Surgery of the ovaries and uterus Flashcards
T/F: Ovarian cysts may be functional or nonfunctional
TRUE
Nonfunctional = incidental
Functional = estrus-producing
What is the most common type of functional ovarian cyst? What are the clinical signs associated with it?
- Follicular (estrogen) most common (esp. dogs)
- Clinical signs
- Prolonged stage of estrus cycle
- Stage depends on hormones involved
What is the signalment associated with ovarian cysts?
Young adults (dogs < 3yrs; cats < 5yrs)
What is the treatment and prognosis for ovarian cysts?
- Surgical excision is curative–good prognosis
Why can pyometra be associated with ovarian neoplasia?
Functional tumors can produce progesterone; pyometra is associated with excess/persistent progesterone
What is the general likelihood of metastatic disease with ovarian neoplasia?
- Metastatic disease is uncommon overall
- Risk varies with tumor type
- Bilateral tumors reported (adenocarcinoma)
Which species is more at risk for metastatic disease with ovarian neoplasia: cats or dogs?
Cats
What is the significance of a functional, metastatic ovarian tumor?
Functional tumors can have secondary effects
If enough estrogen is secreted it can overwhelm and completely suppress the bone marrow
What is the prognosis for a solitary (non-metastatic) ovarian tumor?
Complete excision is curative
What is the etiology of ovarian remnant syndrome (ORS)?
- Surgical error
- Ovarian tissue left behind after OHE/OVE
- Tissue dropped into abdomen revascularizes
- No such thing as ectopic ovarian tissue
What are the clinical signs of ORS?
- Recurrence of estrus cycle
- Vulvar swelling
- Behavioral estrus
T/F: You will typically see vaginal bleeding/discharge with ORS
FALSE
The uterus has been removed (during spay)–there is no endothelial lining available to shed and produce bloody fluid
How is ORS diagnosed in the dog?
- Vaginal cytology
- Mimics normal heat cycle
- Must be done in standing heat
- Hormone assays
- Elevated estrogen and progesterone
- Low LH
When correcting ORS, where should you look for the remnant tissue?
Caudal pole of the kidney
(ID easier during estrus/diestrus)
Follicles or CL present
What are the similarities between an OHE and OVE? What is the difference?
- OVE = removal of ovary alone
- Ligate ovarian vessels for OHE
- Ligate uterine vessels at proper ligament
- Excise ovary
- No difference in implications between OVE and OHE
What is the etiology of pyometra?
- Multifactorial etiology
- Hormonal–progesterone–>uterine secretions
- Bacterial–gram (-) most common (E. coli)
What is the hormone necessary for pyometra to occur?
Progesterone
What are the typical historical findings of a dog with pyometra?
- Recent heat cycle
- PU/PD (bac. toxins)
- Systemic illness–variable
- Anorexia
- Lethargy
- Vomiting
What is the difference between an open and closed pyometra? Which is worse?
- Open–cervix open and purulent material trying to drain out
- Closed–cervix is closed
- Worse–purulent material cannot drain
How is pyometra diagnosed?
- CBC/chem consistent with sepsis/SIRS
- Neutrophilia with left shift
- Mild-thrombocytopenia–inflammation
- Hypoalbuminemia
- Mild cholestasis (bilirubin, liver enzymes)
- Imaging–large, fluid-filled uterus
- Radiographs–good
- U/S–ideal
What is the immediate treatment/steps for pyometra?
-
Stabilize first
- IV fluids +/- colloids
- IV antibiotics
- Emperical therapy for gram -
- Usually susceptible to ampicillin/enrofloxacin
- Treat SIRS if necessary
What is the medical management for pyometra?
- Prostaglandin F2a–smooth muscle, cervix
- Systemic antibiotics
- Close monitoring
What is the surgical treatment for pyometra?
- Surgical treatment is preferred
- OHE only after adequate resuscitation
- Large incision–xiphoid to pubis
- Usually no need to break suspensory
- Milk purulent material away from cervix
- Noncrushing clamps
- Ligate prior to clamp placement–friable
- Iatrogenic rupture possible
What are the indications for medical management of pyometra?
- Not systemically ill
- Open pyometra ONLY
- Owner highly motivated and aware of risks
Why is medical treatment of a closed pyometra contraindicated?
- Prostaglandin with a closed cervix can lead to rupture
- Systemic deterioration is possible
- Risk of recurrence
What is the likelihood of medical management of a pyometra preserving fertility?
> 50%
What procedure is used to surgically manage pyometra?
OHE (only after adequate resuscitation)
What is the difference between a standard OHE and an OHE for the treatment of pyometra?
Use non-crushing clamps and ligate prior to clamp placement (uterus very friable)
What is the typical history of a dog with metritis?
- Occurs postpartum (12h - 1wk)
- Signs of systemic illness (fever, anorexia)
What are the clinical signs of metritis (dog)?
