Postpartum complications in the Mare Flashcards
1
Q
Things to examine on the postpartum mare exam
A
- General heatlh and physical exam
- Digestive tract
- Urinary tract
- External evaluation of the perineal region
- Repro tract examination
2
Q
General health and PE of a mare
A
- Demeanor
- Comfort level
- Signs of colic and endotoxemia
- Mothering bheavior
- Temperature
- Mm color and CRT
- Presence of abrasions around eyes or buter coxae
- Heart rate, respiratory rate, and chest auscultation
3
Q
What are some of the most concerning findings on a postpartum exam of the mare?
A
- FEVER***
4
Q
What physical exam findings can indicate dystocia if foaling was not witnessed?
A
- Abrasions around the eyes or tuber coxae
5
Q
Aspects of GI tract exam in the postpartum exam of a mare?
A
- GI sounds in all quadrants
- Fecal production (not too dry)
- Often reduced in quantity in postpartum mares due to pain and perineal swelling
- Retention in rectum
- Early colic signs
- +/- administration of mineral oil
6
Q
Urinary tract signs in the postpartum exam of the mare?
A
- Squatting (alminitis)
- Full stream (pain)
- Urometra
- Urethral damage
- Bladder atony
7
Q
External evaluation of the perineal region?
A
- Swelling (unilateral or bilateral)
- Vulva
- Peri-vulvar hematoma
- Perineal body trauma (1st, 2nd, and 3rd degree)
- Vaginal discharge
8
Q
Repro tract exam - what does it normally include?
A
- Usually not transrectal ultrasound
- Vaginal speculum exam though
9
Q
When is transrectal ultrasound indicated?
A
- Retained placenta, metritis, other medical emergency conditions
10
Q
Things to look for with vaginal speculum exam?
A
- Traumatic lesions on the vaginal walls, urethral opening, or cervix
11
Q
Normal appearance and smell of lochia?
A
- Mix of mucus, endometrial cells (brownish)
- SHOULD NOT SMELL BAD
12
Q
Cervical palpation - what can injure?
A
- Oversized fetus
- Obestetrical chains or fetotomy wire
- Even so-called “normal” parturition
13
Q
How to palpate the cervix?
A
- Put one or two fingers inside the cervix
- Palpate all around the lumen of the cervix
14
Q
Normal appearance of the mammary gland after foaling?
A
- Soft, symmetrical
- Colostrum analysis
- Monitor for mastitis
15
Q
Signs of mastitis
A
- Heat, asymmetry, hind limb lameness
16
Q
Colostrum - what’s good, average, and low?
A
- 30% is good
- Average is 15-20%
- <15% you worry about FPTI due to low IgG
17
Q
What info should clients get from the placenta?
A
- Time in minutes from foaling to passage of the placenta
- Record the weight and the weight of the foal
- Keep it refrigerated but DO NOT freeze
- Collect the amnion and chorioallantois
18
Q
When should the clients call you if the placenta hasn’t been passed?
A
> 3 hours
- DO not encourage the use of oxytocin before exam
19
Q
What % of the foal’s weight should the placenta be?
A
10-12%
20
Q
Which horn of the placenta does the umbilical cord attach to?
A
- Base of the fetal horn
21
Q
Which side of the placenta is in contact with the endometrium?
A
- Chorionic side
22
Q
How can you differentiate the fetal horn from non-fetal horn?
A
- Umbilical cord always at the base of the fetal horn
- Fetal horn is usually bigger and more edematous
23
Q
How can you make sure the placenta is complete?
A
- Pump it up with water and close at the level of the cervix
24
Q
What are some abnormalities of the placenta that can happen?
A
- Plaques
- Mucopurulent discharge or film
- Avillous areas
- Too small for the size of the mare/uterus
- Incomplete
25
What to do with plaques or pus on the placenta?
- Impression smears and cytology
- Uterine culture and cytology
- Look at the foal (blood cultures)
- Rule out placentitis (bacterial or fungal)
26
Avillous area on the placenta
- Can be incidental
- Are the avillous areas large enough to have inhibited nutrient exchange?
