Attempts at manual removal are limited to puppies and kittens protruding from the vaginal vault. Use of water-based sterile lubricant and gentle traction with fingers is the safest approach.
Once maternal and fetal obstructions have been ruled out with radiographs, uterine inertia is usually successfully managed with oxytocin. Oxytocin is given at a dose of 1–2 IU/kg (maximal dose 20 IU) IM in the bitch and 2–4 IU IM in the queen. The dose can be repeated at 30-minute intervals. If no puppy is born after two doses of oxytocin then a caesarean section is indicated. Oxytocin should not be used in cases of narrowed birth canal, fetal malpositioning or fetal oversize.
Calcium gluconate increases the strength of myometrial contractions while oxytocin increases the frequency of the contractions. Calcium gluconate 10% administered over 5 minutes (2–10 ml IV for the bitch and 1–2 ml IV for the queen) is given for ineffective, weak uterine contractions or after several unsuccessful doses of oxytocin. Ideally an ECG should be performed whilst the calcium gluconate is administered. If the dam fails to produce a fetus with medical management, a caesarean section is indicated.
The placenta should pass within 5–15 minutes of each puppy or kitten. If a placenta is retained within the uterus it can predispose the dam to metritis. Clinical signs include a foul-smelling discharge, fever, vomiting, anorexia, lethargy, toxaemia and possibly death. Retention of the placenta is suspected based on clinical signs and palpation, and can be confirmed using ultrasound. Treatment with antibiotics, oxytocin and, if necessary, IV fluids should be instituted. Be aware that if the bitch is not watched very closely she may eat the placenta before it is seen. Puppies or kittens should be allowed to nurse if the dam is not systemically affected.
Pyometra is an endocrine-related disease in the bitch. Although a bacterial infection is involved, it is the presence of progesterone (during dioestrus) that has allowed the disease to occur. The disease occurs almost exclusively in bitches in the 2 months following oestrus. It tends to be a disease of middle-aged dogs and the frequency of occurrence increases with increasing age. It has been reported in dogs from 4 months to 18 years of age with an average age of 6–8 years. The cause of pyometra is related to progesterone-induced excess glandular activity, low myometrial activity and cervical closure, causing an accumulation of secretions that result in bacterial overgrowth. The most common bacteria involved is Escherichia coli.
Most animals have pyometra for days to weeks before the animal shows any symptoms. Patients can present with acute clinical signs related to sepsis and a systemic inflammatory response. More commonly, patients have a slow onset of disease typified by non-specific clinical signs such as polyuria/polydipsia (PU/PD), inappetance, vomiting and weight loss. Pyometra can be categorised as open or closed depending on whether the cervix is open or closed, respectively. Patients with an open pyometra will have a purulent vaginal discharge in comparison to those patients with a closed pyometra. Owners may be less likely to detect a problem in patients with a closed pyometra, delaying their presentation to the clinic. Depending on the severity of the disease, the bitch may also be anaemic and dehydrated. Untreated, pyometra leads to worsening dehydration, endotoxaemia, shock, coma and ultimately death.
The diagnosis of pyometra is commonly based on clinical signs but this method can be unreliable and closed pyometra often cannot be diagnosed without further investigation. Abdominal radiographs may lend supportive evidence if a soft tissue density, tubular mass in the area of the uterus is seen. It can be difficult to differentiate early pregnancy from pyometra. Abdominal ultrasound may demonstrate pyometra by a well-defined tubular structure with a hypoechoic to anechoic lumen. It may be challenging to differentiate pyometra from the surrounding intestines if they are of similar size.
Initial medical stabilisation may be required in pyometra patients with significant illness. Animals presenting in shock will need immediate resuscitation prior to any diagnostic procedures. Intravenous antibiotic therapy should be started as soon as possible; the drug should be bactericidal and effective against E. coli. Rapid bacterial death following antibiotic therapy can lead to a systemic release of endotoxin resulting in acute endotoxic shock. For this reason antibiotic therapy should not be started until the animal is initially resuscitated.
