Common Reproductive Cases in Practice

Transcription

1 Common Reproductive Cases in Practice 1. Vulvar/Vaginal Disorders i. Hooded Vulva excess skin/fat found dorsal to the vulva ii. Juvenile Vulva very small vulva, usually recessed so surrounded by skin folds 1. Generally seen in juvenile bitches prior to 1 st heat cycle or older bitches with recurrent UTI problems 2. Note in record and watch to see if it corrects prior to spaying a. If still present at 6m, allow bitch to cycle 1-2x, then spay. NEVER SPAY UNTIL AFTER HEAT CYCLE OR WILL REQUIRE EPISIOPLASTY!!!!! 3. Episioplasty is treatment of choice if heat cycle does not resolve problem a. Simple, fast, can be done in a clean practice iii. Juvenile Vaginitis 1. Bitches prior to their 1 st heat cycle, mild to copious amounts of discharge. Can be mucoid to purulent. Cytology will show polymorphonuclear leukocytes +/- bacteria. Not always irritating to bitch, but owners do notice. 2. DO NOT TREAT WITH ANTIBIOTICS!!!!, conservative treatment is best (84% resolve) 3. Let bitches go through 1 heat cycle to a. Correct conformation issues b. Estrogen s effect on the vaginal epithelium 2. Intact? a. Either unknown status when they present or past history of sterilization i. No scar, tattoo, ear tip b. Vaginal Cytology i. Fast, cheap, and highly valuable clinically ii. Superficial epithelial cells Estrogen influence iii. Basal epithelial cells no estrogenic influence c. LH assay/level i. If she is in heat LH levels will be high naturally, if she is not in heat and it is high she is spayed due to the lack of negative feedback on the pituitary (think about this one) ii. Colorado State University has radio immunoassay (RIA) that is validated for cats/dogs 1. BET labs is not validated for cats/dogs d. AMH (anti-mullerian hormone) level i. More sensitive in cats than dogs; females more than males e. Ultrasound is not generally rewarding 1

2 f. Males i. LH can be used just as in females ii. AMH can be used although it s more sensitive in females than males iii. Can use GnRH stimulation test 3. Mismating/Abortion Protocol (remember we can always spay!) a. Confirm Pregnant via U/S 1 st at 30 days post breeding i. remember only 50% get pregnant anyway! b. P4 level prior to administration of drugs! Hospitalization recommended i. PGF2α Lutalyse at 0.1mg/kg TID SQ (SE vomiting, cramping, diarrhea which minimize with each subsequent dose) ii. Bromocriptine/Cabergaline mg/kg PO TID, give 30 minutes after PGF2α to prevent dog from throwing up pill (SE vomiting) iii. Cerenia can be used to ease vomiting c. Confirm P4 levels at time of vaginal discharge, usually 3-4 days after protocol is initiated i. Want P4 less than 2ng/ml ii. u/s to confirm empty uterus! d. Intravesicle administration of PGF2α i. Experimental, good results in Italy ii. Need to confirm pregnant first, then sedation with ultrasound guided injection iii. Less side effects, one injection iv. Results in complete abortion within 7 days of treatment 4. Estrus Supression (only in dogs intended for breeding) DO NOT USE IN PREPUBERAL BITCHES! i. Mibolerone (check drops) Compounded (Roadrunner Pharmacy ; Premier Pharmacy ) 1. Must start greater than 30 days from expected beginning of proestrus µg/d depending on size of the dog (see pg 177, table 9-5 in Johnston, Kustritz, Olson. Canine and Feline Theriogenology for specifics) 3. Follow liver enzymes on this drug. 1 sample prior to treatment and every 3-6months during. 4. Keep on drug until estrus is wanted. Avg is 2.5 months after cessation. ii. Megestrol Acetate (WalMart $10 drug!) 1. Anestrus a. SID for 32d at 0.55mg/kg dose PO b. Come back in 4-6m later c. Side effects: Lethargy, increased appetite 2. Proestrus (Start within the first 3 days of bleeding) a. 2.2mg/kg SID for 8d PO b. Come back in 4-6m later (may be a bit shorter) 2

