An 18-month-old 8.1-lb (3.7-kg) intact female toy poodle was presented for evaluation of inappetence and lethargy of 48 hours' duration.
An 18-month-old 8.1-lb (3.7-kg) intact female toy poodle was presented for evaluation of inappetence and lethargy of 48 hours' duration. The owners reported one episode of vomiting and multiple bouts of diarrhea.
Four days before presentation, the patient had whelped four live puppies with no apparent complications. The owners reported that the dog had delivered two previous litters of three puppies each without complications, and that a veterinarian had not examined the dog before any of the breedings or deliveries. The owners stated that they had not purposefully bred the dog and were not certain when the breedings had occurred. However, an intact male toy poodle lived in their household and was presumed to have sired the puppies.
With the most recent litter, there had been no reported complications during parturition, and each puppy had been delivered within 30 minutes. The puppies had thrived initially, but in the 24 hours before presentation, the puppies had started crying continuously. The owners were concerned that the bitch was not producing sufficient milk, so they had begun to bottle-feed the pups commercial milk replacer.
The bitch was lethargic on physical examination and showed no interest in eating. It was thin (body condition score of 1.5/5) and febrile with a rectal temperature of 103.5 F (39.7 C). Foul smelling yellow diarrhea covered the dog's perineum, making identification of vulvar discharge difficult. Mammae development was minimal to absent, with bloody crusts on the ends of the dog's nipples. The dog's heart and respiratory rates were normal. Its mucous membranes were slightly gray and tacky. Abdominal palpation elicited signs of pain.
An in-house complete blood count (CBC) and serum chemistry profile showed anemia (hematocrit 23%; reference range = 27% to 55%) and an amylase activity that was suspected to be too high to be readable, although dilution was not done at this time. Sodium (141 mEq/L; reference range = 144 to 160 mEq/L), potassium (3.4 mEq/L; reference range = 3.5 to 5.8 mEq/L), and chloride (106 mEq/L; reference range = 109 to 122 mEq/L) concentrations were low. Albumin, calcium, and glucose concentrations were normal. Radiographs revealed a soft tissue opacity in the mid to caudal abdomen.
The differential diagnoses included a retained fetus, a gastrointestinal foreign body, postpartum mucometra or pyometra, enterocolitis that was stress-induced or infectious in origin, and pancreatitis.
The patient was given intravenous lactated Ringer's solution (22 ml/hr) supplemented with 20 mEq/L potassium chloride and vitamin B complex. Intravenous sodium ampicillin (20 mg/kg) was given every eight hours. Medical treatment after an abdominal ultrasonographic examination and an exploratory laparotomy were discussed with the owners, and they chose surgery.
The dog was given buprenorphine intramuscularly, and anesthesia was induced with propofol and diazepam intravenously. The dog was intubated, and anesthesia was maintained with isoflurane.
The exploratory laparotomy revealed a moderate amount of burgundy-colored fluid within the abdomen. The uterus showed brown discoloration and had four distinct full-thickness perforations. The ovarian pedicles and uterus were ligated by using a Miller's suture tie with 2-0 polydioxanone suture. The uterus was oversewn by using a Parker-Kerr suture pattern, and the uterus and ovaries were removed (Figure 1). The abdomen was copiously and repeatedly flushed with about 100 ml of warm 0.9% sodium chloride solution and suctioned. Further exploration of the abdomen revealed brown discoloration of the entire omentum. The abdomen was closed in three layers with 3-0 polydioxanone suture.
1. The dog's uterus immediately after ovariohysterectomy. The proximal aspect of the left uterine horn contains a large, complete uterine wall rupture, and two smaller complete ruptures of uterine wall are noted at the junction of the right horn and uterine body. An incomplete rupture of the uterine wall can be seen in the proximal aspect of the right uterine horn.
A sample of uterine tissue was submitted to Antech Diagnostics for aerobic bacterial and Mycoplasma species culture. The remaining uterus was submitted to Stanford University's Department of Comparative Medicine for histologic examination.
The patient recovered quickly and without complications from anesthesia. The dog was given intravenous lactated Ringer's solution at twice the maintenance rate and continued to receive intravenous sodium ampicillin every eight hours and buprenorphine intramuscularly as needed for pain. The dog's hematocrit, which was rechecked by using the capillary tube technique, was 24% with a total protein concentration of 8 g/dl. The dog was transferred to the local emergency clinic for continued overnight care.
The emergency clinician reported that the dog did not vomit overnight but had continual diarrhea and inappetence. Its hematocrit remained stable at 24%, and it was normothermic throughout the night, with an average rectal temperature of 100 F (37.8 C).
Once adequate hydration had been achieved, gentamicin (2 mg/kg intravenously every 24 hours) was empirically initiated to target gram-negative bacteria. An in-house canine pancreas-specific lipase test (Snap cPL Test—Idexx) was performed at the emergency clinic, and the results were abnormal, indicating pancreatitis. The patient was transferred back to the presenting hospital the next morning for continued care.
On re-examination, the dog was quiet, alert, and responsive. Its temperature was 100 F (37.8 C), and its mucous membranes were light pink with a capillary refill time of < 2 sec. A blood sample submitted to Antech Diagnostics revealed that the patient's hematocrit had increased to 30%, the amylase activity was increased (2,271 IU/L; reference range = 290 to 1,125 IU/L)—most likely because of pancreatic inflammation—and the lipase activity was normal (537 IU/L; reference range = 77 to 695 IU/L). All other serum chemistry profile results were normal.
Unfortunately, the patient continued to have bouts of vomiting and diarrhea throughout the day. The dog was given maropitant citrate (Cerenia—Pfizer Animal Health) (1 mg/kg) and famotidine (0.7 mg/kg) subcutaneously every 24 hours, and 2.5% dextrose was added to the intravenous fluids. A fecal examination was submitted to Antech Diagnostics for centrifugal flotation and revealed no abnormalities. The patient remained inappetent, so canned food was administered as a slurry through an oral syringe.
Because of financial constraints, the owners elected to take the patient home after 32 hours of hospitalization despite its inappetence. The previously described medications were discontinued, and at discharge, amoxicillin trihydrate-clavulanate potassium (17 mg/kg orally every 12 hours for 14 days), metronidazole (13.5 mg/kg orally every 12 hours for 14 days), and tramadol (1.7 mg/kg orally every eight hours for five days) were prescribed. The owners were instructed to feed the dog chicken and rice or another bland diet and to seek a veterinary evaluation if the patient's condition worsened.
The following morning, the patient was reportedly much brighter and alert and eating chicken and rice with no vomiting or diarrhea. Over the next several days, the dog's condition continued to improve, and by postoperative day 5, the owners reported the dog's appetite and behavior were normal, and it began eating commercial dog food again.
The uterine bacterial culture yielded light growth of Escherichia coli, Proteus mirabilis, and Enterococcus species, and the Mycoplasma species culture yielded no growth in 14 days. The E. coli and Enterococcus species exhibited sensitivity to amoxicillin-clavulanate, and P. mirabilis exhibited intermediate sensitivity. These results became available when the patient was at home and showing no signs of illness. It was determined that the bacterial growth may have been an ascending infection associated with the patient's open cervix during parturition. No change in antibiotic therapy was recommended.
Microscopic examination of multiple sections of the uterus revealed multifocally extensive areas of partial- to full-thickness (transmural, perforating) ulceration of the uterine wall (Figure 2). Ulcerated areas were characterized by defects of the endometrium, myometrium, or epimetrium and were lined by a thick rim of uterine tissue that displayed lytic (liquefactive) necrosis admixed with moderate numbers of neutrophils and multifocal colonies of cocci and bacilli. Neighboring veins within the myometrium were dilated with acute fibrin thrombi. The mesothelium of the epimetrium was prominent and exhibited mesothelial cell hyperplasia and a few neutrophils in the subserosa (indicative of acute peritonitis).
2. A histologic section of the dog's uterine wall. Note the full-thickness ulceration of the wall, which is lined by a rim of necrosuppurative material containing mixed bacterial colonies (dots). This ulcer has perforated focally (asterisk). Fibrin thrombi are noted occluding nearby myometrial veins (arrows). Normal adjacent endometrium (e), the inner layer of the myometrium (i.m.), and the outer layer of the myometrium (o.m.) are present (hematoxylin-eosin stain).
Based on the histologic examination results, acute suppurative endometritis (pyometra) with partial to full-thickness, perforating ulcers and secondary bacterial infection was diagnosed.
Uterine rupture can occur spontaneously during an otherwise normal parturition.1 In another case report, uterine rupture in a cat was discovered when the cat was presented for an elective ovariohysterectomy eight weeks after parturition. During surgery an irregular mass with bone protruding from it was found encasing the right ovary, ovarian vessels, and spleen. It was speculated that during parturition a kitten had been liberated into the peritoneal cavity through the ruptured portion of the right uterus.2
Uterine rupture in general is more common in dogs than in cats and is more commonly seen as a complication secondary to dystocia or exogenous oxytocin or prostaglandin administration.1 Uterine rupture in a pregnant bitch can also occur after uterine torsion,3 iatrogenic trauma,3 or pyometra4 or can develop as a result of a preexisting injury, such as a scar or perforation.5 In people, the most common cause of uterine rupture is dehiscence of a previous cesarean section scar.6 Women with a history of two previous cesarean deliveries have an almost fivefold greater risk of uterine rupture than those with only one previous cesarean delivery.7 Complete and incomplete uterine ruptures are distinguished by whether the serous coat of the uterus is involved.5 With incomplete ruptures, the serous coat is intact, and the fetus and placenta are inside the uterine cavity.8
In this case, many possible causes may have led to the uterine ruptures. First, the dog's pyometra and bacterial infection could have led to uterine wall friability and a complete uterine rupture with secondary peritonitis. However, pyometra commonly occurs in older, nonbred bitches a few weeks after estrus when the cervix is completely or almost completely closed in response to luteal hormones.3 The dog in this report did not fit this scenario since the bitch had been successfully bred three times and its cervical canal was most likely open as the most recent parturition occurred only four days before presentation.
Second, since the bitch had whelped three litters in 12 months, it is possible that incomplete uterine ruptures had previously occurred, leading to weakened areas within the uterine wall. As noted previously, partial- to full-thickness perforated ulcers were noted on histologic examination of the dog's uterus. Under the stress of the third litter, incomplete ruptures could have become complete ruptures, penetrating the uterine serosa.
Third, although the owners reported that the dog showed no signs of distress or pain during whelping, the possibility that dystocia occurred during the last parturition cannot be ruled out.
In summary, this information could be used to help emphasize to clients the importance of veterinary examinations after whelping and responsible breeding practices.
This case report was provided by Amy Long, DVM, Pet's Friend Animal Clinic, 158 San Lazaro Ave., Sunnyvale, CA 94086 and C. Tyler Long, DVM, and Richard Luong, BVSc, DACVP, Department of Comparative Medicine, Stanford University, Stanford, CA 94305. Dr. Amy Long's current address is Parktown Veterinary Clinic, 1393 South Park Victoria Drive, Milpitas, CA 95035.
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