Introduction

Garret Pachtinger, VMD, DACVECC

COO, VETgirl

UNIVERSITY OF MINNESOTA Veterinary Medical Center

Introduction Introduction

Jusne A. Lee, DVM, Dr. Margaret V. Root DACVECC, DABT Kustritz, DVM, PhD, CEO, VETgirl DACT

Professor, Small Animal Reproducon

UNIVERSITY OF MINNESOTA Veterinary Medical Center

• The tech-savvy way to get online veterinary CE! • A subscription-based podcast and webinar service offering veterinary RACE-approved CE

50-60 podcasts/year plus 24+ hours of webinars! • $199/year • 30+ hours of RACE-CE

1 • Up to 5 members: $599/year

• Up to 10 members: $999/year

• > 10 members: $1399/year

Easier playback, less buffering – better!

! No need to raise your hand! ! Type in quesons ! Emailed to you 48 hours aer the webinar ! Acve parcipaon = no quiz ! Watching video later, must complete quiz ! ELITE members only ! Email / contact with ANY quesons ! [email protected] ! jus[email protected]

2 Introduction

Dr. Margaret V. Root Kustritz, DVM, PhD, DACT

Professor, Small Animal Reproducon

UNIVERSITY OF MINNESOTA Veterinary Medical Center

PYOMETRA Pyometra - Pathogenesis * Primary pathologic change = cystic Margaret V. Root Kustritz, DVM, PhD, DACT (CEH) University of Minnesota

UNIVERSITY OF MINNESOTA UNIVERSITY OF MINNESOTA Veterinary Medical Center Veterinary Medical Center

Pyometra - CEH develops due to prolonged exposure of the -primed to . - CEH develops due to unique cycle of the bitch, can also occur after administration of exogenous estrogen and/or progesterone.

UNIVERSITY OF MINNESOTA UNIVERSITY OF MINNESOTA Veterinary Medical Center Veterinary Medical Center

3 Cystic endometrial hyperplasia Cystic endometrial hyperplasia

UNIVERSITY OF MINNESOTA UNIVERSITY OF MINNESOTA Veterinary Medical Center Veterinary Medical Center

Pyometra Pyometra - Pathogenesis - Common question – Did she get this from the * Secondary pathologic change = infection stud ? – No, because… E. coli beta hemolytic Streptococcus sp. - The bacteria causing the secondary infection alpha hemolytic Streptococcus sp. are invariably those of the bitch’s normal flora Pasteurella sp. Staphylococcus sp. and CEH / are more common in nulliparous Proteus mirabilis bitches than in pluriparous bitches. Bacillus sp. Corynebacterium sp. Pseudomonas aeruginosa Klebsiella sp. Mycoplasma sp.

UNIVERSITY OF MINNESOTA UNIVERSITY OF MINNESOTA Veterinary Medical Center Veterinary Medical Center

Pyometra Pyometra Pathogenesis timeline -> CEH present – bacteria ascend during Incidence? proestrus / estrus and colonize the abnormal uterus – closes at onset of diestrus – progesterone inhibits uterine contractility, Reported incidences are 15.2% in greater promotes secretion of endometrial glands, than 4 years of age and 23-24% in dogs 10 makes “hyper-reactive” – years of age or older. subsequent disease dependent on cervical patency

UNIVERSITY OF MINNESOTA UNIVERSITY OF MINNESOTA Veterinary Medical Center Veterinary Medical Center

4 Pyometra Pyometra - Presentation - Presentation Bitch greater than 5-6 yrs of age Breed predisposition? In heat 1-12 wks ago - Rottweiler, rough collie, Cavalier King Charles spaniel, golden retriever, chow chow, St. Bernard, Bernese mountain dog, English cocker spaniel at increased risk - German shepherd dog, dachshund at decreased risk

UNIVERSITY OF MINNESOTA UNIVERSITY OF MINNESOTA Veterinary Medical Center Veterinary Medical Center

Pyometra - Clinical signs Pyometra Anorexia, vomiting - Diagnosis Fever, depression CBC - Leukocytosis with left shift Polyuria / polydipsia Reported in 70-87% of cases. More +/- abdominal distension severe in cases with closed cervix. +/- purulent vulvar discharge

UNIVERSITY OF MINNESOTA UNIVERSITY OF MINNESOTA Veterinary Medical Center Veterinary Medical Center