Foul-smelling reddish-brown discharge
What is the etiology of metritis in dogs?
- Dystocia
- Obstetric manipulation
- Retained fetus or placenta
- Devitalized uterine tissue
How is metritis diagnosed?
- Based on timing following parturition
- CBC/chem chages similar to pyometra
- Imaging
- Similar to pyometra
- Gas/air consistent with anaerobes
*
T/F: Vaginal cytology is not helpful in diagnosing metritis
TRUE
Will only show degenerative neutrophils and intracellular bacteria–normal postpartum finding
How can you differentiate between metritis and pyometra?
Only done with timing following parturition
What are the treatment options for dogs with metritis (broad categories)?
Medical or surgical management
What are the indications for medical treatment of metritis?
-
Only if ALL are true
- Valuable breeding animal
- Good response to initial therapy
- No devitalized tissue/retained placenta or fetus
T/F: Depending on the severity, treatment for metritis might be an emergency
TRUE
Which surgical procedure is generally used for a case of metritis? What is the prognosis?
- OHE is default procedure
- Hysterotomy if you need to preserve breeding
- Healthy uterine wall
- Remove debris
- Levage/suction to flush uterus
- Prognosis good with OHE
T/F: An OHE following metritis will have an impact on milk production
FALSE
What is the typical history compatible with cystic endometrial hyperplasia?
Failure to conceive
Muco/hydro/hematometra
What are the clinical signs of cystic endometrial hyperplasia?
- Most dogs (67%) BAR
- May show signs similar to pyometra
- Systemic illness usually less severe
- May include vaginal discharge and PU/PD
- Lab changes minimal
How do you diagnose cystic endometrial hyperplasia?
ID cysts on ultrasound
T/F: Cystic endometrial hyperplasia is typially an emergency situation that should be treated immediately
FALSE–not typically an emergency
What are the (broad) categories of treating CEH?
OHE (default)
Medical therapy
Which treatment of CEH is preferred?
OHE
What is uterine torsion? Is it an emergency?
Rotation of uterine horn along its long axis
Surgical emergency
What might uterine torsion result from?
Dystocia
What treatment is typically used for uterine torsion?
OHE is treatment of choice
Remove viable pups via C-section
T/F: Following uterine torsion, the uterine horn should NEVER be de-rotated
TRUE–that would be BAD
What are the implications of uterine rupture with pyometra?
Can cause septic peritonitis
What is the most common/preferred treatment choice for uterine rupture?
OHE
What is uterine prolapse a complication of?
Parturition
- Up to 48 hrs following final fetus
In which species is uterine prolapse following parturition most common?
Cats
What are the treatment options for uterine prolapse?
Manual reduction
OHE if manual reduction impossible
What is the main (general) difference between uterine neoplasia in cats and dogs?
- Dogs = benign leiomyoma–not serious
- Cats = malignant, likely metastatic cancers–prognosis guarded
Describe the 3 stages of labor
- Stage 1 = restless, nesting behavior
- Stage 2 = expulsion of fetus
- Stage 3 = expulsion of placenta
What is the criteria for diagnosing dystocia?
- Prolonged gestation (>68 days)
- Signs of toxemia during gestation
- Stage 1 lasting > 24hrs
- No puppies > 36hrs after temperature drop
- Active stage 2 contractions > 30min
- > 4hrs between puppies
When is medical management of dystocia contraindicated?
- Active contractions > 30min
- Palpation consistent with uterine obstruction
- Imaging showing fetal malposition or distress
What are the 2 surgical treatments for dystocia?
C-section; En-bloc C-section with OVH
What should be done at the beginning of a Cesarian section (before actually cutting into the uterus)?
- Linea alba stretched thin
- Distended uterus fills abdomen
- Laceration risk!
- Gently handle uterus
- Friable, vascular
- Pack uterus off w/ lap sponges
What is the procedure for a hysterotomy?
- Ventral midline incision into uterus
- Do not make incision over fetus
- “Milk” fetuses to incision
- Gentle traction to remove fetuses
- Clamp umbilical cord
- Resuscitate fetuses
How is an en-bloc C-section with OVH performed?
- Breakdown broad ligament
- Clamp pedicles, transect w/o ligating
- Hand uterus off to sterile assistant
- Remove puppies < 60min after clamping
- Ligate pedicles, close abdomen routinely
What procedure is performed as a simultaneous OHE and dystocia treatment? What does it decrease?
- En bloc C-section with OVH
- Decreased anesthesia time
What is the holding layer for the closing incision in the uterus?
Submucosa
What suture should be used when closing the uterus?
3-0 or 4-0 absorbable monofilament
What is the prognosis for dogs undergoing surgery for dystocia?
Survival of bitch = 99%
What is the prognosis for puppies undergoing surgery for dystocia?
Survival of puppies 87% 2hrs post-op
T/F: An OHE does not affect milk production
TRUE