3 5. Prostate Problems (BPH, Cysts, Abscesses) a. Diagnosis i. Rectal examination, ultrasound ii. Collect prostatic fraction via manual collection, prostatic wash, or ultrasound guided aspiration of cyst/abscess b. Treatment i. Correct any underlying condition 1. UTI, BPH, urolithiasis, neoplasia, etc. c. Surgical (Neuter) i. Will remove active form of testosterone (DHT) which is contributing and effectively reduce the size of the prostate 1. 80% reduction within 12 weeks of surgery d. Chemical Reduction of DHT levels i. 5 alpha reductase inhibitors 1. Finasteride (Proscar) 5mg tab PO SID for 8w a. Does not affect libido if stud dog needs to breed ii. Progestagens 1. Megestrol Acetate (Ovaban) 0.5mg/kg PO SID for 8w a. Best clinical improvement in size of prostate b. NOT IN CATS, causes irreversible diabetes mellitus e. Antibiotics i. Baytril for 6-8w (ciprofloxacin and marbofloxacin work as well) ii. TMS for 6-8w SE: KCS, anemia, neutrophilic hepatitis f. Recheck i. 7d, 1m, 6m ii. Culture and MIC if possible at each one 6. Brucella canis testing/recommendations a. Gram negative intracellular bacteria b. Reportable in the state of VA due to zoonotic potential c. NO reliable treatment known d. Causes abortions in females and epididymitis in males i. Transmitted via urine, abortive fluids, mucous membrane secretions ii. Males and females are sub-clinical carriers e. Tests i. RSAT card test, good screen 1. Can trust a negative result 2. Tests for surface antibodies ii. AGID 1. More specific, confirmatory test 3

4 2. Tests for cytoplasmic antigens iii. Blood Culture 1. Gold standard, but very hard to grow 2. Use only in cases of fresh abortion or clinical signs in a male f. Recommended Testing Guidelines For breeding animals i. Females every time they are bred, prior to the breeding ii. Males every 3-6 months or before being bred g. No treatment can clear the organism, but will test negative!!! i. If positive found report to health department and quarantine kennel ii. Recommended treatment is euthanasia 7. Resources for health testing/genetic diseases a. Canine Health Information Center i. b. Orthopedic Foundation for Animals i. c. Canine Inherited Disease Database at the University of Prince Edward Island i. d. National Breed Club 4

5 Reproductive Emergencies: an update on diagnosis and treatment 1. Dystocia (Medical vs. Surgical) a. Indications of a Problem i. 4h of weak contractions and no puppy ii. >2h between puppies iii. >30min of active contractions and straining without a puppy iv. Black or excessive green vulvar discharge and no puppy produced v. Large amount of frank blood coming from the vulva b. Medical i. Indications for medical treatment 1. Active pushing for 30min and no puppy, can feel puppy in cranial vagina 2. No pushing or contractions for >2h, sleeping for >3h and walking doesn t stimulate contractions. a. Make sure no puppies are left! (same for C-sections) RADIOGRAPH! ii. Vaginal exam use sterile gloves, if you palpate puppy in cranial vagina 1. Red-rubber catheter with lots of lube. Pass catheter past puppy and deposit STERILE lube around puppy, grasp behind head or shoulders with peace fingers, pull with contractions. Can stand dog up on back legs to get help from gravity. c. Plan i. PE if HR are ok and no pup engaged in birth canal start tx ii. Give oxytocin and pull Ca level 1. If Ca is low start treatment iii. If puppy is produced but it takes longer than 30min to deliver the next puppy consider c-section d. Drugs i. Oxytocin U-2U SQ q 30-40min 2. Do not exceed 20U/dog 3. Limit to 1-2 injections if not getting response ii. Ca Gluconate (10% soln) ml/kg IV with EKG monitoring or 1-5ml SQ/dog ml per cat IV iii. Glucose 1. Sugar water (karo in warm water) with syringe 2. Fluids with dextrose added iv. Walk Take dog out ON LEASH with a towel and friend, dogs will often posture to urinate and push out a puppy 5

