International Congress on Modern Concepts in Canine Health and Diseases of Human Concern and IX Annual Convention of Indian Society

for Advancement of Canine Practice 9th11th February 2012 Bikaner Rajasthan India Compendium page 339-345 Management of post partum genital complications in the bitch G N Purohit1, DK Bihani2 and AA Gauri3 Department of Veterinary Gynecology and Obstetrics 2 Department of Veterinary Medicine College of Veterinary and Animal science Rajasthan University of Veterinary and Animal Science Bikaner Rajasthan 334001 email: gnpobs@gmail.com
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ABSTRACT The post-partum period in the bitch is different from other domestic animals and so are the post-partum genital complications. The incidence of post- partum complications in the bitch appear to be low and two complications appear to be most frequent; the sub-involution of placental sites and metritis. Eclampsia is a metabolic disorder of the post partum period commonly affecting poorly managed bitches and is common in the Pomeranian breed. Placental retention, uterine prolapse/rupture and vaginitis are infrequent in the bitch and their clinical diagnosis is often complicated. Bitch owners and clinicians often prefer ovariohysterectomy when complications do not respond to usual therapy. The incidence, diagnosis and therapeutic approaches for the common genital post-partum complications of the bitch are described. Key Words: Bitch, eclampsia, metritis, SIPS, uterine prolapse. Canine post-partum problems are different from other domestic animals. The parturition is prolonged in the bitch (second stage of labor sometimes requiring up to 24 hours) hence the first thing a clinician must look for is the presence of any fetus. A novice owner may think that the whelping is completed when the bitch is taking rest after delivery of a few fetuses and would be worried when the bitch is again straining to deliver the remaining pups. Alternatively, a bitch may deliver a part of the litter and then show no signs of delivery although she may still have some pups retained. In canines, normal postpartum discharge is dark green or greenish black in colour for the first 1 to 2 days which then becomes bloody and persists for 1 or 2 weeks or even up to 1 month. There is usually a lot of discharge for the first 5 to 7 days. It should gradually decrease in volume and become thick and clear or grey by day 10. Abnormal, excessive or foul smelling vaginal discharge may indicate an infection. Discharge having an offensive odour, bright red colour, profuse or lasting longer than 3 weeks requires immediate attention. Post partum haemorrhage Some degree of post-partum haemorrhage is inevitable but when the blood loss is profuse it is a matter of serious concern. True maternal blood loss should never exceed a slow drip from the vulva and any level greater than this should be investigated (Jackson, 2004). Uterine or vaginal injury resulting from the treatment of dystocia is the most likely source of blood loss. The anterior vagina can only be inspected if a long speculum or paediatric endoscope is available. The bleeding points in the vagina when accessible should be located and standard haemostatic procedures adopted. However, when this is not possible cotton wool soaked with adrenaline must be placed in the vagina. Blood loss