The recommended treatment of pyometra is ovariohysterectomy. Medical therapy with prostaglandin administration (PGF2α) should only be considered in young, valuable, breeding animals that are essentially healthy. Medical therapy of animals with a closed pyometra is to be considered with caution as there is an increased risk of uterine rupture. Prostaglandin therapy takes at least 48 hours to start having an effect and it is not recommended for use in the clinically sick.
Ovariohysterectomy is a routine surgery although it is important the surgeon takes care to prevent rupturing a friable uterus (see Figure 15.2).
Septic mastitis is most commonly due to E. coli, beta-haemolytic streptococci or staphylococci. One or more glands may be affected. The source of bacterial infection is most commonly via an ascending infection but penetrating wounds or haematogenous spread are other possible causes. The affected gland becomes very inflamed and painful. It can lead to abscessation (see Figure 15.3) and even necrosis of the gland (see Figure 15.4). In severe cases the animal can develop significant systemic illness and deaths have been reported.
Mastitis should be considered in any lactating bitch or queen that develops sudden malaise and/or discomfort. Clinical signs of bacterial mastitis include pyrexia, lethargy and inappetance. Commonly, the affected mammary gland will become hot and painful, any milk produced from these glands is usually discolored and if the animal is still nursing the neonates may be weak and crying because they have been unable to feed. Animals with non-septic mastitis are generally systemically healthy, although again the glands are swollen and painful.
The majority of animals with mastitis do not required hospitalisation unless they are significantly ill, in which case they may require hospitalisation for fluid therapy and nursing care. Animals with septic mastitis require systemic antibiotics. Care must be taken with drugs such as enrofloxacin and tetracyclines which can have detrimental effects on the puppies. Antibiotics selected should be effective against E. coli, streptococci and staphylococci until culture and sensitivity results are available. Warm compresses of affected glands may provide some comfort to the patient. Puppies should be encouraged to continue nursing as it will promote drainage of the glands but owners need to ensure puppies are receiving adequate nutrition. Daily weighing of puppies is a good means of monitoring their continued growth. Supplemental feeding of puppies may be required in some cases. If puppies are not feeding from the glands then manual stripping is required to ensure adequate drainage. If glands are abscessed (see Figure 15.3) or necrotic (see Figure 15.4), they may require surgical debridement and/or drainage followed by frequent flushing and open wound management. In these situations it is often necessary to remove the puppies and hand raise them. In severe necrotic mastitis a mastectomy may be indicated.
Uterine prolapse usually occurs during whelping or in the 48 hours following whelping or queening when the cervix is open. It is more commonly reported in cats than dogs. Both horns of the uterus can prolapse, usually after the entire litter is delivered. On some occasions a single uterine horn will prolapse, the remaining horn may still have viable puppies/kittens present. External reduction should be attempted as soon as possible, because the longer the tissue is exposed the higher the risk of contamination, trauma and necrosis. The animal should be anaesthetised and sterile lubricant applied liberally to the exposed tissue. The uterine horn is flushed with sterile saline under pressure. Topically applied mannitol or hypertonic saline can be used to reduce oedema if necessary before attempting reduction. Once the uterus is replaced, the animal should be given 5–10 IU oxytocin IM to cause uterine involution. If the uterus remains reduced for 24 hours, further risk of prolapse is unlikely because the cervix should be closed. If the tissue is damaged or necrotic, ovariohysterectomy is recommended. Internal reduction of the prolapse can usually be achieved through a ventral abdominal incision. In some cases, reduction is impossible due to extreme engorgement of the prolapsed tissue. In these cases, the external segment can be amputated followed by ovariohysterectomy.
The volume of normal blood loss during whelping and queening varies widely. The fetal fluids mixed in with the blood may make volumes of blood lost during the birthing process appear to be larger, especially to the inexperienced breeder. Although rare, it is possible for blood loss to be excessive. This can happen due to rupture of uterine vessels, uterine rupture, haemorrhage from the placental sites or coagulation disorders. Clinical signs include passage of bright red blood from the vulva, passage of large blood clots, pale mucus membranes, weakness, neglect of puppies, shock and death.
Diagnosis of excessive haemorrhage involves demonstration of a low packed cell volume (PCV), especially one that is trending downward. Ultrasound of the uterus can occasionally identify rupture of the wall or a blood-filled uterus but is not always diagnostic. Coagulation panels or clotting times may be helpful to diagnose underlying coagulation disorders. Treatment with oxytocin injections and calcium to assist in uterine involution is helpful to stop bleeding. IV fluid therapy may be necessary to treat shock and fluid loss. Puppies or kittens should be allowed to nurse in order to stimulate endogenous oxytocin production. If PCV continues to drop blood transfusion may be necessary. Surgery to stop the bleeding and/or spay the dam may be necessary in extreme cases.
Also called puerperal tetany or hypocalcaemia, this is a moderately common condition in bitches but has been only rarely reported in cats. The term eclampsia is often used to describe this condition in the bitch; however, this can cause some confusion as ‘eclampsia’ is also used to describe periparturient disorders in other species that are not associated with hypocalcaemia. Hypocalcaemia is a medical emergency in affected animals. The condition occurs most commonly in small breed dogs (especially when nursing large litters), usually within the first 1–4 weeks after whelping when the metabolic stress of lactation is highest but can also occur prior to delivery as mammary glands begin to produce milk.
Early signs include restlessness, panting, pacing, whining, salivation, tremors and stiffness. Signs progress to tonic–clonic muscle spasms, fever, tachycardia, seizures and death. Any periparturient dam presenting to the emergency clinic with suspicious signs should have a blood calcium level (ideally, ionised calcium) evaluated. Treatment must be administered immediately, based on the history, clinical signs and blood calcium levels (total calcium <1.6 mmol/l or ionised calcium <0.8 mmol/l). However, if suspected, treatment should not be delayed for the confirmation of hypocalcaemia as response to treatment is also diagnostic. Treatment consists of 10% calcium gluconate (50–150 mg/kg calcium) administered slowly IV until signs improve (the required dose is generally 0.5–1.5 ml/kg of 10% solution). Too rapid an infusion can cause bradycardia, cardiac arrhythmias and/or cardiac arrest. The patient should be monitored closely during administration by auscultation of the heart or with an ECG. Fever, dehydration, tachycardia and hypoglycaemia should be treated with intravenous fluids. Oral calcium treatment (50–250 mg/kg body weight t.i.d.) as well as vitamin D (10,000–25,000 IU) should be continued throughout the rest of the lactation. Puppies should be removed from the bitch and supplemented with milk replacer for a period of 12–24 hours based on the severity of clinical signs and response of the dam. After that period the puppies are allowed to nurse and should be hand raised only if the problem reoccurs.
Male Reproductive System Emergencies
It is important to recognise the common presentations of male reproductive emergencies as well as their potential for life-threatening complications. Many of the common presenting conditions of male dogs that owners present for emergency care may not be life-threatening; however, accurate diagnosis and early intervention preserve the future reproductive capability of those dogs.
Paraphimosis is a fairly common genital reason for males to seek emergency care. It is the inability of the penis to retract into the preputial cavity. It may be caused by a small preputial orifice, a ring of fur encircling the penis, ineffective preputial muscles, preputial hypoplasia, trauma, infection, neoplasia or it may be idiopathic (see Figure 15.5). Due to the devastating consequence of penile necrosis and the resulting need for penile amputation, exposure of the penis should be treated as an emergency and addressed as soon as possible to avoid permanent damage to the penis. The exposed penis is susceptible to drying, excoriation, ischaemia and thrombosis, and secondary urethral obstruction may result. If constriction is present, penile necrosis can result in permanent damage to the penis and necessitate penile amputation. Determination of the underlying cause is required for effective treatment.