Abnormalities of pregnancy, parturition and puppies

Question 1

If there is one dead pup in the litter (before mineralisation), do we need to take any action?

Answer 1

•Do we need to take any action?

–Find out if the other one is alive, scan all of the other conceptus and see if its affecting all of them – in this case, just this one

–If all dead, terminate pregnancy – is the bitch well, any other clinical signs? Any repro signs?

–If a single failed pregnancy, will likely go and resorb, rest of pregnancy might carry on to term – might just watch and see

–If after mineralisation – need some sort of expulsion, so pregnancy loss may just occur at an isolated manner in this case as its not mineralised yet

Question 2

What are the most common causes of conception failure in the bitch?

Answer 2

• Inappropriate timing of mating
• Male factor infertility
• Abnormal mating
• Abnormal uterine environment

Question 3

What are the most common causes of conception failure in the queen?

Answer 3

• Inadequate mating, inappropriate time
• Male factor infertility
• Abnormal mating

Question 4

What percentage of resorption of one of the embryos seen in?

Answer 4

Resorption of one of the embryos (with continuation of the pregnancy) is seen in 10% of pregnancies

Question 5

What is spontaenous isolated resorption?

Answer 5

•May be spontaneous isolated resorption:

–Resorption of one of the embryos (with continuation of the pregnancy) is seen in 10% of pregnancies

–Possibly to reduce abnormal embryos or embryo number

–Does not appear to be infectious

–Table – study that was done, showed that resorbtion is more common when a lot of conceptuses there – inferred it may just be due to competition between fetuses. Most go to term and no abnormal outcome

Question 6

With regards to other causes of resorption/abortion in the bitch, what should most cases be examined by?

Answer 6

•Most cases should be examined assuming an infectious cause

–Send unfrozen fetus and membranes for investigation

Question 7

What are some possible causes of infectious causes for resorption/abortion in the bitch?

Answer 7

•Canine herpes virus

–venereal pathogen

–viral recrudescence at subsequent pregnancies

• Canine parvovirus
• Canine adenovirus
• Canine distemper virus
• (Brucella canis)* important in most countries but not currently the UK

Question 8

What are some possible causes of non-infectious causes for resorption/abortion in the bitch?

Answer 8

• Abnormal uterine environment
• Fetal abnormalities
• Low progesterone

Question 9

What are some possible causes of infectious causes for resorption/abortion in the queen?

Answer 9

•Most cases should be examined assuming an infectious cause

–Send unfrozen aborted fetus and membranes for investigation

–Possible causes

• Feline leukaemia virus
• Feline herpes virus
• Feline panleucopenia virus
• Feline infectious peritonitis virus
• Chlamydia psittaci
• Toxoplasma gondii

Question 10

What are some possible causes of non-infectious causes for resorption/abortion in the queen?

Answer 10

• Abnormal uterine environment
• Fetal abnormalities
• Low progesterone

Question 11

If we are managin abortion, what treatment should we give to the dam at the time of abortion?

Answer 11

–Systemic antimicrobial preparations, broad spectrum

–Ecbolic agents (oxytocin) – aid expulsion process

–Parenteral fluid therapy

Question 12

Do progesterones prevent abortion?

What happens if you use them?

Answer 12

–No data to show progestogens prevent abortion

•But if you use progestogens you may

–increase the incidence of pyometra

–result foetal abnormalities

–impair or delay parturition

Question 13

With dystocia, what things from the clinical history do we need to know and ask about?

Answer 13

• Has the dam given birth before – if so where there complications and what where these?
• What has recently been observed in this dam?
• Has there been recent vulval discharge?
• Have uterine / abdominal contractions been noted and if so when?
• Have any fetal membranes / fluid been expulsed?
• Have any fetuses been delivered?
• Any other relevant information (inguinal hernia etc)

Question 14

What is the normal length of pregnancy in a dog from what point?

Answer 14

Remember length of normal pregnancy is 63 + 1 days from ovulation (but that the time of mating around ovulation is variable)

Question 15

What are some methods of assessing possible dystocia cases?