when suspected to be of uterine origin, a dose of oxytocin would be helpful in reducing the size of the uterus and stopping the bleeding. Incidence The incidence of the post partum complications in the bitch appears to be low. At our referral centre the number of bitches presented with some or other complications was merely 17 in a period of two years (Table 1). All except one bitch presented for therapy of eclampsia were of the Pomeranian breed. Retained foetal membrane This is not a common condition in the bitch but may be difficult to diagnose. Placentae are usually passed within 15 min of a birth of a puppy. Many a times placental retention is suspected when in fact it has been eaten by the mother. The condition is common in toy dog breeds. Initially there are no systemic signs. Placental retention is often suspected if a green or black discharge persists after labour. The uterus may appear distended on palpation and occasionally a portion of placenta can be felt on vaginal examination. Radiographic and sonographic examination is suggested for complicated cases. Primary treatment involves administration of oxytocin injection (0.5 U/Kg up to 20 U IM) when retention is suspected for the first 24-48 hours. If the placenta can be palpated in the vagina it should be removed by gentle traction using artery or whelping forceps (Jackson, 2004). If a bitch develops signs of systemic illness because of metritis that infrequently develops, surgical removal is indicated. If metritis develops, the prognosis for future reproduction is fair to poor (Smith, 1986). Sub involution of placental sites (SIPS) Some degree of vulval discharge is normal for a week or so after whelping. However the persistence of a serosanguineous to hemorrhagic vaginal discharge beyond 16 weeks post partum indicate sub-involution of the placental sites of attachment (SIPS) in the bitch. SIPS is a disorder that occurs in healthy bitches post-whelping (Beck and Mc Entee, 1966). It is characterised by a bright red (fresh) bloody discharge passing through the vulva for 7-12 weeks post-whelping (Mshella and Chaudhari, 2001) and sometimes excessive uterine bleeding (metrorrhagia) (Dickie and Arbeiter, 1993; Al-Mehaisen et al., 2008). Young bitches (less than 3 years of age) are most commonly affected following the first whelping (Burke, 1977; Al-Bassam et al., 1981a; Wheeler, 1986). The etiology of the condition continues to be obscure, although some of the predisposing factors described include obesity, high calcium and low zinc in the diet, sub-clinical hypoglycaemia, uterine inertia and premature birth (Mshella and Chaudhari, 2001). Normally, at whelping the placenta separates from the endometrium through the spongy layer due to some degenerative changes in the endometrium (Priedkalns, 1981). However, in SIPS the uterus continues to supply blood to these tissue tags (Olson et al., 1984) resulting in the bloody discharges seen in SIPS. The trophoblastic cells do not regress or degenerate normally, and instead they continue to invade deep into the glandular layer or even up to the myometrium, preventing normal uterine involution (Slatter, 1985). The trophoblastic cells are considered to be of fetal origin (Fernandez et al., 1998) and characteristic to SIPS (Sontas et al., 2011). There is lack of thrombosis of endometrial vessels, failure of exposed placental blood vessels to occlude and damage to the uterine vessels. This results into continued haemorrhage.

The dogs are generally healthy in other respects except a vaginal discharge. Sometimes progressive weakness, anaemia and death may occur following perforation of the uterus (Wheeler, 1986). Abdominal palpation may reveal pain. Vaginal cytology differentiates SIPS from metritis and lochial discharges by the predominant presence of erythrocytes and decidua-like cells in the smear (Dickie and Arbeiter, 1993; Orfanou et al., 2008). Additionally sonographic features of diagnosis have been described (Davidson and Baker, 2009a) besides the histopathological changes described previously (Al-Bassam et al., 1981b). Histological examination of the uterus is indicated to confirm the diagnosis. The condition is said to be self-limiting, bitches are mildly febrile, but systematically healthy and hence treatment is generally not necessary, as recovery is spontaneous and fertility is not affected (Schall et al., 1971). In the uncommon situation where vaginal bleeding from SIPS is copious enough to cause serious anaemia, coagulopathies (likely defects in the intrinsic pathway or thrombocytopenia / thrombocytopathies), trauma, neoplasia of the genitourinary tract, metritis and proestrus should be ruled out. Vaginal cytology, vaginoscopy, coagulation testing and abdominal ultrasound assist in the diagnosis. Treatment in these cases can be attempted with ergonovine (0.2 mg/15kg IM) administered once or twice (Orfanou et al., 2008; Davidson and Baker, 2009b). The benefit of therapeutic prostaglandins and/or oxytocin is questionable and not proven in any controlled study. The preventative value of oxytocin given in the immediate postpartum period is also unproven. Ergonovine maleate 0.2 mg/15 Kg single to multiple IM doses have been suggested with limited success (Reberg et al., 1992). A single injection of progestagens (Arbeiter, 1975) like Niagestin (25-50 mg per bitch) (Dickie and Arbeiter, 1993) or medroxy-progesterone acetate (2 mg/Kg) (Jackson, 2004) are considered good for treating the condition, but have the potential dangers of predisposing the uterus to infection. Laparotomy with curettage of selected sites can be done or ovario-hysterectomy performed when further breeding is not required or when anaemia due to blood loss is life threatening. Post partum metritis Metritis is an acute infection of the postpartum uterine endometrium. It is a serious condition and sometimes preceded by dystocia, contaminated obstetrical manipulations, or retained fetuses and/or placentae (Orfanou et al., 2008). Unlike pyometra, metritis in the bitch is most often a bacterial uterine infection that develops in the immediate postpartum period and occasionally after an abortion. It is often associated with retained fetus or placentas. Bacterial ascension from the lower genitor-urinary tract is more common than haematogenous spread, and Escherichia coli is the most common causative organism in bitches (Orfanou et al., 2008; Davidson and Baker, 2009b) although infections with Streptococcus and Staphylococcus are also seen (Magne, 1986). Affected bitches normally present with a foul smelling red discharge from the vulva (Magne, 1986). They are lethargic, depressed, off food, initially have a temperature rise and produce no milk. Haematological and biochemical changes often suggest septicaemia, systemic inflammatory reaction and endotoxemia (Orfanou et al., 2008; Davidson and Baker, 2009b). Vaginal cytology shows a hemorrhagic to purulent septic discharge. Ultrasound of the abdomen allows evaluation of intrauterine contents and the uterine wall (Davidson and Baker, 2009a). Retained fetuses and placentae can also be identified with ultrasound. A guarded cranial vaginal culture is likely representative of intrauterine flora and should be submitted for both aerobic

