Breeding It Easy: Repro Emergencies

Adapted with love from the fine presentation given to me in residency by Erin Runcan, DVM, DACT

Pyometra

Clinical Signs

Recent estrus
+/- vulvular discharge
- thick, foul smelling
- “tomato soup”
polyuria/polydipsia in 50% of cases
lethargy
vomiting
fever NOT common

CONSIDER PYOMETRA IN ANY INTACT BITCH THAT IS SICK!!

Laboratory Results

Bloodwork

Leukocytosis with left shift
- 25% may be normal
Mild anemia (PCV 30-35%)
Azotemia
Increased ALKP
Hyperproteinemia
Hyperglobulinemia
Urinalysis? – AVOID CYSTO!!

Radiographs

Does not differentiate early pregnancy!
Enlarged uterus

Abdominal Ultrasound

Rule out pregnancy
Thick uterine wall
Mixed echogenicity uterine contents

Treatment

Progressive disease – no cure
CEH – irreversible
High chance of pyometra next cycle

Ovariohysterectomy:

Same as routine OVH

Stabilize!

IV fluids

Pre-op antibiotics

NO STEROIDS/NSAIDS!

Culture uterine contents

Lavage the abdomen

Send home on oral meds once able

Pain control (NO NSAIDS)

Antibiotics if pre-operative contamination

Medical Management Criteria

Open cervix only
Young patients preferred
Good body condition
Valuable breeding animal
Normal renal function

Closed cervix?

Can be done…choose carefully
Client communication essential
- Uterine rupture
- Peritonitis
- Salpingitis
- DIC
- Death

Management

Culture vulvar discharge
IV antibiotics
- Culprit is E. coli until proven otherwise
- Amoxicillin Clavamox, Cephalosporins, TMS
- Continue 10-14 days post resolution
  - Monitor ultrasound, bloodwork, and physical examination
Antiemetics
Pain control – opioids, lidocaine
IV fluids
- Solution to pollution is dilution
Monitor:
- Serial POCUS
  - Uterine size at least daily
    - With medical management, should see size reduction within 3=5 days
    - If no response – warn owner – may need OVH
    - If no response after 2-5 additional days – OVH
  - Presence of uterine fluid
  - Presence of peritoneal fluid
- Electrolytes
- Renal values
- Progesterone
Treatments
- Dinoprost (PGF, Lutalyse)
  - 10-50 mcg/kg SQ q6-8h
  - Increase dose gradually
    - 10 mcg/kg SQ q6h Day 1
    - 25 mcg/kg SQ q6h Day 2
    - 50 mcg/kg SQ q6h Day 3 until complete
  - Lutalyse preferred over cloprostenol
  - Can be used as sole treatment or with combo
- Cabergoline
  - Elevated P4 (>5 ng/ml)
  - Addition of prolactin inhibitor
  - Used in combination with PGF
  - Bromocriptine
  - Cabergoline – 5 mcg/kg/day
    - Cervical opening after 1-2 days
    - Average 7 days of treatment
- Misoprostol
  - Intravaginal application
  - 100-400 mcg/kg, 1-2 tablets applied daily
    - Crush and dissolve in water
    - Apply with red rubber catheter to cranial vagina
  - Facilitates cervical opening and drainage
Aftercare
- Recheck exam 2 weeks after treatment
  - Physical exam
  - Progesterone
  - Bloodwork
  - Ultrasound
  - Continue antibiotics if:
    - Vaginal discharge
    - Fever
    - Neutrophilia
- Breed on next cycle
- Antibiotics encouraged at every estrus
- Shortened inter-estrous interval (30-45 days)
  - Postpone next cycle to allow for regeneration
- OVH once finished whelping
Prognosis for open cervical medical management
- Excellent prognosis for life
- Fair to good prognosis for fertility
  - Recurrence rate
    - 10-40% on next cycle
    - 77% in next 2 years
  - Fertility after treatment 50-70%

Parturition and Dystocia

Predicting parturition

Canine gestational length
- Single breeding: 57-72 days
- LH surge: 65 days +/- 1 day
- Ovulation: 63 days +/- 1 day
- Cytologic diestrus: 57 days +/- 1 day
1-2 weeks before
- Small amount of clear/tan vulvar discharge
- Anorexia and panting
- +/- Mammary development
- “Nesting” behavior
Body temperature
- Owner takes q6-12h
- Drops >1 degree 12-36 hours (average 24 hours) prior to parturition (30-70%)
Serum progesterone
- <2 ng/ml
- Drops 12-48 hours prior to parturition
Radiographs
- Ossification of tail, teeth, and paws
- ~4 (3-8) days before whelping
Ultrasonographic Examination
- Measure biparietal head diameter and body diameter
- Various formulas
- Estimate with organ development
  - GI layering: 58-60 days; 2-8 days before parturition
    - Hypoechoic lumen
    - Hyperechoic muscular layer
  - GI peristalsis: 62-64 days
Fetal Monitoring – Whelplwise(R)
- Uterine tocodynamometry
- Records uterine contractions and fetal HR
- Sends data to human OB nurses
- Make recommendations on treatment

Normal Parturition

Stage 1

Period of cervical dilation
No abdominal contractions
Restless
Panting
Anorexia/vomiting
“Nesting”
Up to 12 hours
Primiparous – 36 hours