- Look at the foal
- Look for signs of a dummy foal or endotoxemia
27
What % of the weight of the dam should the foal be?
-10% approximately
28
Incomplete placenta - what to do?
- MEDICAL EMERGENCY
- Often small placental tags are retained
- Here the base of the fetal horn is not retained
29
What are some of the most common postpartum emergencies you'll see?
- Urogenital hemorrhage
- Large colon volvulus
- Septic metritis
- Uterine tears
- Open diagnosis
30
Urogenital hemorrhage - who gets?
- Mares >13 years
31
Signs of urogenital hemorrhage
- Anemia
- Hypoproteinemia
- Hypofibrinogenemia
32
Signs of septic metritis or associated with it
- Dystocia
33
SIgns associated with uterine tears
- Leukopenia common
34
What should you consider if placenta is incomplete?
- Retained placenta
35
What to consider if fever, sweating, muscle fasciculations; depression; vaginal discharge; swollen hind end, lacerated, hemorrhage; poor mothering; incomplete or absent urination?
- Retained placenta
- Toxic or septic metritis
- Rectovaginal tears and perineal lacerations
- Perineal bruising and vulvar hematomas
- Periparturient hemorrhage
- Uterine tear/rupture
- Colic
- Urinary tract complications
36
Instructions to owner in case of emergency on the farm
- Confine mare and foal to a quiet area
- Keep foal near the mare but out of harm's way
- Don't administer tranquilizers until you examine the mare
37
Why should owners mostly not administer tranquilizers until you examine the mare?
- Often they have acepromazine, which causes hypotensive effects in mares with broad ligament hemorrhage
38
Instructions to owners if need to be transported to the hospital
- Bring foal
- Keep foal next to but separate from mare (stall divider or straw bales)
- Bring placenta if available
39
How long can postpartum complications occur after foaling?
-Up to weeks
40
Risk factors for post-partum complications
- Age (very young or >17 years)
- Breeds (mini, heavy horses)
- Previous history of foaling or postpartum conditions
- History of retained placenta
- Previous injury to the birth canal (perineal or cervical laceration)
41
Risk factors for retained placenta?
- Dystocia
- Abortion or stillborn
- Fetal membrane hydrops
- Placentitis
- Metabolic disorders
- Breeds
42
Which part of the placenta is most often retained?
- Tip of the non-pregnant horn
| - Less stimulation
43
Hydrops in horses
- This was in the 2nd or 3rd lecture - probably worth reviewing
44
What therapy is usually recommended for retained placenta?
- Oxytocin therapy
| - Evaluate calcium and potentially rule out hypocalcemia
45
How to give oxytocin for retained placenta?
- Low dose bolus every 2 hours
- Continuous rate drip in LRS or saline
- Some mare may experience severe colic with large doses of oxytocin and cause injury to the foal
46
Chorioallantois distension
- used for retained placenta
- Need access to the vulva
- Distend with 12-20 L sterile aline
- REsults usually seen within 5-40 minutes
47
Forced extraction of the placenta
- DON'T DO IT
48
Why should you not forcibly extract the placenta?
- Tears
- Partial retention
- Uterine invagination/eversion or prolapse
- necrotic tissue may remain within the endometrial crypts causing further complications with metritis and toxemia
49
What to do if retained placenta has gone on for more than 6-8 hours?
- Borad spectrum systemic antibiotics
- Monitor for complications (anorexia, fever, depression, laminitis, warm feet, and increased digital pulse)
- Transabdominal ultrasound exam while uterine flushing may reveal remnant
- Supportive therapy for toxemia such as NSAIDs and tetanus prophylaxis
50
Broad spectrum antibiotics that may work for RP
- Ampicillin, gentamicin, kanamycin, penicillin, ticarcillin, ceftiofur, TMS
51
What can happen as a consequence of a retained placenta?
- Toxic or septic metritis
52
Risk factors for toxic metritis
- Dystocia in 70% of cases
- Retained placenta
- Excessive obstetrical manipulations (based on lesions produced or if delivery wasn't complete)
53
Clinical signs in the mare with septic metritis
- Endotoxemia, fever, depression, tachycardia
| - Injected mucous membranes, toxic line***, bounding digital pulses, laminitis, gastric reflux
54
Transrectal palpation and ultrasonography findings with septic metritis?