Answer 15

• Clinical history (mating 58 to 72 days before onset parturition)
• Decline in plasma progesterone (1.5 days before onset parturition)
• Decline in rectal temperature (24 hours before onset parturition)
• Onset of uterine contractions (2 to 4 hours before onset parturition)
• Onset of abdominal contractions (30 to 120 minutes before onset parturition)

Question 16

With bitch dystocia, what do we want to look for on a clinical exam?

Answer 16

–Is she bright or dull / what are her clinical parameters?

–What is her body condition?

–Is she able to stand and walk?

–Can any fetal parts been seen at the vulva?

–What is the identity of the fetal parts?

–Is there any vulval discharge and if so what colour is it?

–Is there evidence of fetal life?

Question 17

With bitch dystocia, what do we want to look for on a digital exam?

Answer 17

–Is the vestibule / vagina dilated?

–What is the state of lubrication of the tract?

–Are any fetuses present, are they alive, what is their presentation, position and posture?

–Are any fetal membranes present, are they intact, are they detached?

–What is the relative size of the birth canal and the likelihood of fetuses being delivered?

–Are any lacerations present?

Question 18

With bitch dystocia, what do we want to look for on endoscopic, ultrasonographic and radiographic exam?

Answer 18

•Endoscopic examination

–Is the cervix open (cannot detect in bitch or queen)?

•Ultrasonographic examination

–Are fetuses alive, what is their size?

–What is the fetal heart rate?

•Radiographic examination

–Number and size of fetuses

–Signs of fetal death: change in posture, overlapping skull bones, fetal/uterine gas

•Measure Progesterone

Question 19

What is normal foeatal heart rate?

Answer 19

•Normal fetal heart rate at term 170-230 bpm

–Or, at least four times maternal heart rate

–Transient increases with foetal movement

Question 20

If the fetal heart rate is less than 150bpm, what make this indicate?

Answer 20

•Fetal heart rates less than 150 bpm

–Indicates stress (hypoxia)

Question 21

If the fetal heart rate is less than 130bpm, what is the survival like?

Answer 21

•Fetal heart rates less than 130 bpm

–Poor survival if not delivered within 2 to 3 hours

Question 22

If the fetal heart rate is less than 100bpm, what intervention is required?

Answer 22

•Fetal heart rates less than 100 bpm

–Immediate (medical or surgical) intervention to hasten delivery before demise of the pups

Question 23

How can we correct foetal orientation as a treatment for dystocia?

Answer 23

•Correction of foetal orientation

–Retropulsion, correct position / posture

–Traction

Question 24

How can we use oxytocin administration to treat dystocia? How does it help/work?

Answer 24

–After correction of obstruction

–Half life is short

–Oxytocin doses are often too high and cause tetany not coordinated contractions

• 0.04 IU/kg is appropriate given every 30 mins for 3 doses
• (30 kg Labrador = 1.2 IU = 0.12 ml of 10 IU/ml)

–Oxytocin compresses placenta and worsens fetal hypoxia so is contraindicated if fetuses are bradycardia

–In large litters may be better option to go to Caesarean

Question 25

Other than oxytocin, what else could we administer to help as a treatment for dystocia?

Answer 25

Calcium

1.0 ml/kg s/cut of 2.5% solution (need to dilute 20% solution 1:7)

Question 26

What are the most likely outcomes for dystocia in terms of medical management and surgical - which is more often used?

Answer 26

Manipulation / medical treatment:

• Successful in 28% of bitches
• Successful in 30% of queens
• Overall approximately 70% ultimately undergo caesarean

–Worthwhile thinking about it if you get the phone call and a case is on its way in – prepare for it

Question 27

What is the normal involution of the uterus in the bitch and the queen?

Answer 27

• Normal involution takes 12 weeks in the bitch
• Normal involution takes 6 weeks in the queen

Question 28

What is the normal length of time for vulval discharge to be present after parturtion in the bitch?

What should it be like?

Answer 28

•There is a normal vulval discharge for 3-4 weeks

–Not odorous, not associated with illness, but may be coloured

•Takes a reasonable length of time compared to other animals such as sheep and pig. There is no need for speed in the dog as she will be in anoestrous in the dog! And in queens they don’t often come into oestrous whilst they are lactating

Question 29

What are the most common post-partum diseases in dogs and cats?

