across your body so you can’t see what’s being done – the doctors and nurses will let you know what’s happening
    a cut about 10-20cm long will usually be made across your lower tummy and womb so your baby can be delivered
  • you may feel some tugging and pulling during the procedure
  • you and your birth partner will be able to see and hold your baby as soon as they’ve been delivered

The whole operation normally takes about 40-50 minutes.

Occasionally a general anaesthetic, where you’re asleep, may be used, particularly if the baby needs to be delivered more quickly.

Figure 1. Cesarean section scar

Cesarean section scar

C-section recovery time

Recovering from a cesarean usually takes longer than recovering from a vaginal delivery. You might need to stay in hospital for three or four days, compared with one or two days for a vaginal birth.

You may experience some discomfort in your tummy for the first few days, and you’ll be offered painkillers to help with this.

When you go home, you’ll need to take things easy at first. You may need to avoid some activities such as driving for six weeks or so.

The wound in your tummy will eventually form a scar. This may be red and obvious at first, but it should fade with time and will often be hidden in your pubic hair.

Future pregnancies after a cesarean section

If you have a baby by cesarean section, it doesn’t necessarily mean that any babies you have in the future will also have to be delivered this way.

Most women who have had a cesarean section can safely have a vaginal delivery for their next baby, known as vaginal birth after cesarean section.

However, you may need some extra monitoring during labor just to make sure everything is progressing well.

Some women may be advised to have another cesarean section if they have another baby. This depends on whether a cesarean section is still the safest option for them and their baby.

Reasons for cesarean section

A cesarean section may be recommended as a planned (elective) procedure or done in an emergency if it’s thought a vaginal birth is too risky. For example, a cesarean delivery is often the recommended approach if a woman has had a prior classical cesarean scar or previous uterine rupture. However, due to the potential complications of cesarean birth, much study has been done looking for ways to reduce the cesarean rate.

Planned cesareans aren’t usually done before the 39th week of pregnancy.

There has been an emphasis decreasing the number of first-time cesarean births, as many women who have one cesarean birth will ultimately have the remainder of their children via cesarean section. She may choose another cesarean birth for various reasons or she may not be a candidate for a subsequent vaginal birth. For example, if a woman has an unfavorable cervix at term, cervical ripening with medications such as misoprostol is not recommended due to an increased risk of uterine rupture with those agents. In the 2011 article “Safe Prevention of the Primary Cesarean Delivery” 5, the authors addressed the most commonly documented indications for first-time cesarean deliveries (labor dystocia, abnormal fetal heart rate pattern, malpresentation of the fetus, multiple gestations, and suspected fetal macrosomia), and mitigation of how these factors.

One study in 2007 6 looked at what level of additional fetal risk a woman or her caregiver considered to be acceptable to achieve a vaginal delivery and to avoid a cesarean section. They concluded that both the pregnant patients and those taking care of them had a low tolerance for risk. It is understandable and justifiable for a woman to have high expectations for the outcome of her delivery. The goal of reducing cesarean rates may be difficult to achieve, considering this hesitance to expose the fetus to risk.

A cesarean may be carried out because:

  • Breech presentation: your baby is in the breech position (feet first) and your doctor has been unable to turn them by applying gentle pressure to your tummy, or you would prefer they didn’t try this
  • You have a low-lying placenta (placenta previa)
  • You have pregnancy-related high blood pressure (pre-eclampsia)
  • You have certain infections, such as a first genital herpes infection occurring late in pregnancy or untreated HIV
  • Your baby isn’t getting enough oxygen and nutrients – sometimes this may mean the baby needs to be delivered immediately
  • Your labor isn’t progressing or there’s excessive vaginal bleeding
  • Failure of labor to progress—contractions may not open the cervix enough for the baby to move into the vagina.
  • Concern for the baby—For instance, the umbilical cord may become pinched or compressed or fetal monitoring may detect an abnormal heart rate.
  • Multiple pregnancy—you’re pregnant with twins, a cesarean birth may be necessary if the babies are being born too early, are not in good positions in the uterus, or if there are other problems. The likelihood of having a cesarean birth increases with the number of babies a woman is carrying.
  • A very large baby. Larger infants are at risk for complications during delivery. These include shoulder dystocia, when the infant’s head is delivered through the vagina but the shoulders are stuck 7. Women with gestational diabetes, especially if their blood sugar levels are not well controlled, are at increased risk for having large babies.
  • Maternal infections, such as human immunodeficiency virus (HIV) or herpes, that could be passed to the baby during vaginal birth. Cesarean delivery could help prevent transmission of the virus to the infant.
  • Sometimes the placenta is not formed or working correctly, is in the wrong place in the uterus, or is implanted too deeply or firmly in the uterine wall. These issues can cause problems, such as preventing needed oxygen and nutrients from reaching the fetus or causing vaginal bleeding 8.
  • Maternal medical conditions, such as diabetes mellitus or high blood pressure

Maternal indications for Cesarean section 9:

  • Prior cesarean delivery
  • Maternal request
  • Pelvic deformity or cephalopelvic disproportion
  • Previous perineal trauma
  • Prior pelvic or anal/rectal reconstructive surgery
  • Herpes simplex or HIV infection
  • Cardiac or pulmonary disease
  • Cerebral aneurysm or arteriovenous malformation
  • Pathology requiring concurrent intraabdominal surgery
  • Perimortem cesarean

Uterine and anatomic indications for Cesarean birth 9:

  • Abnormal placentation (such as placenta previa, placenta accreta)
  • Placental abruption
  • Prior classical hysterotomy
  • Prior full-thickness myomectomy
  • History of uterine incision dehiscence
  • Invasive cervical cancer
  • Prior trachelectomy
  • Genital tract obstructive mass
  • Permanent cerclage

Fetal indications for Cesarean birth 10:

  • Nonreassuring fetal status (such as abnormal umbilical cord Doppler study) or abnormal fetal heart tracing
  • Umbilical cord prolapse
  • Failed operative vaginal delivery
  • Malpresentation
  • Macrosomia
  • Congenital anomaly
  • Thrombocytopenia
  • Prior neonatal birth trauma

If there’s time to plan the procedure, your midwife or doctor will discuss the benefits and risks of a cesarean compared with a vaginal birth.

Is a cesarean birth necessary if I have had a previous cesarean birth?

Women who have had a cesarean birth before may be able to give birth vaginally. The decision depends on the type of incision used in the previous cesarean delivery, the number of previous cesarean deliveries, whether you have any conditions that make a vaginal delivery risky, and the type of hospital in which you have your baby, as well as other factors. Talk to your obstetrician–gynecologist (ob-gyn) or other health care professional about your options.

Can I request cesarean birth?

Some women choose to have a cesarean for non-medical reasons. If you ask your midwife or doctor for a cesarean when there aren’t medical reasons, they will explain the overall benefits and risks of a cesarean compared with a vaginal birth.

Regardless of the type of delivery, unless there is a medical necessity, delivery should not occur before 39 weeks of pregnancy (called “full term”).

If you’re anxious about giving birth, you should be offered the chance to discuss your anxiety with a healthcare professional who can offer support during your pregnancy and labor.

If after discussion and support you still feel that a vaginal birth isn’t an acceptable option, you’re entitled to have a planned cesarean.

Cesarean section procedure

Cesarean sections are carried out in hospital. You may be asked to come in for an appointment a few days beforehand, and you might need to stay in hospital for a few days afterwards.

Preoperative appointment

If there’s time to plan your cesarean, you’ll be given an approximate date for it to be carried out.

You’ll also be asked to attend an appointment at the hospital in the week before the procedure is due to be performed.

During this appointment:

  • you can ask any questions you have about the procedure
  • a blood test will be carried out to check for a lack of red blood cells (anemia)
  • you’ll be given some medication to take before the procedure – this may include antibiotics, anti-sickness medication (anti-emetics) and medication to reduce the acidity of your stomach acid (antacids)
  • you’ll be asked to sign a consent form

You’ll need to stop eating and drinking a few hours before the procedure – your doctor or midwife will tell you when.

Cesarean section preparation

You’ll be asked to change into a hospital gown when you arrive at the hospital on the day of the procedure.

Before you have a cesarean delivery, a nurse will prepare you for the operation. An intravenous line (IV) will be put in a vein in your arm or hand. This allows you to get fluids and medications during the surgery. Your abdomen will be washed, and your pubic hair may be clipped or trimmed. You will be given medication to prevent infection.

A thin, flexible tube called a catheter will be inserted into your bladder to empty it while you’re under the anaesthetic, and a small area of pubic hair will be trimmed if necessary. Keeping the bladder empty decreases the chance of injuring it during surgery.

You’ll be given the anaesthetic in the operating room. You will be given either general anesthesia, an epidural block, or a spinal block. If general anesthesia is used, you will not be awake during the delivery. An epidural block numbs the lower half of the body. An injection is made into a space in your spine in your lower back. A small tube may be inserted into this space so that more of the drug can be given through the tube later, if needed. A spinal block also numbs the lower half of your body. You receive it the same way as an epidural block, but the drug is injected directly into the spinal fluid. This means you’ll be awake during the delivery and can see and hold your baby straight away.

It also means your birth partner can be with you.

General anaesthetic – where you’re asleep – is used in some cases if you can’t have a spinal or epidural anaesthetic.

What happens during cesarean surgery

During the cesarean section procedure:

  • you lie down on an operating table, which may be slightly tilted to begin with
  • a screen is placed across your tummy so you can’t see the operation being done
  • a 10-20cm cut is made in your tummy and womb – the skin incision may be transverse (horizontal or “bikini”) cut just below your bikini line although sometimes a vertical cut below your bellybutton may be made
  • the muscles in your abdomen are separated and may not need to be cut. Another incision will be made in the wall of the uterus. The incision in the wall of the uterus also will be either transverse or vertical.
  • your baby is delivered through the opening, the umbilical cord will be cut, and then the placenta will be removed– this usually takes 5-10 minutes and you may feel some tugging at this point
  • your baby will be lifted up for you to see as soon as they’ve been delivered, and they’ll be brought over to you
  • you’re given an injection of the hormone oxytocin once your baby is born to encourage your womb to contract and reduce blood loss
  • your womb is closed with dissolvable stitches, and the cut in your tummy is closed either with dissolvable stitches, or stitches or staples that need to be removed after a few days

The whole procedure usually takes around 40-50 minutes.

Cesarean section techniques

The four main cesarean section techniques are:

  1. Pfannenstiel-Kerr method
  2. Joel-Cohen method
  3. Misgav-Ladach method
  4. Modified Misgav-Ladach method

The cesarean section is a complicated procedure.During the surgery itself, several techniques are utilizable at each step or tissue layer. Many factors contribute to a surgeon’s decisions on technique. As with any aspect of medical practice, basing those decisions on evidence is recommended.

The following is a summary of the four general operative methods 11:

Figure 2. Cesarean section techniques

Pfannenstiel-Kerr method

  • Pfannenstiel skin incision
  • Sharp dissection of the subcutaneous layer
  • Sharp extension of the fascial opening
  • Sharp entry into the peritoneum
  • Sharp superficial then blunt entry into the uterus
  • Manual removal of the placenta
  • Single-layer interrupted closure of the uterus
  • Closure of the peritoneum
  • Interrupted closure of the fascia
  • Continuous suture of the skin

Joel-Cohen method

  • Joel-Cohen skin incision
  • Blunt dissection of the subcutaneous layer
  • Blunt extension of the fascial opening
  • Blunt entry into the peritoneum
  • Sharp superficial then blunt entry into the uterus
  • Spontaneous removal of the placenta
  • Single-layer interrupted closure of the uterus
  • Non-closure of the peritoneum
  • Interrupted closure of the fascia
  • Continuous suture of the skin

Misgav-Ladach method

  • Joel-Cohen skin incision
  • Blunt dissection of the subcutaneous layer
  • Blunt extension of the fascial opening
  • Blunt entry into the peritoneum
  • Sharp superficial then blunt entry into the uterus
  • Manual removal of the placenta
  • Single-layer running closure of the uterus
  • Non-closure of the peritoneum
  • Continuous closure of the fascia
  • Mattress suture closure of the skin

Modified Misgav-Ladach method

  • Pfannenstiel skin incision
  • Blunt dissection of the subcutaneous layer
  • Blunt extension of the fascial opening
  • Blunt entry into the peritoneum
  • Sharp superficial then blunt entry into the uterus
  • Spontaneous removal of the placenta
  • Single-layer running closure of the uterus
  • Closure of the peritoneum
  • Continuous closure of the fascia
  • Continuous suture of the skin

Cesarean section recovery

You’ll usually be moved from the operating room to a recovery room straight after the cesarean section procedure. If you are awake for the surgery, you can probably hold your baby right away.

Once you’ve started to recover from the anaesthetic, the medical staff will make sure you’re well and continue to observe you every few hours. Your blood pressure, pulse rate, breathing rate, amount of bleeding, and abdomen will be checked regularly.

If you are planning on breastfeeding, be sure to let your doctor know.

Having a cesarean delivery does not mean you will not be able to breastfeed your baby. You should be able to begin breastfeeding right away.

You’ll be offered:

  • painkillers to relieve any discomfort
  • treatment to reduce the risk of blood clots – this may include compression stockings or injections of blood-thinning medication, or both
  • food and water as soon you as you feel hungry or thirsty
  • help with breastfeeding your baby if you want it – read more about the first few days of breastfeeding

The catheter will usually be removed from your bladder around 12-18 hours after the procedure, once you’re able to walk around.

You may be in hospital for a few days after a cesarean section, and may need to take things easy for several weeks.

Recovering in hospital

The average stay in hospital after a cesarean is around three or four days. You may be able to go home sooner than this if both you and your baby are well.

While in hospital:

  • you’ll be given painkillers to reduce any discomfort
  • you’ll have regular close contact with your baby and can start breastfeeding
  • you’ll be encouraged to get out of bed and move around as soon as possible. The first few times you get out of bed, a nurse or other adult should help you.
  • you can eat and drink as soon as you feel hungry or thirsty
  • a thin, flexible tube called a catheter will remain in your bladder for at least 12 hours
  • your wound will be covered with a dressing for at least 24 hours

A hospital stay after a cesarean birth usually is 2–4 days. The length of your stay depends on the reason for the cesarean birth and on how long it takes for your body to recover.

When you’re well enough to go home, you’ll need to arrange for someone to give you a lift as you won’t be able to drive for a few weeks.

When you go home, you may need to take special care of yourself and limit your activities.

Looking after your wound

The abdominal incision will be sore for the first few days. Your midwife should also advise you on how to look after your wound.

Your doctor can prescribe pain medication for you to take after the anesthesia wears off. A heating pad may be helpful. There are many different ways to control pain. Talk with your ob-gyn or other health care professional about your options.

You’ll usually be advised to:

  • gently clean and dry the wound every day
  • wear loose, comfortable clothes and cotton underwear
  • take painkillers if the wound is sore – see controlling pain
  • watch out for signs of infection – see when to get medical advice

Non-dissolvable stitches or staples will usually be taken out by your midwife after five to seven days.

Your cesarean section scar

The wound in your tummy will eventually form a scar.

This will usually be a horizontal scar about 10-20cm long, just below your bikini line.

In rare cases, you may have a vertical scar just below your belly button.

The cesarean section scar will probably be red and obvious at first, but it should fade with time and will often be hidden in your pubic hair.

Controlling pain and bleeding

Most women experience some discomfort for the first few days after a cesarean, and for some women the pain can last several weeks.

You should be given regular painkillers to take at home, for as long as you need them.

Paracetamol is usually recommended for mild pain, co-codamol for moderate pain, and a combination of co-codamol and ibuprofen for more severe pain.

You may also have some vaginal bleeding. Use sanitary pads rather than tampons to reduce the risk of spreading infection into the vagina, and get medical advice if the bleeding is heavy.

What should I expect during recovery?

While you recover, the following things may happen:

  • Mild cramping, especially if you are breastfeeding
  • Bleeding or discharge for about 4–6 weeks
  • Bleeding with clots and cramps
  • Pain in the incision

To prevent infection, for a few weeks after the cesarean birth you should not place anything in your vagina or have sex. Allow time to heal before doing any strenuous activity. Call your Obstetrician–Gynecologist or other health care professional if you have a fever, heavy bleeding, or the pain gets worse.

If you experience severe mood swings, loss of appetite, overwhelming fatigue and lack of joy in life shortly after childbirth, you might have postpartum depression. Contact your health care provider if you think you might be depressed, especially if your signs and symptoms don’t fade on their own, you have trouble caring for your baby or completing daily tasks, or you have thoughts of harming yourself or your baby.