- Non-involuted, fluid-filled, flaccid uterus
- Possible to identify placental tags
- Usually edematous
55
Vaginal exam findings with septic metritis?
- Fluid is thick, brown, malodorous
| - Differentiate from normal lochia
56
CBC with septic metritis
- CBC can show endotoxemia with high fibrinogen and leukopenia
- May have leukocytosis
57
Abdominocentesis findings with septic metritis
- Elevated TP and WBC
58
Uterine culture findings with septic metritis
- Often gram negative
- E. coli
- Klebsiella pneumonia often
- However, you can't wait for the cultures to come back to start treatment
59
Treatment for septic metritis
- NSAIDs
- Broad spectrum antibiotics
- IV fluids +/- polymyxin B
- +/- Pentoxyfylline B
- Laminitis preventatives
- Larve volume uterine lavage
60
Laminitis preventatives
- Soft bedding, ice boots, foot pads
61
Large volume uterine lavage - how to do?
- Warm fluid (40-45°C) with added salt and iodine
- Monitor with ultrasound for uterine tears/rupture or placental tags
- 2-3 flushings a day up to 4 maximum
62
Prognosis for septic metritis
- Can be fatal, especially with severe endotoxemia and laminitis
- If no complications, future fertility not compromised
- No increased risk of metritis in subsequent pregnancies
63
How long to wait after septic metritis for breeding again?
- At least 1 cycle after recovery
64
First degree perineal laceration?
- Mucous membrane of the vestibule and skin of the vulvar lip
65
Second degree perineal laceration
- Mucosa, submucosa, and muscularis
66
Treatment for first or second degree lacerations
- Not life-threatening
| - Surgical management with Caslick's or vulvoplasty (primarily second degree)
67
Medical management for 1st or 2nd degree perineal lacerations
- Antimicrobials, NSAIDs, tetanus
- Fecal softener (important; mineral oil or bran mash)
- Artificial insemination if it's an option
68
Tampon for rectovaginal tears - how to do?
- Cotton wrapped with gauze and put penicillin ointment (mix of penicillin or PPG with lanolin
- Tie to keep it outside of the vagina
- Avoid adhesions in the process of healing
- Anti-inflammatories to keep the mare comfortable
- Keep it in for a day
69
3rd degree perineal laceration
- I'm pretty sure this is where there's communication between the rectum and vagina
- This requires surgical correction for sure
70
Most common locations for perineal bruising and vulvar hematoma?
- Vestibule and vulvar areas involving the perineal area
71
Etiology of perineal bruising and vulvar hematoma
- Ruptured obturator or internal pudendal artery during foaling
- Hematomas may occur in conjunction with bladder atony
72
Possible complications of perineal bruising and vulvar hematoma?
- Large contained hematomas may dissect along the fascial plane within the pelvic cavity and cause retroperitoneal hemorrhage
- Pressure necrosis from the foaling may lead to seroma or abscess formation within the pelvic canal which may eventually break out into the vagina, perineum, or into the abdominal cavity
73
Peritoneal fluid changes with perineal bruising or vulvar hematoma?
- Increased TP and WBC
| - Conditions can be complicated by abscess formation and drainage either into the vagina or the retroperitoneal cavity
74
Diagnosis of perineal bruising
- Vaginal examination (look at the swelling by the vulva
- Transrectal ultrasonography
- Abdominocentesis (if peritonitis due to seroma abscess or rupture
- Elevated TP and WBC (TP 30-60 g/L; WBC up to 100 x 10^9)
75
Treatment for perineal bruising and vulvar hematoma
- Antibiotics (systemic)
- Anti-inflammatories
- Tetanus toxoid
- Close monitoring especially if hemorrhage, abscess, or seroma
76
What are some risks of perineal bruising and vulvar hematoma that you will want to monitor for?
- Bacterial contamination into a sterile abscess/seroma
| - Monitor for colic, depression, fever, difficulty passing manure/urinating
77
Postpartum hemorrhage - what can cause internal hemorrhage?