Answer 29

1. Haemorrhage
2. Suspected retained fetal membranes
3. Post partum metritis
4. Hypocalcaemia
5. Sub-involution of placental sites

Overall they are not that common though!!

Question 30

What are some things that can cause post-partum haemorrhage?

What is the treatment for it?

Answer 30

• Due to physical injuries of the birth canal
• Or, lack of involution of the uterus
• Or, following on from a caesarean
• Most aren’t as dramatic as you think it will be

Treatment

–Use of vaginal tampon – helps stop bleeding

–Ecbolic agents – oxytocin to increase speed of involution

–If uterine origin and severe may need OVX

–Also if severe in specific breeds may consider a coagulopathy – had situations in some GSD where they had significant bleeding post partum and they had von Willebrand’s disease

Question 31

How quickly should the placenta be passed in the bitch?

Answer 31

Placenta usually passed within 20 minutes of each pup

Question 32

What is suspected if there is green/black discharge persisting after parturition?

Answer 32

•Retention suspected if green/black discharge persists after parturition

May be associated with retained pup and placenta

Question 33

How can we diagnose retained fetal membranes?

Answer 33

•Diagnosis requires ultrasound (radiographic) examination: palpation is unreliable

Question 34

If we suspect retain fetal membranes, what should we give to these cases?

Answer 34

In suspected cases oxytocin and antibiotic should be given

Question 35

What is the problem with giving oxytocin to a dog with suspected retain fetal membranes after 36h from parturition?

What should we consider instead?

Answer 35

Remember few oxytocin receptors after 36 hours therefore consider low dose prostaglandin

Question 36

What is a common sequelae to suspected retained fetal membranes?

Answer 36

Metritis is a common sequelae

Question 37

What can be seen in this US?

Answer 37

Can see retained placenta nicely in the US above – can see entirety of the placenta and none at the 2 edges

Question 38

What can cause post-partum metritis?

Answer 38

•Bacterial infection following on from

–Difficult or prolonged birth

–Placental retention

–Abortion

–When there has been damage to endometrium and this is most likely at parturition, bacterial contamination can invade more deeply and animal can be quite sick!

Question 39

What are the clinical signs of post-partum metritis?

Answer 39

–Depression, pyrexia, anorexia

–Purulent vulval discharge

–Neutrophilia with left shift

–Uterine enlargement

Question 40

Is there a hormonal issue with post-partum metritis?

Answer 40

No

It is a contamination/infection of the uterus

Question 41

What conservation mnaagement if faesible with regards to post-partum metritis?

Answer 41

•Conservative management is feasible

–Broad spectrum antimicrobial drugs

–Fluid therapy

–Ecbolic agents

•Prostaglandins (synthetic naturally occurring)

Question 42

With regards to post partum hypocalcaemia, when breeds is it most common in and when are we most likely to see it?

Answer 42

• Eclampsia
• Most common in small breeds
• Commonly in early lactation (rarely in late pregnancy)

Question 43

What are the clinical signs of post partum hypocalcaemia?

Answer 43

• Clinical signs: nervousness, panting, whining, hypersalivation, stiff gait, tetany
• Can become recumbent, panting, paddling etc.
• Frequently there is marked pyrexia

Question 44

What is the treatment for post partum hypocalcaemia?

Answer 44

• Treatment is calcium borogluconate slowly by IV infusion (see next slide), followed by same dose SC
• Feed pups artificially for 24 hours
• May consider cabergoline (Galastop) to stop lactation and wean pups if difficult to control
• Oral calcium supplementation can be given using ‘Rennie’ but usually not as preventative as depresses PTH and may exacerbate hypocalcaemia if given before whelping

Question 45

What is sub-involution of placental sites?

What do you see and what do we do about it?