Pyometra

Pyometra - Diagnosis CBC - Leukocytosis with left shift Palpation / Radiography / - Uterine enlargement

UNIVERSITY OF MINNESOTA UNIVERSITY OF MINNESOTA Veterinary Medical Center Veterinary Medical Center

5 Pyometra Pyometra - Diagnosis CBC - Leukocytosis with left shift Palpation / Radiography / Ultrasound - Uterine enlargement Chemistry profile - Azotemia Renal disease develops secondary to endotoxemia, with decreased renal tubular function and formation of antigen/antibody complexes causing glomerulonephritis

UNIVERSITY OF MINNESOTA UNIVERSITY OF MINNESOTA Veterinary Medical Center Veterinary Medical Center

Pyometra - Diagnosis Pyometra CBC - Leukocytosis with left shift - Treatment Palpation / Radiography / Ultrasound - - Closed cervix = Ovariohysterectomy is best Uterine enlargement in all cases Chemistry profile - Azotemia Cytology - Purulent vulvar discharge Successful medical therapy of closed cervix pyometra has been reported. Possible complications include uterine rupture or movement of purulent fluid through the uterine tubes into the – both of the above will be cause .

UNIVERSITY OF MINNESOTA UNIVERSITY OF MINNESOTA Veterinary Medical Center Veterinary Medical Center

Pyometra Pyometra - Treatment - Treatment - Closed cervix = Ovariohysterectomy is best Ovariohysterectomy always is the best in all cases therapy for pyometra. Medical therapy will not cause resolution of CEH.The bitch will be - Open cervix = Ovariohysterectomy is best; predisposed to pyometra after each subsequent prostaglandin therapy is possible estrus.

UNIVERSITY OF MINNESOTA UNIVERSITY OF MINNESOTA Veterinary Medical Center Veterinary Medical Center

6 Pyometra Pyometra - Assess uterine size. - Treatment Palpation, imaging Medical therapy with prostaglandins may be considered if: * The cervix is open, evidenced by vulvar discharge. * The bitch is of breeding age. * The bitch is valuable in a breeding program. * The bitch is not azotemic.

UNIVERSITY OF MINNESOTA UNIVERSITY OF MINNESOTA Veterinary Medical Center Veterinary Medical Center

Pyometra Pyometra - Assess uterine size. - Assess uterine size. - Culture vulvar discharge, if present. - Culture vulvar discharge. - Institute therapy and correct fluid deficits. Amoxicillin or ampicillin are common empirical choices; may need to alter therapy once culture/sensitivity results are back.

UNIVERSITY OF MINNESOTA UNIVERSITY OF MINNESOTA Veterinary Medical Center Veterinary Medical Center

Pyometra Pyometra - Assess uterine size. - Assess uterine size. - Culture vulvar discharge. - Culture vulvar discharge. - Institute antibiotic therapy and correct fluid - Institute antibiotic therapy and correct fluid deficits. deficits. - Administer PGF2-alpha at a dose of 250 - Administer PGF2-alpha at a dose of 250 mcg/kg SQ once to twice daily x 2-7 mcg/kg SQ once to twice daily x 2-7 days. days, until uterine size nears normal. Give twice daily if serum - Leave on an appropriate antibiotic for one progesterone concentration > 2 ng/ml. Treat month. until uterine size nears normal or until no fluid is visible in uterine horns by ultrasound.

UNIVERSITY OF MINNESOTA UNIVERSITY OF MINNESOTA Veterinary Medical Center Veterinary Medical Center

7 Pyometra Pyometra Other medical therapies? - At the bitch’s next season: - Aglepristone - Perform anterior vaginal culture early in proestrus, institute appropriate antibiotic Progesterone receptor blocker therapy Available in Europe and South - Breed her – pregnancy is protective America against development of pyometra Reported successful in 81.8 – - If she does not become pregnant, 92.8% of cases (with antibiotic consider treatment with prostaglandin to lyse therapy) CL and decrease progesterone exposure.

UNIVERSITY OF MINNESOTA UNIVERSITY OF MINNESOTA Veterinary Medical Center Veterinary Medical Center

Pyometra Pyometra - What kind of fertility can we expect after - Perform ovariohysterectomy as soon as medical treatment for pyometra? the bitch’s breeding life is over. Recurrence averages 31.5% within one year of treatment – usually due to same organism Reported conception rate after medical treatment for pyometra is 40-68%.