and anaerobic culture and sensitivities, and permits retrospective assessment of empirically selected antibiotic therapy. Hysteroscopic visualization of the bitch uterus is possible up to day 17-23 post whelping and specimens can be collected from the uterus for microbiology and cytology to confirm the diagnosis (Watts and Wright, 1995; Watts et al., 1997) however, sufficient expertise is required for such procedures. The therapy of metritis consists of intravenous fluid and electrolyte support, appropriate broad spectrum antibiotic administration and pharmacologic uterine evacuation, usually with prostaglandin F2 alpha (0.10-0.20 mg/Kg every 12-24 h for 3-5 days). An ovariohysterectomy may be indicated if the bitchs condition permits, and she is poorly responsive to medical management (Bencharif et al., 2010). Ergonovine (0.2 mg/15 kg given once IM or repeated twice daily for 2-3 days) is also an effective ecbolic agent (Magne, 1986), but may cause rupture of a friable uterine wall (Orfanou et al., 2008). Synthetic prostaglandins offer more uterine specific therapy where available. Oxytocin is unlikely to promote effective uterine evacuation when administered >2448 hours postpartum. Metritis can become chronic and cause infertility (Smith, 1986). The intra-uterine administration of antibiotics is not possible with the routine techniques because of the anatomy of the cervix. Vaginitis Occasionally a genital infection involving only the vagina is seen in bitches after parturition (Jackson, 2004). A vaginal discharge is present but examination reveals no evidence of uterine or urinary tract infection. It is usually due to bacterial infection. The most common clinical sign is a vulvar discharge. Licking of the vulva, attraction of males and frequent micturition may also be seen. Signs of systemic illness are not present, and the hemogram and biochemical profile are normal. The absence of these abnormalities helps differentiate vaginitis from metritis, the most important differential diagnosis. The diagnostic evaluation should include a digital examination of the vagina, vaginoscopy, cytology and culture of the exudates (Johnson, 1991), endoscopy (Lindsay, 1983) and if necessary, abdominal radiographs or ultrasonography to evaluate the uterus. An anterior vaginal culture may be obtained using a guarded sterile culture swab. The vagina contains normal bacterial flora; therefore, culture results must be interpreted cautiously. A heavy growth, especially of one organism, is probably more significant than a light growth of several organisms (Bjurstrom, 1993). Bacterial infection may respond to local treatment (i.e., vaginal douches), with antibiotics. Systemic, broadspectrum, bactericidal antibiotics may be needed for persistent infections. Prolapsed uterus/ Uterine rupture Complete or partial prolapse of the uterus is an uncommon postpartum condition in the bitch (Grundy, 1980; Honparkhe et al., 2006; Orfanou et al., 2008), and usually results because of obstetric manipulations or intense tenesmus. Uterine prolapse with associated rupture has been recorded in a bitch (Pavan-Carreira et al., 2011) The prolapse may involve one or both uterine horns (Grundy, 1980) and occurs during or after parturition or abortion, when the cervix is dilated (Woods, 1986; Deori et al., 2009). The diagnosis is based on palpation of a firm, tubular mass protruding from the vulva postpartum, and inability to identify the uterus with abdominal ultrasonography. Vaginal discharge, abdominal pain and restlessness may be evident subsequent to uterine prolapse (Woods, 1986; Honparkhe et al., 2006). Vaginal hyperplasia and prolapse, secondary to a hypersensitivity of focal