Answer 45

Incomplete involution in at least one of the areas where one placenta attached. These dogs have a low volume of blood leaking from vulvar usually until the next oestrous. Often a concer from owner due to red coloured discharge – part of the uterus doesn’t involute and leaks a small amount. After oestrous, there will be re-vascularisation of the uterus and the area that is leaking often involutes and the bleeding stops. Often its just reassuring the owner

Question 46

This is a uterus

Is this normal or abnormal?

Answer 46

Normal

• White line at bottom – dorsal surface of uterus
• Top – ventral uterus
• Longitudinal scan through body of uterus
• Normal involution of the uterus, big broad, central echogenic areas
• Uterus is not concertinaing on itself

Question 47

What percentage of neonatal deaths are known compared to not known?

Answer 47

• 45% of causes of neonatal deaths are known
• 55% of causes are unknown

Question 48

What are some causes of known reasons for neonatal deaths?

Answer 48

–Maternal/management linked causes:

• Injuries and reduced viability due to dystocia or caesarean
• Temperament factors and poor mothering
• Concurrent illness in the dam - poor lactation

–Infections (most important Canine Herpes Virus) during passage through birth canal or due to environment

–Birth trauma or poor mothering, poor colostrum or milk

–Low birth-weight

–Severe congenital abnormality

Question 49

How does canine herpesvirus affect neonates?

Answer 49

–acutely fatal disease

–sudden death

–haemorrhage

–vomiting/diarrhoea

–weight loss and failure to suck (“fading puppy”), become dehydrated, then enter spiral or decline. Become hypothermic, so don’t suck, more dehydrated etc.

–constant complaining

–neurological signs

–ocular disorders

Question 50

How does canine herpesvirus affect adults?

What are some reproductive problems?

Answer 50

–If mother infected at time of mating, the pregnancy is lost and it doesn’t get to term

–respiratory tract disease

–carrier

–re-activates during periods of stress

–reproductive problems:

• infertility in males and females
• genital lesions
• abortion
• placentitis => weak puppies

Question 51

How can we diagnose canine herpesvirus?

Answer 51

–serology

•demonstrates exposure not infection

–send whole fresh carcass and placenta to pathologist

• pathology of kidneys, liver, lungs, placenta
• virus isolation

Question 52

With an unknown cause of neonatal mortality, what is the similar progression of the disease that causes them to die?

Answer 52

Many have a similar progression of disease

–Appear normal at birth

–Then:

• Depressed
• Progressive weight loss
• Persistent crying
• Failure to feed
• Hypothermia
• Dehydration
• Generalised weakness
• Die mostly between days 3 to 5
• Die with no identifiable cause

Question 53

What is the role of lung surfactant and how does this relate to true fading puppy syndrome?

Answer 53

•Often described as ‘True Fading Puppy Syndrome’

–Role of lung surfactant?

• > Poor respiratory function
• > Respiratory distress
• > Inability to suck
• > Fatal cycle of hypoxia, dehydration, low blood sugars, hypothermia and death

Question 54

What is wrong wtih the lungs of puppies that fade?

Answer 54

Most of pups that faded have poor lung function and abnormal surfactant, so they structure to suck if they cannot breath, takes a couple of days for clinical manifestation to show. Poor lung function à not enough milk à Hypoglycaemic à failure to thrive à death

Question 55

What is the difference between immature vs mature lung?

Answer 55

Immature

• Low surfactant levels
• Not conducive to gas exchange
• Thick blood gas barrier
• Low compliance
• Immature epithelial cells
• Small area for gas exchange
• Poorly vascularized
• High resistance to blood flow

Mature

• Adequate surfactant
• Conducive to gas exchange
• Thin blood gas barrier
• Highly compliant
• Mature epithelial cells
• Large area for gas exchange
• Highly vascular
• Low resistance to blood flow

Question 56

In human babies, what can treatment of abnormal surfactant include?

Answer 56

•In babies, treatments may include:

–Corticosteroids prior to pre-term delivery

–Endo-tracheal intubation and surfactant administration at birth

–Monitor oxygen saturation and intubation and oxygen administration

–They aren’t taken enough milk –> early intervention of these puppies (with oxygen etc.), often the key critical thing causing them to survive

Question 57

If a neonate shows minor signs of disease such as lethargy, slow to feed, lack of weight gain etc, what should we do?

