Pyometra management Flashcards
Bonnie is presented to you during a busy Saturday morning surgery on a hot summer’s day. She is a 6 year old entire female golden retriever with a history of lethargy of 5-7 days duration. Her last season was approximately 6 weeks ago. The owners report a foul smelling discharge leaking from the dog’s vulva.
Clinical examination reveals a quiet, depressed dog. Subjectively the dog appears to be ‘dehydrated’, with tacky mucous membranes and a suggestion of prolonged skin tenting. The heart rate is 130 beats per minute, and respiration rate is increased and is slightly laboured. CRT is 2 seconds. The dog is pyrexic. The abdomen is difficult to palpate due to extreme obesity. A scant amount of green pus is visible on the vet bed the dog is lying on. The dog weighs 43kg, eats meat, kibble and table scraps (lots). The owner thinks the dog is drinking 1 medium stainless steel water bowl of water roughly per day, and asks you if this is within normal limits. What do you reply?
I cant comment if I dont know the exact size of bowl, have you measured exact water intake?
Yes that’s definitely way too much
It would be too much in the winter, but in this heat that is within normal limits.
Yes that’s too much, but its likely the salt content of the table scraps are to blame.
That is within normal limits.
I’m not sure really what a normal dog should drink, but I will go and look it up, hang on a minute…
That is within normal limits.
Polydipsia is typically defined as > 100ml/kg/day, and say you estimate the large bowl holds 2.5L water, its not really PD.
Despite not being able to quantify the amount Bonnie is drinking the owner reports they were able to catch some urine from Bonnie, and hand you a sample they collected and decanted into a Tesco’s finest Seville Marmalade jar. You are able to perform urinalysis and these are the results from the dipstick:
The urine is an amber colour and has some floating deposits, which look a like little orange peel.
Glucose +++
Bilirubin +
Ketones negative
Specific Gravity 1.040
Blood negative
pH 8
Proteins +++
Creatinine normal
Nitrite positive
Leucocytes +++
Microalbumin negative
What do you conclude? Try to explain each finding before you click on the suggestions
- This sample indicates a water deprivation test is a sensible next step
- This sample confirms Bonnie is also diabetic
- This sample indicates Bonnie is suffering from metabolic ketoacidosis
- This sample indicates Bonnie has concurrent protein losing nephropathy and a pyometra
- The urine is dilute and supports your suspicion that Bonnie is PU/PD
- The protein, nitrite and leucocytes confirm a bladder infection and a pyometra
- The protein, nitrite and leucocytes could be a result of a vulval discharge contamination of the sample, and you advise a cystocentesis under heavy sedation immediately
- The sample is of limited value and you are reluctant to make a diagnosis of diabetes, but it is likely that Bonnie has an infection
- Bonnie has metabolic alkalosis and an arterial blood gas is a sensible next step
The sample is of limited value and you are reluctant to make a diagnosis of diabetes, but it is likely that Bonnie has an infection
Some dogs with a pyometra present with PU/PD. What is the mechanism for this clinical sign?
- The PU/PD in pyometra is example of primary polydipsia
- The PU/PD is an example of central polydipsia caused by progesterone inhibition of ADH release by the pituitary gland
- The PU/PD only occurs in diabetic bitches with pyometra and is often initiated by inappropriate insulin administration by the owners
- Escherichia Coli endotoxin interfere with sodium reabsorption and damage ADH receptors and may result in an immune-complex glomerulonephritis and this causes the PU/PD
- Excessive fluid loss from the uterus stimulates drinking
- The PU/PD is usually caused by the use of progesterone receptor antagonist use in breeding bitches
Escherichia Coli endotoxin interfere with sodium reabsorption and damage ADH receptors and may result in an immune-complex glomerulonephritis and this causes the PU/PD
What is the commonest cause of pyometra - ie which bacteria are most often isolated/implicated in the disease?
- This is academic - no need to know this
- Klebsiella spp
- Escherichia Coli
- Streptococcus spp
- Proteus spp
- Nocardia spp
- Clostridium perfringens
- Ring Mike Jones to ask
E. coli
After abdominal ultrasound you confirm an enlarged uterus, you go and to talk to Bonnie’s owner about all the possible treatments. What will you suggest as the most appropriate course(s) of action to take? Make sure you can justify your choice(s).