The American College of Obstetricians and Gynecologists recommends that postpartum care be an ongoing process rather than just a single visit after your delivery. Have contact with your health care provider within the first three weeks after delivery. Within 12 weeks after delivery, see your health care provider for a comprehensive postpartum evaluation. During this appointment your health care provider will check your mood and emotional well-being, discuss contraception and birth spacing, review information about infant care and feeding, talk about your sleep habits and issues related to fatigue and do a physical exam. This might include a check of your abdomen, vagina, cervix and uterus to make sure you’re healing well. In some cases, you might have the checkup earlier so that your health care provider can examine your C-section incision. Use this visit to ask questions about your recovery and caring for your baby.

Returning to your normal activities

Try to stay mobile and do gentle activities, such as going for a daily walk, while you’re recovering to reduce the risk of blood clots. Be careful not to overexert yourself.

You should be able to hold and carry your baby once you get home. But you may not be able to do some activities straight away, such as:

  • driving
  • exercising
  • carrying anything heavier than your baby
  • having sex

Only start to do these things again when you feel able to do so and don’t find them uncomfortable. This may not be for six weeks or so.

Ask your midwife for advice if you’re unsure when it’s safe to start returning to your normal activities. You can also ask your doctor at your six-week postnatal check.

When to get medical advice

Contact your midwife or Obstetrician–Gynecologist straight away if you have any of the following symptoms after a cesarean:

  • severe pain
  • leaking urine
  • pain when peeing
  • heavy vaginal bleeding
  • your wound becomes more red, painful and swollen
  • a discharge of pus or foul-smelling fluid from your wound
  • a cough or shortness of breath
  • swelling or pain in your lower leg

These symptoms may be the sign of an infection or blood clot, which should be treated as soon as possible.

Cesarean section complications

A cesarean section is generally a very safe procedure, but like any type of surgery it carries a certain amount of risk of complications. The maternal mortality rate in the USA is approximately 2.2 per 100,000 cesarean deliveries 12. Though this is overall low, it is significantly greater than for vaginal delivery. The maternal mortality for a vaginal birth is approximately 0.2 per 100,000 12.

It’s important to be aware of the possible complications, particularly if you’re considering having a cesarean for non-medical reasons.

The level of risk will depend on things such as whether cesarean section procedure is planned or carried out as an emergency, and your general health.

If there’s time to plan your cesarean section, your doctor or midwife will talk to you about the potential risks and benefits of the procedure.

Possible complications include:

  • infection of the wound or womb lining
  • blood clots in the legs, pelvic organs, or lungs
  • excessive bleeding
  • damage to nearby areas, such as the bowel or the bladder or the tubes that connect the kidneys and bladder (ureter)
  • temporary breathing difficulties in your baby
  • accidentally cutting your baby when your womb is opened.

As with any delivery and with surgery in general, there is a risk of excessive bleeding during and after a cesarean section. Bleeding (hemorrhage) is the leading cause in the United States of serious maternal morbidity 13. Certain conditions preceding a cesarean, such as prolonged labor or fetal macrosomia or polyhydramnios, may increase the risk of uterine atony and subsequent hemorrhage. Intraoperative conditions such as the need for significant adhesiolysis or extension of the hysterotomy laterally into the uterine vessels could also lead to excessive blood loss. Hemorrhage during delivery may then lead to the need for blood product transfusion, which itself has risks of complications. Sheehan syndrome is a known complication of hemorrhage at delivery 13. Approximately ten percent of maternal mortality in the United States is secondary to obstetric hemorrhage 13.

As previously discussed, there is a significant risk of infection after cesarean delivery. In addition to postpartum hemorrhage, wound infection and endometritis are the other most common complications that occur after a cesarean section. In a study 14 examining the efficacy of vaginal cleansing, postoperative endometritis was reduced from 8.7% to 3.8% with cleansing. A study 15 investigating adjunctive azithromycin saw a decrease in wound infection from 6.6% to 2.4% with the additional antibiotic, and serious adverse events decreased from 2.9% to 1.5%. However, given that over a million women have a cesarean every year, these percentages still represent a significant number of women suffering from infectious complications.

In data reported in 2010, the overall risk of infectious morbidity was 3.2% in elective repeat cesarean deliveries as compared to 4.6% in women undergoing a trial of labor 3. This same data reported elective repeat cesareans to have a blood transfusion rate of 0.46%, a surgical injury rate of 0.3 to 0.6%, and a hysterectomy rate of 0.16% 3. Thromboembolism and anesthetic complications can also occur.

While the cesarean section often has the perception of being safer for the fetus, there are risks to fetal delivery in this fashion. The risk of fetal trauma during cesarean is approximately 1%, including skin laceration, fracture of the clavicle or skull, facial or brachial plexus nerve damage, and cephalohematoma 16. Overall, these risks are lower than in vaginal deliveries. With regards to the neonate, there are risks of respiratory complications as well as higher rates of asthma and allergy in those born via cesarean compared to vaginal delivery 3. In 2010 transient tachypnea of the newborn was reported in 4.2% of elected repeat cesareans, and the need for bag-and-mask ventilation was 2.5% 3.

In addition to short-term and surgical risks, cesarean delivery also confers long-term risk, both to the patient and to her subsequent pregnancies. As stated previously, the presence of a vertical scar on the uterus requires a woman to delivery subsequent pregnancies via cesarean. As the number of cesarean sections increases, so too do the surgical risks. Adhesion formation can make each subsequent cesarean more difficult and increase the risk of inadvertent injury. The risks of abnormal placentation also increase with each subsequent surgery. For a woman who has had one cesarean section, the risk of placenta accreta is 0.3%, while the risk increases to 6.74% with five or more cesarean deliveries 17. A morbidly adherent placenta carries with it a risk of significant hemorrhage and possible loss of fertility if a hysterectomy becomes necessary.

Risks to you

Some of the main risks to you of having a cesarean section include:

  • infection of the wound (common) – causing redness, swelling, increasing pain and discharge from the wound
  • infection of the womb lining (common) – symptoms include a fever, tummy pain, abnormal vaginal discharge and heavy vaginal bleeding
  • excessive bleeding (uncommon) – this may require a blood transfusion in severe cases or possibly further surgery to stop the bleeding
  • deep vein thrombosis (DVT) (rare) – a blood clot in your leg, which can cause pain and swelling and could be very dangerous if it travels to the lungs (pulmonary embolism)
  • damage to your bladder or the tubes that connect the kidneys and bladder (rare) – this may require further surgery
  • reaction to medications or to the anesthesia that is used

Women are now given antibiotics before having a cesarean, which should mean infections become much less common.

Risks to your baby

A cesarean doesn’t affect the risk of some of the rarest and most serious birth complications, such as an injury to the nerves in the neck and arms, bleeding inside the skull, or death.

But a cesarean section can sometimes cause the following problems in babies:

  • a cut in the skin (common) – this may happen accidentally as your womb is opened, but it’s usually minor and heals without any problems
  • breathing difficulties (common) – this most often affects babies born before 39 weeks of pregnancy; it will usually improve after a few days and your baby will be closely monitored in hospital

If you think your baby is experiencing breathing difficulties after you’ve left hospital, contact your doctor straight away.

Risks to future pregnancies

Women who have a cesarean will usually have no problems with future pregnancies.

Most women who have had a cesarean section can safely have a vaginal delivery for their next baby – known as vaginal birth after cesarean. But sometimes another cesarean may be necessary.

Although uncommon, having a cesarean can increase the risk of certain problems in future pregnancies, including:

  • the scar in your womb opening up
  • the placenta being abnormally attached to the wall of the womb, leading to difficulties delivering the placenta
  • stillbirth

Speak to your doctor or midwife if you have any concerns.

Vaginal birth after cesarean section

If you’ve delivered a baby by C-section and you’re pregnant again, you might be able to choose between scheduling a repeat C-section or attempting vaginal birth after C-section (vaginal birth after cesarean section).

For many women, vaginal birth after cesarean section is an option. In fact, research on women who attempt a trial of labor after cesarean shows that about 60 to 80 percent have a successful vaginal delivery.

Vaginal birth after cesarean section isn’t right for everyone, though. Certain factors, such as a high-risk uterine scar, can make vaginal birth after cesarean section inappropriate. Some hospitals don’t offer vaginal birth after cesarean section because they don’t have the staff or resources to handle emergency C-sections. If you’re considering vaginal birth after cesarean section, your health care provider can help you understand if you’re a candidate and what’s involved.

Why vaginal birth after cesarean section is done?

Women consider vaginal birth after cesarean section for various reasons, including:

  • Shorter recovery time. You’ll have a shorter hospital stay after a vaginal birth after cesarean section than you would after a repeat C-section. Avoiding surgery will help your energy and stamina return more quickly, as well as reduce the expense of childbirth.
  • More participation in the birth. For some women, it’s important to experience a vaginal delivery. Your labor coach and others also may be able to play a greater role.
  • Impact on future pregnancies. If you’re planning a larger family, vaginal birth after cesarean section might help you avoid the risks of multiple cesarean deliveries.

The chances of a successful vaginal birth after cesarean section are higher if:

  • You’ve had only one prior low transverse uterine incision — the most common type for a C-section
  • You and your baby are healthy and your pregnancy is progressing normally
  • The reason you had your prior C-section isn’t a factor this time
  • Your labor begins naturally on or before your due date
  • You’ve had a previous successful vaginal delivery

The chances of a successful vaginal birth after cesarean section are lower if:

  • Your pregnancy continues beyond your due date
  • You have an unusually large baby — suspected fetal macrosomia
  • You’ve had two or more cesarean sections

You’re not a candidate for vaginal birth after cesarean section if you had a uterine rupture during a previous pregnancy. Similarly, vaginal birth after cesarean section isn’t recommended if you have had a vertical incision in the upper part of your uterus (classical incision) due to the risk of uterine rupture.

Vaginal birth after cesarean section risks

Vaginal birth after cesarean section poses potentially serious risks, including:

  • Failed attempt at labor. Labor can results in a repeat C-section.
  • Uterine rupture. Rarely, the uterus might tear open along the scar line from a prior C-section. If your uterus ruptures, an emergency C-section is needed to prevent life-threatening complications, including heavy bleeding and infection for the mother and brain damage for the baby. In some cases, the uterus might need to be removed (hysterectomy) to stop the bleeding. If your uterus is removed, you won’t be able to get pregnant again.

How you prepare for vaginal birth after cesarean section

If you choose vaginal birth after cesarean section, boost your odds of a positive experience:

  • Learn about vaginal birth after cesarean section. Take a childbirth class on vaginal birth after cesarean section. Include your partner or another loved one, if possible. Also discuss your concerns and expectations with your health care provider. Make sure he or she has your complete medical history, including records of your previous cesarean section and any other uterine procedures.
  • Plan to deliver the baby at a well-equipped hospital. Close monitoring can decrease the risk of complications. Look for a facility that’s equipped to handle an emergency cesarean section.
  • Allow labor to begin naturally, if you can. Drugs to induce labor can make contractions stronger and more frequent, which might contribute to the risk of uterine rupture — especially if the cervix is tightly closed and not ready for labor.
  • Be prepared for a cesarean section. Some complications of pregnancy or delivery might require a cesarean section. For example, you might need a cesarean section if there’s a problem with the placenta or umbilical cord, your baby is in an abnormal position or your labor fails to progress.

What you can expect

If you choose vaginal birth after cesarean section, your prenatal care will be just like the care you’d receive during any other healthy pregnancy.

When you go into labor, you’ll follow the same process as any woman expecting to deliver vaginally — although you and your baby will be more closely monitored during labor. Your health care provider will be prepared to do a repeat cesarean section if needed.

  1. Cesarean Birth (C-section). https://www.acog.org/Patients/FAQs/Cesarean-Birth-C-Section[]
  2. Sung S, Mahdy H. Cesarean Section. [Updated 2019 Nov 10]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2020 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK546707[]
  3. ACOG Practice Bulletin No. 205: Vaginal Birth After Cesarean Delivery. Obstet Gynecol. 2019 Feb;133(2):e110-e127[][][][][]
  4. Clapp MA, Barth WH. The Future of Cesarean Delivery Rates in the United States. Clin Obstet Gynecol. 2017 Dec;60(4):829-839.[]
  5. American College of Obstetricians and Gynecologists (College). Society for Maternal-Fetal Medicine. Caughey AB, Cahill AG, Guise JM, Rouse DJ. Safe prevention of the primary cesarean delivery. Am. J. Obstet. Gynecol. 2014 Mar;210(3):179-93.[]
  6. Walker SP, McCarthy EA, Ugoni A, Lee A, Lim S, Permezel M. Cesarean delivery or vaginal birth: a survey of patient and clinician thresholds. Obstet Gynecol. 2007 Jan;109(1):67-72.[]
  7. Chatfield, J. (2001). ACOG issues guidelines on fetal macrosomia. American Family Physician, 64(1), 169–170.[]
  8. American College of Obstetricians and Gynecologists. (2016). FAQ: Bleeding during pregnancy. https://www.acog.org/Patients/FAQs/Bleeding-During-Pregnancy[]
  9. Boyle A, Reddy UM, Landy HJ, Huang CC, Driggers RW, Laughon SK. Primary cesarean delivery in the United States. Obstet Gynecol. 2013 Jul;122(1):33-40.[][]
  10. Barber EL, Lundsberg LS, Belanger K, Pettker CM, Funai EF, Illuzzi JL. Indications contributing to the increasing cesarean delivery rate. Obstet Gynecol. 2011 Jul;118(1):29-38.[]
  11. Dahlke JD, Mendez-Figueroa H, Rouse DJ, Berghella V, Baxter JK, Chauhan SP. Evidence-based surgery for cesarean delivery: an updated systematic review. Am. J. Obstet. Gynecol. 2013 Oct;209(4):294-306.[]
  12. Clark SL, Belfort MA, Dildy GA, Herbst MA, Meyers JA, Hankins GD. Maternal death in the 21st century: causes, prevention, and relationship to cesarean delivery. Am. J. Obstet. Gynecol. 2008 Jul;199(1):36.e1-5; discussion 91-2. e7-11.[][]
  13. Committee on Practice Bulletins-Obstetrics. Practice Bulletin No. 183: Postpartum Hemorrhage. Obstet Gynecol. 2017 Oct;130(4):e168-e186.[][][]
  14. Haas DM, Morgan S, Contreras K, Enders S. Vaginal preparation with antiseptic solution before cesarean section for preventing postoperative infections. Cochrane Database Syst Rev. 2018 Jul 17;7:CD007892[]
  15. Tita ATN, Boggess K, Saade G. Adjunctive Azithromycin Prophylaxis for Cesarean Delivery. N. Engl. J. Med. 2017 Jan 12;376(2):182.[]
  16. Alexander JM, Leveno KJ, Hauth J, Landon MB, Thom E, Spong CY, Varner MW, Moawad AH, Caritis SN, Harper M, Wapner RJ, Sorokin Y, Miodovnik M, O’Sullivan MJ, Sibai BM, Langer O, Gabbe SG., National Institute of Child Health and Human Development Maternal-Fetal Medicine Units Network. Fetal injury associated with cesarean delivery. Obstet Gynecol. 2006 Oct;108(4):885-90.[]
  17. Marshall NE, Fu R, Guise JM. Impact of multiple cesarean deliveries on maternal morbidity: a systematic review. Am. J. Obstet. Gynecol. 2011 Sep;205(3):262.e1-8.[]
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Procedures

Episiotomy

episiotomy

What is an episiotomy

An episiotomy  also known as perineotomy, is a minor surgical incision that widens the opening of the vagina and perineum during childbirth. Episiotomy is usually carried out by a skilled birth attendant to enlarge the vaginal opening 1. An episiotomy is a cut to the perineum — the skin and muscles between the vaginal opening and anus. Episiotomy is usually performed during second stage of labor to quickly enlarge the opening for the baby to pass through. An episiotomy, which can be done at a 90 degree angle from the vulva towards the anus (midline episiotomy) or at an angle from the posterior end of the vulva (medio-lateral episiotomy), is performed under local anesthetic (pudendal anesthesia), and is sutured after delivery. You shouldn’t feel any pain while your health care provider making the incision or repairing it after delivery.

Normally, once the baby’s head is seen, your healthcare provider will ease your baby’s head and chin out of your vagina. Once the baby’s head is out, the shoulders and the rest of the body follow. Sometimes the vaginal opening does not stretch enough for the baby’s head. In this case, an episiotomy aids your healthcare provider in delivering your baby. It’s important to make a surgical incision rather than letting the tissue tear. Your provider will usually do an episiotomy when the baby’s head has stretched your vaginal opening to several centimeters.

Your healthcare provider may advise an episiotomy in these situations:

  • The baby does not have enough oxygen (fetal distress)
  • Complicated birth, such as when the baby is positioned bottom or feet first (breech) or when the baby’s shoulders are trapped (shoulder dystocia)
  • Long pushing stage of labor
  • The mother needs a forceps or vacuum-assisted delivery
  • Large baby
  • Preterm baby
  • Birth is imminent and the perineum hasn’t had time to stretch slowly
  • The baby’s head is too large for the vaginal opening
  • The mother isn’t able to control her pushing.

