Periparturient period Flashcards
What species get vaginal prolapses most commonly?
Bovine!
- See in Herefords and Shorthorns most commonly –> must cull because it is heritable!!!!!
When does vaginal prolapse occur?
- Usually pre-partum but can be post-partum
What is a grade 1 vaginal prolapse?
Floor of the vagina protrudes intermittently –> usually when laying down, goes in when standing
- Will usually progress to worse situation
- Starts off mucousy but then dries and becomes uncomfortable
What is a grade 2 vaginal prolapse?
- Floor of vagina protrudes permanently
What is a grade 3 vaginal prolapse?
- Part of cervix and vagina protrude permanently
What is a grade 4 vaginal prolapse?
- 2nd or 3rd degree that has been exposed
long enough to cause necrosis/fibrosis
How do you treat vaginal prolapse in the cow?
- Reduction!!!!!
- Give an epidural and clean with mild antiseptic
- May also need to clean and debride
- Sugar
- Manually reduce with oven mitts –> less traumatic
Why do you want to use sugar to treat vaginal prolapse?
- Causes osmosis
- Useful for reducing osmosis alongside manual edema reduction
What are some vaginal prolapse treatment options that prevent reoccurence?
- Buhner technique - place needle through vulva, wind in and around through vulva, basically a purse string suture that allows the cow to urinate
▪ Halstead technique/Horizontal mattress
▪ Bootlace
▪ Jorvet prolapse kit - Minchev technique - send a suture dorsally from caudal vagina to lower back and securing in place
T/F
Uterine and vaginal prolapses are occur together
False –> no relationship between the two
How do you diagnose uterine prolapse?
- Must look for descriptors to differentiate between placenta and uterine prolapse
** a true food animal emergency**
How do you treat uterine prolapse in the cow?
- Epidural
- Clean and debride –> elevate uterus with tarp, towel, tray when standing
- When animal sternal, extend hindlimbs caudally (frog legs –> tilts pelvis forward)
- Punch the uterine horns back in place
- Reduce the uterus with a large bottle (wine bottle, etc.) and place vulvar retention sutures
- ABs, calcium therapy
- LAST RESORT –> Uterine amputation cranial to cervix
What are the follow-up pathologies that can occur from a uterine prolapse?
▪ Uterine artery rupture –> Hypovolemic shock, DEATH
▪ Septicemia –> Devitalized tissue
▪ Hypothermia –> Due to exposed tissue
▪ Strangulation of other abdominal viscera
within prolapse
▪ Reperfusion injury
What is the prognosis of uterine prolapse?
▪ Depends upon initial state (calcium status, shock,
dehydration, length of time prolapse)
▪ Recurrence is NO more likely in these animals than
animals that have never prolapsed.
▪ Long-term: potential for metritis and subfertility
▪ Radical: amputation of uterus cranial to cervix may
be used as last resort procedure.
What are the most common causes of perineal lacerations?
- Iatrogenic from dystocia
What is a first degree perineal laceration?
▪ Only mucosa of vulva or vestibule
▪ May involve perivaginal fat- excise
▪ Spontaneously heal
What is a second degree perineal laceration?
▪ Entire wall of vulva/vestibule and portion of perineal body but not
the anus or rectum
▪ Tissues contaminated wait 6-8 wks before sx
What is a third degree perineal laceration?
▪ Entire wall of vagina, perineal body, rectum and anus leaves cow
with common opening for vagina/rectum
▪ Wait 6-8 wks before sx
What are some other perineal lacerations that occur alongside recto-vaginal tears?
▪ Vulva or vestibule- covered under RV tears
▪ Caudal uterus or cervix –> fix by Blind stitch
▪ repair of a rent in a uterine horn may be attempted:
▪ via laparotomy
▪ In the cow by prolapsing the uterus after 10ml epinephrine
(1:1000) IV slug/push, repair, replace
▪ Bleeding from vagina
▪ Check for tears, may be torn caruncle
▪ Administer oxytocin
▪ Uterine artery rupture
▪ Usually associated with uterine prolapse
▪ Usually fatal
▪ Could attempt transfusion, laparotomy, oxytocin
What are some examples of periparturient diseases?
