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Reproductive emergencies in the mare (Proceedings)

November 1, 2009
Jennifer Brown, DVM, DACVS

Assement of reproductive emergencies in the mare

Occurrence

• Breeding

     o Rectal tears

          • Palpation

          • Penetration by stallion

     o Vaginal Tears

          • Penetration by stallion

• Peri-parturient

     o Dystocia

     o Hemorrhage

     o Uterine

          • Torsion

          • Prolapse

          • Rupture / tear

          • Retained fetal membranes

          • Metritis

     o Vagina

          • Rectovaginal Tears

     o Gastro-intestinal

          • Damage to viscera

          • Rectal prolapse

Breeding associated emergencies

• Rectal Tears

     o Associated with:

          • Palpation

          • Penile penetration of rectum by stallion

     o Signs

          • "Feeling" of release of rectal tissue around arm

          • Blood on sleeve or penis

          • Onset of shock

          • Signs of peritonitis

          • Usually colic

          • Straining to defecate

     o Types

          • Grade 1

               - Involves only rectal mucosa and submucosa

          • Grade 2

               - Through muscular layer

          • Mucosa and submucosa intact

               - No bleeding

               - Forms diverticulum

          • Grade 3a

               - Only serosal layer is intact

          • Grade 3b

               - Occurs dorsally

               - Mesorectum and retroperitoneal tissues are intact

          • Grade 4

               - All layers disrupted

               - Fecal contamination of peritoneum

     o Incidence

          • Most occur dorsally

          • 15 – 55 cm from the anus

          • In one retrospective study of 85 horses with rectal tears (Eastman TG et al Equine Vet Edu 2000 12(5):263-266.)

               - 47/85 associated with routine pregnancy exams

               - Grade 1 - 93% survived to discharge

               - Grade 2 – 66% (2/3) survived to discharge

               - Grade 3a – 70%

               - Grade 3b – 69%

               - Grade 4 – 6%

          • Few cases of penile penetration in literature

               - 2 at MDS-EMC in last 5 years

               - Both lateral wall

               - Grade 3b

               - Both survived

     o First-Aid for Rectal Tears

          • Exam of tear

          • Sedation

          • Buscopan

          • Careful palpation

          • Remove feces

          • Pack rectum

               - 20 cm cranial to tear

          • Close anus

          • Epidural

               - Transportation concerns

          • Antibiotics

               - Broad spectrum

               - Penicillin (potassium or sodium penicillin 22,000 IU; IV)

               - Gentamicin – 6.6 mg/kg IV

               - Metronidazole – 15 mg/kg PO

          • Flunixin meglumine – 1.1 mg/kg IV

          • Tube with oil

          • IV fluids

               - If in shock

          • Withhold food

          • Refer for evaluation

• Vaginal Tears

     o Occur during intromission

     o Uncommon

     o Mild to severe trauma to vagina

     o Vaginal rupture

          • Usually adjacent to cervix

          • Dorsolateral

          • Can also affect lateral wall of vestibule

          • Semen is not sterile

          • Results in peritonitis

          • Evisceration (Tulleners EP et al JAVMA 1985 186(4): 385-7)

     o Partial thickness

           • Peri-vaginal abscessation if not identified acutely

     o Signs

           • Vaginal bleeding

           • Colic

               - Minutes to hours post-breeding

           • Straining

           • Peritonitis (signs)

           • Fever

            • Depression

           • Lethargy

     o First Aid for Vaginal Rupture

           • Broad spectrum antibiotics

            • Peritonitis

           • Flunixin meglumine

           • If evisceration:

               - Reduce and pack with sterile soaked towels

               - Large enough so they won't pass into the abdomen through the tear

               - Close vulva

               - Clamps or suture closed

           • Treat shock

           • Refer for medical and surgical treatment

Peri-parturient emergencies

• Dystocia

     o Epidemiology

            • 4% Thoroughbreds (McKinnon and Voss Equine Reproduction 1993 pp 578)