6 e. Indications for C-section i. Cephalopelvic disproportion, anatomical malformation (D-V band), breed (Bulldogs, Frenchies), Owner preference ii. Uterine inertia, trauma, stressed puppies (HR <160), Whelping not progressing, if only 1 puppy in litter may not give enough signal for mom to go into labor, Medical intervention not working iii. Breeding Dates Only---- NEVER, do P4 every day until <2 ng/ml or bitch goes into labor 1. Can use GI motility as an indicator of fetal maturity 2. Emergency C-section i. When? 1. Fetal Heart Rate Guide a. < Do not pass go, Take to surgery b consider medical treatment or c-section c. >180 wait and see 2. Other parameters for surgical intervention a. Obvious physical barrier (fetal oversize, vaginal band, etc) b. No response to medical treatment c. Need to have one of the following to proceed with sx i. P4 <2ng/ml or P4 timing at breeding ii. Active labor (stage II) or signs of stage I labor (you observe) iii. Presence of GI motility in fetus(s) iv. For cats >71d past the first breeding v. NEVER GO TO SX OFF BREEDING DATES!!! ii. What 1. Drugs a. Fast acting opioids (reversible in puppies) b. Propofol c. Inhalant (Iso or Sevo) 2. Ancillary Pain control a. Epidural b. Local Blocks c. NSAID tx i. Rimadyl is ok for up to 3 days d. Tramadol is ok for animals that are not well controlled with Rimadyl 3. Clip, clean, etc. prior to inducing if possible a. Can pre-oxygenate the bitch during this time 4. FAST get puppies out in less than 30min from induction iii. Sx Technique 1. Ventral abdomen incision (xyphoid to pubis) and pack off well 6

7 2. Incision in each horn, remove ALL puppies 3. Remove placentas if they come easily 4. Close Uterus with inverting pattern can give 1ml oxytocin IV a. Give more pain meds to mom once puppies are out 5. Lavage abdomen and close 6. Take care in introducing puppies to mom after surgery, esp. if maiden bitch iv. Puppy Recovery 1. Lots of clean towels and hands. Rub puppies with vigorous movements on thorax, tilt head down to drain any remaining secretions. Suction nose and throat with bulb syringe. Have flow-by O2. 2. Drugs a. Epi ml per rectum b. Atropine ml per rectum c. Naloxalone to reverse opioids if necessary, per rectum d. Dopram is contraindicated! A lot of breeders ask about this because it has been used in the past but current research shows it has significant negative effects on puppies. 3. Other Problems a. Agalactia i. Metoclopramide mg/kg SQ q8h 2. Milk will come in after 3-5 doses b. Poor Mothering i. Sepia pills per hour to effect II. Intranasal oxytocin III. Adaptil spray/infuser 4. Cystic Endometrial Hyperplasia-Pyometra Complex a. Discuss options with owner Spay vs. medical Tx, can always start medical tx, stabilize then go to surgery after! Must be in the hospital if systemically ill! b. Keys to success LYSE THE CL and GET IT OUT OF THE UTERUS, aka PGF2α! c. Protocol i. P4 level, MDB, guarded swab culture of cranial vagina with culture and MIC ii. Start on Clavamox (or Baytril if very sick, let s not over do a big hitter antibiotic); change if necessary after MIC results are back. iii. PGF2α 0.1mg/kg SQ TID for 2-4 days to lyse CL, confirm by subsequent P4 levels (<2) and continue till uterus is empty (confirmed by U/S) iv. Bromocriptine/Cabergaline mg/kg PO TID, give 30 minutes after PGF2α to prevent dog from throwing up pill (SE vomiting) 7