Stage 2

Cervix dilated
Coordinated abdominal contractions
Clear vulvar discharge
Active delivery of pups
Up to 4 hours until first pup
<2 hours in between pups
Anterior or posterior

Stage 3

Passage of placentas
Retained placentas are rare
Bitch does not need to eat them!
- Gastroenteritis
- Obstruction
- Choke
- Diarrhea

Dystocia

Rules of Dystocia

Prolonged gestation
Stage 1 labor >12 hours
Stage 2 labor >4 hours with no pup produced
Stage 2 labor with hard contractions >30 minutes
>2 hours since a pup was born
Bitch is systemically ill
Frank vulvar hemorrhage
Green vulvar discharge before pups
Obvious abnormal presentation

Breed Predispositions

Border terrier
Boston terrier (92.3%)
English bulldog (86.1%)
Chihuahua
Clumber spaniel
Cocker spaniel
Dachshund
French bulldog (81.3%)
Greyhound
Mastiff
Miniature poodle
Pekingese
Pomeranian
Scottish terrier
Sealyham terrier
Welsh corgi
Yorkshire terrier

Fetal Causes

Fetal oversize
- Singleton litters
- Gestational diabetes
- Hydrocephalus/anasarca
Abnormalities of presentation or posture
- Transverse
- Breech
- Deviation of head/neck or limbs

Maternal Causes

Uterine inertia – inability for uterine muscle to contract
- Primary: Lochia without puppy
  - Singleton litter
  - Hypocalcemia
- Secondary
  - Obese animals
  - Fetopelvic disproportion
  - Elderly animals
- Most common cause of dystocia!
Inadequate size of birth canal
- Breeds with large heads and small pelvis (Bulldog)
- Vaginal strictures or septae
Uterine torsion
- One or both uterine horns

Workup

Thorough but quick history!
Digital examination of vulva
“Feathering” vagina
Bloodwork
- CBC
- Chemistry
- Ionized Calcium
Abdominal ultrasound
- Fetal HR: 2-2.5x dam
  - > 200 – normal
  - < 180 – fetal distress
  - <160 – crash C-section
Radiographs

Medical Management

Treatment depends on cause
Oxytocin
- 2-5 IU SQ or IM
- Redose 20-30 minutes
- Monitor the bitch
- Do not use with obstruction!
- 3 strikes and you need a C-section
Hypocalcemia
- 10% Calcium Gluconate
  - Dilute 1:1 with saline for 1-5 ml SQ
  - 10-20 m/kg IV or SQ
    - 1 ml/10 lbs
  - Helps efficacy of oxytocin
  - Uterine hypocalcemia before serum!
  - Repeat in 6-8 hrs

Specific Scenarios:

Assisted Vaginal Delivery

Must be in correct position and posture
Clean perineum
Use LOTS of lube
Heads or pelvis
- Don’t pull limbs
Bandage snare

Pregnancy Toxemia

Lack of energy (carbohydrates) to meet demands
Negative energy balance “Starvation”
Clinical Signs
- Ketonuria without glucosuria
- Hypoglycemia
- Weakness
- Tremors
- Seizures
- Coma
Causes
- Thin body condition
- Anorexia in late gestation
- Large litters
Breeds
- Labrador retrievers
- Yorkshire terriers
Treatment = prevention
- Provide adequate nutrition
- Terminate pregnancy if systemically ill

Gestational Diabetes

Insulin resistance in late pregnancy
- Progesterone
- Cortisol
- Placental lactogen
- Growth hormone
Clinical signs
- PU/PD
- Hyperglycemia
- Glucosuria
Predisposition
- Nordic breeds (~85% of dogs)
- Genetic predisposition
Treatment
- Termination of pregnancy
  - Dystocia – large pups (80%)
  - Diabetes forever
- Insulin

Singleton Litters

Small and toy breeds predisposed
Dystocia due to fetal oversize
Delayed or absent onset of parturition
C-section often warranted
Close fetal monitoring essential
Serial progesterone monitoring
- MAY NOT FALL!
- Monitor fetal heart rates and maturation

Infectious Causes

Can cause complications at any stage of gestation
Ascending or hematogenous spread
Pyometra with pregnancy
Can lead to abortion or premature delivery

Hydropic conditions in Goldens

Does NOT equal HYDROPS
Genetic predisposition for large amount of fetal fluids
DO NOT USE DIURETICS!
Clinical signs
- Ill, anorexic
- Dehydrated – check for diuretic use
- Vomiting
- Peripheral limb edema
Treatment
- Stabilization, correct shock
- Monitor fetuses for distress
- If extremely ill-terminate pregnancy
- Elective C-section

Preterm Labor

Only when true due date is known (so rarely)
Symptomatic depending on cause
Management
- Progeterone supplementation
- Broad spectrum antibiotics
- Tocolytics (terbutaline)
  - 0.03 mg/kg PO q8h
  - Causes smooth muscle relaxation
  - Stops uterine contractions
  - Possible cardiac side effects reported
  - Dicontinue 24-36 hrs prior to due date
    - Labor will resume 8-24 hours after discontinuing drug
- Often in conjunction with tocodynamometry

Progesterone

Must be >2 ng/ml to maintain pregnancy
Single digits common in late gestation
<3 ng/ml consider supplementation
When to evaluate:
- Fetal death or resorption
- Not pregnant despite good breeding management
- Abortion
- Vulvar discharge

Specific Scenarios:

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