           • 10% Draft breeds (McKinnon and Voss Equine Reproduction 1993 pp 578)

           • 10% Miniature Horses

     o Signs

           • Colic in term mare with other signs of imminent parturition

           • No amnion visualized after 5 minutes in Stage 2 labor

           • No foal after rupture of chorioallantois

           • One hoof but no further progress despite abdominal contractions of mare

           • Nose is presented first

           • See the ventral portion of the foot

           • Nothing palpable in vagina despite signs of active labor

     o Types of Malposition

           • Anterior presentation

               - Head and neck reflection

               - Limb malposture

               - Foot-nape posture

               - Rotated

               - Dorsal, lateral, ventral

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           • Posterior presentation

           • Transverse presentation

     o Treatment

           • Assisted vaginal delivery

               - Sedation

               - Epidural

               - Lubrication

           • Controlled vaginal delivery

               - Anesthesia

               - Hindquarters elevated

               - Lubrication

           • Fetotomy

           • Cesarean section

               - Referred for surgery

           • Time is of the essence for foal survival!

               - In a large retrospective study of 247 horses (Byron et al EVJ 2002 35(1):82-85)

               - Time from chorioallantoic rupture to delivery

                      • Foals survived to discharge = 71.7 min ± 34.3 min

                      • Non-survivors = 85.3 ± 37.4 min

                      • 42% of foals delivered alive

                      • 29% survived to discharge

                      • 91% of mares discharged

                      • Treatment

               - Except for fetotomy there is no effect of method of delivery on** +

                      • Mare survival

                      • Mare fertility

• Peri-parturient Hemorrhage

     o Older, multiparous mares

     o Most common cause of death in older foaling mares

     o When?

          • At parturition

          • Post-partum (24-48 hours)

          • Pre-partum

     o Where?

          • Middle uterine artery

          • Utero-ovarian artery

          • External iliac artery

     o Why?

          • Degenerate process in arterial wall (Rooney JR. Cornell Vet 1964)

          • Low serum copper levels (Stowe HD J Nutr 1968)

          • Predisposing factors (McCarthy PF Equine Pract 1994)

               - Large foal

               - Assisted delivery

     o Retrospective studies (Rooney. Cornell Vet 1964)

          • 10 mares

               - 2/10 died at 7 months of gestation

               - 8/10 died at foaling

               - 3/10 ruptured left utero-ovarian artery

               - 7/10 ruptured right utero-ovarian/middle uterine/ external iliac artery

               - Histology

                    • Degeneration of the internal elastic lamina

                    • Intimal fibrosis

                    • Thickening and accumulation of metachromatic, mucoid material in the intima and media at aneurysm site

                    • → Lesions are related to the aging process!

• 13 mares (Pascoe RR. Vet Rec 1979)

               - Group 1 - 8 mares

                    • 6/8 mares - death within 30 min to 20 hours postpartum

                    • 2/8 mares - death 3 days/25 days postpartum (ruptured the hematoma)

                    • 7/8 rupture of right ovarian or utero-ovarian artery

               - Group 2 – 5 mares

                    • No clinical signs

                    • 5/5 hematoma in right broad ligament

                    • 1 died at parturition due to acute hemorrhage

                    • 1/4 re-bred after hematoma resolved (died postpartum)

                    • 3/4 palpable masses in broad ligament- not re-bred

     o Signs

          • Colic

          • Sweating

          • Pale mucous membranes

          • Rapid pulse

          • Anemia

          • Intra-peritoneal

               - Rapid deterioration

               - Acute shock signs

          • More subtle signs if hemorrhage is contained in broad ligament

     o Diagnosis

          • History

          • Clinical signs

          • Physical examination

          • Hematology

          • Transabdominal ultrasound

          • Abdominocentesis

          • Transrectal palpation/ultrasound

     o Treatment

          • Prevent activity/excitement

          • Quiet, dark environment

          • Warmth

          • Sedation (acepromazine)

