Postpartum complications in the mare

Question 1

Postpartum emergencies

Answer 1

• Retained placenta
• Toxic (septic) metritis
• Perineal body lacerations
and rectovaginal tears
• Perineal
bruise/hematoma
• Periparturient
hemorrhage
• Uterine tear
• Urinary tract trauma
• Colic

Question 2

Cervical laceration causes

Answer 2

• oversized fetus
• obstetrical chains/
fetotomy wire
• “normal” parturition

Question 3

• Clients should call you if placenta is retained for how long?

Answer 3

greater than 3 hours

Question 4

abnormal placenta

Answer 4

• Plaques
• Mucopurulent discharge/film
• Avillous areas
• Too small for size of mare/uterus
• Incomplete

Question 5

Plaques or pus - diagnostics

Answer 5

• Impression smears + cytology
• Uterine culture + cytology
• LOOK AT THE FOAL
• Blood cultures
• First rule-out = placentitis (bacterial or
fungal)

Question 6

incomplete placenta is…

Answer 6

a medical emergency

Question 7

most common diagnosed postpartum emergencies

Answer 7

 Urogenital hemorrhage (16.6%)
– Mares > 13 years of age more represented
– Anemia (32%), hypoproteinemia (36%), hypofibrinogenemia
(26%)
 Large colon volvulus (15.9%)
 Septic metritis (8%)
– Dystocia (70%)
 Uterine tears (5%)
– Leukopenia common (88%)

Question 8

Instructions to owner in case of emergency - on farm

Answer 8

• Confine mare and foal to a
quiet area
• Keep foal near mare but out
of harm’s way
• Even if owners have
tranquilizers, recommend not
to administer until you
examine the mare
• Hypotensive effects in mares
with broad ligament
hemorrhage

Question 9

Instructions to owner in case of emergency - transport to hospital

Answer 9

• Bring foal
• Keep foal next to but
separate from mare
• Stall divider
• Straw bales
• Risk for humans who want to
ride with the foal
• Bring placenta if available
• Postpartum complications can
occur even weeks after foaling

Question 10

risk factors to postpartum conditions

Answer 10

• Age (very young or older
mares > 17 years)
• Breeds (miniature, heavy
horses)
• Previous history of foaling or
postpartum conditions
• History of retained placenta
• Previous injury to the birth
canal (perineal or cervical
laceration)

Question 11

Retained Placenta (RP)

Answer 11

3 hours postpartum
• This definition may be too
conservative
• The incidence of RP in mares
varies from 2 to 10%.

Question 12

Risk factors for Retained Placenta

Answer 12

• Dystocia
• abortion or still born
• fetal membrane hydrops
• Placentitis
• metabolic disorders
• Breeds
• The tip of the non-pregnant horn

Question 13

Oxytocin therapy

Answer 13

• Low dose bolus (10-20 IU) every 2 hours
• Continuous rate drip (1 IU/minute) in LRS or saline
• Some mares may experience severe colic with large
doses of oxytocin and cause injury to the foal.

Question 14

Chorioallantoic distension associated to what?

Answer 14

low dose oxytocin

Question 15

Forced extraction of the placenta

Answer 15

Forced extraction of the placenta
• Contraindicated
• Manual removal (Sevinga et al 2002)
• Risks
 Tears
 partial retention
 uterine invagination/eversion or prolapse.
 Necrotic tissue may remain within the endometrial
crypts causing further complications with metritis
and toxemia

Question 16

Placental retained for more than 6 to 8 hours

Answer 16

• Broad spectrum systemic antibiotics: ampicillin,
gentamicin, kanamycin, penicillin, ticarcillin,
ceftiofure, trimethoprim sulfamethazole
• The mare should be monitored for signs of
complications : anorexia, fever, depression, laminitis,
warm feet, and increased digital pulse)
• Transabdominal ultrasound during the flushing
process may reveal remnant
• Supportive therapy in mares showing signs or at risk
for toxemia should include fluid therapy and nonsteroidal
anti-inflammatory drugs (NSAID’s) and
tetanus prophylaxis.