UNIVERSITY OF MINNESOTA UNIVERSITY OF MINNESOTA Veterinary Medical Center Veterinary Medical Center

VAGINITIS: AN UPDATE * Prepuberal (puppy) vaginitis

Margaret V. Root Kustritz, DVM, PhD, DACT * Adult-onset vaginitis University of Minnesota

UNIVERSITY OF MINNESOTA UNIVERSITY OF MINNESOTA Veterinary Medical Center Veterinary Medical Center

8 PREPUBERAL (PUPPY) VAGINITIS PREPUBERAL (PUPPY) VAGINITIS There is no evidence that dogs that exhibit puppy vaginitis are more likely to suffer from adult-onset vaginitis. There is no evidence that the tucked-up (juvenile) seen in dogs spayed young and sometimes associated with perivulvar disease is permanently changed by allowing a dog to go through one heat cycle.

UNIVERSITY OF MINNESOTA UNIVERSITY OF MINNESOTA Veterinary Medical Center Veterinary Medical Center

PREPUBERAL (PUPPY) VAGINITIS PREPUBERAL (PUPPY) VAGINITIS If clinical signs are mild to moderate, If clinical signs are severe, more aggressive conservative therapy is best: therapy may be warranted: - Collect vaginal culture sample and treat only if - As for conservative therapy there is significant growth - Consider use of (close growth - Clean the perivulvar area as needed with baby plates in young dogs) or glucocorticoids (altered wipes or non-alcohol otic cleanser pharmacokinetics and perhaps increased side- effects in young dogs) - +/- of going through one heat cycle?

UNIVERSITY OF MINNESOTA UNIVERSITY OF MINNESOTA Veterinary Medical Center Veterinary Medical Center

ADULT-ONSET VAGINITIS VAGINITIS For adult-onset vaginitis, the most common underlying conditions are: - Spayed dogs - Urinary tract infection - Onset of clinical signs variable - Vaginal anatomic anomalies - Most common presenting complaints are passage of mucoid vulvar discharge and vulvar licking, +/- urinary incontinence

UNIVERSITY OF MINNESOTA UNIVERSITY OF MINNESOTA Veterinary Medical Center Veterinary Medical Center

9 VAGINITIS VAGINITIS - Diagnosis Dogs are not reported to get yeast vaginitis, as Digital vaginal examination is common in women, in North America. Vaginal culture and cytology, urine culture and UA (cysto) Vaginoscopy Vaginography?

UNIVERSITY OF MINNESOTA UNIVERSITY OF MINNESOTA Veterinary Medical Center Veterinary Medical Center

VAGINITIS VAGINITIS E. coli When evaluating for vaginal anatomic beta hemolytic Streptococcus sp. anomalies, which is best? alpha hemolytic Streptococcus sp. Pasteurella sp. Staphylococcus sp. Proteus mirabilis Bacillus sp. Corynebacterium sp. Pseudomonas aeruginosa Klebsiella sp. Mycoplasma sp.

UNIVERSITY OF MINNESOTA UNIVERSITY OF MINNESOTA Veterinary Medical Center Veterinary Medical Center

VAGINITIS VAGINITIS When evaluating for vaginal anatomic How do we determine if a vaginal anomaly is a anomalies, which is best? significant contributor to disease in a given case? - Urine pooling - Site of inflammation on vaginoscopy

UNIVERSITY OF MINNESOTA UNIVERSITY OF MINNESOTA Veterinary Medical Center Veterinary Medical Center

10 VAGINITIS VAGINITIS One study defined “significant” stricture in the as a vestibulovaginal ratio of less than What about changes in vulvar conformation and 0.20. A subsequent study identified many subsequent perivulvar dermatitis? asymptomatic dogs with strictures that would be defined as moderate to severe using this scheme. Crawford JT et al. Influence of vestibulovaginal stenosis, pelvic bladder, and recessed vulva on response to treatment for clinical signs of lower urinary tract disease in dogs: 38 cases (1990-1999). JAVMA 2002;221:995. Wang KY et al. Vestibular, vaginal, and urethral relations in spayed dogs with and without lower urinary tract signs. J Vet Intern Med 2006;20:1065.