Your healthcare provider may have other reasons to recommend an episiotomy.

The first documented episiotomy dates back to over 270 years ago 2. Rates of episiotomy increased substantially during the first half of the 20th century. At that time, there was an increasing move for women to give birth in a hospital and for physicians to manage normal uncomplicated childbirths. Since then, episiotomy has become one of the most commonly performed surgical procedures in the world 3. Reported rates of episiotomies vary from as low as 9.7% (Sweden) to as high as 100% (Taiwan) 4. The large differences in episiotomy rates closely relate to the differences in policies regarding the use of episiotomy. Episiotomy rates are high in some countries, such as Argentina and China, with a policy of routine use of episiotomy for nearly all first births 5. Other places adopt a policy of ‘selective’ use of episiotomy where the use of episiotomy is restricted rather than universally performed – clinicians use their clinical judgement to determine the need for episiotomy where the benefits likely outweigh the harms in situations such as impending severe perineal tear, prolonged second stage of labor, shoulder dystocia, instrumental delivery, and non-reassuring fetal heart rate 6. In the USA, the episiotomy rate decreased from 60.9% in 1979 to 24.5% in 2004 7. In Finland, the episiotomy rate decreased from 71.5% to 54.9% between 1997 to 1999 and 2006 to 2007 among primiparous women, and from 21.5% to 9.2% between 1997 to 2001 and 2006 to 2007 among multiparous women 8.

Episiotomy is made with scissors or scalpel and requires repair by suturing 9. There are seven ways of performing an episiotomy, with ‘midline’ and ‘mediolateral’ being the two main types of episiotomy in the literature and medical practice 10. A midline (sometimes called ‘median’) episiotomy is “a vertical incision from the posterior fourchette and runs along the midline through the central tendon of the perineal body” 10. Critics point out that if a midline episiotomy extends, it is likely to extend into the anal sphincter causing a third- or fourth-degree tear. A mediolateral episiotomy is “an incision beginning in the midline and directed laterally and downwards away from the rectum” 10. In theory, if a mediolateral tear extends, it will extend away from the anal sphincter. An episiotomy is generally done late in second stage when the perineum is stretched thin. Prior to the incision, local anaesthesia is injected to numb the perineum, if a mother does not have regional anaesthesia 11.

Normal birth can cause tears to the vagina and the surrounding tissue, usually as the baby’s head is born, and sometimes these tears extend to the rectum. These are repaired surgically, but take time to heal. To avoid these severe tears, doctors have recommended making an episiotomy (surgical cut) to the perineum with scissors or scalpel to prevent severe tearing and facilitate the birth. Both a tear and an episiotomy need sutures, and can result in severe pain, bleeding, infection, pain with sex, and can contribute to long term urinary incontinence.

Many women get through childbirth without tearing their vagina on their own, and without needing an episiotomy. In fact, recent studies involving 11 randomized controlled trials (with 5977 women) that compared episiotomy as needed (selective episiotomy) with routine episiotomy in terms of benefits and harms for mother and baby in women at low risk of instrumental delivery 12 show that not having an episiotomy is best for most women in labor. Overall, the findings show that selective use of episiotomy in women (where a normal delivery without forceps is anticipated) means that fewer women have severe perineal trauma. Thus the rationale for conducting routine episiotomies to prevent severe perineal trauma is not justified by current evidence, and the research authors could not identify any benefits of routine episiotomy for the baby or the mother 12.

Episiotomy Key Findings

Routine episiotomies are no longer recommended. Routine use of episiotomy procedure does not result in maternal or fetal benefit and should be restricted, according to a practice bulletin from the American College of Obstetricians and Gynecologists 13. Still, episiotomy procedure is warranted in some cases (e.g., avoiding severe maternal lacerations, facilitating or expediting difficult deliveries). A systematic review comparing routine episiotomy with restrictive use reported that 72.7 percent of women in the routine-use group underwent episiotomy compared with 27.6 percent in the restricted-use group. The restricted-use group had significantly lower risks of posterior perineal trauma, suturing, and healing complications but a significant increase in anterior perineal trauma. No statistically significant differences were reported for severe vaginal or perineal trauma, dyspareunia, or urinary incontinence.

Episiotomies don’t heal better than tears. Episiotomies often take longer to heal since the surgical cut is often deeper than a natural tear. In both cases, the surgical cut or tear must be stitched and properly cared for after childbirth. At times, an episiotomy may be needed to ensure the best outcome for you and your baby.

  • Labor is stressful for the baby and the pushing phase needs to be shortened to decrease problems for the baby.
  • Your baby’s head or shoulders are too big for the mother’s vaginal opening.
  • Your baby is in a breech position (feet or buttocks coming first) and there is a problem during delivery.
  • Your baby is large (fetal macrosomia)
  • Your baby needs to be delivered quickly
  • Instruments (forceps or vacuum extractor) are needed to help get the baby out. Research shows that in some births, particularly with forceps deliveries, an episiotomy may prevent third-degree tears, where the tear affects the anal muscle.
  • You have a serious health condition, such as heart disease, and it’s recommended that delivery should be as quick as possible to minimize any further health risks
  • You have been trying to give birth for several hours and are now tired after pushing

Studies suggest that in first-time vaginal births, it’s more common to have severe injuries involving the anal muscle if the perineum tears spontaneously rather than if an episiotomy is performed.

The National Institute for Health and Care Excellence (NICE) recommends that an episiotomy should be considered if:

  • the baby is in distress and needs to be born quickly, or
  • there is a clinical need, such as a delivery that needs forceps or ventouse suction cup, or a risk of a tear to the anus

Episiotomy and Maternal Postpartum Outcomes

Trials of fair to poor quality provide consistent findings that clearly support limited use of episiotomy. Routine episiotomy achieves no short‐term goals that it has been hypothesized to achieve. Indeed, routine use is harmful to the degree that it creates a surgical incision of greater extent than many women might have experienced had episiotomy not been performed.

Episiotomy Incision Type and Maternal Morbidity

A single study found that women with midline episiotomy had a significantly greater rate of anal sphincter injuries than women with mediolateral episiotomy 14. Treatment groups did not report differences in pain or satisfaction with intercourse at 3 months. Because of considerable methodological flaws in this trial (poor internal validity), any conclusions must be drawn cautiously. However, because differences in sphincter injury rates are clinically important, the study authors 15 consider the finding of increased risk of severe injury with midline episiotomy compared to mediolateral episiotomy to be relevant observational evidence.

Repair of Perineal Defect and Maternal Morbidity

Limited but consistent evidence favored two‐layer repair over three‐layer repair; limited and inconsistent evidence favored continuous over interrupted sutures. Evidence was insufficient to comment on comparisons between standard and rapidly absorbed sutures, tissue adhesive and absorbable sutures, or nonabsorbable and absorbable sutures. The study authors 15 found no evidence that treated catgut is superior to untreated catgut with regard to perineal morbidity; the former may in fact be associated with higher morbidity. The evidence suggests short‐term advantages for perineal repeat associated with the use of polyglycolic‐acid sutures compared to chromic‐catgut sutures.

Three major classes of suture material (nonabsorbable, absorbable, and tissue adhesive) and two subtypes of sutures (treated versus untreated and standard versus rapidly absorbed) were studied, all in the presence of different approaches to the method of suturing; thus, individual effects of the materials themselves cannot be examined. Likewise, methods of repair were examined in the context of different materials both among and within studies for different stages of repair. The study authors 15 are unable to assess the true effects of a certain method of repair because they cannot tell whether outcomes are confounded or modified by suture material.

Episiotomy and Urinary Incontinence, Fecal Incontinence, and Pelvic Floor Defects

These prospective studies did not identify improvements in continence for urine or stool or in pelvic floor muscle function among women who had had episiotomy compared to those who had not. This finding includes comparison to women who had spontaneous lacerations of similar severity.

Several authors reported decrements in pelvic floor function among women who had had episiotomy. Only a single study, using multivariable models, found that episiotomy was an independent predictor of urinary continence 16. In the majority of other studies using multivariate models, adjusting for factors such as parity, neonatal weight, and length of second‐stage labor, episiotomy was not an independent risk factor for incontinence. Taken in total, this literature, predominantly of fair to poor quality, does not support use of episiotomy for the purpose of preventing pelvic floor defects, urinary incontinence, or incontinence of stool or flatus.

These studies are limited because they do not follow women long enough to detect disease occurrence. At present, the assumption that intermediate variables, such as pelvic muscle strength measured by perineometry, urodynamic test results, or early reports of symptoms, can predict later disease has not been validated. Prospective evaluation only during the months after birth when the pelvic floor is still in a recovery and stabilization period may be misleading. Conclusions about whether episiotomy prevents or increases risk for incontinence and prolapse later in adult life cannot be reached from currently available randomized and cohort studies.

The data available show that at one-year follow-up, immediate primary overlap repair of the external anal sphincter compared with immediate primary end-to-end repair appears to be associated with lower risks of developing fecal urgency and anal incontinence symptoms 17. At the end of 36 months there appears to be no difference in flatus or fecal incontinence between the two techniques. However, since this evidence is based on only two small trials, more research evidence is needed in order to confirm or refute these findings.

Episiotomy and Future Sexual Function

The studies addressing this question need to be considered in two groups: mediolateral episiotomy and midline episiotomy. From the clinical trials of episiotomy strategy—liberal versus restrictive—one trial addressed each type of incision and one directly compared the two incision types. None found substantive differences in sexual function. The preponderance of the studies, however, supported a conclusion that degree of perineal trauma is associated with probability of pain with intercourse, in a dose‐response fashion such that greater perineal injury is associated with greater probability of pain.

Measures that are more complex than those typically used in the literature are needed to understand properly the relationships between perineal trauma and future sexual function. Specific factors such as prior sexual function and current libido, in addition to factors such as duration of second‐stage labor, size of infant, and lactation status, need to be incorporated into multivariable models to derive more informative and less biased estimates of the long‐term effects of episiotomy or to determine that they do not exist.

Figure 1. Episiotomy

episiotomytypes-of-episiotomy

Figure 2. Female reproductive system

female reproductive system

Female pelvic floor

The pelvic floor is a complex layer of muscles and ligaments which stretches like a hammock from the pubic bone at the front of your pelvis to the coccyx at the bottom your spine (see Figure 3).

The muscles of the pelvic floor are the levator ani and ischiococcygeus. Along with the fascia covering their internal and external surfaces, these muscles are referred to as the pelvic diaphragm, which stretches from the pubis anteriorly to the coccyx posteriorly, and from one lateral wall of the pelvis to the other. This arrangement gives the pelvic diaphragm the appearance of a funnel suspended from its attachments. The pelvic diaphragm separates the pelvic cavity above from the perineum below. The anal canal and urethra pierce the pelvic diaphragm in both sexes, and the vagina also goes through it in females. The three components of the levator ani muscle are the pubococcygeus, puborectalis, and iliococcygeus. The levator ani is the largest and most important muscle of the pelvic floor. It supports the pelvic viscera and resists the inferior thrust that accompanies increases in intraabdominal pressure during functions such as forced exhalation, coughing, vomiting, urination, and defecation. The muscle also functions as a sphincter at the anorectal junction, urethra, and vagina. In addition to assisting the levator ani, the ischiococcygeus pulls the coccyx anteriorly after it has been pushed posteriorly during defecation or childbirth.

Figure 3. Pelvic floor female

pelvic floor - female

Episiotomy vs Tear

Vaginal birth can cause tears to the vagina and perineum. Estimates of the frequency vary, with some estimates (that include episiotomy) indicating this occurs in 85% of births 18, compared with a more recent retrospective cohort reporting that 4% of 1785 Australian women sustained a perineal scrape and 34% sustained a first- or second-degree perineal tear 19. While minor tears may heal quickly without intervention, some are more severe, damaging tissue, muscle and sometimes extending to the anal sphincter. These more severe tears need surgical repair, and depending on the extent, may cause a number of problems in the early postnatal period. Women may experience pain, bleeding, infection, dyspareunia (pain during sexual intercourse), and have a prolonged hospital stay. In a small percentage of women, the damage to the vaginal and perineal tissues can result in some long-term problems such as pain, urinary fistula (an abnormal connection between vagina and bladder), urinary incontinence (the inability of control causing urinary ‘accidents’), rectal fistula (an abnormal connection between the vagina and rectum), fecal incontinence (the inability of control causing fecal ‘accidents’), dyspareunia and genital-urinary prolapse (the pelvic organs descending from their normal position) 18.

Tears of the perineum and vagina are classified as follows 17:

  1. First degree: involving the fourchette, perineal skin and vaginal mucous membrane, but not the underlying fascia and muscle;
  2. Second degree: involving the perineal muscles and skin but not involving the anal sphincter;
  3. Third degree: injury to the anal sphincter complex;
    • 3a: less than 50% of the external anal sphincter torn;
    • 3b: 50% of the external anal sphincter torn; and
    • 3c: the external and internal anal sphincter are torn;
  4. Fourth degree: injury extends through the anal sphincter complex (external anal sphincter and internal anal sphincter) to ano-rectal epithelium epithelium.

Severe perineal trauma usually refers to a third-degree or fourth-degree tear 20.

Preventing a perineal tear

A midwife can help you avoid a tear during labor when the baby’s head becomes visible.

The midwife will ask you to stop pushing and to pant or puff a couple of quick short breaths, blowing out through your mouth.

This is so your baby’s head can emerge slowly and gently, giving the skin and muscles of the perineum time to stretch without tearing.

The skin of the perineum usually stretches well, but it may tear, especially in women who are giving birth for the first time.

Research suggests massaging the perineum in the last few weeks of pregnancy can reduce the chances of having an episiotomy during birth.

A review of four trials showed massaging the perineum from 35 weeks of pregnancy reduced the likelihood of tears, needing an episiotomy, and pain in women who had not given birth vaginally before.

The type and frequency of massage varied across the trials. Most involved inserting one or two fingers into the vagina and applying downward or sweeping pressure towards the perineum.

The benefit was more marked among those women who carried out perineal sweeping twice a week.

The role of warm compresses and tissue massage

During the second stage of labor — when you’re pushing — your health care provider might apply warm compresses or warm mineral oil to the tissue between your vaginal opening and your anus. This might soften the tissue and help prevent tears in the skin.

Although the evidence for warm compresses is stronger, some health care providers also massage the area between the vaginal opening and the anus as labor progresses. This is known as perineal massage.

Your health care provider might even recommend trying perineal massage at home after week 34 of pregnancy. To get started, wash your hands and rub a mild lubricant, such as K-Y jelly, on your thumbs. Place your thumbs just inside your vagina and press downward toward your rectum. Hold for one to two minutes. Then, slowly massage the lower half of your vagina. Repeat the massage once a day for 10 minutes at a time until delivery.

How episiotomy might work

Episiotomy, a surgical cut of the vagina and perineum, is sometimes used in an attempt to prevent serious perineal damage caused by tearing and to facilitate the birth of the baby.

It is thought that enlarging the vaginal outlet by episiotomy would reduce vaginal soft tissue stretching and tension during childbirth, thereby preventing higher degrees of perineal traumas and their subsequent complications 21. More space also allows for instrumentation of assisted deliveries by forceps or vacuums 22. At other times, episiotomy is performed to shorten second stage of labor for various maternal and fetal indications 23 such as maternal exhaustion and fetal bradycardia.

Clinicians who advocate routine episiotomies reason that perineal tears, including severe tears, can occur in women who are not thought likely to have serious tears and who have not had an episiotomy under a selective regimen. However, the effectiveness of routine episiotomy preventing severe perineal trauma has been questioned and the procedure has its own associated complications. Since not all vaginal births result in perineal trauma, some women are subjected to unnecessary incisions and their associated complications and morbidity as a result of a ‘routine’ episiotomy policy. Even in obstetrical emergencies such as shoulder dystocia, and in instrumental-assisted deliveries, episiotomy may not reduce severe perineal tears 24.

Complications associated with episiotomy include bleeding, pain and discomfort of the wound and sutures (which may cause pain while sitting, and in turn affect breastfeeding), wound scarring, dyspareunia, or complications in subsequent vaginal births. Other adverse effects of episiotomy include: (a) extension of episiotomy through the anal sphincter and rectum by the clinician making the incision, or by spontaneous extension of the incision; (b) unsatisfactory anatomic healing resulting in skin tags, asymmetry or excessive narrowing of the introitus, vaginal prolapse, recto-vaginal fistula and fistula-in-ano 25; (c) increased blood loss and hematoma; (d) pain and oedema around the episiotomy wound; (e) infection and dehiscence 25; (f) dyspareunia, which may be a short-term consequence, or may become more established and cause persistent dyspareunia 26; and finally, (h) at least one woman has died as a result of infection complicating an episiotomy wound 27.