Question 17

Toxic (Septic) metritis treatment

Answer 17

• Similar for any inciting cause
of endotoxemia
 IV fluid therapy +/- polymixin B
 Flunixin meglumine
 Systemic IV antibiotics
 +/- pentoxifylline PO
• Laminitis preventives
• Large volume uterine lavage
with warm fluid (40-45º C)
with added salt, iodine
 Monitor with ultrasound for uterine
tears/rupture or placental tags

Question 18

Prognosis septic metritis

Answer 18

• Metritis can be fatal, especially in cases of severe
endotoxemia and laminitis
• Typically, if there are no complications, future
fertility is not compromised
• No increased risk of metritis in subsequent
pregnancies
• Wait at least 1 cycle after recovery to breed

Question 19

Rectal vaginal Tears and Perineal Lacerations

Answer 19

• First degree lacerations
 mucous membrane of the vestibule and skin of
vulvar lip.
• Second degree laceration
 deeper tissue of the perineal body
• Both these conditions are not life-threatening
• Surgical management: Caslick’s or vulvoplasty
• Medical management
 Antimicrobials, NSAID’s and tetanus
 Fecal softener (mineral oil, bran mash)
 artificial insemination if it is an option.

Question 20

Perineal bruising and vulvar hematoma

• Etiology

Answer 20

 Ruptured obturator or internal pudendal artery during foaling
 Hematomas may occur in conjunction with bladder atony

Question 21

Perineal bruising and vulvar hematoma -

Progression

Answer 21

 Large contained hematomas may dissect along the fascial plane
within the pelvic cavity (retroperitoneal hemorrhage)
 Pressure necrosis from the foaling may lead to seroma/abscess
formation within the pelvic canal which may eventually break out
into the vagina, perineum, or into the abdominal cavity

Question 22

diagnosis of Perineal bruising and vulvar hematoma

Answer 22

 Vaginal examination
 Transrectal ultrasonography
 Abdominocentesis (if peritonitis due to seroma/abscess rupture)
– Elevated TP and WBC (TP 30-60g/L, WBC up to 100 x 109/L)

Question 23

• Treatment

Answer 23

 Antimicrobials
 Anti-inflammatories
 Tetanus toxoid if not boostered in late gestation
 Close monitoring, especially if hemorrhage, abscess, or seroma

Question 24

Postpartum hemorrhage - internal

Answer 24

• Broad ligament
• Intra-uterine
• Intra-abdominal

Question 25

Postpartum hemorrhage - external

Answer 25

• Vaginal • Vestibular-vaginal sphincter

Question 26

Predisposing factors to postpartum hemorrhage

Answer 26

• Age • Dystocia • The mean age of mares with uterine hemorrhage seen by the author was 17.5 (range 8 to 21, n=18). • Histological changes that modify the elasticity of the arteries “pregnancy sclerosis” • Copper deficiency • The right side seems to be more prone to this injury probably due to displacement of the cecum.

Question 27

Periparturient hemorrhage | • Clinical signs

Answer 27

 Colic, sweating, pale or normal mucous membranes, tachycardia, Flehman response, muscle fasciculations  Typically evident within 24 hours of foaling (or of artery rupture)  Intrauterine/vaginal hemorrhage may result in hemorrhagic vaginal discharge

Question 28

Periparturient hemorrhage - Dx

Answer 28

 Weak thready pulse; signs of hypovolemic shock  Transrectal palpation of distended broad ligament (if it is the site of hemorrhage)  Ultrasonography transrectally or transabdominally – Demonstrate site of hemorrhage  Abdominocentesis (hemoabdomen) CBC – Anemia (32% of cases) or normal PCV due to splenic contraction – Hypoproteinemia (36%) – Hypofibrinogenemia (26%) – Leukopenia or leukocytosis

Question 29

Supportive care for periparturent hemorrhage

Answer 29

Minimize excitement, Place in dark, quite stall • Analgesics: Flunixin meglumine + butorphanol • Prevent chock:  Corticosteroids (Prednisolone Na succinate IV, 1 to 2 mg/kg)  Nasal insufflation (5 to10 L/min) + Pentoxyfylline (7.5 mg/kg IV  Fluid therapy 2 to 3 L hypertonic saline followed by 10 o 20 L of LRS • Whole blood transfusion (5 to 8 liters over several hours) is indicated if the PCV < 15% • Others  Nalaxone hydrochlorade (block effect of endogenous opioids)  Aminocaproic acid (antifibrinolytic, loading dose 20 g in 6 L of LRS + 10 g every 6 hours)  Yunnan Baiyou