UNIVERSITY OF MINNESOTA UNIVERSITY OF MINNESOTA Veterinary Medical Center Veterinary Medical Center

VAGINITIS VAGINITIS In dogs presenting with a recessed vulva and Treatment subsequent perivulvar dermatitis and - May resolve spontaneously associated chronic UTIs or vaginitis, 13 of 20 dogs (65%) showed clinical improvement in one study and 28 of 34 dogs (82%) in another study. Crawford JT et al. Influence of vestibulovaginal stenosis, pelvic bladder, and recessed vulva on response to treatment for clinical signs of lower urinary tract disease in dogs: 38 cases (1990-1999). JAVMA 2002;221:995. Hammel SP et al. Results of vulvoplasty for treatment of recessed vulva in dogs. JAAHA 2002;38:79083.

UNIVERSITY OF MINNESOTA UNIVERSITY OF MINNESOTA Veterinary Medical Center Veterinary Medical Center

VAGINITIS VAGINITIS Treatment Treatment - If an underlying cause can be identified, - If no underlying cause is identified or if the treat for that. problem continues: UTIs – treat for underlying causes of recurrent UTI, appropriate culture and therapy DES and/or PPA Surgical repair of vaginal anomalies? Glucocorticoids Treatment for atopy?

UNIVERSITY OF MINNESOTA UNIVERSITY OF MINNESOTA Veterinary Medical Center Veterinary Medical Center

11 VAGINITIS VAGINITIS Treatment Treatment - If no underlying cause is identified or if the - If no underlying cause is identified or if the problem continues: problem continues: Antibiotics – based on culture and DES and/or PPA – as for urinary sensitivity – consider low-dose long-term incontinence – subclinical urinary incontinence therapy at night, as for chronic UTIs as cause of inflammation?

UNIVERSITY OF MINNESOTA UNIVERSITY OF MINNESOTA Veterinary Medical Center Veterinary Medical Center

VAGINITIS VAGINITIS Treatment Treatment - If no underlying cause is identified or if the - If no underlying cause is identified or if the problem continues: problem continues: Glucocorticoids – not used in dogs with Treatment for atopy? – work-up for significant urinary incontinence allergies or treatment trial with diphenhydramine or hydroxyzine

UNIVERSITY OF MINNESOTA UNIVERSITY OF MINNESOTA Veterinary Medical Center Veterinary Medical Center

CESAREAN SECTION DYSTOCIA Planned (elective) Emergency Margaret V. Root Kustritz, DVM, PhD, DACT University of Minnesota

UNIVERSITY OF MINNESOTA UNIVERSITY OF MINNESOTA Veterinary Medical Center Veterinary Medical Center

12 CESAREAN SECTION CESAREAN SECTION Planned (elective) Planned (elective) Reasons Reasons – bitch or breed predisposed to dystocia, excessively small or large litter size Timing – history of C-section? Emergency Timing Emergency

UNIVERSITY OF MINNESOTA UNIVERSITY OF MINNESOTA Veterinary Medical Center Veterinary Medical Center

CESAREAN SECTION CESAREAN SECTION Planned (elective) Planned (elective) Reasons Determination of term pregnancy Timing – Surfactant not laid down until Ovulation timing 57-60 days of gestation – cannot take pups Decline in serum progesterone prematurely! Radiographs / ultrasound Emergency

UNIVERSITY OF MINNESOTA UNIVERSITY OF MINNESOTA Veterinary Medical Center Veterinary Medical Center

Proestrus - Early Proestrus - Late BREEDING MANAGEMENT - Physical changes - Vaginoscopic changes

Estrus Diestrus

UNIVERSITY OF MINNESOTA UNIVERSITY OF MINNESOTA Veterinary Medical Center Veterinary Medical Center

13 PROGESTERONE ASSAY - ELISA - Quick, +/- accurate

- RIA - Slow, +++ accurate

UNIVERSITY OF MINNESOTA UNIVERSITY OF MINNESOTA Veterinary Medical Center Veterinary Medical Center

PROGESTERONE EVENT CONCENTRATION (ng/ml) < 1.0 Anestrus or early proestrus; must re-test CESAREAN SECTION 1.0 – 1.9 May be three days prior to ovulation; re-test Planned (elective) 2.0 – 2.9 Two days prior to ovulation Determination of term pregnancy 3.0 – 3.9 One day prior to ovulation

4.0 – 10.0 Ovulation day Ovulation timing > 10.0 with cornified Within 5 days of ovulation; Decline in serum progesterone cytology breed ASAP > 10.0 with non-cornified Diestrus Radiographs / ultrasound cytology

UNIVERSITY OF MINNESOTA UNIVERSITY OF MINNESOTA Veterinary Medical Center Veterinary Medical Center