▪ Metabolic and Nutritional Diseases –> Ketosis, Hypocalcemia, LDA +/-
▪ Mastitis
▪ Uterine infections–> Metritis, endometritis, pyometra
▪ Retained Placenta
How long does uterine involution take? What anatomic and physiologic processes take place during that time?
▪ Usually takes 25-50 days ▪ Lochia is expelled ▪ Blood-tinged fluid, tissue, debris ▪ Blood vessels to caruncles undergo vasoconstriction and slough after necrosis ▪ Endometrial epithelium repairs
What are some factors that can affect involution?
▪ Systemic Factors
▪ Retained fetal membranes (have foul odor and don’t look good)
▪ Negative energy balance
▪ Local Factors
▪ Hormone factors –> Presence of progesterone, Oxytocin (Suckling response, Milking)
▪ Inflammation
▪ Presence of leukocytes
How do you treat retained fetal membranes?
▪ Historically –> “Clean her out” = manual removal, Infusions (Antibiotics, antiseptics)
▪ Hormones- ecbolics –> PGF2a- questionable value but many vets use, Oxytocin – causes uterine contractions in early post-partum
▪ Antibiotics
▪ Collagenases- most promising therapy (sloughs caruncle to release fetal membrane) –> Injected into umbilical artery, Not approved in USA
What is metritis?
▪ Severe inflammation involving all layers of the uterus –> Endometrial mucosa and submucosa, Muscularis, Serosa
▪ Occurs within 21 days post calving
What is endometritis?
▪ Inflammation of the endometrium extending no deeper than the stratum spongiosum
▪ Occurs at least 21 days after calving
▪ Uterus is normally protected from bacterial contamination by the vulva, vestibular
sphincter, and cervix –> During parturition, mechanical barriers are breached
What is pyometra?
▪ Collection of purulent exudate of variable amount within the endometrial cavity ▪ Persistence of a corpus luteum ▪ Suspension of the estrous cycle ▪ Purulent exudate in uterus ▪ Presence of a CL ▪ No estrus
What are the clinical signs of metritis?
▪ Fetid red-brown watery uterine discharge
▪ Within 21 days post calving
What is puerperal metritis?
▪ Usually within 10 days after parturition ▪ Pyrexia* (Sheldon, et. al., 2006) ▪ Reduced milk yield ▪ Dullness ▪ Inappetance or anorexia ▪ Elevated heart rate ▪ Dehydration
How do you diagnose metritis?
▪ Abnormally large uterus post calving –> Within 21 days (usually a week post calving, rare >2 weeks)
▪ Presence of purulent discharge
▪ +/- Pyrexia
How do you treat metritis?
▪ Systemic antibiotics –> Ceftiofur, Penicillin, Oxytetracycline
▪ Anti-inflammatory
▪ +/- Uterine lavage
What are some risk factors for endometritis?
Retained fetal membranes (big one!!!!), stillbirth, twins, assisted calving, primiparity
What are the clinical signs of clinical endometritis?
Purulent discharge detectable in the vagina days or more after calving
How do you diagnose clinical endometritis?
▪ Rectal palpation
▪ Transrectal ultrasound
▪ Examining contents of vagina –> Gloved hand, Speculum, Metricheck device
▪ Presence of >50% purulent material (score 3) in uterine discharge detectable in
vagina 21 days or more after parturition
▪ Presence of mucopurulent material (score 2) in vagina after 26 days postpartum
What are some treatment options for clinical endometritis?
▪ Penicillin* –> 21,000 IU/kg Procaine Penicillin G IM SID 3-5 days, Milk: 96 hours (TEST); Meat: 10 days
▪ Ceftiofur Sodium* –> 1 mg/kg IM or SQ 3-5 days
▪ Ceftiofur Crystalline Free Acid –> 6.6 mg/kg SQ SID; 72 hours second dose, Meat: 13 days
▪ Oxytetracycline* –> 11 mg/kg IV BID – Not effective
▪ Hormone Therapy –> Prostaglandin F2a, Mechanism unknown
▪ Oxytocin –> Increase uterine tone
▪ Estrogen –> Increase oxytocin receptors, Not proven effective
▪ Supportive Care
What is the etiology of pyometra?