(peri-urethral) vaginal mucosa to estrogens, can recur near parturition and should be ruled out by physical examination, vaginoscopy, or contrast radiography. The prolapsed uterine tissues are at risk for maceration and infection from exposure and contamination. When possible the prolapsed portion must be replaced under sedation or general anaesthesia however, the size of most bitches precludes manual replacement; laparotomy and ovariohysterectomy are usually indicated. Two to five IU of oxytocin must be given after replacement and general care of the animal should be done including administration of antibiotics, analgesics and antihistamines wherever required (Davidson and Baker, 2009b). Rupture of the uterus occurs most commonly with very large litters causing marked stretching and thinning of the uterine wall, especially in multiparous dams with dystocia (Hayes, 2004; Davidson and Baker, 2009b). The condition is considered an obstetrical emergency (Biddle and Mcintire, 2000). External trauma is also a common cause. Rupture during or after birth is most likely to occur in cases where the uterine wall is compromised by the presence of infection, a dead fetus, uterine torsion, tumors (Newell-Fugate and Lane, 2009) or careless obstetric procedures (Bomzon, 1977; Dunn and Foster, 1977). It is also known to be caused by excessively large doses of oxytocin (Humm et al., 2010). Immediate laparotomy for retrieval of fetuses and repair or removal of the uterus, as well as culture and lavage of the abdominal cavity, is indicated (Davidson and Baker, 2009b). Eclampsia (hypocalcaemia or puerperal tetany) Eclampsia is an acute, life-threatening disease affecting bitches (Mudaliar and Hussain, 1967; Jirima, 1974; Austad and Bjerkas, 1976; Aroch et al., 1999; Drobatz and Casey, 2000) and caused by low calcium levels. It is most often seen in small to medium-sized bitches at peak lactation, although it can be seen in late pregnancy through 45 days postpartum. The disorder is more likely in small bitches with a heavy litter (Kaufman, 1986) and generally occurs when the puppies are 2 to 5 weeks of age. Excessive prepartal calcium supplementation can lead to development of puerperal tetany by promoting parathyroid gland atrophy and inhibiting parathyroid hormone release, thus interfering with the normal physiologic mechanisms to mobilize adequate calcium stores and utilize dietary calcium sources (Davidson and Baker, 2009b). Metabolic conditions favouring protein binding of serum calcium can promote or exacerbate hypocalcaemia, such as alkalosis resulting from prolonged hyperpnoea during prolonged labor or dystocia. Hypoglycaemia and hyperthermia can occur concurrently. The initial signs may be subtle and vague, such as restlessness, nervousness, and pacing, panting, whining, loss of maternal behaviour, high body temperature (107 0 F), irritability, increased salivation, stiff gait, in coordination, muscle tremors, and pain. The bitch can progress quickly (minutes to hours) to tetany and seizures. Hyperthermia is primarily caused by increased muscular activity (Kaufman, 1986). The diagnosis is based on history and clinical signs. Blood tests will confirm a low blood calcium. Eclampsia can be rapidly fatal and hence represents a medical emergency. The immediate goal is to return the serum calcium level to normal by slow intravenous infusion of 10% calcium gluconate (1-20 mL) given to effect. Cardiac monitoring for bradycardia should accompany the administration and their presence warrants temporary discontinuation of therapy and a slower subsequent infusion rate (Davidson and Baker, 2009b). A response should be seen within