How can I avoid an episiotomy?

You can do things to strengthen your body for labor that may lower your chances of needing an episiotomy.

  • Practice Kegel exercises.
  • Perform perineal massage during the 4 to 6 weeks before birth. To get started, wash your hands and rub a mild lubricant, such as K-Y jelly, on your thumbs. Place your thumbs just inside your vagina and press downward toward your rectum. Hold for one to two minutes. Then, slowly massage the lower half of your vagina. Repeat the massage once a day for 10 minutes at a time until delivery.
  • Practice the techniques you learned in childbirth class to control your breathing and your urge to push.
  • A slowed second stage of labor where pushing is controlled
  • Warm compresses and support during delivery
  • Use of perineum massage techniques
  • Avoiding lying on your back while pushing
  • Good nutrition–healthy skin stretches more easily.

Keep in mind, even if you do these things, you may still need an episiotomy. Your obstetrician will decide if you should have one based on what happens during your labor.

How to do Kegel Exercises

Pelvic floor, or Kegel, exercises involve strengthening pelvic floor muscles. Strong pelvic floor muscles more effectively hold pelvic organs in place. A woman does not need special equipment for Kegel exercises.

The exercises involve tightening and relaxing the muscles that support pelvic organs. A health care provider can help a woman learn proper technique.

A Kegel exercise is like pretending you have to urinate and then holding it. You relax and tighten the muscles that control urine flow. It is important to find the right muscles to tighten.

Next time you have to urinate, start to go and then stop. Feel the muscles in your vagina (for women), bladder, or anus get tight and move up. These are the pelvic floor muscles. If you feel them tighten, you have done the exercise right. Your thighs, buttock muscles, and abdomen should remain relaxed.

If you still are not sure you are tightening the right muscles:

  • Imagine that you are trying to keep yourself from passing gas.
  • Women: Insert a finger into your vagina. Tighten the muscles as if you are holding in your urine, then let go. You should feel the muscles tighten and move up and down.

Let your doctor, nurse, or therapist help you. Many people have trouble finding the right muscles. Your doctor, nurse, or therapist can check to make sure you are doing the exercises correctly. You can also exercise by using special weights or biofeedback. Ask your health care team about these exercise aids.

Don’t squeeze other muscles at the same time. Be careful not to tighten your stomach, legs, or other muscles. Squeezing the wrong muscles can put more pressure on your bladder control muscles. Just squeeze the pelvic muscle. Don’t hold your breath.

Step 1

Sit comfortably with your knees slightly apart. Imagine that you are trying to stop yourself passing wind from your bowel. To do this, you must squeeze the muscle around the back passage. Try lifting and squeezing the muscle as if you have wind. If you sense a “pulling” feeling, you are squeezing the right muscles for pelvic exercises. You should be able to feel the muscle move and your buttocks or legs should not move at all. You should notice that the skin around your back passage tightens up and creates the sensation of lifting you from your chair.

Step 2

Imagine that you are sitting on the toilet to pass urine and try to stop yourself from producing a stream of urine. You should be using the same group of muscles that you used before but you will find this a little more difficult. Do not try to stop the urinary stream when you are actually passing water because it can cause problems with bladder emptying.

Or you can lie down and put your finger inside your vagina. Squeeze as if you were trying to stop urine from coming out. If you feel tightness on your finger, you are squeezing the right pelvic muscles.

Step 3

Try to tighten the muscles around your back passage and vagina, by lifting up inside as if you are trying to stop passing wind and urine at the same time. Do not tense your abdomen, squeeze your legs together, tighten your buttocks or hold your breath. If you can master this, most of the muscle contraction should be coming from the pelvic floor.

How do you practice the exercises?

You need to develop two types of muscle activity, slow and fast.

  • to practice slow contractions
    • do the exercises above and try to hold the pelvic floor tight for up to ten seconds. Rest for four seconds and then repeat the contraction as many times as you can, up to a maximum of ten
  • to practice quick contractions
    • draw the pelvic floor rapidly upwards and hold this for one second. Repeat up to a maximum of ten times. This will protect you against sudden leakage during coughing, laughing or exercise
    • Aim to do one set of slow contractions followed by one set of fast contractions up to six times a day. Do not over-do it or the muscles will get tired. The exercises can be performed standing, sitting or lying down but you may find it easier at first to do them sitting down.

Once you know what the movement feels like, do Kegel exercises 3 times a day:

  • Make sure your bladder is empty, then sit or lie down.
  • Tighten your pelvic floor muscles. Hold tight and count to 8.
  • Relax the muscles and count to 10.
  • Repeat 10 times, 3 times a day (morning, afternoon, and night).

Breathe deeply and relax your body when you are doing these exercises. Make sure you are not tightening your stomach, thigh, buttock, or chest muscles.

After 4 to 6 weeks, you should feel better and have fewer symptoms. Keep doing the exercises, but do not increase how many you do. Overdoing it can lead to straining when you urinate or move your bowels.

Some notes of caution:

  • Once you learn how to do them, do not practice Kegel exercises at the same time you are urinating more than twice a month. Doing the exercises while you are urinating can weaken your pelvic floor muscles over time or cause damage to bladder and kidneys.
  • In women, doing Kegel exercises incorrectly or with too much force may cause vaginal muscles to tighten too much. This can cause pain during sexual intercourse.
  • Incontinence will return if you stop doing these exercises. Once you start doing them, you may need to do them for the rest of your life.
  • It may take several months for your incontinence to lessen once you start doing these exercises.

Other things that help

  • Get into the habit of doing your exercises regularly and linking them to everyday activities e.g. do them after emptying your bladder, while answering the telephone, standing in a queue or whenever you turn on a tap. Do your pelvic exercises at least three times a day. Every day, use three positions: lying down, sitting, and standing. You can exercise while lying on the floor, sitting at a desk, or standing in the kitchen. Using all three positions makes the muscles strongest.
  • At first, find a quiet spot to practice—your bathroom or bedroom—so you can concentrate. Lie on the floor. Pull in the pelvic muscles and hold for a count of 3. Then relax for a count of 3. Work up to 10 to 15 repeats each time you exercise.
  • If you are not sure you are doing the exercises correctly, insert a thumb or two fingers into the vagina and try the exercises; you should feel a gentle squeeze as the muscles contract
  • Use the pelvic floor exercises to prevent leakage before you do anything which might make you leak; this way, your control will gradually improve
  • Drink normally – six to eight cups (two liters) per day – avoiding caffeine and alcohol if you can
  • Avoid going to the toilet “just in case”; go only when you feel that your bladder is full
  • Watch your weight; extra weight puts more strain on your pelvic floor muscles and your bladder
  • Avoid constipation. Straining can put excessive pressure on your bladder and bowels
  • Pelvic floor exercises take three to six months to produce maximum benefit, but you should continue them for life to prevent problems recurring or worsening; you should seek help from a health professional there is little or no change in your symptoms after exercising for three months
  • Other methods which help some women include weighted vaginal cones, biofeedback and electrical stimulation; consult your doctor, urologist or specialist nurse for more details

Be patient. Don’t give up. It’s just 5 minutes, three times a day. You may not feel your bladder control improve until after 3 to 6 weeks. Still, most women do notice an improvement after a few weeks.

Use the Exercise Log below to keep track of your sessions.

Week: ______________

My Pelvic Muscle Exercise Log

Sunday

  • I exercised my pelvic muscles ____ times.
  • I spent ____ minutes exercising.
  • At each exercise session, I squeezed my pelvic muscles ____ times.

Monday

  • I exercised my pelvic muscles ____ times.
  • I spent ____ minutes exercising.
  • At each exercise session, I squeezed my pelvic muscles ____ times.

Tuesday

  • I exercised my pelvic muscles ____ times.
  • I spent ____ minutes exercising.
  • At each exercise session, I squeezed my pelvic muscles ____ times.

Wednesday

  • I exercised my pelvic muscles ____ times.
  • I spent ____ minutes exercising.
  • At each exercise session, I squeezed my pelvic muscles ____ times.

Thursday

  • I exercised my pelvic muscles ____ times.
  • I spent ____ minutes exercising.
  • At each exercise session, I squeezed my pelvic muscles ____ times.

Friday

  • I exercised my pelvic muscles ____ times.
  • I spent ____ minutes exercising.
  • At each exercise session, I squeezed my pelvic muscles ____ times.

Saturday

  • I exercised my pelvic muscles ____ times.
  • I spent ____ minutes exercising.
  • At each exercise session, I squeezed my pelvic muscles ____ times.

Figure 4. Pelvic floor muscle exercise log – use this sheet as a master for making copies that you can use to record your exercises week after week.

Pelvic floor muscle exercise log

Episiotomy risks

There are some risks to having an episiotomy. Because of the risks, episiotomies are not as common as they used to be. The risks include:

Complications associated with episiotomy include:

  • Bleeding,
  • Pain and discomfort of the wound and sutures (which may cause pain while sitting, and in turn affect breastfeeding),
  • Wound scarring,
  • Dyspareunia (painful sex). Sex may be painful for the first few months after birth.
  • Complications in subsequent vaginal births.
  • The cut may tear and become larger during the delivery. The tear may reach into the muscle around the rectum, or even into the rectum itself.
  • There may be more blood loss.
  • The cut and the stitches may get infected.

Other adverse effects of episiotomy include:

  • (a) extension of episiotomy through the anal sphincter and rectum by the clinician making the incision, or by spontaneous extension of the incision;
  • (b) unsatisfactory anatomic healing resulting in skin tags, asymmetry or excessive narrowing of the introitus, vaginal prolapse, recto-vaginal fistula and fistula-in-ano 25;
  • (c) increased blood loss and hematoma;
  • (d) pain and oedema around the episiotomy wound;
  • (e) infection and dehiscence 25;
  • (f) dyspareunia, which may be a short-term consequence, or may become more established and cause persistent dyspareunia 26; and finally,
  • (h) at least one woman has died as a result of infection complicating an episiotomy wound 27.

What happens if you need an episiotomy?

Just before your baby is born and as the head is about to crown, your doctor or midwife will give you local anaesthetic to numb the area so you won’t feel any pain (if you have not already had an epidural). If you’ve already had an epidural, the dose can be topped up before the cut is made.

Next, a small incision (cut) is made. There are 2 types of cuts: midline (median) and medio-lateral.

  1. A midline episiotomy is the most common type. It is a straight cut in the middle of the area between the vagina and anus (perineum). A midline incision is the easiest to repair, but has a higher risk of extending into the anal area. Median episiotomy is associated with a greater risk of extension to the anal sphincter (third-degree extension) or rectum (fourth-degree extension).
  2. mediolateral episiotomy is made at an angle. It is less likely to tear through to the anus, but it takes longer to heal than the median cut and might be more difficult to repair. Reported disadvantages of the mediolateral procedure include greater blood loss, and, possibly, more discomfort during the early postpartum period. Although the data are insufficient to determine the superiority of either approach, the procedures seem to have similar outcomes, including pain from the incision and time to resumption of intercourse.

Generally, an episiotomy follows this process:

  • You will lie on a labor bed, with your feet and legs supported for the birth.
  • If you have not been given any anesthesia, your provider will inject a local anesthetic into the perineal skin and muscle. This will numb the tissues before the incision is made. If epidural anesthesia is used, you will have no feeling from your waist down. In this case, you won’t need more anesthesia for the episiotomy.
  • During the second stage of labor (pushing stage), as your baby’s head stretches your vaginal opening, your healthcare provider will use surgical scissors or a scalpel to make the episiotomy incision.
  • Your health care provider will then deliver the baby through the enlarged opening.
  • Next, your provider will deliver the placenta (afterbirth).
  • He or she will check the incision for any further tearing.
  • Your provider will use stitches (sutures) to repair the perineal tissues and muscle. The stitches will dissolve over time.

You shouldn’t feel any pain while your health care provider making the incision or repairing it after delivery.

Episiotomy healing

After an episiotomy, you may have pain at the incision site. An ice pack may help reduce swelling and pain. Warm or cold shallow baths (sitz baths) may ease soreness and speed healing. Medicated creams or local numbing sprays may also be helpful.

You may take a pain reliever as recommended by your doctor. Be sure to take only recommended medicines.

Keep the incision clean and dry using the method your healthcare provider recommends. This is important after urination and bowel movements. If bowel movements are painful, stool softeners recommended by your healthcare provider may be helpful.

Do not douche, use tampons, or have sex until your healthcare provider says it’s OK. You may also have other limits on your activity, including no strenuous activity or heavy lifting.

You may go back to your normal diet unless your healthcare provider tells you otherwise.

Your healthcare provider will tell you when to return for further treatment or care.

Your healthcare provider may give you other instructions after the procedure, based on your situation.

Wait 6 weeks before you:

  • Use tampons
  • Have sex
  • Do any other activity that might rupture (break) the stitches

Coping with pain

It’s common to feel some pain after an episiotomy. Painkillers such as acetaminophen (Tylenol) can help relieve pain and are safe to use if you’re breastfeeding.

You shouldn’t take ibuprofen if you’re breastfeeding and your baby was born premature (before 37 weeks of pregnancy), had a low birth weight, or has a medical condition.

Aspirin also isn’t recommended as it can be passed on to your baby through your breast milk. Your midwife will advise you if you’re not sure what painkillers to take.

Research suggests around 1% of women (1 in 100) feel severe pain that seriously affects their day-to-day activities and quality of life after having an episiotomy.

If this happens, it may be necessary to treat the pain with stronger prescription-only painkillers, such as codeine.

However, prescription-only medicine may affect your ability to breastfeed safely. Your doctor or midwife will be able to advise you about this.

To ease the pain, you can try:

  • placing an ice pack or ice cubes wrapped in a towel on the incision – avoid placing ice directly on to your skin as this could cause damage
  • using a doughnut-shaped cushion or squeezing your buttocks together while you’re sitting to help relieve pressure and pain at the site of your cut

Exposing the stitches to fresh air can help encourage the healing process. Taking off your underwear and lying on a towel on your bed for around 10 minutes once or twice a day may help.

It’s unusual for postoperative pain to last longer than two to three weeks. If the pain lasts longer than this, you should speak to a doctor, health visitor, or another health professional.

How long does it take for an episiotomy to heal?

Stitches should heal within one month of the birth. Most women heal without problems, although it may take many weeks. If you have an episiotomy or tear during delivery, the wound might hurt for a few weeks — especially when you walk or sit. If the incision or tear is extensive, the tenderness might last longer. Any stitches used to repair the episiotomy will usually be absorbed on their own.

You can return to normal activities when you feel ready, such as light office work or house cleaning.

To promote healing:

  • Soothe the wound. Cool the wound with an ice pack, or place a chilled witch hazel pad between a sanitary napkin and the wound.
  • Take the sting out of urination. Pour warm water over your vulva during urination, and rinse yourself with a squeeze bottle afterward.
  • Take warm baths, but wait until 24 hours after you have given birth. Make sure that the bathtub is cleaned with a disinfectant before every bath.
  • Prevent pain and stretching during bowel movements. Press a clean pad against the wound when passing a bowel movement.
  • Sit down carefully. Tighten your buttocks as you lower yourself to a seated position. Sit on a pillow or padded ring.
  • Use medication as needed. Your health care provider might order prescription medications or recommend an over-the-counter pain reliever or stool softener. However, pain-relieving creams or ointments haven’t been found to be effective for episiotomy wounds.
  • Consider complementary treatments. Some research suggests that lavender might help relieve pain after a tear or episiotomy. If your health care provider approves, add a few drops of lavender essential oil to your bath water or apply the oil directly to the tissue between your vaginal opening and your anus.

You can do many other things to help speed up the healing process, such as:

  • Use sitz baths (sit in water that covers your vulvar area) a few times a day. Wait until 24 hours after you have given birth to take a sitz bath as well. You can buy tubs in any drug store that will fit on the rim of the toilet. If you prefer, you can sit in this kind of tub instead of climbing into the bathtub.
  • Change your pads every 2 to 4 hours.
  • Keep the area around the stitches clean and dry. Pat the area dry with a clean towel after you bathe.
  • After you urinate or have a bowel movement, spray warm water over the area and pat dry with a clean towel or baby wipe. DO NOT use toilet paper.
  • Do Kegel exercises. Squeeze the muscles that you use to hold in urine for 5 minutes. Do this 10 times a day throughout the day.
  • Take stool softeners and drink lots of water. This will prevent constipation. Eating lots of fiber will also help. Your health care provider can suggest foods with plenty of fiber.