PARTURITION CESAREAN SECTION - Onset of parturition is an endocrine event, initiated by the fetus(es) Planned (elective) - Progesterone decline prior to parturition Determination of term pregnancy causes a transient decrease in body Ovulation timing temperature; rectal temperature will fall to less than 99-100°F within the 24 hrs Decline in serum progesterone preceding onset of parturition. Radiographs / ultrasound

UNIVERSITY OF MINNESOTA UNIVERSITY OF MINNESOTA Veterinary Medical Center Veterinary Medical Center

14 CESAREAN SECTION Planned (elective) Reasons Timing – Ovulation timing, decline in progesterone, radiography or ultrasonography Emergency

UNIVERSITY OF MINNESOTA UNIVERSITY OF MINNESOTA Veterinary Medical Center Veterinary Medical Center

NORMAL PARTURITION CESAREAN SECTION - Onset of parturition is an endocrine event, initiated by the fetus(es) Planned (elective) - Progesterone decline prior to parturition Emergency – relieving dystocia causes a transient decrease in body temperature; rectal temperature will fall to less than 99-100°F within the 24 hrs preceding onset of parturition.

UNIVERSITY OF MINNESOTA UNIVERSITY OF MINNESOTA Veterinary Medical Center Veterinary Medical Center

NORMAL PARTURITION NORMAL PARTURITION - Stage I = cervical dilation Bitch restless, panting, may vomit - Three stages: Abdominal contractions not visible Stage I = cervical dilation Length variable; may last 6-12 hrs Stage II = expulsion of fetuses Stage III = expulsion of placentas

UNIVERSITY OF MINNESOTA UNIVERSITY OF MINNESOTA Veterinary Medical Center Veterinary Medical Center

15 NORMAL PARTURITION NORMAL PARTURITION - Stage II = expulsion of fetuses - Stage II = expulsion of fetuses - Abdominal contractions strong and coordinated - Length variable; dependent on litter size - Pups usually born every 30-60 minutes; should deliver first pup within 4 hrs of onset of stage II, subsequent pups within 2 hours

UNIVERSITY OF MINNESOTA UNIVERSITY OF MINNESOTA Veterinary Medical Center Veterinary Medical Center

NORMAL PARTURITION NORMAL PARTURITION - Stage II = expulsion of fetuses - Stage III = expulsion of placentas - Usually pass within 5-15 minutes of fetus - Bitch may eat them; no known physiologic value

UNIVERSITY OF MINNESOTA UNIVERSITY OF MINNESOTA Veterinary Medical Center Veterinary Medical Center

NORMAL PARTURITION DYSTOCIA - Normal postpartum discharge = lochia "Dys" = difficult - Slight elevation in body temperature "Tokos" = birth

UNIVERSITY OF MINNESOTA UNIVERSITY OF MINNESOTA Veterinary Medical Center Veterinary Medical Center

16 DYSTOCIA DYSTOCIA Maternal causes Fetal causes - Obstruction of passage - Obstruction of passage - Abnormal uterine function – primary versus - Developmental abnormality secondary uterine inertia - Abnormality of presentation - Abnormal pregnancy

UNIVERSITY OF MINNESOTA UNIVERSITY OF MINNESOTA Veterinary Medical Center Veterinary Medical Center

DYSTOCIA

UNIVERSITY OF MINNESOTA UNIVERSITY OF MINNESOTA Veterinary Medical Center Veterinary Medical Center

DYSTOCIA DYSTOCIA Is dystocia present? Is dystocia present? - Obvious malpresentation - Abnormal vulvar discharge - Timing - Labor not progressing - Stage I more than 12 hrs - Bitch systemically ill - Stage II more than 4 hrs (weak - Prolonged gestation contractions) - High risk pregnancy - Stage II more than 30 min (strong - Client concerned contractions) - Time between pups greater than 2 hrs - Rectal temperature drop more than 24 hrs ago

UNIVERSITY OF MINNESOTA UNIVERSITY OF MINNESOTA Veterinary Medical Center Veterinary Medical Center

17 DYSTOCIA Diagnostics * Complete physical examination * Digital vaginal examination * Radiographs * Ultrasound? Calcium? Others?

UNIVERSITY OF MINNESOTA UNIVERSITY OF MINNESOTA Veterinary Medical Center Veterinary Medical Center

DYSTOCIA DYSTOCIA Manipulative treatment Pharmacologic treatment - Feathering - Oxytocin - Digital manipulation - Calcium - Instruments - Glucose

UNIVERSITY OF MINNESOTA UNIVERSITY OF MINNESOTA Veterinary Medical Center Veterinary Medical Center

DYSTOCIA Surgical treatment - Cesarean section CESAREAN SECTION - With medical therapy as first choice for treatment, over 50% of bitches will eventually go to C-section anyway because of lack of complete response to medical therapy - Breeds at greatest risk are Boston terrier, English bulldog and French bulldog - Scheme for dystocia management

UNIVERSITY OF MINNESOTA UNIVERSITY OF MINNESOTA Veterinary Medical Center Veterinary Medical Center

18 Key for dystocia management:

1. The puppy is present in the birth canal and can be manipulated for delivery ----- 2 1'. The puppy is not present in the birth canal or cannot be manipulated for delivery ------3

2. Attempt delivery with lubrication and gentle traction. After that pup is passed or if other pups are present in utero ------3 CESAREAN SECTION 2'. Attempt delivery with lubrication and gentle traction. If the pup cannot be delivered ----- 4

3. Fetal heart rate is less than 150 beats per minute ----- 4 Anesthesia – prep and pre-oxygenate bitch 3'. Fetal heart rate is 150 beats per minute or more ------5 4. Perform Cesarean section. Hysterotomy versus en-bloc 5. Abdominal radiographs have been taken ------6 5'. Abdominal radiographs have not been taken ----- 7 ovariohysterectomy

6. Pups are too large to pass or are malpositioned ----- 4 6'. Pups are not too large to pass and are not malpositioned ----- 8 Contraindications to OHE (spay) at time of C- 7. Take abdominal radiographs and go to ----- 6 section? 8. Four or fewer pups are present ----- 9 8'. More than four pups are present ----- 4

9. Oxytocin therapy may be attempted as follows: Give 2-5 IU IM, watch for effect for 20 minutes. If no effect is seen, give 2-5 IU oxytocin IM plus a 5 ml bolus of 10% calcium gluconate SQ and watch for effect for 20 minutes. If no effect seen ----- 4

UNIVERSITY OF MINNESOTA UNIVERSITY OF MINNESOTA Veterinary Medical Center Veterinary Medical Center

PUPPY RESUSCITATION PUPPY RESUSCITATION Stimulation and removal of fluids Stimulation and removal of fluids – Rub, rub rub – suction of nose and mouth External source of heat External source of heat Oxygen Oxygen

UNIVERSITY OF MINNESOTA UNIVERSITY OF MINNESOTA Veterinary Medical Center Veterinary Medical Center

PUPPY RESUSCITATION PUPPY RESUSCITATION Stimulation and removal of fluids Stimulation and removal of fluids External source of heat – Hypothermia External source of heat associated with slow heart rate, lack of Oxygen oxygenation of tissues, metabolic pH changes – all of these hamper resuscitation Oxygen

UNIVERSITY OF MINNESOTA UNIVERSITY OF MINNESOTA Veterinary Medical Center Veterinary Medical Center

19 Apgar scores in pups? QUESTIONS? Pain management after C-section and possible effect on pups? Non-steroidal anti-inflammatories contraindicated Opioids?

UNIVERSITY OF MINNESOTA UNIVERSITY OF MINNESOTA Veterinary Medical Center Veterinary Medical Center

Dr. Peggy Root Kustritz Ph = 612-624-7290 Fx = 612-624-0751 Email = [email protected] Website = https://sites.google.com/a/umn.edu/margaret-v- peggy-root-kustritz/home

UNIVERSITY OF MINNESOTA Veterinary Medical Center

@VetGirlOnTheRun

VetGirlOnTheRun

This material is copyrighted by VETgirl, LLC. None of the materials provided may be used, reproduced or transmitted, in whole or in part, in any form or by any means, electronic or otherwise, including photocopying, recording or the use of any information storage and retrieval system, without the consent of VETgirl, LLC. Unless expressly stated otherwise, the findings, interpretations and conclusions expressed do not necessarily represent the views of VETgirl, LLC. Medical information here should be references by the practitioner prior to use. Under no circumstances shall VETgirl, LLC. be liable for any loss, damage, liability or expense incurred or suffered that is claimed to have resulted from the use of the information provided including, without limitation, any fault, error, omission, interruption or delay with respect thereto. If you have any questions regarding the information provided, please contact [email protected]

20