15 minutes. Other treatments include glucose, anticonvulsants and lowering of body temperature may be required. Because cerebral edema can occur from uncontrolled seizures; diazepam (1-5 mg IV) can be used to control persistent seizures. Mannitol may be indicated for reducing cerebral inflammation and swelling. Corticosteroids must be avoided as they promote calciuria and decrease intestinal calcium absorption. Once the neurologic signs are controlled, a subcutaneous infusion of an equal volume of calcium gluconate, diluted 50% with saline, should be given and repeated every 6-8 h till the dam is stable and able to take oral supplementation (Davidson and Baker, 2009b). Calcium gluconate or carbonate (10-30 mg/Kg every 8 h) should be given orally for a couple of days. Once detected and treated it is important not to put the puppies back on the mother because further feeding from the mother will cause another eclampsia episode. The puppies need to be hand reared until weaning. Diets high in legumes (soy beans) or cottage cheese may tie up calcium and should therefore be avoided in the lactating bitch. References
Al-Bassam MA, Thomson RG, ODonnell L (1981a). Normal postpartum involution of the uterus in the dog Can J Comp Med 45:217. Al-Bassam MA, Thomson RG, ODonnell L (1981b). Involution abnormalities in the postpartum uterus of the bitch. Vet Pathol 18:208-18. Al-Mehaisen L, Al-Kuran O, Amarin ZO, Beitawi S, Muhtaseb A (2008) Secondary postpartum hemorrhage following placental site vessel subinvolution: a case report. Arch Gynecol Obstet 278: 585-87. Arbeiter K (1975). The use of progestins in the treatment of persistent uterine hemorrhage in the postpartum bitch and cow: a clinical report. Theriogenol 4:11-13. Aroch I, Srebo H, Shpigel NY (1999). Serum electrolyte concentrations in bitches with eclampsia Vet Rec 145:318-20. Austad R, Bjerkas E (1976) Eclampsia in the bitch. J Small Anim Pract 17:793-98. Beck A M, Mc Entee K (1966). Subinvolution of placental sites in a postpartum bitch. A case report. Cornell Vet 56: 269-277. Bencharif D, Amirat L, Annabelle G, Tainturier D (2010) Ovariohysterectomy in the bitch. Obst Gynecol Int 2010:542693. Biddle D, Mcintire DK (2000) Obstetrical emergencies. Clin Tech Small Anim Pract 15:88-93. Bjurstrom L (1993). Aerobic bacteria occurring in the vagina of bitches with reproductive disorders. Acta Vet Scand 34:29-34. Bomzon L (1977). Rupture of the uterus following caesarean section in a bitch. Vet Rec 101:38. Burke TJ (1977). Postparturient problems in the bitch. Vet Clin North Am 7:695. Davidson AP, Baker TW (2009a) Reproductive ultrasound of the bitch and queen. Topics Companion Anim Med 24:55-63. Davidson AP, Baker TW (2009b). Postpartum disorders in bitches, queens and neonates. Topics Companion Anim Med 24:10563. Deori S, Sarkar M, Debnath M (2009). Post parturient uterine prolapse in a bitch-A case report. Indian J Anim Reprod 30:78. Dickie MB, Arbeiter K (1993). Diagnosis and therapy of the subinvolution of placental sites in the bitch. J Reprod Fertil Suppl 47:471-5. Drobatz KJ, Casey KK (2000). Eclampsia in dogs: 31 cases (1995-1998). J Am Vet Med Assoc 217:216-9. Dunn TJ, Foster RC (1977). Perforated uterus in a bitch. Mod Vet Pract 58:240-41. Fernandez PE, Portiansky EL, Barbeito CG, Gimeno EJ (1998) Characterisation of cytotrophoblastic-like cells present in subinvolutioned placental sites of the bitch. Histol Histopathol 13:995-1000. Grundy AM (1980). Partial uterine prolapse in a bitch. Vet Rec 106:420-21. Hayes G (2004). Asymptomatic uterine rupture in a bitch. Vet Rec 154: 438-39. Honparkhe M, Singla VK, Singh J, Bedi M, Sathya A (2006). Post parturient uterine prolapse in a bitch. Indian J Anim Reprod 27:91-92. Humm KR, Adamantos SE, Benigni L, Armitage-Chan EA, Brockman DJ, Chan DL (2010) Uterine rupture and septic peritonitis following dystocia and assisted delivery in a Great Dane bitch. J Am Anim Hosp Assoc 46: 353-357. Jackson PGG (2004). Ed. Postparturient problems in the dog and cat. Handbook of Veterinary Obstetrics. Saunders Elsevier. Pp 233.