While you’re healing, expect the discomfort to progressively improve. Contact your health care provider if the pain intensifies, you develop a fever or the wound produces a pus-like discharge. These could be signs of an infection.

Going to the toilet

Keep the cut and the surrounding area clean to prevent infection. After going to the toilet, pour warm water over your vaginal area to rinse it.

Pouring warm water over the outer area of your vagina as you pee may also help ease the discomfort.

You may find squatting over the toilet, rather than sitting on it, reduces the stinging sensation when passing urine.

When you’re passing a stool, you may find it useful to place a clean pad at the site of the cut and press gently as you poo. This can help relieve pressure on the cut.

When wiping your bottom, make sure you wipe gently from front to back. This will help prevent bacteria in your anus infecting the cut and surrounding tissue.

If you find passing stools particularly painful, taking laxatives may help. This type of medication is usually used to treat constipation and makes stools softer and easier to pass.

Most laxatives work within 3 days. They should only be used for a short time.

The most common causes of constipation include:

  • not eating enough fiber – such as fruit, vegetables and cereals
  • not drinking enough fluids
  • not exercising or being less active
  • often ignoring the urge to go to the toilet
  • changing your diet or daily routine
  • stress, anxiety or depression
  • a side effect of medication

Constipation is also common during pregnancy and for 6 weeks after giving birth.

In much rarer cases, constipation may be caused by a medical condition.

How you can treat constipation yourself

Simple changes to your diet and lifestyle can help treat constipation. It’s safe to try these simple measures when you’re pregnant.

You may notice a difference within a few days. Sometimes it takes a few weeks before your symptoms improve.
Make changes to your diet

To make your stool softer and easier to pass:

  • drink plenty of fluids and avoid alcohol
  • increase the fiber in your diet
  • add some wheat bran, oats or linseed to your diet

Increase your activity

A daily walk or run can help you to defecate more regularly.

Improve your toilet routine

Keep to a regular time and place and give yourself plenty of time to use the toilet. Don’t delay if you feel the urge to poo.

To make it easier to poo, try resting your feet on a low stool while going to the toilet. If possible, raise your knees above your hips.

Pain during sex

There are no rules about when to start having sex again after you’ve given birth.

In the weeks after giving birth, many women feel sore as well as tired, whether they’ve had an episiotomy or not. Don’t rush into it. If sex hurts, it won’t be pleasurable.

If you’ve had a tear or an episiotomy, pain during sex is very common in the first few months.

Studies have found around 9 out of 10 women who had an episiotomy reported resuming sex after the procedure was very painful, but pain improves over time.

If penetration is painful, say so. If you pretend everything is all right when it isn’t, you may start to see sex as a nuisance rather than a pleasure, which won’t help you or your partner.

You can still be close without having penetration – for example, through mutual masturbation.

Pain can sometimes be linked to vaginal dryness. You can try using a water-based lubricant available from pharmacies to help.

Don’t use an oil-based lubricant, such as Vaseline or moisturising lotion, as this can irritate the vagina and damage latex condoms or diaphragms.

You can get pregnant as little as three weeks after the birth of a baby, even if you’re breastfeeding and your periods haven’t started again.

Use some kind of contraception every time you have sex after giving birth, including the first time (unless you want to get pregnant again).

You’ll usually have an opportunity to discuss your contraceptive options before you leave hospital (if you’ve had your baby in hospital) and at the postnatal check.

You can also talk to your doctor, midwife or health visitor, or go to a contraception clinic at any time.

Pelvic Floor Exercises

Strengthening the muscles around the vagina and anus by doing pelvic floor exercises can help promote healing, and will reduce the pressure on the cut and surrounding tissue.

Pelvic floor exercises involve squeezing the muscles around your vagina and anus as though to stop yourself from going to the loo or passing wind (farting).

Episiotomy infection

Tell your healthcare provider if you have any of the following:

  • Bleeding from the episiotomy site
  • Your pain gets worse.
  • You go for 4 or more days without a bowel movement.
  • You pass a blood clot larger than a walnut.
  • Foul-smelling vaginal drainage
  • Fever or chills
  • Severe perineal pain

Episiotomy scar tissue

For a few women, excessive, raised or itchy scar tissue forms around the place where a tear happened or where an episiotomy was performed. If your scar tissue is causing problems for you, tell your doctor.

Scar tissue doesn’t stretch, so you may need an episiotomy again if you have excessive scar tissue and you have another baby. You can talk to your midwife or doctor about this.

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  14. Coats PM, Chan KK, Wilkins M. et al. A comparison between midline and mediolateral episiotomies. Br J Obstet Gynaecol. 1980;87(5):408–12.[]
  15. Viswanathan M, Hartmann K, Palmieri R, et al. The Use of Episiotomy in Obstetrical Care: A Systematic Review: Summary. 2005 May. In: AHRQ Evidence Report Summaries. Rockville (MD): Agency for Healthcare Research and Quality (US); 1998-2005. 112. Available from: https://www.ncbi.nlm.nih.gov/books/NBK11967[][][]
  16. Viktrup L, Lose G. The risk of stress incontinence 5 years after first delivery. Am J Obstet Gynecol. 2001;185(1):82–7.[]
  17. Fernando RJ, Sultan AH, Kettle C, Thakar R. Methods of repair for obstetric anal sphincter injury. Cochrane Database of Systematic Reviews 2013, Issue 12. Art. No.: CD002866. DOI: 10.1002/14651858.CD002866.pub3. http://cochranelibrary-wiley.com/doi/10.1002/14651858.CD002866.pub3/full[][]
  18. Kettle C, Tohill S. Perineal care. Clinical Evidence 2008;9:1401.[][]
  19. Catling-Paull C, Coddington RL, Foureur MJ, Homer CSE, on behalf of the Birthplace in Australia Study and the National Publicly-funded Homebirth Consortium. Publicly funded homebirth in Australia: a review of maternal and neonatal outcomes over 6 years. Medical Journal of Australia 2013;198(11):616-20. https://www.mja.com.au/journal/2013/198/11/publicly-funded-homebirth-australia-review-maternal-and-neonatal-outcomes-over[]
  20. Priddis H, Dahlen H, Schmied V, Sneddon A, Kettle A, Brown C, et al. Risk of recurrence, subsequent mode of birth and morbidity for women who experienced severe perineal trauma in a first birth in New South Wales between 2000 – 2008: a population based data linkage study. BMC Pregnancy and Childbirth 2013;13:89. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3635942/[]
  21. Cunningham FG. Conduct of normal labor and delivery. In: Cunningham FG, MacDonald PC, Gant NF, Leveno KJ, Gilstrap LC III editor(s). Williams Obstetrics. 19. Norwalk, CT: Appleton and Lange, 1993:371-93.[]
  22. Murphy DJ, Macleod M, Bahl R, Goyder K, Howarth L, Strachan B. A randomised controlled trial of routine versus restrictive use of episiotomy at operative vaginal delivery: a multicentre pilot study. BJOG: an international journal of obstetrics and gynaecology 2008;115(13):1695-703.[]
  23. Hartmann K, Viswanathan M, Palmieri R, Gartlehner G, Thorp J, Lohr KN. Outcomes of routine episiotomy: a systematic review. JAMA 2005;293(17):2141-8.[]
  24. Steiner N, Weintraub AY, Wiznitzer A, Sergienko R, Sheiner E. Episiotomy: the final cut?. Archives of Gynecology and Obstetrics 2012;286(6):1369-73.[]
  25. Homsi R, Daikoku NH, Littlejohn J, Wheeless CR Jr. Episiotomy: risks of dehiscence and rectovaginal fistula. Obstetrical & Gynecological Survey 1994;49:803-8.[][][][]
  26. Garner P. Dyspareunia after episiotomy. British Journal of Sexual Medicine 1982;1:1-3.[][]
  27. Lynch CM, Pinelli DM, Cruse CW, Spellacy WN, Sinnott JT, Shashy RG. Maternal death from postpartum necrotizing fasciitis arising in an episiotomy: a case report. Infectious Diseases in Obstetrics and Gynecology 1997;5(5):341-4.[][]
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Procedures

Tracheostomy

tracheostomy

What is a tracheostomy

A tracheostomy is also known as a tracheotomy, is a small surgical hole (stoma) that is made through the front of the neck into the windpipe (trachea) that provides an alternative airway for breathing.

A curved plastic tube, known as a tracheostomy tube, is inserted through the hole allowing air to flow in and out of the windpipe and is secured in place with a strap around your neck. The tracheostomy tube does not extend into the lungs.

The tracheostomy tube allows the person to breathe through the throat, bypassing their upper airway, including their nose and mouth. A tracheostomy may be temporary or permanent, done as an emergency or done as a planned procedure. For example, if the tracheostomy tube is inserted to bypass a trachea that is blocked by blood or swelling, it will be removed once regular breathing is once again possible. A person with permanent damage or loss of function around the larynx or swallowing area may need a permanent tracheostomy tube to help them breathe at night.

There is a variety of tracheostomy tubes available. Tracheostomy tubes are made from either plastic or silver. All fit into the following categories: cuffed/uncuffed; fenestrated/unfenestrated; double/single cannula; minitracheostomy; and those with an adjustable flange. Each tracheostomy tube type requires specific management.

If the upper airway is obstructed, it may be necessary to make a temporary opening through the anterior wall of the trachea inferior to the larynx and insert a tracheostomy tube to allow airflow. A tracheostomy is complicated because large veins and part of the thyroid gland overlie this region.

A small incision is made in the throat and a tracheostomy tube is inserted into the windpipe (trachea). The tracheostomy tube sits in the windpipe and is tied in with tape. At first, there might be a few stitches, but these are usually taken out within a week.

Your speech will be affected and so is your eating and drinking initially.

Many people can start eating and drinking by mouth again once the tracheostomy has stabilized. This may be a week or two after the procedure. However, some people will still need to be fed by a tube.

Although tracheostomy prevents asphyxiation, the inhaled air bypasses the nasal cavity and thus is not humidified. If the opening is left for long, the mucous membranes of the respiratory tract dry out and become encrusted, interfering with the clearance of mucus from the tract and promoting infection.

When a patient is on a ventilator and air is introduced directly into the trachea, the air must be filtered and humidified by the apparatus to prevent respiratory tract damage.

It is normal for people after having a tracheostomy to feel anxious and fearful. People report having many complex feelings and physical sensations when they have a tracheostomy.

Long term outlook

Most people need 1 to 3 days to adapt to breathing through a tracheostomy tube. It will take some time to learn how to communicate with others. At first, it may be impossible for the person to talk or make sounds.

The long term outlook depends on whether the tracheostomy tube is temporary or permanent.

  • If it is temporary tracheostomy, it will be removed when no longer needed and the incision allowed to heal. There may be a small scar.
  • If the tracheostomy is permanent, the hole will stay open. However, the opening tends to narrow with time, and further surgery may be needed to widen the opening. The outer tube of the tracheostomy tube needs to be changed every few months, and the site should be inspected at each change. You may be referred to a speech therapist for voice training.

After training and practice, most people can learn to talk with a tracheostomy tube. People or family members learn how to take care of the tracheostomy during the hospital stay. Home-care service may also be available.

You should be able to go back to your normal lifestyle. When you are outside, you can wear a loose covering (a scarf or other protection) over the tracheostomy stoma (hole). Use safety precautions when you are exposed to water, aerosols, powder, or food particles.

Removal of the Tracheostomy Tube

Your doctor will remove your tracheostomy tube when you no longer need it. You won’t need to have surgery to do this. The opening will close on its own and you won’t need sutures (stitches).

Before the tube is removed, a closed inner cannula will be inserted in your tracheostomy tube. You will have the closed inner cannula in place for at least 24 hours. If you’re able to breathe normally with the closed inner cannula in place, your tube will be removed. You won’t feel any pain when the tube is taken out.

After the tube is removed, your doctor will put a dressing (bandage) over the tracheostomy site. Keep the dressing on the site until the opening is completely closed. This usually takes about 1 to 2 weeks.

When you cough or speak, put your finger over the tracheostomy site dressing. This will help the site to close.

Change the dressing over the tracheostomy site twice a day, or more often if it gets dirty. Each time you change the dressing, clean the skin at the site with moistened pieces of 4 x 4 gauze. Once the tracheostomy site is closed, you won’t need to wear a dressing.

What are the alternatives to a tracheostomy?

Tracheostomies are usually performed as a last resort. If there are other options suitable, your doctor will likely recommend them instead. In an emergency situation, a tracheostomy could save your life.

Figure 1. Tracheostomy

tracheostomy

Tracheostomy tube

A tracheostomy tube has 2 pieces (see Figure 2):

  1. The outer cannula, which always stays in place. This keeps your tracheostomy site open. Do not remove the outer cannula. Only your doctor or nurse should remove it.
  2. The inner cannula, which slides in and out for cleaning. Do not leave the inner cannula out for more than a few minutes. It should always remain in place when not being cleaned.

You will also have a tracheostomy tie that goes around your neck and connects to the outer cannula. This will keep the tracheostomy tube in place.

Figure 2. Tracheostomy tube – a tracheostomy tube has 2 pieces – inner and outer cannulas

tracheostomy-tube

tracheostomy tube

tracheostomy_tube

Figure 3. Trachea location

trachea location

Figure 4. Trachea anatomy

trachea anatomy

Note: (a) Anterior view. (b) Longitudinal section of the trachea showing the action of the mucociliary escalator. (c) Cross section of the trachea showing the C-shaped tracheal cartilage.

Figure 5. Trachea and the cricothyroid ligament

trachea - airway in the neck

Figure 6. Trachea and the thyroid gland

thyroid gland lying over the trachea

Reasons for tracheostomy

A tracheostomy is performed when an adult or child has a condition that makes normal breathing difficult or impossible. Examples of patients who may have a tracheostomy are those with neuromuscular disorders who have impaired swallowing and coughing, those who have a poor cough or gag reflex after a head injury or a protracted critical illness and patients who have had their larynx removed surgically.

People have tracheostomies for many different reasons, including:

  • Neurological conditions such as stroke or tumors
  • Severe injuries to the head and neck
  • Spinal injuries
  • Paralysis, neurological problems or other conditions that make it difficult to cough up secretions from your throat and require direct suctioning of the windpipe (trachea) to clear your airway
  • Burns
  • Severe pneumonia
  • Acquired and congenital subglottic stenosis (a condition where the windpipe is narrowed)
  • Severe allergic reactions (anaphylaxis)
  • Head and neck cancer, which can affect breathing by pressing on the airway
  • Radiation therapy to the head and neck
  • Severe lung disease
  • A large object blocking the airway
  • An inability to breathe on your own
  • An inherited abnormality of the larynx or trachea
  • Breathed in harmful material such as smoke, steam, or other toxic gases that swell and block the airway
  • Paralysis of the muscles that affect swallowing
  • Severe neck or mouth injuries
  • Surgery around the voice box (larynx) that prevents normal breathing and swallowing
  • Preparation for major head or neck surgery to assist breathing during recovery
  • Medical conditions that require the use of a breathing machine (ventilator) for an extended period, usually more than one or two weeks
  • Other emergency situations when breathing is obstructed and emergency personnel can’t put a breathing tube through your mouth and into your trachea

Emergency tracheostomy

Tracheostomy may be performed as an emergency procedure to provide relief of blockage of airways above the trachea. This is called an emergency tracheostomy. It involves making a cut in the thin part of the trachea just below the larynx (voice box) and inserting a tube that is connected to a supply of oxygen or air, often using a ventilator (breathing machine).

Emergency tracheotomies are difficult to perform and have an increased risk of complications. A related and somewhat less risky procedure used in emergency care is a cricothyrotomy. This procedure creates a hole directly into the voice box (larynx) at a site immediately below the Adam’s apple (thyroid cartilage).

Once a person is transferred to a hospital and stabilized, a cricothyrotomy is replaced by a tracheostomy if there’s a need for long-term breathing assistance.

Non-emergency tracheostomy

A non-emergency tracheostomy may be performed for a variety of reasons: for example, before surgery to the throat or mouth so the patient can breathe after the surgery or to make the prolonged use of ventilators more comfortable and safe.

The surgeon has no time to consult with you on medical issues in an emergency tracheostomy. In the case of a non-emergency tracheostomy, some of the medical issues to consider include:

  • Medical history
  • The reasons for the tracheostomy
  • Surgical procedures
  • Risks and complications of the surgery and tracheostomy
  • After care
  • Long term outlook.

Tracheostomy procedure

A tracheotomy is most commonly performed in an operating room with general anesthesia, which makes you unaware of the surgical procedure. A local anesthetic to numb the neck and throat is used if the surgeon is worried about the airway being compromised from general anesthesia or if the procedure is being done in a hospital room rather than an operating room.

A tracheostomy is usually performed under a combination of local and a light general anaesthetic.