          • Keep foal close by-if possible/safe

               - If not-foal requires support

          • Plasma expansion therapy

               - Crystalloids (hypertonic saline, LRS)

               - Colloids (Hetastarch, plasma)

               - Whole blood transfusion

               - Blood substitutes (Oxyglobin)

          • Oxygen supplementation via nasal insufflation

          • Antifibrinolytic drugs (aminocaproic acid, tranexamic acid)

          • Anti-inflammatory drugs

          • Glucocorticoids (prednisolone sodium succinate)

          • Analgesic drugs

               - Opioids (butorphanol)

               - Anesthetics (lidocaine)

          • Broad-spectrum antibiotics

          • Anti-oxidant drugs (DMSO, Vitamin E/selenium)

          • Oxytocin – low dose therapy for uterine involution

     o Prognosis for survival

          • Depends on severity and location of hemorrhage

          • Worse if intra-abdominal hemorrhage present

     o Prognosis for future fertility

          • Rebreeding unsuccessful unless hematoma in broad ligament resolves

     o Recurrence

          • High risk with future breeding/foaling

          • Uterine Torsion

     o Incidence 5-10% of all serious equine obstetric problems

          • Less frequent than in cows but greater difficulty in resolving the torsion and lower survival rate in horses

     o Underlying cause unknown

     o Contributing factors:

          • Vigorous fetal movement

          • Sudden falls

          • Large fetus in small fluid volume

          • Lack of tone in the pregnant uterus

     o Signs

          • Colic

          • Restlessness

          • Sweating

          • Anorexia

          • Frequent urination, sawhorse stance

          • Looking at flank, kicking at abdomen

          • TPR – normal to slightly elevated

     o Complications

          • Restriction of blood flow through uterine and utero-ovarian arteries

          • Arterial rupture and fatal hemorrhage

          • Thrombosis of large uterine arteries and veins (common)

          • Rupture of the vessel

     o Diagnosis:

          • Physical examination

          • Transrectal palpation

               - Broad ligaments are tense and spiraling in the direction of the torsion

               - Clockwise vs. counterclockwise

               - Small colon might be constricted by torsion and impede ability to perform complete rectal palpation

               - Determine viability of fetus, integrity of uterus and direction of torsion

          • Vaginal examination – often not helpful

     o Treatment

          • Nonsurgical

               - Mare is term and cervix is dilated → manual detorsion and assisted delivery

               - Mare is preterm and cervix is closed/vagina or cervix are involved → Rolling of anesthetized mare

               - Risks:

                    • Uterine rupture

                    • Risk of placental detachment

                    • Abortion

                    • Fetal/maternal death

                    • Recurrence of uterine torsion during same pregnancy

          • Surgical

               - Flank laparotomy

               - Ventral midline approach (at term gestation)

               - Risks:

                    • Premature placental separation

                    • Uterine wall necrosis, uterine tearing

                    • Peritonitis

                    • Partial or complete dehiscence of incision

                    • Recurrence of torsion during same pregnancy

     o Prognosis

          • Mare survival rate 84% (Chaney KP et al. AAEP proceedings 2006)

               - 97% <10 mo gestation

               - 65% >10 mo gestation

               - 67% successfully rebred

               - Foal survival rate 54%

               - 72% <10 mo gestation

               - 32% >10mo gestation

          • Surgical management 73% survival rate (Pascoe RR et al. JAVMA 1981)

          • Nonsurgical management 85% survival rate (Wichtel JJ et al. JAVMA 1988)

• Uterine rupture

     o Associated with:

          • Fetotomy

          • Excessive manipulation during dystocia

          • Fetal malposition

          • Uterine torsion

          • Uterine lavage

          • Normal delivery

     o Complications:

          • Visceral herniation

          • Peritonitis

          • Hemorrhage

          • Shock

          • Death

     o Most common site:

          • Dorsal aspect of uterus

     o Clinical signs (Dolente BA. Critical peripartum disease in the mare. Vet Clin Equine 2004)

          • Anorexia

          • Fever, malaise

          • Tachycardia, tachypnea

          • Ileus, colic

          • Dehydration

          • Signs of diffuse, severe, septic peritonitis

          • Hypovolemic shock

          • Signs may not be evident until 24-48 hours after parturition

     o Diagnosis

          • Can be challenging

          • Abdominocentesis

          • Transrectal palpation

          • Palpation of the uterine lumen

          • Laparoscopy

          • Exploratory celiotomy

     o Treatment

          • Conservative management

               - Successful if tear is small, on dorsal aspect of uterus, minimal hemorrhage, no uterine therapy required

               - Supportive therapy

               - Treat shock and peritonitis

               - Cross-tying to prevent abdominal herniation through tear

• Surgical management

               - Ventral midline celiotomy

               - Flank approach

• Supportive therapy

               - Antibiotics

               - NSAIDs

               - IV fluids

               - Abdominal lavage

               - Adhesion prevention (heparin, etc)

               - Oxytocin

               - Laxatives

     o Prognosis

          • Variable

• Uterine prolapse

     o Less likely than in cows due to cranial attachments of uterus

     o Associated with:

          • Normal delivery – uncommon

          • Abortion (8-10 months gestation)

          • Prolonged parturition/dystocia

          • Retained placenta

          • Old age

          • May occur several hours after fetal delivery

     o Complications:

          • Retained fetal membranes

          • Uterine rupture

          • Bladder eversion/prolapse

          • Intestinal herniation/rectal prolapse

     o Clinical signs (Perkins NR, Frazer GS. Vet Clin North Am Equine Pract 1994)

          • Mild to moderate tenesmus

          • Restlessness, pain

          • Anxiety, anorexia

          • Tachycardia, tachypnea

          • Hypovolemic/endotoxic shock esp. if excessive bleeding or incarceration of intestines present

          • Rapid weak pulse, rapid shallow respiration

          • Pale mucous membranes

          • Depression, prostration, rapid death

     o Diagnosis

          • Presence of prolapsed organ hanging from vagina

     o Treatment:

          • Sedation and analgesia

          • Lavage and examination of the uterus

          • Gentle replacement of the uterus

          • If uterus is edematous:

               - Compression of the uterus with bandage before replacement

          • Complete reduction must be performed!

          • Placement of vulvar retention sutures/Caslick's

          • Supportive therapy (incl. intrauterine therapy, laxatives)

     o Prognosis

          • Good

          • Future fertility

               - Depends on degree of endometrial damage during the prolapse

          • Recurrence rate

               - Unknown

               - Considered to be low

• Retained fetal membranes

     o Failure of passage of part, or all, of the chorioallantoic membrane within a specific time period of fetal delivery (3 hours)

     o Most common post partum complication

     o Incidence of RFM 2-10%

     o Most common site - tip of the non-gravid horn

          • Microcotyledons more deeply interdigitated

          • Edematous tip of gravid horn more squashed and stunted

     o Predisposing factors

          • Mechanical interference with normal expulsion

          • Hormonal imbalances

     o Complications

          • Severe metritis

          • Septicemia/Endotoxemia

          • Laminitis

     o Clinical signs

          • Portion of fetal membranes protruding through vulvar lips

          • Retention may occur without any membrane appearance

          • Vaginal discharge

          • Fever

          • Anorexia

          • Depression

          • Laminitis

     o Treatment

          • Tetanus prophylaxis

          • Oxytocin (10-40 IU)

               - Stimulate separation of microcotyledons from endometrium

          • Distention of chorioallantoic sac with 5-15L saline and ligation to contain fluid in it

          • Tying of protruding placental remnants in knot above the mare's hocks

          • Tying a weight to protruding fetal membranes

          • Manual removal of RFM

          • Correct calcium imbalance

          • Controlled exercise

          • Systemic treatment

               - Antibiotics

               - NSAIDs

          • Uterine lavage

               - Uterine infusion with antibiotics (oxytetracycline)