▪ Occurs when metritis, endometritis, lochia, or other
contents are present and ovulation occurs resulting in CL
formation
▪ 1
st post-partum ovulation in dairy cow is ~18d
▪ Normal gross uterine involution complete 30d
▪ Uterine contents inhibit PGF2a release, and the CL is
maintained
▪ Pyometra discovered after natural breeding may be more
likely to be due to tritrichomoniasis
How do you diagnose pyometra? What are the clinical signs?
▪ routine reproductive herd health visit (fresh cow checks)
▪ history or compliant of unobserved estrus
▪ no observed estrus after the voluntary waiting period (VWP)
▪ rectal exam:
▪ thin walled, fluid filled uterus,
▪ must be differentiated from pregnancy:
▪ all of the indications (secondary signs) of pregnancy may be present, but there will be no cardinal signs
How do you treat pyometra?
▪ Remove the CL
▪ PGF2a
▪ Prognosis is fair to good, but do not breed on the first heat after CL removal
What are some causes of prepubertal anestrus?
▪ Poor nutrition
▪ Too young
▪ Breed variations: zebu puberty later. Dairy earlier
▪ Genetic components: larger scrotal circumference= earlier
▪ Intersex states
▪ freemartinism
▪ Ovarian aplasia/hypoplasia
What is the pathophysiology of Freemartinism?
▪ Shared chorioallantoic membranes
▪ Testicles of male twin develop prior to female
▪ Leads to production of AMH
▪ Goes to female tract inhibits development of duct
systems of female
What is the clinical appearance of Freemartinism?
▪ Broad variation
▪ Most common apparently normal
▪ Can have small vulva, enlarged clitoris, tuft of
hair on ventral vulva
▪ Internal repro organs are abnormal
▪ Vestigial ovaries
▪ Reduced devlpt of paramesomephric duct system
▪ Some devlpt of male duct system
▪ Most common= small genital tract, hypoplastic ovaries,
short vagina, and absent cervix
How can you diagnose Freemartinism?
▪ Hx of twin birth ▪ Probe vagina ▪ Vagina is 1/3 length of normal vagina ▪ This test finds 80% of affected animals ▪ Lab tests ▪ Look for presence of Y chromosome ▪ PCR ▪ karyotyping
What are some predisposing factors for postpartum anestrus?
▪ Normal 3-5 wks ▪ Metritis ▪ Poor nutrition ▪ High producing dairy cows ▪ Lactational anestrus
What is an ovarian follicular cyst?
▪ Thin walled fluid filled follicular structure >25mm (KNOW THIS)
▪ Can be present on both ovaries
▪ Absence of luteal tissue
▪ Persist for a minimum of 10 days (KNOW THIS)
▪ Interferes with normal ovarian cyclicity
What are the characteristics and signs of ovarian follicular cysts?
▪ Anestrus –> primary sign ▪ Some show nymphomania ▪ Irregular estrus intervals ▪ May have “ Bull like “ appearance ▪ Incidence affects ~ 10% annually ▪ Increases calving interval by ~50 days ▪ Self recovery in early cyst ~ 50%
What is the etiology for ovarian follicular cysts?
▪ GnRH surge center appears to be refractory to estradiol stimulation
therefore no LH surge for ovulation or luteinization
How do ovarian follicular cysts develop?
• COF’s are similar to follicular waves ▪ Recruitment Selection Dominance ▪ The dominant follicle reaches ovulatory size but fails to ovulate ▪ Growth continues until cystic ▪ Cyst produces Estradiol and Inhibin A
How do you diagnose ovarian follicular cysts?
▪ > 80% cows show anestrus
▪ At least 2.5cm diameter large fluid filled in
absence of a CL
▪ Palpation Per Rectum
▪ Ultrasound
▪ May require serial examination as cyst grows in
size
How do you treat ovarian follicular cysts?
▪ Spontaneous recovery ▪ ~ 50% before 1st postpartum ovulation ▪ ~ 20% after 1st postpartum ovulation ▪ Manual rupture- not recommended anymore ▪ Lutenize it/ lyse it ▪ GnRH / PGF2a ▪ hCG / PGF2a ▪ Aspiration ▪ Progesterone (CIDR) for 7 days then lyse