  • The surgical technique depends on whether or not the tracheostomy is being performed as a medical emergency.
  • When possible and safe, the procedure is done under general anaesthesia.

The type of procedure you undergo depends on why you need a tracheostomy and whether the procedure was planned. There are essentially two options:

Emergency tracheostomy – you are positioned on your back, and a rolled-up towel (or equivalent) is placed under your shoulders to help stretch out your neck. Local anaesthetic is injected into the target area, and a skin incision (cut) is made. The surgeon will then open either the trachea (this is called a ‘tracheostomy’) or the cricothyroid membrane – the thinnest part of the airway below the larynx (this is called a ‘cricothyroidotomy’). The airway tube is inserted into the trachea and you are connected to the oxygen supply. The entire procedure is done as quickly as possible.

Non-emergency tracheostomy – the operation is usually performed under general anaesthetic in an operating room. You are positioned on your back, and your neck and chest are swabbed with antiseptic. The cut is made in the lower half of the neck, between the larynx and the sternum (breastbone). First, the skin on your throat is cut horizontally. The underlying muscles are parted, then the thyroid gland may need to be cut or pulled back to expose the trachea. A cut is made through the wall of the trachea. The tracheostomy tube is then placed into the opening. A neck strap attached to the face plate of the tube keeps it from slipping out of the hole, and temporary sutures also can be used to secure the faceplate to the skin of your neck.

Minimally invasive tracheotomy is typically performed in a hospital room. The doctor makes a small incision near the base of the front of the neck. A special lens is fed through the mouth so that the surgeon can view the inside of the throat. Using this view of the throat, the surgeon guides a needle into the windpipe to create the tracheostomy hole. The hole is then expanded to accommodate the tracheostomy tube. A neck strap attached to the faceplate of the tube keeps it from falling out of the windpipe.

What happens after a tracheostomy?

After the tracheostomy procedure, most people spend some time in the intensive care unit. This is to make sure that the wound is healing well and the tracheostomy tube can be changed safely.

A person may have a sense of panic and feel unable to breathe and speak when first waking up after the tracheostomy and placement of the tracheostomy tube. This feeling will lessen over time. Medicines may be given to help reduce the patient’s stress.

After the tracheostomy operation, you can expect the following:

  • A chest x-ray may be taken to check that the tube is correctly in place and there are no complications.
  • Antibiotics may be prescribed to reduce the risk of infection.
  • Later, you and your carers are shown how to care for the tracheostomy tube (for example, how to clean around and in the tube).
  • It takes a few days to get used to breathing through the tracheostomy tube and it will be difficult to make sounds at first. If the tube allows some air to escape and pass over the vocal cords, it may be possible to speak by holding a finger over the tube.
  • Unless there are complications, you will stay in hospital for between three and five days.

Nurses, physiotherapists, dietitians and speech therapists work together to help care for people who have a tracheostomy.

After surgery, nurses may need to suction mucous out of the tube. Physiotherapists can help keep the lungs clear of mucus, and speech therapists can help with swallowing and speaking.

The tracheostomy tube needs to be changed regularly. People who go home with a tracheostomy might be given instructions on how to care for and change the tracheostomy tube. Sometimes they need to come back to hospital to have the tube changed.

If the tracheostomy is temporary, the tube will eventually be removed. Healing will occur quickly, leaving a minimal scar. Sometimes, a surgical procedure may be needed to close the site (stoma).

Occasionally a stricture, or tightening of the trachea may develop, which may affect breathing.

If the tracheostomy tube is permanent, the hole remains open.

You’ll learn skills necessary for maintaining and coping with your tracheostomy:

  • Caring for your tracheostomy tube. A nurse will teach you how to clean and change your tracheostomy tube to help prevent infection. You’ll continue to do this as long as you have a tracheostomy.
  • Speaking. In general, a tracheostomy prevents you from speaking because exhaled air goes out the tracheostomy opening rather than up through your voice box. However, there are devices and techniques for redirecting airflow enough to produce speech. Depending on the tube size and design, the diameter of your trachea, and the condition of your voice box, you may be able to use your voice with the tube in place. If necessary, you’ll meet with a speech therapist or a nurse trained in tracheostomy care, who can suggest options for communicating and help you learn to use your voice again. Many people can speak by covering the opening in the tube with a finger. Your speech therapist or a nurse trained in tracheostomy care will teach you how to do this.
  • Eating. While you’re healing, you’ll receive nutrients through an intravenous (IV) line inserted into a vein in your body, a feeding tube that passes through your mouth or nose, or a tube inserted directly into your stomach. When you’re ready to eat again, you may need to work with a speech therapist, who can help you regain the muscle strength and coordination needed for swallowing.
  • Coping with dry air. The air you breathe will be much drier since it no longer passes through your moist nose and throat before reaching your lungs. This can cause irritation, coughing and excess mucus coming out of the tracheostomy. Directly instilling small amounts of saline into the tracheostomy tube may help loosen secretions and add moisture. A saline nebulizer treatment can be delivered to a mist collar via a tube attached to a nebulizer machine. You may use a device called a heat and moisture exchanger, which captures moisture from the air you exhale and humidifies the air you inhale.
  • Coping with other effects. Your health care team will show you ways to cope with the other common effects of the tracheostomy. For instance, you may also learn to use a suction machine to help you clear secretions from your throat or airway.

Tracheostomy complications

Tracheostomies are generally safe, but they do have risks.

Certain groups, including babies, smokers and the elderly, are more vulnerable to complications.

Some complications are particularly likely during or shortly after surgery. The risk of such problems greatly increases when the tracheotomy is performed as an emergency procedure.

Some of the possible risks and complications of tracheostomy include:

  • Severe bleeding and damage to the throat
  • Blockage of the tracheostomy tube with secretions, which can be breathed into the lungs causing pneumonia (aspiration pneumonia)
  • Damage to the larynx
  • Damage to the esophagus (rare)
  • Air trapped in tissue under the skin of the neck (subcutaneous emphysema), which can cause breathing problems and damage to the trachea or food pipe (esophagus)
  • Buildup of air between the chest wall and lungs (pneumothorax), which causes pain, breathing problems or lung collapse
  • A collection of blood (hematoma) may form in the neck and compress the trachea, which causes breathing problems
  • Lung collapse
  • Blockage of the tracheostomy tube by blood clots, mucus or the pressure of the airway walls
  • Failure of the opening to close once the tracheostomy tube is removed
  • The tube may come out of the trachea (tracheostomy tube displacement) or misplacement of the tracheostomy tube
  • Scar formation
  • Infection

Rarer risks include:

  • narrowing of the windpipe
  • a hole forming between the windpipe and the food pipe
  • windpipe tissue death (tracheal necrosis)
  • a granuloma forms (a small area of inflamed tissue)

The risks for any anesthesia are:

  • Problems breathing
  • Reactions to medicines, including heart attack and stroke, or allergic reaction (rash, swelling, breathing difficulty)

Long-term complications are more likely the longer a tracheostomy is in place. These problems include:

  • Displacement of the tracheostomy tube from the trachea
  • Narrowing of the trachea
  • Abnormal tissue formation in the trachea
  • Obstruction of the tracheostomy tube
  • Development of an abnormal passage between the trachea and esophagus (fistula), which can increase the risk of fluids or food entering the lungs
  • Development of a passage between the trachea and the innominate artery (tracheoinnominate fistula), which can generate life-threatening bleeding
  • Infection
  • Bacterial colonization, which may cause illness, such as pneumonia

Tracheostomy care

If you still need a tracheostomy after you’ve left the hospital, you’ll need to keep regularly scheduled appointments for monitoring possible complications.

Be guided by your doctor, but general suggestions include:

  • Use warm compresses to relieve pain at the incision site.
  • Tracheostomy tubes may have an inner tube (inner cannula) that requires cleaning whenever it gets blocked with secretions – this can vary from once to several times every day.
  • A humidifier attachment is needed for about one month after the surgery, as the trachea is exposed to dry air.
  • It’s important to use a humidifier, especially at night. It will help to keep your secretions loose and prevent clogging.
  • It is important to keep the area dry and clean – wear a scarf over the opening and when going outside. Avoid contact with water, food particles and powdery substances.
  • Avoid vigorous activity in the six weeks following the surgery.
  • It’s important to protect your airway at all times.
  • Don’t submerge yourself in water. You can’t go swimming while your tracheostomy tube is in place, or after the tube is removed until the site is completely closed.
  • When showering, avoid having water spray or splash directly into the tracheostomy.

You’ll also receive instructions about when you should call your doctor about problems, such as:

  • Bleeding at the tracheostomy site or from the trachea
  • Difficulty breathing through the tube
  • Pain or a change in comfort level
  • Redness
  • Swelling
  • A change in the position of your tracheostomy tube

Important Points

  • If you have trouble breathing, remove the inner cannula right away. If your breathing improves, the inner cannula was most likely clogged. Clean the inner cannula well and reinsert it. If your breathing does not get better, call your local emergency services number or go to the nearest emergency room immediately.
  • If the entire tracheostomy tube is removed by accident, do not panic. The tract will stay open for hours to days. Call local emergency services number or go to the nearest emergency room immediately to have it put back in.

Caring for your tracheostomy

Your nurse will teach you how to care for your tracheostomy while you’re in the hospital. If you leave the hospital with the tracheostomy in place, you will continue to care for it at home. You will learn how to:

  • Suction the tracheostomy tube
  • Clean the suction catheter
  • Clean the inner cannula
  • Clean your skin around the tracheostomy site
  • Moisturize the air you breathe

Suctioning the tracheostomy tube

Suctioning the tracheostomy tube will keep your airway free of secretions (mucus) and allow you to breathe without difficulty. Your nurse will teach you how and tell you how often to do this.

Instructions

  1. Gather your equipment.
    • 1 suction machine with plastic tubing
    • 1 suction catheter
    • 1 bowl or large cup filled with water
    • 1 mirror
    • 2 to 4 dry gauze pads
  2. Wash your hands thoroughly with soap and water or use an alcohol-based hand sanitizer.
  3. Open the package with the suction catheter. Connect the catheter to the plastic tubing of the suction machine.
  4. Position the mirror so you can see the opening of your tracheostomy tube.
  5. Turn on the suction machine. (If you’re in the hospital, you must open the clamp on the suction tubing instead).
  6. Pinch the suction catheter between your thumb and forefinger to block the suction.
  7. Cough deeply to bring up any secretions.
  8. Keep the suction catheter pinched. Insert it about 3 to 5 inches (8 to 13 centimeters) into your tracheostomy tube.
  9. Un-pinch the suction catheter to begin suctioning. Do not keep the suction catheter in your trachea for longer than 10 seconds, or you may have shortness of breath.
  10. Using a rotating motion, slowly pull the suction catheter out of your tracheostomy. Rotating the catheter allows secretions on all sides of your trachea and the tube to be suctioned.
  11. Wipe off the secretions from the suction catheter with dry gauze.
  12. Rinse the secretions from the suction catheter by suctioning the water through it.
  13. Repeat the steps above if you feel that you have more secretions that need to be cleared out.
  14. If you need to repeat the suctioning more than 2 or 3 times, rest for a few minutes before doing it again.

Cleaning the suction catheter

Each time you finish suctioning your tracheostomy tube, you must clean the suction catheter.

Instructions while you’re in the hospital

Gather your equipment:
1 jar of Dakin’s® solution or another antiseptic
1 bowl or large cup filled with water
Rinse the suction catheter with water and then suction more water through it.
Close the clamp.
Put the suction catheter into a jar of Dakin’s solution or another antiseptic fluid.

While you’re in the hospital, a patient care technician will give you a new suction catheter each day.

Instructions when you’re at home

  1. Gather your equipment:
    • 1 clean, dry cloth or paper towel
    • 1 bowl or large cup filled with water
  2. Rinse the suction catheter with water and then suction more water through it.
  3. Dry the suction catheter with the dry cloth or paper towel.
  4. Disconnect the suction catheter from the plastic tubing on the suction machine.
  5. Place the suction catheter on the dry cloth or paper towel.

While you’re at home, change the suction catheter once a week, or more often if it becomes dirty or clogged.

Empty the secretions from the inside of the suction machine into the toilet. Don’t empty them into the sink or the drain could become clogged.

Clean the canister of the suction machine as needed with soap and water.

Cleaning the inner cannula and your skin around the tracheostomy site

Clean the inner cannula every 2 to 4 hours, or more often as needed, to keep it free of secretions. This will make it easier for you to breathe.

Don’t start changing the tracheostomy tube ties that hold the tracheostomy tube in place until your doctor tells you it’s safe to do so.

Instructions

  1. Gather your equipment:
    • 4 to 6 cotton swabs, or as many as needed
    • A mirror
    • A nylon brush
  2. Wash your hands thoroughly with soap and water or use an alcohol-based hand sanitizer.
  3. Stand or sit in front of a sink with a mirror.
  4. With the fingers of one hand, hold the outer cannula in place. With the fingers of your other hand, unlock the inner cannula by twisting it, then slide it out (see Figure 7). Do not keep the inner cannula out for more than a few minutes.
  5. Hold the inner cannula under warm running water. Clean it with the nylon brush (see Figure 8). Once the cannula is clean, shake out the excess water.
  6. Slide the inner cannula back into the outer cannula right after you clean it. This will prevent the outer cannula from becoming blocked with secretions.
  7. Gently clean the skin around your tracheostomy tube with moistened cotton swabs.

If you will have a tracheostomy for an extended period of time, your doctor or nurse will change the entire tracheostomy tube during office visits. This includes the inner and outer cannulas and the tracheostomy tube ties that keep your tracheostomy tube in place. Do not do this on your own since you may not be able to reinsert it into your trachea.

Figure 7. Unlocking the inner cannula

Unlocking the inner cannulaFigure 8. Cleaning the inner cannula

Cleaning the inner cannula

Moisturizing the air you breathe

Placing a moist piece of gauze in front of your tracheostomy tube will help filter, moisturize, and warm the air you breathe in. Try to do this as often as possible. This will keep your secretions fluid and will make it easier to suction them and clean your trachea.

Instructions

  1. Gather your equipment.
    • One 4 inch x 4 inch piece of gauze
    • Neck string
    • Scissors
  2. Wash your hands thoroughly with soap and water or use an alcohol-based hand sanitizer.
  3. Stand or sit in front of a sink with a mirror.
  4. Moisten the 4 x 4 piece of gauze with water. Cut a piece of neck string that’s long enough to fit comfortably around your neck.
  5. Open the gauze and drape it over the neck string. Put the gauze in front of the tracheostomy tube opening (see Figure 9). Tie the neck string in a bow at the back of your neck to keep it in place.
  6. Keep the gauze in place until it becomes dry. Once the gauze is dry, throw it away. Repeat the steps above to replace it.

Figure 9. Moistened gauze placed over the tracheostomy tube opening

Moistened gauze placed over the tracheostomy tube opening

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Procedures

ileostomy

Ileostomy

What is an ileostomy

An ileostomy is a surgically made opening on the skin of the belly where the small bowel (small intestine) called the ileum is brought to the surface of your abdomen to form the stoma (the opening). An ileostomy replaces the rectum as the place where waste of the digestive system (stool) leaves your body. An ileostomy is typically made in cases where the end part of the small bowel is diseased, and is usually made on the right-hand side of your abdomen. Stools in this part of the small intestine are generally fluid or thick liquid and it is not solid like the stool that came from your rectum. Because a stoma has no muscle to control defecation, stools will need to be collected in an ileostomy bag. An ileostomy bag is placed over the stoma to collect waste products that usually pass through the colon (large intestine) and out of the body through the rectum and back passage (anus).

An ileostomy may be needed if the colon is damaged, inflamed or doesn’t work properly.

Most often the colon (large intestine) absorbs most of the water that you eat and drink. With an ileostomy in place, the colon is no longer being used. This means that the stool from your ileostomy has far more liquid than a typical bowel movement from the rectum.

The stool now comes out from the ileostomy and empties into a pouch that is attached to the skin around your stoma. The ileostomy bag is made to fit your body well. You must wear it all the time.

The waste that collects will be liquid or pasty, depending on what you eat, what medicines you take, and other things. Waste collects constantly, so you will need to empty the ileostomy bag 5 to 8 times a day.

Stomas do vary in size and shape from person to person. It will be shiny, wet and red, much like the inside of your mouth. You can expect it be swollen after surgery but the swelling will go down in time and your stoma may get smaller.

Figure 1. Small intestine

small intestine

Figure 2. Ileostomy

ileostomy

When is an ileostomy needed?

An ileostomy is formed to either temporarily or permanently stop digestive waste passing through the full length of the small intestine or colon.

An ileostomy may be needed if the colon is damaged, inflamed or doesn’t work properly.

Some of the most common reasons why ileostomy surgery to form an ileostomy is carried out are described below.