- Cabergoline + cloprostenol and systemic antibiotics
- Aglepristone and systemic antibiotics
- Intravaginal infusion of prostaglandins
- Laparoscopic ovariectomy
- Laparascopic ovariohysterectomy
- Abdominal ovariohysterectomy
Abdominal ovariohysterectomy
Bonnie’s haematology and biochemistry results are now available. Most notably there is a leukocytosis, with neutrophilia and left shift, and monocytosis is present. There is also a normocytic, normochromic regenerative anaemia and thrombocytopaenia. Liver enzymes are elevated, and there is hypokalaemia. A mild hypoalbuminaemia is noted and lactate is elevated. Other parameters are unremarkable (within normal limits) Suggest a preoperative intravenous fluid therapy protocol. Heart rate and respiratory rate remain elevated, and the dog is becoming agitated and her blood pressure is 111/38 (MAP 62). Make sure you can explain why these changes can occur
- 7.2% NaCl (Hypertonic) 4ml/mg and norepinephrine constant rate infusion for 30 minutes then reassess
- 0.18 % NaCl and 4% dextrose at 2 x maintenance rate for 30 minutes then reassess
- Plasma transfusion if funds permit
- 4% geloplasma (Gelofusine) 10ml/kg bolus repeat every 45 minutes if blood pressure does not improve
- Lactated Ringers solution fluid challenge 10ml/kg over 10-15 minutes then reassess blood pressure, repeat 2-3 times if necessary
Lactated Ringers solution fluid challenge 10ml/kg over 10-15 minutes then reassess blood pressure, repeat 2-3 times if necessary
What size cephalic catheter would you like to place in Bonnie the 43 kg golden retriever?
- Blue
- Yellow
- Green
- Pink
- 18g
- 20g
- 22g
- 25g
- 14g
- 12g
Green
Pink
18G
20G
Bonnie tolerated the placement of a cephalic cannula with little restraint or resistance. Which of the following premedication would you like to administer. (Remember there may be more than one option)
- Methadone
- Acepromazine, dexmedetomidine and morphine
- Dexamethasone and torbugesic
- Buprenorphine and medetomidine
- Methadone and acepromazine
- Dexmedetomidine and methadone
- Methadone
- Buprenorphine and medetomidine
- Methadone and acepromazine
- Dexmedetomidine and methadone
Harley is a 52Kg XL Bully with a bite history, and a suspicion of a pyometra from the remote examination and limited history you’ve gleaned in the car park. The dog is wearing a muzzle but will not permit close examination. You decide to dispense some medication for the owner to give and re-book the dog in for the next day. What combination would you recommend? (There may be more than one option)
- Pentobarbitone (20%) 20ml in a syringe and instruct the owner to squirt 5ml into 4 meatballs, and then feed to the dog
- Dexmedetomidine oral gel squirted through muzzle on arrival
- Gabapentin at home tonight, then more tomorrow morning before arrival
- Gabapentin and melatonin at home tonight, then more gabapentin tomorrow am, plus oral transmucosal acepromazine (IV liquid) just before arrival
- Trazodone or alprazolam or diazepam orally 1-2 hours before visit
- Acepromazine tablets tomorrow morning
- Gabapentin and melatonin at home tonight, then more gabapentin tomorrow am, plus oral transmucosal acepromazine (IV liquid) just before arrival
- Trazodone or alprazolam or diazepam orally 1-2 hours before visit
A cockerpoo is admitted following suspicion of a pyometra by your colleagues in a branch practice and on presentation is in hypovolaemic shock. The dog weighs 12kg and you decide that it needs a bolus of fluids. You decide to give it a 10mL/kg bolus over 10 minutes. The giving set delivers 20 drops/mL.What would the drip rate be? (sorry all the infusion pumps are in use 😉)
- 8 drops a second
- 6 drops a second
- 4 drops a second
- 1 drop every other second
- no idea where to start with this question
4 drops a second
The Cockerpoo improves slightly after 2 boluses of IVFT, but also requires analgesia prior to surgery, and has vomited several small amounts of foul smelling gastric contents. Which of the following do you chose, make sure you can justify why.
- methadone IM, meloxicam IV
- dexamethasone and methadone both IV
- morphine and lidocaine epidural
- bupivicaine CRI
- ketamine and methadone IM and meloxicam IV
- methadone slow IV and maropitant IV
- morphine and lidocaine epidural
- methadone slow IV and maropitant IV
Consider the difference between cystic endometrial hyperplasia (CEH) and pyometra and decide which of the following statements is correct
- They are actually the same condition
- Cystic endometrial hyperplasia is a thickening of the uterine tissue which then makes for an ideal environment for a pyometra to occur.
- A pyometra is a severe bacterial infection in the reproductive tract that causes the formation of purulent material to develop in the uterus. This occurs secondary to hormonal changes in female dogs and always follows CEH.
- CEH is more likely to lead to an open rather than a closed pyometra
- All of the above
Cystic endometrial hyperplasia is a thickening of the uterine tissue which then makes for an ideal environment for a pyometra to occur.