8 v. Confirm with serial U/S examinations. We can always SPAY if medical treatment is not working! 1. Do not discharge the patient until the uterus is empty and P4 is less than 2ng/ml! vi. IF closed cervix PGE2 can be used intravaginal to open cervix with above protocol d. Remember P4 is the underlying cause of this disease and most older bitches usually have pathology of their uterus (CEH-cystic endometrial hyperplasia). Breed the next heat cycle and spay after litter b/c they will be repeat offenders. It is important to realize that breeding on next cycle is not protective for recurrence of pyo, just allows best chance to get a litter before pyo recurs. i. 80% will recur within the next 3 cycles 5. Vaginal prolapse a. Most commonly seen at peak estrus (during late proestrus) b. Grades 1-3 c. Catheterize the urethra and relieve bladder d. Medical vs surgical i. Need to remove the estrogen source 1. Surgical results in faster resolution 2. Medical treatment a. Reduce tissue mass, replace, and suture b. Induce ovulation to decrease estrogen ii. Will reoccur iii. Is heritable 8

9 Neonatology 1. Puppies And Kittens Basic requirements a. Colostrum in first 4-8 hours b. Warm, draft-free environment i. Ideal temperature (remember puppies are poikilothermic for a few weeks!) 1. Week , week , week 4 on ii. Humidity at 55-60% c. Daily weight gain i. 10% of birth weight daily ii. Exception is first hours 1. May lose or maintain d. Biosecurity i. 6 week rule 1. No new humans, animals, etc. 3 weeks prior to whelping and 3 weeks post whelping 2. NO NEW DOGS IN KENNEL! 2. Neonatal Reflexes a. Righting Place puppy on back Should right itself quickly b. Rooting Circle thumb and forefinger around muzzle c. Suckling Tip of finger in mouth d. If reflexes are weak or non-existent Severe problems present 9

10 Viability Scoring for Neonates Parameter 0 points 1 point 2 points Activity/Muscle tone Flaccid Moderate tone (flexion) in extremities Active movements Pulse/HR Absent or <110bpm bpm >220 bpm Reflexes when stressed Absent Moderate Movement Crying Out MM color Pale or cyanotic Slightly cyanotic Pink Respiratory Rate Absent Weak, irregular >15/min, rhythmic Points Stamina, vitality 0-3 Weak 4-6 Average 7-10 Normal 10

11 Normal Physical Parameters Puppies Kittens Heart Rate 200bpm 250bpm Respiratory Rate 15-35bpm 15-35bpm Temperature 97 (95-99) 97 (95-99) 3. Fluid Therapy a. Intravenous access i. IO easier and more rewarding ii. Sites (intertrochanteric fossa or tibial crest) b. Weight is best indicator of hydration i. Use a pediatric scale c. WARM Crystalloids(LRS preferred) i. Bolus of 30-40ml/kg ii ml/kg/day Enteric Supplementation a. Warm small feedings iii. must be warm iv. For the first 2 weeks of life must be done q2h! b. How to tube feed v. Measure tube from nose to last rib vi. Gently insert tube per os vii. Make sure puppy can cry before feeding c. Solid food can be introduced at 3 weeks of age viii. Warm gruel 11

12 Puppy Caloric Requirements Week of Life Daily Caloric Requirement/ oz body weight cal/oz 2 4.5cal/oz 3 5cal/oz 4 5.5cal/oz Kitten Caloric Requirements Week of Life Daily Caloric Requirement/ oz body weight cal/oz cal/oz 6. Drugs for Neonates a. Unsafe Antibiotics i. Tetracyclines ii. TMS iii. Gentamicin iv. Enrofloxacin* v. Metronidazole b. Dewormers i. Pyrantel ii. Fenbendazole iii. Sulfadimethozine c. Pain Management* i. Buprenorphine: mg/kg SC up to 4 times daily 2. Give injectable form orally in kittens less than 4 weeks ii. Butorphanol: mg kg SC, IM, or IV every 1-4 hours as needed 12

