Disorders of the puerperium

Question 1

peurperium - define

Answer 1

The period after parturition when reproductive tract
returns to its non-pregnant condition so that the female may become pregnant again
shortest time desirable

Question 2

Normal processes that occur during the puerperium

Answer 2

Involution
Regeneration of endometrium
Elimination of contaminants of the reproductive tract
Resumption of ovarian cyclical activity

Question 3

Disorders that affect normal puerperium

Answer 3

Dystocia
Uterine Prolapse
Retention of foetal membranes (RFM)
Uterine Disease

Question 4

involution - uterus

Answer 4

Reduction in the size of uterus and cervix after calving
greatest decrease in uterine size in 1st few days
after calving [myometrial contractions; ease of discharge of fluids/tissue debris, compression of uterine vasculature]
diameter of the previously gravid horn will halve in a period of 5 days, length will be halved by 15 days postpartum.
By 8-10 days postpartum whole of the uterus should be palpable per rectum.
Complete involution occurs within 26-50 days; changes after 25 days pp are minimal

Question 5

involution - cervix

Answer 5

Difficult to fit a hand through cervix into the uterus by 10-12hrs postpartum
by 96h postpartum only 2 fingers can be admitted through the cervix reduction in external diameter of the cervix is also appreciable when palpated per rectum;
In case of normal involution, by 25 days postpartum the diameter of the cervix starts to exceed than that of the previously gravid uterine horn.

Question 6

involution

Answer 6

Shift from hypertrophy (due to increase in collagen and smooth muscle) to atrophy (due to loss of smooth muscle, and collagen degradation) Reduction in the size of myofibrils
Prostaglandins may control involution, so their (and possibly oxytocin) exogenous use may be used to accelerate involution

Question 7

regeneration of endometrium

Answer 7

Uterine caruncles undergo degenerative changes probably due to vasoconstriction and ischaemia and this results in necrosis + sloughing of caruncular tissue. Size of caruncles is considerably reduced by 25 days pp
Necrotic material when sloughed, along with blood and foetal fluids, constitutes the post partum lochial discharge.
lochial discharge occurs at days 2-9 post-partum - usually yellowish or reddish brown
Volume of lochia is variable. Normal lochial discharge does not have fetid odour
A systemic response (Acute phase proteins) is observed
Covering of the caruncular and inter-caruncular surfaces withendometrial epithelium…centripetal growth of cells from UGs

Question 8

bacterial contamination

Answer 8

Bacterial species from the uterine lumen include;
Arcanobacterium pyogenes, E. coli, streptococci Staphylococci, Fusobacterium necrophorum
Lochial material provides an ideal growth medium

Question 9

elimination of uterine bacterial contamination

Answer 9

phagocytosis by migrating leucocytes plus physical expulsion by uterine contractions and secretions
By about 5 weeks, 50% will be sterile and by 8-9 weeks most animals will have a sterile uterine lumen

Question 10

Resumption of Ovarian Cyclical Activity

Answer 10

-ve feedback effect of high P4 during pregnancy,
pituitary is refractory to GnRH postpartum.
7-10 days post-partum - increase in plasma FSH
concentrations, associated with 1st post-partum follicular wave.
Ovulation will only occur if the follicle produces enough oestradiol to stimulate adequate LH secretion [LH receptors +IGFBPs proteases].
Dominant follicle on contra-lateral ovary and possibility of silent ovulation. Suckling delays ovarian cyclical activity
Luteal phase may be of normal length, or may be much shorter due to poor preovulutary development of the follicle leading to inadequate luteinisation of the CL

Question 11

dystocia

Answer 11

breaks the host defence mechanisms - physical barriers of vulva and cervix
tissue damage, so more prone to contamination,
uterine inertia
Lack of sterility/hygiene due to obstetrical interventions and poor practice inc load of pathogens in uterus
Predisposes RFM & Uterine Disease

Question 12

uterine prolapse

Answer 12

Previously gravid horn becomes invaginated
0.1-0.6% of calvings
More in pluriparous cows than in heifers
More in grossly protracted and assisted parturitions Usually in the first 24hrs post calving
Abdominal straining and flaccid uterus - Hypocalcaemia
REQUIRES URGENT ATTENTION
Survival rate – 75 to 80%
Increased calving to conception interval

Question 13

uterine prolapse - risk factors

Answer 13

Prolonged dystocia 
Foetal traction or oversize 
Extreme laxity of the perineum and vulva 
Hypocalcaemia 
Paresis 
Retained Foetal Membranes.