Jirima K (1974). Therapy of canine eclampsia. Berl Tierarztl Wochenschr 87:15-16. Johnson CA (1991). Diagnosis and treatment of chronic vaginitis in the bitch. Vet Clin North Am Small Anim Pract 21:523-31. Kaufman J (1986). Eclampsia in the bitch. In: Morrow DA eds. Current Therapy in Theriogenology. Phildelphia, WB Saunders Co pp 511. Lindsay FEF (1983) The normal endoscopic appearance of the caudal reproductive tract of the cyclic and non-cyclic bitch: postuterine endoscopy. J Small Anim Pract 24: 1-15. Magne ML (1986). Acute metritis in the bitch. In: Morrow DA eds. Current Therapy in Theriogenology. Phildelphia, WB Saunders Co pp 505. Mshella GD, Chaudhari SUR (2001). Sub-involution of placental sites (SIPS): Possible predisposing factors and consequences on the fertility of bitch. Int J Agri Biol 3:263-65. Mudaliar RAS, Hussain MM (1967). Peurperal tetany in a bitch. Indian Vet J 44:804-5. Newell-Fugate A, Lane E (2009). Intrapartum uterine rupture with coincidental uterine adenomyosis in an African wild dog (Lycaon pictus). J Zoo Wildl Med 40:791-95. Olson PN, Nett TM, Bowen RA, Thrall MA, Wykes PM, Husted PW, Sawyer HR (1984). Vaginal cytology II: Its use in diagnosing canine reproductive disorders. Comp Cont Edu 6:385-90. Orfanou CD, Ververidis NH, Fthenakis CG (2008). Post-partum pathological conditions in the bitch-Part II. J Hellenic Vet Med Soc 59:126-138. Pavan-Carreira R, Albuquerque C, Abreu H, Maltez I (2011) Uterine Prolapse with Associated Rupture in a Podengo Bitch. Reprod Domest Anim doi: 10.1111/j.1439-0531.2011.01944.x. Priedkalns J (1981). Female reproductive system. In: Delman H, Brown EM eds. Textbook of Veterinary Histology 2nd ed. Philadelphia Lea & Febriger pp 309-36. Reberg SR, Peter AT, Blevins WE (1992). Subinvolution of placental sites in dogs. Comp Cont Edu Pract Vet 14:789-93. Schall WD, Duncan JR, Finco DR, Knecht CD (1971). Spontaneous recovery after subinvolution of placental sites in a bitch. J Am Vet Med Assoc 159:1780-2. Slatter DH (1985). Ed Textbook of Small Animal Surgery Vol 2. Philadelphia WB Saunders Co. pp1665. Smith FO (1986). Postpartum diseases Vet Clin North Am Small Anim Pract 16:521-4. Sontas HB, Stelletta C, Milani C, Mollo A, Romagnoli S (2011) Full recovery of subinvolution of placental sites in an American Staffordshire terrier bitch. J Small Anim Pract 52:42-45. Watts JR, Wright PJ (1995). Investigating uterine disease in the bitch: uterine cannulation for cytology, microbiology and hysteroscopy. J Small Anim Pract 36:201-06. Watts JR, Wright PJ, Lee CS, Whithear KG (1997). New techniques using transcervical uterine cannulation for the diagnosis of uterine disorders in bitches. J Reprod Fert Suppl 51:283-93. Wheeler SL (1986). Subinvolution of placental sites in the bitch. In: Morrow DA eds. Current Therapy in Theriogenology. Phildelphia, WB Saunders Co pp 513-15. Woods DS (1986). Canine uterine prolapse. In:Morrow DA eds. Current Therapy in Theriogenology. Phildelphia, WB Saunders Co pp 510.

Table 1 Incidence of post-partum genital complications in bitches at referral centre between 2008-2010 Clinical condition Retained fetal membranes Sub involution of placental sites Metritis Uterine prolapse Eclampsia 6 1 5 Number of cases 1 4 Breed German Shepherd German Shepherd 1 Non-descript Pomeranian 2 Non-descript 1 Pomeranian Doberman 1 % age of cases 5.88% 23.52%

2;

Pomeranian 1; Labrador 4; 35.29% 5.88% 29.41%

4;

Total

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