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Flashcards in Disorders of the puerperium Deck (28)
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1

peurperium - define

The period after parturition when reproductive tract
returns to its non-pregnant condition so that the female may become pregnant again
shortest time desirable

2

Normal processes that occur during the puerperium

Involution
Regeneration of endometrium
Elimination of contaminants of the reproductive tract
Resumption of ovarian cyclical activity

3

Disorders that affect normal puerperium

Dystocia
Uterine Prolapse
Retention of foetal membranes (RFM)
Uterine Disease

4

involution - uterus

Reduction in the size of uterus and cervix after calving
greatest decrease in uterine size in 1st few days
after calving [myometrial contractions; ease of discharge of fluids/tissue debris, compression of uterine vasculature]
diameter of the previously gravid horn will halve in a period of 5 days, length will be halved by 15 days postpartum.
By 8-10 days postpartum whole of the uterus should be palpable per rectum.
Complete involution occurs within 26-50 days; changes after 25 days pp are minimal

5

involution - cervix

Difficult to fit a hand through cervix into the uterus by 10-12hrs postpartum
by 96h postpartum only 2 fingers can be admitted through the cervix reduction in external diameter of the cervix is also appreciable when palpated per rectum;
In case of normal involution, by 25 days postpartum the diameter of the cervix starts to exceed than that of the previously gravid uterine horn.

6

involution

Shift from hypertrophy (due to increase in collagen and smooth muscle) to atrophy (due to loss of smooth muscle, and collagen degradation) Reduction in the size of myofibrils
Prostaglandins may control involution, so their (and possibly oxytocin) exogenous use may be used to accelerate involution

7

regeneration of endometrium

Uterine caruncles undergo degenerative changes probably due to vasoconstriction and ischaemia and this results in necrosis + sloughing of caruncular tissue. Size of caruncles is considerably reduced by 25 days pp
Necrotic material when sloughed, along with blood and foetal fluids, constitutes the post partum lochial discharge.
lochial discharge occurs at days 2-9 post-partum - usually yellowish or reddish brown
Volume of lochia is variable. Normal lochial discharge does not have fetid odour
A systemic response (Acute phase proteins) is observed
Covering of the caruncular and inter-caruncular surfaces withendometrial epithelium...centripetal growth of cells from UGs

8

bacterial contamination

Bacterial species from the uterine lumen include;
Arcanobacterium pyogenes, E. coli, streptococci Staphylococci, Fusobacterium necrophorum
Lochial material provides an ideal growth medium

9

elimination of uterine bacterial contamination

phagocytosis by migrating leucocytes plus physical expulsion by uterine contractions and secretions
By about 5 weeks, 50% will be sterile and by 8-9 weeks most animals will have a sterile uterine lumen

10

Resumption of Ovarian Cyclical Activity

-ve feedback effect of high P4 during pregnancy,
pituitary is refractory to GnRH postpartum.
7-10 days post-partum - increase in plasma FSH
concentrations, associated with 1st post-partum follicular wave.
Ovulation will only occur if the follicle produces enough oestradiol to stimulate adequate LH secretion [LH receptors +IGFBPs proteases].
Dominant follicle on contra-lateral ovary and possibility of silent ovulation. Suckling delays ovarian cyclical activity
Luteal phase may be of normal length, or may be much shorter due to poor preovulutary development of the follicle leading to inadequate luteinisation of the CL

11

dystocia

breaks the host defence mechanisms - physical barriers of vulva and cervix
tissue damage, so more prone to contamination,
uterine inertia
Lack of sterility/hygiene due to obstetrical interventions and poor practice inc load of pathogens in uterus
Predisposes RFM & Uterine Disease

12

uterine prolapse

Previously gravid horn becomes invaginated
0.1-0.6% of calvings
More in pluriparous cows than in heifers
More in grossly protracted and assisted parturitions Usually in the first 24hrs post calving
Abdominal straining and flaccid uterus - Hypocalcaemia
REQUIRES URGENT ATTENTION
Survival rate – 75 to 80%
Increased calving to conception interval

13

uterine prolapse - risk factors

Prolonged dystocia
Foetal traction or oversize
Extreme laxity of the perineum and vulva
Hypocalcaemia
Paresis
Retained Foetal Membranes.