• Septic Metritis

     o Sequelae of retained fetal membranes

     o Following dystocia:

          • Greater risk of toxic metritis and laminitis

     o Delayed uterine involution

     o Increased autolysis of the placenta

     o Severe bacterial infection

     o Diagnosis

          • Rectal examination

               - Large, thin walled uterus

               - Flaccid tone

               - Moderate to large amount of intraluminal fluid

          • Transrectal ultrasound

     o Complications (Blanchard T et al. Comp Cont Educ Pract Vet 1990

          • Septicemia

          • Endotoxemia

          • Laminitis

     o Treatment

          • Antibiotics

          • NSAIDs

          • IV fluid therapy

          • Large volume uterine lavage

          • Uterine infusion with antibiotics

          • Oxytocin

          • Controlled exercise

          • Laminitis prevention

          • Recto-vaginal Tears

     o Three grades

     o Although they can look severe acutely immediate surgery is rarely necessary

     o Treat symptomatically

           • NSAIDS

           • Antibiotics

     o Metritis

           • Chronic

     o Incontinence

           • Occasionally

• Gastro-intestinal Related Emergencies

     o Bowel rupture

           • Cecal/colonic rupture

           • Most common gastrointestinal catastrophe associated with parturition (Rossdale 1994)

     o After normal parturition or dystocia

     o Occasionally before parturition

     o Why?

           • Trauma during delivery

           • Focal necrosis of intestinal wall

           • Thromboembolism

           • Tapeworms

           • NSAID administration

     o Clinical Signs

           • Acute abdominal pain

           • Septic shock

     o Results in

           • Peritoneal contamination

           • Severe peritonitis

           • Profound endotoxemia

           • Death within 24 hours

     o Diagnosis

           • Physical examination

           • Abdominocentesis

           • Transrectal palpation

               - Roughened peritoneal surface

               - Pneumoperitoneum

     o Treatment

           • Euthanasia

     o Trauma to small colon/small intestine

           • Injury to

               - Bowel wall

               - Mesocolon/mesojejunum

               - Ischemic necrosis of colon/jejunum

           • Associated with

               - Normal parturition

               - Dystocia

               - ± type III or IV rectal prolapse

           • Clinical signs

               - Depression

               - Moderate to severe colic

               - Absence of fecal passage

               - Febrile

               - Decreased gastrointestinal motility, gastric reflux

           • Diagnosis

               - Physical examination

               - Rectal examination

                      • May be non-specific

               - Abdominocentesis

                      • Septic/non-septic peritonitis

               - Laparoscopy

               - Exploratory celiotomy

           • Treatment

               - Resection and anastomosis

               - Colostomy

           • Prognosis

               - Variable (36% small colon)

• Rectal prolapse

     o Due to prolonged or forceful tenesmus

     o Parturition/dystocia

     o Rectal mucosa is apparent

     o Variable degree of inflammation, cyanosis, trauma, necrosis

     o 4 types

           • Type I – only rectal mucosa involved

           • Type II – complete prolapse of rectal ampulla

           • Type I and II – usually no signs of colic

           • Type III – prolapse of rectum with evagination of descending colon

           • Type IV – prolapse of descending colon or rectal intussusception (associated with dystocia in mares)

           • Type III and IV may be associated with tearing of the mesocolon, avascular necrosis of descending colon – may result in abdominal pain

     o Diagnosis

           • Examination and palpation of prolapsed tissue

           • Abdominocentesis

     o Treatment

           • Epidural anesthesia

           • Manual reduction

               - Reduce edema

               - Application of glycerin, dextrose

          • Placement of purse string suture

          • Administration of laxatives

          • Laparoscopy

          • Ventral midline celiotomy

     o Prognosis

          • Depends on viability of small colon and rectum

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