Answer 57

• Any neonate with minor signs of disease (lethargy, slow to feed, lack of weight gain) should have early supplemental feeding
• If concern over intake of colostrum, a source of frozen-thawed or replacement colostrum should be given before day 3
• If necessary use tube feeding
• Want to give them milk! If pup will sick, allow it to suck, but in many cases we need to tube them to feed them

Question 58

How can we tell if a puppy is dehydrated?

Answer 58

one simple thing to do, get a piece of white cotton wool and rub perineum, normally hydrated will have urine which is almost colourless – if coloured, usually mean it is dehydrated.

Question 59

What are the principles of tube feeding?

Answer 59

• The tube is used to measure the distance from the tip of the nose to the last rib
• With the puppy upright the tube is gently fed into the mouth. Most puppies will swallow the tube
• Check for negative pressure when drawing back on the plunger of the syringe

Question 60

For minor disease, what is the treatment of the sick puppy?

Answer 60

• Want to make sure the pup doesn’t become hypothermic, provide oxygen, keep warm and dry, monitor weight, urine colour and providing general nursing care. These things done early will be really useful for fading puppies – the longer they stay alive, the more likely they are to have expansion of their lungs and they may become normal
• During this early phase it is essential to maintain body temperature, which should be recorded every few hours
• Environmental temperature should also be monitored using a thermometer placed adjacent to the neonates
• Adequate hydration should be ensured and can be estimated from:

–Urine examination: normal urine is colourless, and the presence of colour in the urine may be a useful and simple indicator of dehydration

–Recordings of weight gain (measured three times daily)

–Evaluating skin elasticity

• General nursing care is also important and should include regular perineal stimulation to ensure urine and faecal voiding
• Antimicrobial preparations may be considered

–Not because there is a primary bacterial infection

–But, the neonate is susceptible to commensal overgrowth

•Oral clavulanic acid potentiated amoxycillin at 12.5 to 25 mg/kg twice daily

–It is prudent to collect bacteriological samples prior to administration to allow for a change once culture sensitivity is established

Question 61

For significant disease, what is the treatment of the sick puppy?

Answer 61

•Absence of feeding, dehydration or other clinical signs necessitate immediate aggressive treatment:

–Reverse hypothermia

–Reverse hypoxia

–Treat / prevent dehydration

–Prevent commensal organism overgrowth

• Despite such treatment the mortality rate can be high
• Might need to think about more intensive support – providing additional things, but in many cases once you are here, you are very further advanced in this decline and prognosis for these are often really poor

Question 62

With treatment of the sick puppy, what are some general points to consider?

Answer 62

–Rigorous clinical examination should be undertaken every 4 hours to include:

• Rectal temperature
• Mucous membrane colour and capillary refill time
• Respiratory rate and heart rate
• Urine colour and skin elasticity

Question 63

With treatment of the sick puppy, what are some general points to consider with hypothermia?

Answer 63

• Slow re-heating (1C per hour)
• Pads/lamps/bottles
• Do not feed if colder than 34C
• Add dextrose to fluids (as increased calorific demand)
• Maintain environmental temperature 29-32C
• Medium humidity

Question 64

With treatment of the sick puppy, what are some general points to consider with oxygen administration?

Answer 64

• Incubator, or using a homemade oxygen tent
• Alternatively a tracheal catheter may be placed
• Especially useful for pups with concomitant upper respiratory tract problems.
• Oxygen can help overcome hypoxia and artificial ventilation may be useful to reverse acidosis and encourage lung surfactant production

Question 65

With treatment of the sick puppy, what are some general points to consider with fluid therapy?

Answer 65

–Pups with pale and dry mucous membranes and a slow capillary refill time are usually at least 10% dehydrated.

–This deficit needs to be replaced along with the ongoing maintenance requirement

•Fluid requirements for general maintenance are approximately 60 to 100 ml/kg/day

–IV

–Intraosseous

–(IP?)

–(Oral?)

–If cannot get IV line, place catheter into BM, works well as can run fluids in almost at same rate as IV – simple procedure to do. Difficult to get IV line in small neonate