Post partum period Flashcards
Transition period definition
= 3 weeks pre- to 3 weeks post- calving
Postpartum period definition
- Post-calving
- Lactation, uterine involution, return to cyclicity, regeneration of endometrium, efficient control of uterine bacteria
Post-partum pathophysiology
- Late gestation immunosuppression continues in early post-partum
- Around calving physical barriers to infection are compromised (uterus becomes open allowing bacteria in) (change in pH during calving compromises barriers)
- Lochia
- Uterine involution
- Closed cervix is a great barrier for ascending infection
How long does uterine involution post-partum take?
- 3-6wks
What is lochia and how long is it normal for postpartum?
- normal for ~23 days
- Red brown – White discharge, lacks odour
- Brown as blood becomes oxidised - don’t mistake for metritis
- white - not pus, usually inflammatory material, esp WBCs
Retained foetal membranes definition
- “The non-expulsion of foetal membranes beyond 24 hours post calving”
When is normal placental expulsion?
- within 6h of calving
Cotyledonary placenta physiology
- Foetal cotelydon + maternal
caruncle = placentome - Collagen links interface together
- Breakdown of theses links= factor in placental separation
- Facilitated by relaxin secretion and decline of progesterone
Risk factors of FRM
- induced parturition
- shortened gestation
- infectious dz e.g. BVDV
- uterine trauma (c-section, dystocia, fetotomy)
- twinning
- nutritional deficiency (e.g. vitamin E/selenium deficiency, NEB)
- abortion
- immunosuppression (failure to switch off immuno-protective mechanisms from pregnancy)
- flunixin meglumine
RFM tx
▪No consensus
▪Manual removal
– 5-7 days after calving
– Risks: haemorrhage, tearing
– No benefit on repro performance or milk yield
▪Systemic antibiotic therapy
–Systemic signs of illness
– Amoxicillin 3-5days
– Routine parental antimicrobial treatment not supported by research (i.e. when no evidence of infection present)
▪Benign neglect
– Usually expelled 2-11 days
Future developments?
▪Collagenase into umbilical arteries
▪Ozone treatment
RFM - impact on production
- Production losses
– 753kg milk/lactation lost - Reproductive disorders
– delayed uterine involution and cyclicity
– longer time to 1st service
– increased service/conception
– lower pregnancy rates - Increased culling risk
- Increased likelihood to develop secondary health problems
– metritis, endometritis, ketosis, displaced abomasum, mastitis, etc
RFM target
- <5%
RFM in sheep
- retained if >18h
- relatively uncommon
Normal placental expulsion in sheep
- within 6h
Causes/risk factors for RFM in sheep
▪Post c-section or dystocia
▪Selenium or vit A deficiency
▪Infectious abortion ▪Obesity of dam
▪ Hypocalcaemia
Metritis definition
= infection of all layers of the uterus
Clinical metritis
- Not systemically ill
- Abnormally enlarged uterus
- Purulent uterine discharge
- Within 21 days post-partum
Puerperal metritis
- Systemic signs of illness
– Decreased milk yield, dullness, inappetence, signs of toxaemia - Fever >39.5oC
- Abnormally enlarged uterus
- Fetid watery red-brown discharge
- Within 21 days post-partum
– Usually <10days
Metritis risk factors
▪Following abnormal stage 1 or 2 of labour
–Severe dystocia
–Prolonged traction
–Damage to birth canal
▪Uterine inertia
▪Uterine prolapse
▪Premature calving and abortion
▪Induced calving
▪ Twins
▪ RFM
▪Dairy > beef
What is metritis often associated with in sheep
▪Dead foetus
▪Assisted delivery of multiple lambs without proper hygiene
▪Uterine prolapse
Metritis diagnosis
▪ Clinical signs of illness and straining
▪ Foetid uterine discharge detectable on clinical exam
Metritis grade 1
- Abnormally enlarged uterus
- purulent uterine discharge
- without any systemic signs of ill health
Metritis grade 2
- Abnormally enlarged uterus
- purulent uterine discharge
- with additional signs of systemic illness such as decreased milk yield, dullness, and fever
Metritis grade 3
- Sometimes called puerperal metritis, or toxic metritis
- abnormally enlarged uterus
- purulent uterine discharge, with signs of toxaemia such as inappetence, cold extremities, depression, and/or collapse
- high risk of sepsis, peritonitis, UTI and reproductive adhesions.
- Other complications include endocarditis, pneumonia, polyarthritis etc.
Metritis tx
Dependent on clinical signs and severity of disease
* Do not treat grade 1
Systemic antimicrobials
* Intrauterine (e.g. Metricure) alone insufficient
* Penicillin (amoxicillin)
* 3-5 days
Supportive therapy (if systemically unwell)
* NSAIDs**
* Fluid therapy
* Calcium borogluconate (often sub clinically hypocalcaemic)
Uterine lavage?
* Saline only
* Peritonitis and toxaemia risk if tear the uterine wall
Endometritis definition
= infection of the endometrium only
Clinical endometritis
- Purulent uterine discharge (>50% pus) ≥21 days after parturition
OR - Mucopurulent uterine discharge (~50% pus. 50% mucus) >26 days after parturition
- “Whites” (as purulent white discharge)
Subclinical endometritis
- > 18% neutrophils in uterine cytology sample collected 21-33 days after parturition
OR - > 10% neutrophils in uterine cytology sample collected 34-47 days after parturition
- Uterine discharge not yet seen
Endometritis risk factors
▪Trauma
▪ Hygiene
– Calving environment
– Post partum housing
– Personnel
▪ Metabolism
– NEB
▪Herd size
– Larger herds
Clinical endometritis diagnosis
▪ Transrectal palpation +/- ultrasonography (may see purulent content in uterus on US)
▪ Vaginal examination (inc. cervix)
– Manual
– Metricheck
Subclinical endometritis diagnosis
▪ Cytology on cervical swabs or lumen flush
▪ Uterine biopsy
Endometritis diagnosis – transrectal palpation
▪Delayed uterine involution
▪“doughy” feeling uterus
▪Palpation alone not particularly sensitive or specific
▪Combination of transrectal ultrasound
– + vaginal examination most commonly performed on routine fertility visit
care not to cause discomfort to the cow
Endometritis diagnosis - Metricheck
▪Rubber diaphragm on steel rod
▪Inserted into vagina
▪Diaphragm collects fluid from vaginal floor
Endometritis diagnosis - Cytobrush
▪For subclinical endometritis diagnosis ▪Same as human cervix analysis
▪Brush inserted through the cervix into uterus
▪Looking for proportion of polymorphic neutrophils (PMNs)
– >5% abnormal?
– >50 days post partum should be none
Endometritis diagnosis - endometrial biopsy: pros
- Predictive for subsequent fertility
Endometritis diagnosis - endometrial biopsy: cons
- Costly
- Time consuming
- Not often clinically
accessible - May depress fertility
Endometritis diagnosis - cytology: pros
- More practical
- Can diagnose subclinical endometritis
Endometritis diagnosis - cytology: cons
- Does not produce a rapid diagnosis
Endometritis diagnosis - CE: pros
- Rapid and not time consuming
- No specialist equipment required
- Minimal risk of further contamination
Endometritis diagnosis - CE: cons
- Cannot differentiate vaginitis/cervicitis
- Cannot detect subclinical endometritis
- Palpation for tone and size is subjective
Endometritis grading - vaginal mucus score, grade 0
Clear or translucent mucus
Endometritis grading - vaginal mucus score, grade 1
Mucus containing flecks of white or off-white pus
Endometritis grading - vaginal mucus score, grade 2
Discharge containing ≤ 50% white or off-white mucopurulent material
Endometritis grading - vaginal mucus score, grade 3
Discharge containing ≥ 50% purulent material, usually white or yellow, but occasionally sanguineous
Endometritis - Pathogens most commonly identified
▪E. coli
▪T. pyogenes
▪F. necrophorum
(Opportunistic bacteria)
Endometritis tx - 2 problems
- spontaneous self cute (33-46%)
- imperfect diagnostics
- little merit to C&ST
- intrauterine infusion of antiseptics = limited value, risk of injury, peritonitis, septicaemia, etc
- treat only >3w calved
Commercial sheep:
- AM diagnosis rare
- tx generally impractical
Endometritis treatment
PGF2α:
▪500mcg Cloprostenol ▪Stimulate uterine defences
▪Luteolysis of CL→reduced progesterone→ return to oestrus
▪Increased uterine tone + open cervix
▪Withdrawal – 0 hours milk, 1 day meat
Intrauterine antibiotics:
▪500mg Cefaprin (Metricure)
▪Withdrawal – 0 hours milk, 1 day meat
Endometritis - impact on production
Reduced fertility:
* Reduced chance of conception
* Increased risk of cull
Clinical endometritis:
▪ Increases the interval to first insemination by 11
days
▪ Delays conception by 32 days
Cows with clinical endometritis between 20 and 33 days post partum:
▪ 1.7 times more likely to be culled for reproductive failure (cf. cows without clinical endometritis
Endometritis - target % within a herd
- <10%
Pyometra definition
= Purulent or mucopurulent material within uterine lumen, causing uterine distension, in the presence of a closed cervix and functional corpus luteum
Is pyometra common in cows and small ruminants
- it is uncommon
Pyometra diagnosis
- Transrectal palpation and ultrasonography; history of anoestrus
Pyometra tx
PGF2α→luteolytic→expulsion of exudate and bacterial clearance; needs repeating in ~20% of cases
Intrauterine infusions of AB must work:
- Against gram +ve and gram –ve, aerobic and anaerobic bacteria
- In microaerophilic uterine environment
- In an evenly distributed fashion across uterine lumen, with good penetration in endometrial layers
- Without inhibiting uterine defence mechanisms
- Without traumatising endometrium (e.g. not cause irritation)
- Without reducing infertility by producing irreversible changes
- In a cost-effective manner
- With a known excretion pattern so appropriate withdrawal times can be applied
For uterine infection in a cow within 21d of parturition will it be endometritis or metritis?
- metritis
When is endometrial biopsy used?
- only really for research purposes
Which ABs are justified/used for these conditions?
Amoxicillin
– Cat D
– Ceftiofur is not warranted in these cases as amoxicillin is adequate to tx the type of bacteria likely to be present and penetrates the inflamed uterus well
Cefapirin
– Category C
– good for endometritis
– localised use justified for endometritis, but not for other conditions