13 iii. Oxymorphone: d. mg/kg once every 24 hours with similar side effects 7. 3 Leading Causes of Neonatal Death a. Hypothermia* b. Hypoglycemia i. Dextrose administration (ml/oz in canine) 1. 5% solution IV 2. 10% solution IV 3. 50% solution 0.25 to PO c. Hypovolemia dehydration 8. Colostrum Deprived Neonates a. Pooled adult serum within 24-48h of birth b. 10ml/# in puppies, 15ml total in kittens c. Administer slowly SQ/PO or 3 doses q6-12h d. Serum IgG in puppies Colostrum fed 1700 mg/dl Colostrum deprived 0 mg/dl Sub-Q serum 241 mg/dl 9. Juvenile Cellulitis (Puppy Strangles) a. Juvenile cellulitis ii. Dermatitis of face, ears, and LN involvement b. DX iii. Definitive is biopsy c. Immune mediated iv. Heritable? v. Treatment 1. Prednisone 2.2mg/kg SID for 7-10 days, then taper 2. Ab if secondary bacterial involvement 10. Congenital Defects of Consequence a. Clefts b. Atresia ani/coli c. Extra toes d. Midline defects 11. Important Behavioral Stages in puppies a. First three weeks Puppies should eat, sleep, actively dream Dam stimulates urination and defecation b. Eyes and ears open days Sight and hearing develop over next week c. Four week Protect puppies from strong stimuli 13

14 d. Fifth-Seventh week Socialization with litter mates Differentiation between people and canids 12. Other Puppy Resources a. Books: vi. *Another Piece of the Puzzle: Puppy Development by Pat Hastings & Erin Ann Rouse vii. contains the "Rule of 7s" and environmental enrichment viii. *The Dog Breeder's Guide to Successful Breeding & Health Management by Margaret Kustritz ix. good all-around breeding & whelping book b. Articles: x. *Early Neurological Stimulation by Carmen Battaglia xi. _en.pdf xii. There are a lot of other useful articles on his site as well, breedingbetterdogs.com 14

15 Selected References PETERSON ME, KUTZLER MA: SMALL ANIMAL PEDIATRICS. ST. LOUIS: ELSEVIER; JOHNSON SD, KUSTRITZ MVR, OLSON PNS: CANINE AND FELINE THERIOGENOLOGY. PHILADELPHIA: SAUNDERS; KUSTRITZ MVR: THE DOG BREEDER S GUIDE TO SUCCESSFUL BREEDING AND HEALTH MANAGEMENT. PHILADELPHIA: SAUNDERS; TRAAS AM: RESUSCITATION OF CANINE AND FELINE NEONATES. THERIO 2008; 70: KAROL A. MATHEWS, DVM, DVSC. PAIN MANAGEMENT FOR THE PREGNANT, LACTATING, AND NEONATAL TO PEDIATRIC CAT AND DOG. VET CLIN SMALL ANIM 38 (2008) PLUMB DC: DRUGS IN NEONATES: PRINCIPLES AND GUESSES. SOC FOR THERIO PROCEEDINGS, UEHARA H, YSHIOKA H, NAGAI H, ET AL: DOXAPRAM ACCENTUATES WHITE MATTER INJURY IN NEONATAL RATS FOLLOWING BILATERAL CAROTID ARTERY OCCLUSION. NEUROSCI LETT 2000; 281: SFT CONFERENCE PROCEEDINGS 2003-PRESENT. PRETZER, S. D. MEDICAL MANAGEMENT OF CANINE AND FELINE DYSTOCIA. THERIO 2008; 70: TRASS, A.M. SURGICAL MANAGEMENT OF CANINE AND FELINE DYSTOCIA. THERIO 2008; 70: SMITH, F.O. CHALLENGES IN SMALL ANIMAL PARTURITION TIMING ELECTIVE AND EMERGENCY CESARIAN SECTIONS. THERIO 2007; 68: