Post-Partum Problems: the Top Ten List

IN-DEPTH: PERINATOLOGY—END OF PREGNANCY THROUGH BEGINNING OF LIFE Post-Partum Problems: The Top Ten List Regina M. Turner, VMD, PhD, Diplomate ACT This article reviews the top ten post-partum problems in mares. The problems are broadly broken down into two main categories: those that cause pain or systemic illness and those that do not. Problems resulting in pain or systemic illness include: septic metritis, hemorrhage from uterine or ovarian vessels, gastrointestinal problems/colic, uterine laceration and uterine horn intussusception/ uterine prolapse. Issues in systemically healthy mares include: retained fetal membranes, post- Cesarean section management, post-dystocia management, hypogalactia/agalactia, and urovagina/ urometra. For each topic, practical management and treatment options are presented and the prognosis for future reproductive success is discussed. Author’s address: New Bolton Center, De- partment of Clinical Studies, School of Veterinary Medicine, University of Pennsylvania, 382 West Street Road, Kennett Square, PA 19348; e-mail: [email protected]. © 2007 AAEP. 1. Introduction tion. Using these data as a starting point, this Problem post-partum mares often fit into one of two manuscript will review the most common findings in broad categories: mares presenting as painful or mares presenting with one of the top five causes for systemically ill and mares presenting as systemi- post-partum pain or systemic illness. Common cally healthy but with post-partum problems that treatment options will be reviewed, and prognosis can affect their future wellbeing and/or fertility. for recovery and future reproductive success will be The objective of this manuscript is to review the discussed. most common problems seen in these mares and to review practical management and treatment op- 1. Septic Metritis tions for their problems. Additionally, prognosis Post-partum metritis can vary in severity. In its for future reproductive success will be described. worst form, toxic metritis can be life threatening, particularly if the affected mare becomes laminitic. 2. The Post-Partum Painful/Systemically Ill Mare The first broad group of problem mares are those Signalment/History with pain or systemic illness as the presenting com- Septic metritis can affect mares of any age or parity. plaint. In these cases, components of the general History often includes dystocia and retained fetal workup include signalment/history, general physi- membranes. cal examination, clinical hematology and chemistry evaluation, abdominocentesis, palpation and ultra- Physical Examination sonography of the reproductive tract per rectum, Mares may present with classic signs of endotox- manual examination of the reproductive tract per emia. Most are tachycardic. Fever is often vagina, and abdominal ultrasonographic examina- present, and in severe cases, the mare’s mucous NOTES AAEP PROCEEDINGS ր Vol. 53 ր 2007 305 IN-DEPTH: PERINATOLOGY—END OF PREGNANCY THROUGH BEGINNING OF LIFE membranes may seem toxic. Malodorous vaginal Prognosis for Future Reproductive Success discharge may be noted. In most cases, there is an underlying cause for the Clinical Hematology and Chemistry metritis (retained membranes or dystocia). As such, barring these problems in the future, recov- The most common hematology and chemistry eval- ered mares often can be bred again and conceive uation findings are leukopenia and hyperfibrinogen- with no increased risk of developing septic metritis emia. Less often, leukocytosis is a finding. after subsequent parturitions. Because metritis Abdominocentesis typically causes delayed uterine involution, one may need to delay rebreeding the mare until involution is Abdominocentesis is often normal unless a concur- complete.2 In general, allowing the mare to have rent uterine laceration is present. one estrous after complete resolution of the metritis Palpation and Ultrasonography of the is usually sufficient. A complete breeding sound- Reproductive Tract per Rectum ness examination may be prudent before rebreeding these animals Palpation and ultrasonography of the reproductive tract per rectum usually finds an atonic, poorly in- 2. Hemorrhage From Uterine or Ovarian Vessels voluted uterus. Often, intrauterine fluid is present Hemorrhage from uterine or ovarian vessels typi- together with fetal membranes. cally occurs during parturition, and problems be- Examination of the Reproductive Tract per Vagina come obvious in the immediate post-partum period. Less commonly, hemorrhage may occur during preg- Malodorous uterine fluid is usually present, and fe- nancy or up to several days post-partum.5–7 Most tal membranes are often retained. cases involve rupture of the middle uterine artery Abdominal Ultrasonographic Examination (MUA), utero-ovarian arteries, or