14

uterine prolapse - treatment

Protect and support the prolapse
Calcium borogluconate
Relieve ruminal tympany
Restrain the cow
Epidural
Clean the uterus
“Frog-Leg” position
Gentle replacement
Insure total inversion.
(Stitch the vulva)
Antibiotics + NSAIDs
Oxytocin

15

retained foetal membranes

Common complication of bovine parturition
Predisposes to uterine infection and therefore, contributes to infertility
Overall incidence is 6-8% but with dystocia 25-40%

16

Separation and Expulsion of the Placenta

Placental Maturation: – Changes in P4 and E2 concs, collagenase + proteases/glucosaminidases
– Reduction in the number of binucleate cells in the trophectoderm
– Exsanguination of foetal side of the Placenta and collapse of trophectodermal villi
– Distortion of the placentomes [Uterine Contractions ]
Lack of antioxidants, stress, oxidative injury and the role of PGF and PGE synthesis
IL8, Leukocyte migration and collagenases

17

reasons for retention

Failure of maturation of the placenta (e.g., in pre-mature calving)
Failure of detachment of foetal and maternal villi of the placentome
Inadequate uterine contractions due to hypocalcaemia or dystocia

18

reasons for retention - predisposing factors

Abortion
Stillbirth
Multiple Birth
Dystocia, premature calving
Infectious Placentitis (Brucellosis, Salmonellosis etc)
Hypocalcaemia
Hydrallantois
Increasing age of the dam
Prolonged gestation
Micronutrient deficiencies – Se, Vit E & A

19

retention - clinical features

Morbidity: lack of appetite, reduced milk yield
Mortality: 1-4% mainly related to metritis / toxaemia
Duration of retention depends on myometrial contractions; they cease by 36h after parturition
Fertility: No effect on its own if mating 60 days post-calving, Along with metritis, increases days open, services per conception, calving to 1st oestrus / service interval

20

retention - treatment

Traction: damage to endometrium, uterine infection and impaired reproductive performance
Wait until cow is 5 days calved before a veterinary exam
If the cow is pyrexic with depressed appetite and milk yield, treat for metritis
Antibiotics: parenteral or intrauterine?
Hormones
Prostaglandins?
Oxytocin?
Collagenase infusion into stumps of umbilical arteries of retained membranes

21

uterine disease

Bacterial contamination of uterus at every calving and its elimination during involution
Development of infection in some animals from contamination
Species of pathogens, degree of colonization and magnitude of immune response determine whether the infection results into -
Endometritis: endometrium and stratum spongiosum of submucosa, no systemic illness, leukocytes but no pus in uterine discharge
Metritis: deeper layers of uterus, systemic illness--mild to v. Severe: puerperal metritis
Pyometra: chronic, purulent exudates, CL, No systemic signs
Uterine disease usually impairs fertility

22

infection

Dystocia (and/or RFM) increases the load of pathogens, causes tissue damage and physical deformity of cervix + vulva, results into uterine inertia and predisposes to RFM

23

pathogenic bacteria

Arcanobacterium pyogenes
Fusobacterium necrophorum
Escherichia coli
Prevotella species (formerly bacteroides)
Clostridium species
Mannheimia haemolytica

24

endometritis

Incidence: 6-43%; does not affect general health but does affect fertility
Opportunist pathogens (like E-coli, subsequent overgrowth of A. pyogenes, F.necrophorum, Prevotella species)
Clinical Signs: mucopurulent discharge in clinical cases, no systemic illness, neutrophils in uterine luminal fluid
Diagnosis: Rectal palpation: poorly involuted uterus, Presence of discharge around cervical os (vaginoscope) - Metricheck to collect discharge:
Presence of neutrophils in cervical swabs;
20-33pp = >18%, 33-49pp = >10%, >50pp = >5%

25

endometritis - treatment

Stimulation of oestrus in both cyclic (PGF2α) and acyclic cows (3-5mg E2 or use of GnRH)
intrauterine cephapirin (metricure, Intervet)

26

Clinical Signs of Metritis—Puerperal metritis

Systemic illness
Purulent fetid fluid in the uterine lumen
Distended, fluid-filled atonic uterus
Elevated rectal temperature 40-41oC
Dullness, depression, milk drop, inappetence
Within few days of parturition, usually follows severe dystocia, uterine inertia, RFM
Sore, swollen and inflamed vagina and vulva
Systemic toxaemia: fast weak pulse, rapid respiration, dehydration, sluggish capillary refill time, diarrhoea
Pyaemia: concurrent peritonitis, mastitis

27

peurperal metritis - treatment

Case dependent – depends on clinical signs; poor prognosis
Supportive therapy (stabilization of circulatory system):
Fluids & non-steroidal anti-inflammatory drugs (Flunixin meglumine 2.2 mg/Kg)
Parenteral antibiotics – cephalosporins, ceftiofur, broad-spectrum pencillins, oxytetracycline
Contraindicated; oestrogens increase absorption of endotoxins
Uterine lavage (after stabilization of circulation) followed by antibiotics like oxytetracycline

28

pyometra

Accumulation of purulent material in the uterus in the presence of an active persistent CL
Uterine horns are large and distended and cervix is closed
Sequel to chronic endometritis
EBD (T. foetus) a predisposing factor
No signs of ill health
Absence of cyclicity
Needs to be differentiated from normal pregnancy by rectal palpation (thickness of uterine wall, slipping of allantochorion, uterine caruncles) and transrectal ultrasonography (speckled echotexture of uterine contents versus black anechoic appearance of normal foetal fluids)
Treatment: PGF2 alpha + intrauterine cephapirin