Question 30

Uterine tears or rupture

Answer 30

``` • Increased incidence with dystocia and obstetrical manipulations  Can occur in a seemingly normal foaling  Pre-partum tears – uterine torsion or hydrops  Tears located dorsocranial to the cervix or at the tip of the gravid horn ```

Question 31

Clinical signs of uterine tears or rupture

Answer 31

```  Depend on site/size of tear and progression of peritonitis  Depression, fever, peritonitis, tachycardia  Severe pain/colic after uterine lavage ```

Question 32

surgical treatment of uterine tears and rupture

Answer 32

``` •Surgical: • Ventral midline celiotomy • Flank laparoscopy • Vaginally in dorsal recumbency ```

Question 33

medical treatment of uterine tears and rupture

Answer 33

``` • If small tear, may heal on its own. • Medical treatment only may incur higher costs than surgery due to ongoing management • Associated with retained placenta •Antibiotics •Anti-inflammatories •Anti-endotoxin therapy •Abdominal lavage •Laminitis prevention •High risk of evisceration into the uterine tear ```

Question 34

``` Partial inversion (intussusception) of the uterine horn and uterine prolapse risk factors ```

Answer 34

 Aggressive traction on a retained placenta |  Excessive use of oxytocin

Question 35

``` Partial inversion (intussusception) of the uterine horn and uterine prolapse - clinical signs ```

Answer 35

 Colic signs which are not responsive to tranquilizers  Tachycardia  Prolapse visible

Question 36

``` Partial inversion (intussusception) of the uterine horn and uterine prolapse - Dx ```

Answer 36

 Physical examination, transrectal palpation |  Abdominocentesis may show an increased TP but stable WBC

Question 37

``` Partial inversion (intussusception) of the uterine horn and uterine prolapse - Tx ```

Answer 37

 Partial inversion: manual replacement and distension of the uterus with large volume of warm water with added salt and iodine  Complete prolapse: clean prolapsed tissue. Can apply osmotic agents (ie, sugar). Manual replacement without perforating the tissues  Caudal epidural or general anesthesia is required for replacement

Question 38

Vaginal or rectal prolapse - secondary to

Answer 38

* Dystocia | * Persistent straining

Question 39

Tx of vaginal or rectal prolapse

Answer 39

``` Treatment • Keep tissues clean and moist • Caudal epidural • Replacement if no evisceration • Fecal softeners • Vaginal – Caslick’s procedure • Prognosis • Depends on extent of tissue damage ```

Question 40

GI tract complications

Answer 40

Large colon volvulus  Ruptured cecum with associated peritonitis  Ischemic necrosis of small intestine, small colon, and/or mesentery due to compression by the foal  Rectal impaction due to soreness from foaling

Question 41

Eclampsia (Lactation tetany)

Answer 41

``` • Risk factor: Breed • Draft horses • Miniature horses • Ponies Clinical signs • Restlessness • Tachypnea • Dull eyes • Muscle fasciculations • Clonic spasm • Recumbency ```

Question 42

Dx/Tx of eclampsia

Answer 42

``` • Diagnosis • Low serum calcium levels • Treatment • IV fluids with added calcium borogluconate ```

Question 43

Non-emergency postpartum conditions

Answer 43

``` • Agalactia  mostly due to fescue toxicosis • Mastitis  Relatively uncommon, most often seen at weaning • Lameness, hind limb • Aggressive behavior towards the foal ```

Question 44

Agalactia

Answer 44

``` • Failure of normal mammary development and lactogenesis  Endophyte-infected fescue toxicosis (58% of all tall fescue)  Malnutrition in late gestation  Failure of passive transfer risk for foals ```

Question 45

treatment of agalactia

Answer 45

Treatment • Domperidone (1.1 mg/kg PO, SID) • FDA approved product 2010 • Start treatment 10-15 days before foaling and continue for 5 days after foaling • Sulpiride 1 mg/kg IM once or twice daily