Disorders of the puerperium Flashcards
Define puerperium
The period after parturition when the reproductive tract returns to its non-pregnancy condition so that the female can become pregnant again. Aim for the shortest time possible
What normally happens during the puerperium? 4
Involution
Endometrial regression
Elimination of contaminants of the reproductive tract
Resumption of ovarian cyclical activity
What disorders can affect the normal puerperium? 4
Dystocia
Uterine prolapse
RFM
Uterine disease
Define involution - discuss timings
Reduction in size of uterus and cervix after calving
Greatest decrease in first few days after parturition
Diameter of gravid horn will halve in 5 days whereas the length will be halved by 15 days pp.
By 8-10 days pp, whole uterus should be palpable per rectum
Complete involution within 25-50 days (changes after 50 days are minimal)
Difficult to find hand through cervix by 10-12 hours pp and by 96 hours pp only 2 fingers can be admitted through the cervix
Reduction in external diameter of cervix is also appreciable when palpated per rectum (15cm at 2 days, 9-11cm at 10 days, 7-8cm by 30 days and 5-6cm at 60 days pp).
In case of normal involution, by 25 days pp the diameter of the cervix starts to exceed that of the previously gravid uterine horn.
What are the physiological changes that occur during involution?
Shift from hypertrophy (due to increase in collagen and smooth muscle) to atrophy (due to loss of smooth muscle and degradation)
Reduction in size of the myofibrils
Prostaglandins may control involution, so their (and possibly oxytocin) exogenous use may be used to accelerate involution
How does the endometrium regenerate?
Uterine caruncles undergo degenerative changes probably due to vasoconstriction and ischaemia and this results in necrosis and sloughing of caruncular tissue. This is considerably reduced by 25 days pp.
Lochial discharge (necrotic sloughing, blood, foetal fluids) Occurs at day 2-9 pp, yellowish-reddish/brown. Variable volume. Normally doesn't have a foetid odour.
Systemic response (APPs) occurs
Endometrial epithelium covers the caruncular and inter-caruncular surfaces with centripetal growth of cells from the uterine glands (UGs).
List bacterial pathogens that may be found in the uterine lumen - 5
Arcanobacterium pyogenes E. coli Streptococci Staphylococci Fusobacterium necrophorum
Lochia provides an ideal growth medium.
How are uterine bacteria eliminated?
Phagocytosis - main mechanism Physical expulsion (contractions and secretions)
By about 5 weeks, 50% will be sterile and by 8-9 weeks, most animals will have a sterile uterine lumen.
What happens leading up to resumption ovarian cyclical activity?
Gestation: pituitary refractive to GnRH pp (P4)
7-10 days pp, plasma FSH increases, associated with 1st pp follicular wave
Ovulation will only occur if the follicle produces enough oestradiol to stimulate adequate LH secretion.
Suckling delays ovarian cyclical activity.
Luteal phase may be normal length OR much shorter due to poor preovulatory development of the follicle leading to inadequate luteinisation of the CL.
What does the fate of the dominant follicle depend on? 2
If it has developed LH-R (granulosa cells)
If it has developed proteases
Why does dystocia affect the normal puerperium?
By breaking host defence mechanisms (e.g. physical barrier of vulva and cervix)
Causes physical deformity (vulva/cervix)
Causes tissue damage (more prone to contamination)
Uterine inertia
Lack of sterility due to obstetrical interventions.
Predisposes RFM and uterine disease.
When does uterine prolapse occur? How often? Predisposition? Survival rate? Physiological risks?
0.1-0.6% calvings, within first 24 hours pp
PREDISPOSITION:
Pluiparous cows > heifers
Grossly protracted and assisted parturitions
SURVIVAL: 75-80%
PHYSIOLOGY: abdominal straining and flaccid uterus –> hypocalcaemia
What are the risk factors for uterine prolapse? 7
Prolonged dystocia Foetal traction Foetal oversize Extreme laxity of perineum and vulva Hypocalcaemia Paresis RFM
Treatment - uterine prolapse
Protect and support the prolapse Calciu borogluconate Relieve ruminal tympany Restrain the cow Epidural (to stop abdominal strain) Clean uterus 'Frog-leg' position (eases manipulation) Gentle replacement Ensure total inversion (Stitch the vulva) ABs + NSAIDs Oxytocin
What is the incidence of RFM?
Overall = 6-8 %
With dystocia = 25-40%