- Broad ligament
- Intra-uterine
- Intra-abdominal
78
Postpartum hemorrhage - what can cause external hemorrhage?
- Vaginal artery
| - Vestibulo-vaginal sphincter
79
WHat is the most common artery that can rupture causing postpartum hemorrhage?
- Middle uterine artery
80
Intra-uterine artery rupture signs?
- Vaginal discharge
81
Intra-abdominal artery rupture signs?
- Hemoabdomen and sudden death
82
Which postpartum hemorrhages are most severe?
- Intra-abdominal (middle uterine) and intra-uterine artery bleeds are most severe
83
Predisposing factors for postpartum hemorrhage?
- Age
- Dystocia
- Mean age was 17.5
- Histologic changes that modify the elasticity of the arteries (pregnancy sclerosis)
- Copper deficiency
- Right side seems to be more prone
84
Which side seems to be more prone to postpartum hemorrhage and why?
- Right side, likely due to displacement of the cecum
85
Timeline of postpartum hemorrhage?
- Usually at the time of parturition or right after
| - USUALLY not more than 24 hours after
86
Clinical signs of periparturient hemorrhage
- Colic, sweating, pale or normal mucous membranes, tachycardia, Flehmen response, muscle fasciculations
- Typically evident within 24 hours of foaling
- Intrauterine/vaginal hemorrhage may result in hemorrhagic vaginal discharge
87
Sedation and pain medications with periparturient hemorrhage?
- BE CAREFUL
- Avoid acepromazine or phenothiazine as they can cause hypotension
- Alpha 2 or butorphanol or avoid until you figure out what's going on
- A twitch can lead to hypertension
88
Diagnosis of periparturient hemorrhage
- Weak, thready pulse and signs hypovolemic shock
- Transrectal palpation of distended broad ligament (CAREFUL)
- Ultrasonography transrectally or transabdominally to demonstrate site of hemorrhage
- Abdominocentesis (hemoabdomen)
- CBC
89
CBC in a case with periparturient hemorrhage
- Anemia (32% of cases) or normal PCV due to splenic contraction
- Hypoproteinemia
- Hypofibrinogenemia
- Leukopenia or leukocytosis
90
Supportive care for periparturient hemorrhage
- Minimize excitement, place in a dark, quiet stall
- Analgesia (flunixin and butorphanol)
- Prevent shock (steroids, nasal insufflation, pentoxyfylline, fluid therapy)
- WHole blood transfusion if PCV <15%
- Others (naloxone, aminocaproic acid, Yunnan baiyao)
91
Methods to prevent shock in postpartum hemorrhage
- Corticosteroids (prednisolone)
- Nasal insufflation and pentoxyfylline
- Fluid therapy 2-3 L hypertonic saline followed by 10-20 L of LRS
92
Aminocaproic acid - what is it?
- Antifibrinolytic to help stabilize the clot
93
Prognosis of postpartum hemorrhage
- pretty poor
| - Worse if intrauterine or intraabdomianl
94
What can lead to an increased incidence of uterine tears or rupture?
- Dystocia and obstetrical manipulations
- Hydrops can be associated
- Uterine torsion
- Retained placenta
- CAN ALSO OCCUR IN A NORMAL FOALING
95
Where do tears occur with uterine tears or rupture?
