17.4.4: Post-partum period

Question 1

When should uterine involution be complete by in the cow?

Answer 1

3-6 weeks post-partum

Question 2

True/false: Lochia is normal in the cow for 60 days after calving.

Answer 2

False
Lochia (red-brown/white discharge that lacks odour) is normal for ~23 days PP in the cow

Question 3

True/false: late gestation immunosuppression continues in early post-partum.

Answer 3

True

Question 4

Retained foetal membranes

Answer 4

the non-expulsion of foetal membranes beyond 24hrs post calving.
* Normal placental expulsion should occur within 6hrs of calving.

Question 5

What substance links the foetal cotyledon and maternal caruncle?

Answer 5

Collagen

Question 6

How is breakage of the collagen links between the cotyledon and caruncles facilitated?

Answer 6

Relaxin secretion and decline of progesterone

Question 7

Use of which NSAID around calving has been associated with significantly increased risk of retained foetal membranes?

Answer 7

Flunixin

Question 8

Risk factors for RFM

Answer 8

• Use of flunixin meglumine
• Induced parturition
• Shortened gestation
• Infectious disease e.g. BVDV
• Uterine trauma: C-section, dystocia, fetotomy
• Twinning
• Nutritional deficiency e.g. Vitamin E/selenium deficiency; NEB
• Abortion
• Immuno-suppression: failure to switch off immuno-protective mechanisms from pregnancy

Question 9

How should you treat RFM?

Answer 9

There is no clear consensus on treatment. Options include:
* Manual removal (should only perform if no pressure required)
* Systemic antibiotic therapy but only if the cow is systemically unwell
* Benign neglect - RFM are usually expelled in 2-11 days and this seems to be the best outcome

Question 10

Why should you not remove RFM by force? What could you do alternatively if they are getting in the way during milking?

Answer 10

• Risk of haemorrhage and uterine tears
• Can tie the RFM to the tail base, keeping them up and out of the way

Question 11

Define retained foetal membranes in the cow and sheep

Answer 11

• In both species, the placenta is usually expelled within 6hrs of parturition
• Sheep = RFM if retained >18hrs
• Cow = RFM if retained >24hrs

Question 12

What are the risk factors for RFM in sheep?

Answer 12

• Uterine trauma: C-section, dystocia
• Selenium or Vitamin A deficiency
• Infectious abortion
• Obesity of dam
• Hypocalcaemia

Question 13

What is the difference between metritis and endometritis?

Answer 13

Metritis: infection of all layers of the uterus.
Endometritis infection of the endometrium only.
Metritis occurs <21 days PP, endometritis is after this.

Question 14

Intrauterine antibiotics are appropriate for
a) metritis
b) endometritis
c) both
d) neither

Answer 14

b) endometritis

Question 15

Define clinical metritis

Answer 15

• Abnormally enlarged uterus with purulent uterine discharge
• The animal is not systemically unwell
• Occurs within 21 days post-partum

Question 16

Define puerperal metritis

Answer 16

• Toxic metritis
• Abnormally enlarged uterus with fetid watery red-brown discharge
• There are systemic signs of illness: decreased milk yield, dullness, inappetance, signs of toxaemia.
• Fever >39.5C
• Occurs within 21 days post-partum, usually <10 days

Question 17

How do we grade metritis in the cow? How is this different to the grading of endometritis?

Answer 17

• Metritis - graded on the clinical signs in the cow. In practice, we tend not to do this - we just say if it is toxic or not.
• Endometritis - graded on the discharge

Question 18

Risk factors for metritis in cows

Answer 18

• Following abnormal stage 1 or 2 of labour: severe dystocia, prolonged traction, damage to the birth canal
• Uterine inertia
• Premature calving and abortion
• Induced calving
• Twins
• RFM
• Dairy > beef

Question 19

Risk factors for metritis in sheep

Answer 19

In sheep, metritis is often associated with:
* Dead foetuses
* Assisted delivery of multiple lambs without proper hygiene
* Uterine prolapse

Question 20

Describe the grades of metritis in the cow

Answer 20

• Grade 1 = abnormally enlarged uterus with purulent uterine discharge; no systemic signs of ill health
• Grade 2 = above but with signs of systemic illness e.g. decreased milk yield, dullness, fever
• Grade 3 = a.k.a. pueperal/toxic metritis. Abnormally enlarged uterus with purulent uterine discharge + signs of toxaemia

Question 21

Clinical signs of toxaemia as with Grade 3 metritis

Answer 21

• Inappetance
• Cold extremities
• Depression
• ± collapse

Question 22

True/false: it is important to treat Grade 1 metritis.

Answer 22

False

Question 23

If you have a case of metritis that requires antimicrobials, which will you choose and how will you deliver it/them?

Answer 23

• Should give systemic antibiotics; intrauterine alone = insufficient
• Penicillin/amoxicilin an appropriate choice
• Need to give for 3-5 days

Question 24

Treatment protocol for metritis with systemic signs

Answer 24

• Systemic antimicrobials e.g. penicillins/amoxicillin for 3-5 days
• Supportive therapy: TLC, NSAIDs, fluid therapy, calcium borogluconate
• Could consider uterine lavage

Question 25

What complications is a cow with Grade 3 metritis at risk of?

Answer 25

* Sepsis * Peritonitis * UTI * Reproductive adhesions * Others: endocarditis, pneumonia, polyarthritis

Question 26

What constitutes TLC for a cow?

Answer 26

* Deep straw bedding * Easy access to feed and water * Companions nearby but not enough cows to generate competition/bullying for resources

Question 27

Why is uterine lavage controversial for cows with metritis?

Answer 27

* The uterus is already inflamed and stretched * There is an argument that by adding more fluid and increasing pressure we could push bacteria through the leaky wall, increasing the risk of peritonitis * If doing this, use sterile saline only and remove the fluid you put in

Question 28

**Clinical endometritis**

Answer 28

* Purulent uterine discharge (>50% pus) >21 days after parturition OR * Mucopurulent uterine discharge (50% pus, 50% mucus) >26 days after parturition ("whites")

Question 29

**Subclinical endometritis**

Answer 29

* >18% neutrophils in uterine cytology sample collected 21-33 days after parturition OR * >10% neutrophils in uterine cytology sample collected 34-47 days after parturition * Uterine discharge is not yet seen

Question 30

Risk factors for endometritis

Answer 30

* Trauma * Hygiene: calving environment, post-partum housing, personnel * Metabolitic state and NEB * Herd size - larger herds more at risk

Question 31

How could you diagnose clinical endometritis?

Answer 31

* Transrectal palpation ± ultrasonography * Vaginal exam (inc. cervix): manual/metricheck

Question 32

How could you diagnose subclinical endometritis?

Answer 32

* Cytology on cervical swabs or lumen flush * Uterine biopsy

Question 33

Describe the findings on this uterine ultrasound

Answer 33

* Thickened uterine wall * "Snowglobe" appearance of pus (flocculant fluid) in the lumen * Suggestive of endometritis

Question 34

What is this and what is it used for?

Answer 34

* Metricheck = rubber diaphragm on steel rod * Inserted into vagina, diaphragm collects fluid from vaginal floor

Question 35

**True/false**: you can use a metricheck (rubber diaphragm + steel rod device) to diagnose subclinical endometritis.

Answer 35

**False** * Need cytology to diagnose subclinical endometritis * Need to use a cytobrush (insert into uterus through cervix)

Question 36

What should you do before inserting a cytobrush into the uterus to investigate subclinical endometritis?

Answer 36

* Make sure the brush is screwed on properly! There is a FB risk of the brush detaching in the uterus.

Question 37

What are the pros and cons of taking an endometrial biopsy in the cow?

Answer 37

✅ Predictive for subsequent fertility ❌ Costly ❌ Time consuming ❌ Not often clinically available ❌ May depress fertility

Question 38

What are the pros and cons of uterine cytology (e.g. using cytobrush) in the cow?

Answer 38

✅ Practical and relatively easy to do ✅ Can diagnose subclinical endometritis ❌ Does not produce a rapid diagnosis

Question 39

What are the pros and cons of uterine cytology (e.g. using cytobrush) in the cow?

Answer 39

✅ Practical and relatively easy to do ✅ Can diagnose subclinical endometritis ❌ Does not produce a rapid diagnosis

Question 40

How do we grade endometritis?

Answer 40

* Based on colour and qualities of discharge * Grade 0-3

Question 41

What grade endometritis is this?

Answer 41

**Grade 1** Mucus contains flecks of white or off-white pus.

Question 42

What grade endometritis is this?

Answer 42

**Grade 2** Discharge contains <50% white or off-white mucopurulent material

Question 43

What grade endometritis is this?

Answer 43

**Grade 3** Discharge containing >50% purulent material, usually white or ywllow but occasionally sangiuneous.

Question 44

What grade endometritis is this?

Answer 44

**Grade 3** Discharge containing >50% purulent material, usually white or ywllow but occasionally sangiuneous

Question 45

True/false: culture and sensitivity is essential before beginning endometritis treatment.

Answer 45

**False** Culture and sensitivity is rarely done as it is time-consuming and we need to treat the cow there are then.

Question 46

Which bacteria are most commonly implicated in endometritis?

Answer 46

* *E. coli * T. pyogenes * F. necrophorum* * Other opportunistic bacteria

Question 47

True/false: some cases (approx. 33-46%) of endometritis in the cow spontaneously self-cure.

Answer 47

**True**

Question 48

What are the possible treatment options for endometritis in the cow?

Answer 48

* Intrauterine infusion of antiseptics * PGF2a * Intrauterine antibiotics

Question 49

What are the pros and cons of using intrauterine infusions of antiseptics for treatment of endometritis?

Answer 49

* Minimal pros really * These are of limited value * Risk of injury, peritonitis, septicaemia (uterine wall is inflamed and leaky)

Question 50

How can be PGF2a be helpful in treating endometritis?

Answer 50

* Stimulates uterine defences * Luteolysis of CL -> reduced progesterone -> return to oestrus * Increased uterine tone and open cervix

Question 51

Which antibiotic is available for intrauterine use?

Answer 51

* **Cefapirin** (Trade name Metricure) * This is a 1st gen cephalosporin (Category C) but as yet the only product licensed for intrauterine use * This may become more difficult to use in future on milk contracts with large retailers

Question 52

**Pyometra**

Answer 52

Purulent or mucopurulent material within the uterine lumen, causing uterine distension, in the presence of a **closed cervix** and a **functional corpus luteum**.

Question 53

How common is pyometra in cattle and small ruminants?

Answer 53

Uncommon

Question 54

How could you diagnose pyometra in cattle?

Answer 54

* Transrectal palpation and ultrasound * History of anoestrus

Question 55

True/false: in a cow with pyometra, you would see discharge on vaginal exam.

Answer 55

**False** The cervix is by definition closed so you would not see discharge on vaginal exam.

Question 56

What characteristics must an intrauterine antibiotic have?

Answer 56

* Must work against gram +ve, gram -ve, aerobic and anaerobic bacteria * Must work in a microaerophilic environment * Must work in an evenly distributed fashion across the uterine lumen, with good penetration in endometrial layers * Must work without inhibiting uterine defence mechanisms * Must work without traumatising the endometrium (must not cause irritation) * Must work without reducing fertility by producing irreversible changes * Must be cost-effective * Must have a known excretion pattern so appropriate withdrawal times can be applied

Question 57

What are the long term impacts of endometritis on the cow?

Answer 57

* Reduced fertility (=reduced chance of conception) * Increased risk of cull (due to reproductive failure)