There are a number of reasons why this may be necessary, including:

  • to allow the small intestine or colon to heal after it’s been operated on – for example, if a section of bowel has been removed to treat bowel cancer
  • to relieve inflammation of the colon in people with Crohn’s disease or ulcerative colitis
  • to allow for complex surgery to be carried out on the anus or rectum

Crohn’s disease

Crohn’s disease is a long-term condition where the digestive system becomes inflamed. Common symptoms include:

  • diarrhea
  • abdominal pain
  • extreme tiredness (fatigue)

Crohn’s disease can usually be controlled with medication, but surgery to create an ileostomy may sometimes be recommended to temporarily divert digestive waste away from the inflamed section of the digestive system to give it a chance to heal.

Ulcerative colitis

Ulcerative colitis is a long-term condition where the lining of the large intestine or large bowel (colon or rectum) becomes inflamed. Common symptoms include:

  • bloody diarrhea
  • abdominal pain
  • a frequent need to pass stools

In most cases symptoms can be controlled with medication. However, surgery to remove the colon and form an ileostomy or ileo-anal pouch – an internal pouch to store stools created using the end of the small intestine – may be recommended if the condition is particularly severe or doesn’t respond to medication.

Bowel cancer

Bowel cancer is a type of cancer that develops inside the colon or rectum. Chemotherapy or radiotherapy, or a combination of both, may be used to shrink the cancer first, before the affected section of bowel is removed.

Depending on the size and position of the removed section of bowel, a temporary ileostomy, permanent ileostomy, or an ileo-anal pouch may be formed during the operation.

In some cases, a section of your colon may need to be diverted out of your tummy (abdomen). This is known as a colostomy, rather than an ileostomy.

Less common uses

Some of the less common reasons why surgery to form an ileostomy is needed are described below.

Familial adenomatous polyposis

Familial adenomatous polyposis (FAP) is a rare condition that triggers the growth of non-cancerous lumps of tissue inside the colon.

Although the lumps are non-cancerous to begin with, there’s a very high risk that, over time, at least one will turn cancerous. More than 99% of people with FAP have bowel cancer by the time they’re 50 years old.

Because of the high risk of developing cancerous lumps, it’s usually recommended that a person diagnosed with FAP has their colon removed. It’s usually replaced with an ileo-anal pouch, or occasionally a permanent ileostomy.

Bowel obstruction

A bowel obstruction occurs when part of the digestive system becomes blocked by food, fluids, or waste products. This can happen if part of the person’s digestive system is scarred or inflamed, or if their digestive system is unusually narrow.

If the colon becomes completely blocked, it’s usually necessary to remove the colon and form an ileostomy. This can be temporary or permanent, depending on the underlying cause of the obstruction.

Injury

A significant injury to the colon, such as a puncture or impact injury, can result in the colon becoming permanently damaged.

In these cases, it may be necessary to remove the colon and form an ileostomy. Whether this is a temporary or permanent ileostomy depends on the type and extent of the injury.

Ileostomy surgery

There are several different ways an ileostomy can be formed, depending on the reason why the operation is being carried out.

The opening in your abdomen where waste material exits the body after the operation (stoma) will normally be located on the righthand side.

However, you’ll usually meet a specialist stoma nurse before the operation to discuss specific possible locations. The stoma nurse may draw a dot on your abdomen to let the surgeon know where the preferred site is.

Ileostomy operations are carried out under general anaesthetic, which means you’ll be asleep during the procedure and won’t experience any pain as it’s carried out.

The main types of ileostomy are described below.

Figure 3. Types of ileostomy surgery

types-of-ileostomyIleostomy types

End ileostomy

An end ileostomy is made when part of your large intestine (colon) is removed (or simply needs to rest) and the end of your small intestine is brought to the surface of the abdomen to form a stoma. An end ileostomy can be temporary or permanent.

The end of the small intestine (ileum) is divided and brought out of the abdomen through a smaller incision, and stitched on to the skin to form a stoma.

Over time, the stitches dissolve and the stoma heals on to the skin. After the operation, waste material comes out of the opening in the abdomen into a bag that goes over the stoma.

This type of ileostomy is often, but not always, permanent.

The permanent ileostomy is chosen in situations where it is too risky or not possible to re-join the two parts of the intestine.

The temporary ileostomy is relevant in situations where the diseased part of the large intestine (colon) has been removed and the remaining part needs to rest before the ends are joined together. It’s sometimes possible to reverse an end ileostomy if most of the large intestine (colon) has been sealed and left inside the abdomen. However, the surgeon will need to make a larger incision to locate and reattach the small and large intestines. It therefore takes longer to recover from this type of surgery and there’s a greater risk of complications.

Loop ileostomy

In a loop ileostomy, a loop of the small intestine is lifted above skin level and held in place with a stoma rod. A cut is made on the exposed bowel loop, and the ends are then rolled down and sewn onto the skin. In this way, a loop ileostomy actually consists of two stomas that are joined together. The colon and rectum are left in place.

The loop ileostomy is typically temporary and performed to protect a surgical join in the bowel. If temporary, it will be closed or reversed in a later operation.

To form a loop ileostomy, a loop of small intestine is pulled out through a cut (incision) in your abdomen.

This section of intestine is then opened up and stitched to the skin to form a stoma.

In these cases, the stoma will have two openings, although they’ll be close together and you may not be able to see both.

One of the openings is connected to the functioning part of your bowel. This is where waste products leave your body after the operation.

The other opening is connected to the “inactive” part of your bowel that leads down to your rectum.

The loop ileostomy is usually temporary and may be reversed during a second operation at a later date. There’s no time limit for having an ileostomy reversed and some people may live with one for several years before it’s reversed. Reversing a loop ileostomy is a relatively straightforward procedure that’s carried out under general anesthesia.

Ileo-anal pouch

In some cases, it may be possible to have a permanent internal ileo-anal pouch, also known as a J pouch, formed instead of an ileostomy.

An ileo-anal pouch is created from the ileum and joined to the anus, so waste material passes out of your body in the normal way. The pouch stores the waste material until you excrete it when you go the toilet.

The area around the pouch usually needs to heal before it’s used, so a temporary loop ileostomy may be created above the pouch. A second, smaller operation is usually carried out a few months later to close the loop ileostomy.

Figure 4. Ileo-anal pouch (J-pouch)

Ileo-anal pouch or J-pouch

J-pouch anatomy

Ileostomy recovery

After an ileostomy surgery, you may need to stay in hospital for up to two weeks. During this time you’ll be taught how to look after your stoma by a specialist stoma nurse.

When you wake up after the operation, you may be attached to a drip placed directly into your vein that provides fluids (an intravenous drip) and have an oxygen mask or nasal tubes (cannula) to help you breathe. These will be removed as you recover.

A special bag is also placed over the opening in your abdomen (stoma). The stoma will initially appear large because the effects of surgery cause it to swell. It usually shrinks during the weeks after the operation, reaching its final size after about eight weeks.

Recovering from an ileostomy procedure can be challenging. Many people experience short-term physical and psychological problems, ranging from skin irritation around the stoma to feelings of anxiety and self-consciousness.

However, with practise and support from a designated stoma nurse, many people adjust and often find their quality of life improves after ileostomy surgery. This is especially true if they’ve been living for years with a condition such as Crohn’s disease.

Stoma nurse

While you’re recovering in hospital, a stoma nurse will teach you how to care for your stoma, including how to empty and change the bag.

They’ll also teach you how to keep your stoma and the surrounding skin clean and free from irritation. The nurse will explain the different types of equipment available and how to get new supplies.

Going home

You may need to stay in hospital for up to two weeks after the operation, although this varies depending on things like your general health and the type of operation.

Your stoma nurse or surgeon will give you advice about activities to avoid while you recover. Most normal activities are usually possible within eight weeks, although you’ll often be advised to avoid more strenuous activities for about three months.

Your abdomen will feel very sore initially during your recovery, but eventually settles down. You may also experience excessive gas (flatulence) and unpredictable discharge from your stoma during the first few weeks of recovery. This should start to improve as you recover from the effects of the operation.

Ileostomy complications

As with any surgical procedure, having an ileostomy surgery carries a risk of complications. Discuss the risks with your surgeon before the ileostomy procedure. Some of the problems people with an ileostomy experience include:

  • a bowel obstruction – where the output of digestive waste is blocked
  • vitamin B12 deficiency – caused by the removal of part of the intestine that absorbs vitamin B12
  • stoma problems – such as widening or narrowing of the stoma, making it difficult to attach the external bag

Some of the main problems that can occur after an ileostomy or ileo-anal pouch procedure are described below.

Obstruction

Sometimes the ileostomy doesn’t function for short periods of time after surgery. This isn’t usually a problem, but if your stoma isn’t active for more than six hours and you experience cramps or nausea, you may have an obstruction.

If you think you may have an obstruction, contact your doctor or stoma nurse for advice. They may recommend:

  • avoiding solid foods for the time being
  • drinking plenty of fluids
  • massaging your tummy and the area around your stoma
  • lying on your back, pulling your knees up to your chest and rolling from side to side for a few minutes
  • taking a hot bath for 15-20 minutes to help relax the muscles in your tummy

In persistent or severe cases, you may be advised to go to your nearest accident and emergency department as there’s a risk your bowel could burst (rupture).

Dehydration

You’re at an increased risk of becoming dehydrated if you have an ileostomy because the large intestine, which is either removed or unused if you have an ileostomy, plays an important role in helping absorb water from food waste.

This makes it important to make sure you drink enough fluids to keep your urine a pale yellow color to prevent complications of dehydration, such as kidney stones and even kidney failure.

Rectal discharge

People who have an ileostomy but have an intact large intestine often experience a discharge of mucus from their rectum.

Mucus is a liquid produced by the lining of the bowel that acts as a lubricant, helping the passage of stools. It’s still produced even though it no longer serves any purpose.

The mucus can vary from a clear “egg white” to a sticky, glue-like consistency. If there’s blood or pus in the discharge, contact your doctor as it may be a sign of infection or tissue damage.

Many people find the most effective method of managing rectal discharge is to sit on the toilet each day and push down as if passing a stool. This should help remove any mucus located in the rectum and prevent it building up.

Contact your doctor if you find this hard to do or it’s not helping, as you may need further treatment.

Vitamin B12 deficiency

Some people who have had an ileostomy will experience a gradual decrease in their levels of vitamin B12. Vitamin B12 plays an important role in keeping the brain and nervous system healthy.

This decrease is thought to occur because the part of the intestine removed during the procedure is responsible for absorbing some vitamin B12 from the food you eat.

In some people, the fall in vitamin B12 levels can cause a condition called vitamin B12 anemia, which is also sometimes known as pernicious anemia.

Symptoms of vitamin B12 anemia include:

  • unexplained fatigue (extreme tiredness) and lethargy (lack of energy)
  • breathlessness
  • feeling faint
  • irregular heartbeats (palpitations)
  • headache
  • hearing sounds coming from inside the body rather than from an outside source (tinnitus)
  • loss of appetite

If you’ve had an ileostomy and experience any of these symptoms, contact your doctor. They’ll be able to arrange a blood test to check your vitamin B12 levels.

It’s important not to ignore these types of symptoms – if vitamin B12 deficiency is left untreated, it can cause more serious problems with your nervous system, such as memory loss and damage to the spinal cord.

If a diagnosis of vitamin B12 deficiency or anemia is confirmed, treating the condition is relatively straightforward and involves taking regular vitamin B12 supplements in the form of injections or tablets.

Stoma problems

Some people with an ileostomy experience problems related to their stoma, such as:

  • irritation and inflammation of the skin around the stoma
  • narrowing of the stoma (stoma stricture)
  • widening of the stoma (stoma prolapse)
  • an internal part of the body, such as an organ, pushing through a weakness in the muscle or surrounding tissue wall (parastomal hernia)
  • the stoma sinking below the level of the skin after the initial swelling goes down (stoma retraction)
  • the stoma may get longer with time as more of the bowel pushes itself out of the abdomen (prolapse)

If you think you may have a problem with your stoma, contact your doctor or stoma nurse for advice.

Skin irritation can usually be treated with topical treatments, such as a spray, but you may need to have further surgery to correct physical problems related to your stoma.

Phantom rectum

Phantom rectum is a complication that can affect people with ileostomies. The condition is similar to a phantom limb, where people who have had a limb amputated feel it’s still there.

People with phantom rectum feel like they need to go to the toilet, even though they don’t have a working rectum. This feeling can continue many years after surgery. Some people have found sitting on a toilet can help to relieve this feeling.

Pouchitis

Pouchitis is when an internal pouch becomes inflamed. It’s a common complication in people with an ileo-anal pouch or continent ileostomy.

Symptoms of pouchitis include:

  • diarrhea, which is often bloody
  • abdominal pains
  • stomach cramps
  • a high temperature (fever)

Speak to your doctor if you have symptoms of pouchitis. The condition can usually be successfully treated with a course of antibiotics.

Short bowel syndrome

This condition happens when surgery is done to remove a large part of the small intestine. Short bowel syndrome needs special attention because there’s not enough intestine left to absorb the nutrients the body needs.

People with short bowel syndrome must be under a doctor’s care. They must be closely watched to make sure they’re taking in enough calories, carbohydrates, proteins, fats, vitamins, and minerals. They can live a normal life, but must be careful to avoid diarrhea, and be within quick reach of medical care. The shorter the small intestine, the more watery the discharge will be. This may reduce the time a pouch can be worn because the skin barrier breaks down more rapidly.

Ileostomy care

A stoma is not sensitive to the touch but may bleed slightly if irritated or rubbed. This bleeding is normal but if it continues or if you see blood in your stool, contact your doctor.

The skin around your stoma (called the peristomal skin) should look and feel like the rest of the skin on your belly. It is important to keep stool off your skin to help prevent skin irritation.

  • Sore Skin

If the skin around the stoma becomes red and inflamed this can be due to damage when removing the flange/base plate. Using an adhesive remover may help to prevent this. With a two-piece or drainable ileostomy bag the flange/base-plate remains in place for several days which reduces skin damage. Sore skin can also result from contact between the contents of the ileostomy bag and the skin. Stomas can change in size and shape so check the size of the stoma every few months to make sure the hole in the flange/base-plate fits snugly around the stoma, so that the skin is not exposed. If the problem continues, consult a stoma care nurse who can advise on special products which can heal the skin and do not interfere with the adhesion of the appliance.

  • Bleeding

The stoma bleeds easily if it is rubbed a bit too hard. If the bleeding does not stop, or the blood is coming from inside the stoma, consult a stoma care nurse. The stoma may bleed more easily if anticoagulant drugs e.g. Warfarin, or aspirin, are being taken.

  • Ballooning

This occurs when gas, expelled through the stoma, collects inside the bag causing it to inflate. Most bags have a filter which allows this gas to escape. Occasionally the filter will become blocked and the bag will need to be changed. If this is happening on a regular basis it may be worth trying a different bag which may have a more effective filter. To ensure the filter doesn’t get wet and become ineffective, when in the bath or shower, cover it with the sticky patch supplied in the box of stoma appliances.

  • Pancaking

This occurs when, instead of dropping to the bottom of the bag, the bowel motion collects around the stoma and may seep between the flange and the skin. One of the reasons this happens is because there isn’t enough air in the bag and the two sides stick together. It may help to cover the filter with a sticky patch to prevent gas escaping from the bag or place a small piece of crumpled tissue inside the bag to keep the sides apart. Lubricating the inside of the bag with baby oil or a special gel may help the motion to drop to the bottom of the bag.

  • Constipation

Eating more fiber and fruit should help to make motions softer. Constipation can also be the result of not drinking enough fluid or the side effect of medication e.g. certain painkillers or antidepressants (check with your doctor or pharmacist). Unless prescribed by the doctor or stoma care nurse do not use suppositories or enemas as the stoma will reject them. If the stoma has not worked for several days or there is pain or vomiting seek medical advice.

  • Loose motions

If a large section of the colon has been removed it is likely that motions will always be fairly liquid and it may be easier to use a drainable bag. If motions are normally formed an episode of diarrhea could be due to a “stomach bug”, stress or emotional upset or certain medication e.g. antibiotics. If diarrhea persists it is important to seek medical advice.

  • Odor

There will only be an odor when emptying or changing the bag. This can be reduced by spraying a deodorant or striking a match. Odor while the bag is in place could indicate a leakage or a faulty filter. Drops, gels, capsules and sachets are available to neutralize any odor inside the bag.

  • Granulomas

Granulomas are very common and are small areas of over granulation tissue that appear as fleshy protuberances like tiny beads of varying sizes. Granulomas occur on the surface of the stoma or more commonly at the muco–cutaneous junction (the join between the bowel and the skin).