- Dorsocranial to the cervix or at the tip of the gravid or fetal horn
96
Clinical signs of uterine tears or rupture
- Depend on site/size of tear and progression of peritonitis
- Depression, fever, peritonitis, tachycardia
- Severe pain/colic after uterine lavage
97
Treatment for uterine tears
- Surgical
| - Medical (if small possibly)
98
Surgical approaches for uterine tears
- May be indicated even with smaller tears
- Ventral midline celiotomy
- Flank laparoscopy
- Vaginally in dorsal recumbence
99
Medical treatment of uterine tears
- Remember that they may incur higher costs than surgery due to ongoing management
- Even with small tears
- Antibiotics
- NSAIDs
- Anti-endotoxin
- Abdominal lavage
- Laminitis prevention
- High risk of evisceration into the uterine tear
100
Risk factors for uterine prolapse or intussusception of the uterine horn
- Aggressive traction on a retained placenta
| - Excessive use of oxytocin
101
Clinical signs with uterine prolapse or intussusception of uterine horn
- Colic signs not responsive to tranquilizers (extremely painful)
- Tachycardia
- Prolapse visible
102
Diagnosis of uterine prolapse
- PE, transrectal palpation
| - Abdominocentesis
103
Abdominocentesis finding with uterine prolapse
- Increased TP but stable WBC
104
Treatment for intussusception or partial inversion
- Manual replacement and distension of the uterus with large volume of warm water with added salt and iodine
- Can give Buscopan to relax too
105
Complete prolapse treatment
- Clean prolapsed tissue
- Can apply osmotic agents (e.g. sugar)
- Manual replacement without perforating the tissues
- Must evaluate to make sure there's no bladder entrapment or other structures
106
What must you give before treatment for uterine horn and uterine prolapse?
- Caudal epidural and/or general anesthesia
107
What can cause vaginal or rectal prolapse?
- Dystocia
| - Persistent straining
108
Treatment of vaginal or rectal prolapse
- Keep tissues clean and moist
- Caudal epidural
- Replacement if no evisceration
- Fecal softeners (discomfort with defecation and urination)
- Caslick's procedure with vaginal prolapse
109
Prognosis for vaginal or rectal prolapse
- Depends on the extent of tissue damage
110
What must you rule out before correcting a vaginal prolapse?
- Must differentiate vaginal prolapse from bladder eversion through a vaginal rent
- Could be the bladder prolapsing through a vaginal rent
- Must evaluate first if it's the bladder or the vagina
111
What is NOT normal with postpartum mares vs what can be normal?
- Crampy and uncomfortable is normal
| - EXTREME pain is not normal
112
What GIT issues are common in postpartum mares?
- Large colon volvulus
- Ruptured cecum with associated peritonitis
- Ischemic necrosis of the small intestine, small colon and/or mesentery due to compression by the foal
113
Large colon volvulus signs?
- VERY painful, tachycardia
- Toxic/blue mucous membranes
- Often unsafe to examine
114
Prognosis with large colon volvulus
- Good with prompt surgical correction (30-60 minutes)
| - Can be fatal if it takes several hours to treat
115
Diagnosis of ruptured cecum with associated peritonitis?
- Abdominocentesis will show feed material in the abdomen
116
Signs of ischemic necrosis of the small intestine, small colon, and/or mesentery due to compression by the foal?
- May only be identified at surgery
| - May have indications on abdominocentesis or transabdominal ultrasonography
117
Rectal impaction after foaling - what can cause?
- If not moving after foaling
118
What is one of the best ways to determine if a GI process is going on?
- Peritoneal fluid highly indicative
| - If brown or serosanguinous, that's not good
119
Risk factors for eclampsia
- Draft horses
- Miniature horses
- Ponies
120
Clinical signs of eclampsia
- Restlessness
- Tachypnea
- Dull eyes
- Muscle fasciculations
- Clonic spasm
- Recumbence
121
Diagnosis of eclampsia
- Low serum calcium levels
122
Treatment of eclampsia
- IVF with added calcium borogluconate
123
Common causes of agalactia?
- Fescue toxicosis
124
When do you see mastitis if it cocurs?
- Relatively uncommon, most often seen at weaning
125
What is agalactia?
- Failure of normal mammary development and lactogenesis
126
Causes of agalactia (and most common)?
- Endophyte-infected fescue toxicosis
| - Malnutrition in late gestation
127
What is a sequela of agalactia?
- Failure of passive transfer risk for foals
128
Treatment for agalactia
- Domperidone (DA antagonist)
- Start 10-15 days before foaling and continue for 5 days after foaling
- Sulpiride 1 mg/kg IM once or twice daily
- Doesn't give you colostrum, so need to plan on a separate source of colostrum or IV plasma
129
High survival postpartum complaints
- Uterine tears
- Toxic metritis
- Urogenital hemorrhage
130
Low survival postpartum complaints
- large colon volvulus
- Small intestinal disease
- Cecal rupture