external iliac arteries.6 Older, multiparous mares are at greatest The abdominal ultrasonographic examination is risk.7,8 It is possible that mild cases of MUA rup- usually non-remarkable unless a concurrent uterine ture may go undiagnosed if the mare does not show laceration is present. clinical signs. However, in moderate to severe Treatment cases, clinical signs are often apparent. The spe- cific signs of this problem can vary, often depending Treatment includes administration of broad-spec- on where the rupture occurs. trum antimicrobials such as potassium penicillina b (22,000 IU/kg, q6 h, IV) and gentamicin sulfate (6.6 Signalment/History mg/kg, q 24 h, IV) and administration of flunixin megluminec (1.1 mg/kg) both for its anti-inflamma- Older, multiparous mares are at higher risk. Often, tory and anti-end toxic effects. If fetal membranes the delivery is uncomplicated. The mare may have a are present, oxytocin therapy is initiated (see section past history of post-partum hemorrhage. on retained fetal membranes for dosages and dosing Physical Examination intervals). Even if membranes are not present, oxytocin may be used in conjunction with large- Severe tachycardia is a common finding, usually volume intrauterine saline lavage to help clear the associated with either pain, hemorrhage, or both. uterus of fluid and debris. Large-volume lavage Pale mucous membranes are suggestive of a MUA typically requires a minimum of3lofsaline and bleed. However, membrane color may be normal may require many more (up to 15 l or more) to be during the acute phase. Classic general signs of effective. Typically, we will continue to lavage un- hemorrhage from the reproductive tract include til the effluent recovered is clear. Additional anti- sweating, flehmen, vocalization, and muscle fascicu- endotoxin therapy may include equine plasma lations. When the artery ruptures such that hem- polymixin B (1.5 million IU/550 kg horse diluted and orrhage occurs into the uterus, the mare may administered slowly, q 12 h, IV for 3 days)d and/or present for colic associated with uterine distension. pentoxifylline (7.5 mg/kg, q 12 h, PO).e1 Affected Alternatively, rupture can occur such that hemor- mares should be monitored carefully for the devel- rhage is in the broad ligament. In these cases, pain opment of laminitis,2–4 and treatments designed to is often more apparent in association with stretch- prevent the development of laminitis (such as icing ing of the broad ligament. Lastly, rupture can oc- of the hooves and stabling the mare on soft footing cur into the abdominal cavity. These mares often such as shavings or sand) should be instituted. are less painful, but they may bleed more profusely and may be at greater risk for sudden death because Prognosis for Systemic Recovery of uncontrolled hemorrhage. If complications of metritis (e.g., laminitis and peri- tonitis) can be avoided, the prognosis for systemic Clinical Hematology and Chemistry recovery is good. Development of complications Interestingly, complete blood counts in the acute will lower the prognosis. In its worst form, septic phase of hemorrhage may show an increase, de- metritis can be life threatening. crease, or no change in packed cell volume (PCV). 306 2007 ր Vol. 53 ր AAEP PROCEEDINGS IN-DEPTH: PERINATOLOGY—END OF PREGNANCY THROUGH BEGINNING OF LIFE This is most likely caused by splenic contraction, mg/kg IV alone or in combination with xylazine,g 0.4 hemoconcentration, and redistribution of red cells. mg/kg) and anti-inflammatory drugs (e.g., flunixin) Hypoproteinemiaisamoreconsistentfinding. How- typically are administered to improve the mare’s ever, if the mare survives the acute phase, a drop in comfort and reduce distress. Acepromazine is to be PCV usually is observed over the next several days. avoided because of its hypotensive effects.2 As soon as is practical, the mare is placed in a quiet stall, Abdominocentesis often with the doors and windows closed to minimize Mares with hemorrhage into the abdomen or into disturbances, and the “wait and see” approach is the broad ligament often have significantly in- taken. In more desperate situations, blood trans- creased numbers of red blood cells (RBCs) in abdom- fusions and/or hypertonic saline may be inal fluid. administered. IV naloxoneh may be administered (0.01–0.02 mg/ Palpation and Ultrasonography of the kg), because there are anecdotal reports that sug- Reproductive Tract per Rectum gest that this may improve survival in This may be diagnostic, because large hematomas hemorrhaging mares. In other species, it has been can often be identified in the uterine wall or in the suggested that the mechanism of action of this opi- broad ligament. Alternatively, or in addition to oid antagonist is to provide analgesia

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