Granulomas develop as a result of over-healing of damaged skin or the stoma surface, possibly due to friction from the bag. Granulomas can be due to inflammation, infection or fecal irritation from the stomal output. Irritation from the ostomy appliance can also be a common cause. Some, but not all, stoma granulomas can cause bleeding and discomfort when touched when the skin around the stoma is being cleaned. This bleeding can cause problems with adherence of the ileostomy bag. Also, if they are large they may prevent pouch adhesion which may result in leakage problems.

What can you do to prevent stoma granulomas?

Ensure that the hole in the flange/baseplate of your pouch is the right size, so that the edge does not rub against the stoma. Good ileostomy bag changing techniques are an important part of reducing the risk of granuloma formation:

  • Remove the used ileostomy appliance slowly and gently. Start at the top and support the skin as you go. Use adhesive remover spray/wipes to reduce damage to the skin.
  • Wipe away any feces with toilet paper then wash the stoma and surrounding skin with warm water and dry the area thoroughly using dry wipes or kitchen
    roll.
  • When fitting a new appliance, bend the top half away from the body so that you can see to fit the bottom half accurately around the stoma, then press the  remainder of the flange into position.

Some people, however, appear to be more susceptible to the formation of granulomas than others.

Figure 5. Stoma granulomas

Stoma granulomas

Available treatment

Your stoma care nurse will take you through the treatment available, the main option being 75% silver nitrate applied to the granulomas approximately two to three times a week. This needs to be done by a healthcare professional, either the stoma consultants, stoma care nurse or your doctor. A stoma Orabase paste can be applied to prevent friction on the stoma surface and a lubricating gel placed in the pouch can help prevent the pouch rubbing on the stoma surface. Other treatment options include the application of Haelan Tape or application of liquid nitrogen.

If you think you may have stoma granulomas, then please contact your stoma care nurse for a review. Some specially trained stoma care nurses and consultants may also use curette and cautery (a special instrument is used to cut out the granuloma and the wound is cauterised or burnt closed).

Will granulomas eventually go away without treatment?

Usually some form of treatment is required, even if it is only the application of Orabase Paste when the granuloma is very small. The earlier the treatment is started the better.

Are granulomas likely to re–occur?

Yes, some people do find that granulomas can re–occur and they should seek a stoma care nurse review as soon as they feel they have re–appeared.

Prolapsed stoma

A prolapse of the stoma occurs when the bowel protrudes through the stomal opening in the skin to a greater extent than was anticipated. The amount of protruding bowel can vary from 2-3cm to more than 10cm. Although when this first happens it can be very distressing and frightening it is usually not serious. However, a review by a stoma care nurse is essential.

A prolapse can occur in any stoma type but is more common in loop ileostomy. There are many causes, the most common are:

  • An over sized hole made in the abdominal wall at surgery
  • Increased abdominal pressure due to tumor, pregnancy, coughing and sneezing
  • Excessive exertion e.g., heavy lifting
  • Poorly developed abdominal muscular support (infants)
  • Obesity

How do I manage a prolapsed stoma?

There are two ways of managing a prolapse:

  • Conservative management

Your stoma care nurse will advise on how you should look after the stoma and give you help in reducing the swelling. He/she will also advise you on which specialist pouches are available and also on the use of abdominal support garments.

  • Surgical management

If a prolapse is too large to manage conservatively, or if it has become discolored, surgical intervention may be required. This will involve removal of the prolapsed section of the bowel and resiting of the stoma.

If you have a prolapse stoma please contact your local stoma care nurse for advice and support.

Ileostomy bag

Ileostomy bag (also called stoma bags) is where you feces are collected as they leave your body via the stoma. Your stoma care nurse will help you to decide which ileostomy bag is best for you after your operation. Once you get home, you’ll soon start to discover that there are lots of different types of stoma bags. These are designed to meet the different needs of people with stoma have. You should consult your stoma care nurse before changing to a new product. There are also a wide range of accessories available. These include deodorizers, wipes, skin protective wipes, lotions and creams.

Table 1. How to choose the right ileostomy bag

how-to-choose-ileostomy-bag

Figure 6. Different types of ileostomy bags

types of ileostomy bags

Living with a ileostomy bag

A ileostomy bag is often used to collect your poo (stools). It needs to be removed and replaced when full, usually one to three times a day.

There are also drainable bags that only need to be replaced every one or two days. These may be suitable for people who have particularly loose stools.

A specialist stoma nurse, who usually sees you before and after the ileostomy operation, will help you choose the most suitable ileostomy equipment.

There’s a wide range of ileostomy appliances available, including:

  • One-piece ileostomy bag – the bag and flange (part that sticks to your skin) are joined together; the appliance is removed when full and then disposed of
  • Two-piece ileostomy bag – the bag and flange are separate, but can be connected; the flange can be left on your skin for several days, and the bag removed and disposed of several times a day
  • Closed ileostomy bags which are mainly used for coping with formed motions. They are usually changed several times a day. Closed bags with a special liner which contains the motions and can be flushed down the toilet are available.
  • Drainable ileostomy bags which are mainly used for coping with liquid motions. They may be worn for longer than closed bags as they can be emptied through an outlet at the bottom and then resealed with an integral Velcro seal or a clip.

Ileostomy appliances are made from non-allergic (hypoallergenic) materials to reduce skin irritation. They also contain special filters to prevent any unpleasant odors.

If you have regular and predictable bowel patterns, you may not always need to wear a ileostomy bag. But as occasional leakages can happen, it’s recommended that you wear a small stoma cap.

Additional products that can make living with a ileostomy more convenient include:

  • support belts and girdles
  • deodorizers that can be inserted into your appliance
  • protective skin wipes
  • sprays to remove adhesive
  • protective stoma rings
  • specially designed underwear and swimwear

Your stoma care nurse will be able to give you more information and advice about equipment.

How to change a ileostomy bag

Before you leave hospital your stoma care nurse will show you how to change your bag. She/he will also teach you how to use a stoma guide to check that the hole in the adhesive flange or base-plate is the correct size. If necessary, you will also be shown how to cut the right size and shape using a template.

A ileostomy bag is best changed when about three-quarters full. This makes the process easier and the ileostomate (a person with ileostomy) more comfortable. It is usually carried out in the bathroom, but if the ileostomate is seated, this can mean folds or creases form around the stoma making it difficult to achieve a good seal between the skin and the flange/base-plate. It may be best to remove the used ileostomy bag and attach the new one when the ileostomate is standing. However, if this is not possible then an alternative might be for the ileostomate to lay flat on a bed.

1. Before you begin

Check you have everything you need: water, soft wipes, a new ileostomy bag, any accessories you use and a plastic disposal bag.

Check whether the hole in the adhesive flange/base-plate has been pre-cut to the size and shape of the stoma. If not, use a template to mark the outline of the stoma and using curved scissors, trim to the correct shape. If the hole is too large skin will show and be irritated by the contents of the bag, which can make it sore. If the hole is too small, it may rub against the stoma and cause it to swell.

Tips:

If you wear a one–piece pouch use the backing paper/film that protects the adhesive on the flange to check that the hole is the correct size. Hold the backing film around your stoma; it can be difficult to see if you are looking down so it may be helpful to stand in front of a mirror or ask someone else to check for you.

There should be a 1–2mm gap all around to prevent the edges of the hole rubbing on the stoma, whilst still ensuring that the contents of the pouch do not come into contact with the skin.

Figure 6. Measuring and cutting a hole in the base-plate of the ileostomy bag

2. Removing the old ileostomy bag

Remove the old bag, working slowly and gently from the top to the bottom of the flange. medical adhesive remover (available on prescription) can be used to avoid damaging the skin. It is wiped or sprayed beneath the flange as it is peeled away from the skin.

Check the skin around the stoma for any early signs of irritation. Gently clean the stoma and surrounding skin with warm water. Do not use soaps, disinfectants, harsh solvents or baby wipes as these often contain perfume or moisturizers and may affect how the flange/base-plate sticks, or may irritate the skin.

Remember the stoma bleeds easily if it is rubbed too hard, but bleeding should stop quickly. If blood comes from inside the stoma, contact your stoma care nurse.

3. Fitting the new ileostomy bag

Gently pat the skin until it is completely dry. If you are prone to sore skin, barrier wipes, sprays and lotions are available.

When your skin is completely dry, fit the new ileostomy bag (or base plate), making sure it is secure all the way round. When fitting a one-piece ileostomy bag, it helps to bend the top half of the flange away from your body, so that you can see to fit the bottom half around the stoma. Then, with the flat of your hand, press the remainder of the flange in position. The warmth of your hand will ensure that it adheres snugly. Press the flange/base-plate in place for at least half a minute to make sure the seal is secure.

If using a two-piece ileostomy bag, then attach the bag to the base-plate.

4. Disposal of used ileostomy appliances

Seal the used appliance inside a disposal bag (provided free by suppliers). In a nursing home this can be disposed of with other clinical waste.

The used ileostomy appliance may be wrapped up well and put in the dustbin. Some people prefer to empty the contents of the stoma bag into the toilet before discarding it in this way.

Ileostomy bags with liners that contain the stools and can be flushed down the toilet are now available.

Ileostomy diet

In the first few weeks after your ileostomy surgery, you’ll usually be advised to follow a low-fiber diet.

This is because having a high-fiber diet can increase the size of your stools, which can cause the bowel to become temporarily blocked. After around eight weeks, you’ll usually be able to resume a normal diet.

As you recover, you should try to eat a healthy, balanced diet that includes plenty of fresh fruit and vegetables – at least five portions a day – and wholegrains.

If you decide to introduce new foods into your diet after surgery, try to introduce them slowly, at the rate of one type of food each meal. This will allow you to judge the effects of the food on your digestive system.

You may find it useful to keep a food diary so you can keep a record of the food you’ve eaten and how you feel afterwards. For example, you may find you experience diarrhea after eating spicy foods, or after drinking alcohol or caffeinated drinks.

Dehydration

If you no longer have a large intestine (colon), you’re at greater risk from dehydration. This is because one of the functions of the colon is to reabsorb water and minerals back into the body.

It’s therefore important to drink plenty of water if you have an ileostomy, particularly in hot weather or during periods where you’re more active than normal. Sachets of fluid replacement solutions to help reduce dehydration are also available from pharmacies.

Living with an ileostomy

Although it can be difficult to adjust at first, having an ileostomy doesn’t mean you can’t have a full and active life.

Many people with a stoma say their quality of life has improved since having an ileostomy because they no longer have to cope with distressing and uncomfortable symptoms.

However, if you’re finding it difficult to adjust after your operation, it may help to get in contact with others who have had similar experiences through support groups.

Ileostomy equipment

Before and after the ileostomy procedure, you’ll see a nurse who specialises in helping people with a stoma. The nurse will advise you about equipment you’ll need and how to manage your stoma.

Stoma bags

Your stoma will produce liquid digestive waste that can range from a watery consistency to a consistency similar to porridge, which is collected in a stoma bag.

There’s a wide range of stoma bags available, but a specialist stoma nurse can help you choose the most suitable appliance for you.

To help reduce skin irritation, stoma bags are made from hypoallergenic (non-allergic) material, and contain special filters to help ensure the bags don’t release any unpleasant odors.

They can be easily drained through an opening in the bottom and can be concealed under everyday clothes.

It’s usually best to empty your bag into a toilet when it’s about one-third full as this prevents the bag bulging underneath your clothes.

You’ll usually be advised to replace the bags and dispose of them in the general rubbish – not down the toilet – every one or two days.

At first, living with an ileostomy can be a distressing experience. It may take some time before you get used to it, but with practise and the support of your stoma nurse and family, using stoma bags will become routine.

Other equipment and products

There are also additional products that can make living with an ileostomy more convenient, including:

  • support belts and girdles
  • deodorizers that can be inserted into your appliance
  • protective skin wipes
  • adhesive remover sprays
  • protective stoma guards

Your stoma care nurse will be able to advise you about the most appropriate equipment to help you manage your ileostomy successfully.

Ordering and paying for equipment

You’ll be given an initial supply of stoma bags before you leave hospital, as well as your prescription information. Let your doctor know your prescription information so they can make a note of it in your medical records and issue prescriptions in the future.

Your prescription can either be taken to the chemist or sent to a specialist supplier who will deliver the appliances. There’s no need to stockpile supplies, but it’s recommended that you order more appliances while you still have plenty left so you don’t run out.

Smell and wind

In the first few weeks after surgery, you may experience a lot of gas (flatulence). This is harmless, but it can be embarrassing and uncomfortable. This problem should subside as your bowels recover from the effects of surgery.

Chewing food thoroughly and not eating foods that cause gas can help. These include:

  • beans
  • broccoli
  • cabbage
  • cauliflower
  • onions
  • eggs

Fizzy drinks and beer also cause gas. Don’t skip meals to try to prevent gas because it will make the problem worse.

If the problem persists, your doctor or stoma nurse should be able to recommend a medicine that can help to reduce gas.

Many people also worry their external bag will smell. However, all modern appliances have air filters with charcoal in them, which neutralises the smell. If necessary, special liquids and tablets that are placed in the bags are available to reduce any odour.

Medication

Many medicines are designed to dissolve slowly in your digestive system. This means some medications may not be as effective if you have an ileostomy because they could come straight out into your bag.

Let your doctor or pharmacist know about your stoma so they can recommend an alternative type of medicine, such as an uncoated pill, powder or liquid.

In women, having a ileostomy can affect the effectiveness of oral contraceptive pills, so you may want to discuss alternative forms of contraception with your doctor or pharmacist.

Physical activities

Once you’ve fully recovered from surgery, there’s no reason you can’t return to most of your normal activities, including work, sports, traveling and having sex.

Speak to your stoma nurse before returning to your normal activities, however, as they can offer advice about issues you may need to take into consideration now you have an ileostomy.

For example, they can advise you about wearing protective stoma guards while playing sports, or stocking up on ileostomy products before traveling.

Living with an Continent Ileostomy (ileo-anal) pouch

Living with an ileo-anal pouch is different from living with an ileostomy because the procedure doesn’t involve creating a stoma in the tummy (abdomen). Instead, digestive waste is stored in an internal pouch and excreted through the rectum and anus.

If you’ve had an ileo-anal pouch (J-pouch), you may find you need to empty it up to 20 times a day during the first few days after the operation.

However, the number of times you need to go to the toilet will slowly reduce as the pouch expands and you get used to controlling muscles that surround it.

Most people find their pouch activity settles down after 6 to 12 months, although the number of bowel movements will differ from person to person.

Improving muscle control

Exercising the muscles that control the passing of stools (pelvic floor muscles) can help make going to the toilet easier if you have an ileo-anal pouch. It can also reduce the likelihood of accidental leaks during the first few weeks after the operation.

Pelvic floor exercises, as outlined below, are a good way of improving your muscle control:

  • sit or lie comfortably with your knees slightly apart
  • without moving your abdominal muscles, squeeze the muscle around the back passage as if you’re trying to stop passing wind
  • hold this contraction as long as you can – at least two seconds, increasing up to 10 seconds as you improve
  • relax for the same amount of time before repeating

Ideally aim for 10 short, fast and strong contractions.

Anal soreness

Anal soreness or itchiness is common in people with an ileo-anal pouch. Having regular baths should help to relieve this. Using a skin protection cream is also recommended. Your doctor will be able to advise you about the best cream for you.

Ileostomy reversal

If your ileostomy is intended to be temporary, further surgery will be needed to reverse it at a later date.

The reversal operation will only be carried out when you’re in good health and fully recovered from the effects of the original ileostomy operation. This will usually be several weeks or months after the initial surgery, or sometimes even longer.

There’s no time limit for having an ileostomy reversed and some people may live with one for several years before it’s reversed.

Reversing a loop ileostomy is a relatively straightforward procedure that’s carried out under general anaesthetic.

A cut (incision) is made around the stoma and the section of small intestine is pulled out of the tummy (abdomen). The area that had been divided to form the stoma is then stitched back together and placed back inside the abdomen.

It’s also sometimes possible to reverse an end ileostomy if most of the large intestine (colon) has been sealed and left inside the abdomen.

However, the surgeon will need to make a larger incision to locate and reattach the small and large intestines. It therefore takes longer to recover from this type of surgery and there’s a greater risk of complications.

Recovering from ileostomy reversal surgery

Most people are well enough to leave hospital within three to five days of having ileostomy reversal surgery.

While you recover, you may have diarrhea and need to go to the toilet more often than normal.

It can take a few weeks for these problems to settle and your bowel activity may never return to the way it was before you had the ileostomy operation.

If necessary, your doctor can prescribe medication to relieve diarrhea until things improve.

You may also experience a sore anus after the reversal operation. This should improve as the anus becomes used to having stools pass through it again, although common barrier creams can help.

The reversal operation is usually a smaller procedure than the initial ileostomy procedure. However, it still takes several weeks to fully recover.

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