Question 14

uterine prolapse - treatment

Answer 14

Protect and support the prolapse 
Calcium borogluconate 
Relieve ruminal tympany 
Restrain the cow 
Epidural 
Clean the uterus 
“Frog-Leg” position 
Gentle replacement 
Insure total inversion. 
(Stitch the vulva) 
Antibiotics + NSAIDs 
Oxytocin

Question 15

retained foetal membranes

Answer 15

Common complication of bovine parturition
Predisposes to uterine infection and therefore, contributes to infertility
Overall incidence is 6-8% but with dystocia 25-40%

Question 16

Separation and Expulsion of the Placenta

Answer 16

Placental Maturation: – Changes in P4 and E2 concs, collagenase + proteases/glucosaminidases
– Reduction in the number of binucleate cells in the trophectoderm
– Exsanguination of foetal side of the Placenta and collapse of trophectodermal villi
– Distortion of the placentomes [Uterine Contractions ]
Lack of antioxidants, stress, oxidative injury and the role of PGF and PGE synthesis
IL8, Leukocyte migration and collagenases

Question 17

reasons for retention

Answer 17

Failure of maturation of the placenta (e.g., in pre-mature calving)
Failure of detachment of foetal and maternal villi of the placentome
Inadequate uterine contractions due to hypocalcaemia or dystocia

Question 18

reasons for retention - predisposing factors

Answer 18

Abortion 
Stillbirth 
Multiple Birth 
Dystocia, premature calving 
Infectious Placentitis (Brucellosis, Salmonellosis etc) 
Hypocalcaemia 
Hydrallantois 
Increasing age of the dam 
Prolonged gestation 
Micronutrient deficiencies – Se, Vit E & A

Question 19

retention - clinical features

Answer 19

Morbidity: lack of appetite, reduced milk yield
Mortality: 1-4% mainly related to metritis / toxaemia
Duration of retention depends on myometrial contractions; they cease by 36h after parturition
Fertility: No effect on its own if mating 60 days post-calving, Along with metritis, increases days open, services per conception, calving to 1st oestrus / service interval

Question 20

retention - treatment

Answer 20

Traction: damage to endometrium, uterine infection and impaired reproductive performance
Wait until cow is 5 days calved before a veterinary exam
If the cow is pyrexic with depressed appetite and milk yield, treat for metritis
Antibiotics: parenteral or intrauterine?
Hormones
Prostaglandins?
Oxytocin?
Collagenase infusion into stumps of umbilical arteries of retained membranes

Question 21

uterine disease

Answer 21

Bacterial contamination of uterus at every calving and its elimination during involution
Development of infection in some animals from contamination
Species of pathogens, degree of colonization and magnitude of immune response determine whether the infection results into -
Endometritis: endometrium and stratum spongiosum of submucosa, no systemic illness, leukocytes but no pus in uterine discharge
Metritis: deeper layers of uterus, systemic illness–mild to v. Severe: puerperal metritis
Pyometra: chronic, purulent exudates, CL, No systemic signs
Uterine disease usually impairs fertility

Question 22

infection

Answer 22

Dystocia (and/or RFM) increases the load of pathogens, causes tissue damage and physical deformity of cervix + vulva, results into uterine inertia and predisposes to RFM

Question 23

pathogenic bacteria

Answer 23

Arcanobacterium pyogenes 
Fusobacterium necrophorum 
Escherichia coli 
Prevotella species (formerly bacteroides) 
Clostridium species 
Mannheimia haemolytica

Question 24

endometritis

Answer 24

Incidence: 6-43%; does not affect general health but does affect fertility
Opportunist pathogens (like E-coli, subsequent overgrowth of A. pyogenes, F.necrophorum, Prevotella species)
Clinical Signs: mucopurulent discharge in clinical cases, no systemic illness, neutrophils in uterine luminal fluid
Diagnosis: Rectal palpation: poorly involuted uterus, Presence of discharge around cervical os (vaginoscope) - Metricheck to collect discharge:
Presence of neutrophils in cervical swabs;
20-33pp = >18%, 33-49pp = >10%, >50pp = >5%

Question 25

endometritis - treatment

Answer 25

Stimulation of oestrus in both cyclic (PGF2α) and acyclic cows (3-5mg E2 or use of GnRH) 
intrauterine cephapirin (metricure, Intervet)

Question 26

Clinical Signs of Metritis—Puerperal metritis

Answer 26

Systemic illness
Purulent fetid fluid in the uterine lumen
Distended, fluid-filled atonic uterus
Elevated rectal temperature 40-41oC
Dullness, depression, milk drop, inappetence
Within few days of parturition, usually follows severe dystocia, uterine inertia, RFM
Sore, swollen and inflamed vagina and vulva
Systemic toxaemia: fast weak pulse, rapid respiration, dehydration, sluggish capillary refill time, diarrhoea
Pyaemia: concurrent peritonitis, mastitis

Question 27

peurperal metritis - treatment

Answer 27

Case dependent – depends on clinical signs; poor prognosis
Supportive therapy (stabilization of circulatory system):
Fluids & non-steroidal anti-inflammatory drugs (Flunixin meglumine 2.2 mg/Kg)
Parenteral antibiotics – cephalosporins, ceftiofur, broad-spectrum pencillins, oxytetracycline
Contraindicated; oestrogens increase absorption of endotoxins
Uterine lavage (after stabilization of circulation) followed by antibiotics like oxytetracycline

Question 28

pyometra

Answer 28

Accumulation of purulent material in the uterus in the presence of an active persistent CL
Uterine horns are large and distended and cervix is closed
Sequel to chronic endometritis
EBD (T. foetus) a predisposing factor
No signs of ill health
Absence of cyclicity
Needs to be differentiated from normal pregnancy by rectal palpation (thickness of uterine wall, slipping of allantochorion, uterine caruncles) and transrectal ultrasonography (speckled echotexture of uterine contents versus black anechoic appearance of normal foetal fluids)
Treatment: PGF2 alpha + intrauterine cephapirin