Bovine Obstetrical Struggle Unveils Double Trouble: A Vital Case Study Analysis

1. 910’s Double TroubleA Bovine’s Obstetrical Struggle Sheila Wilson Advised By: Dr. Misty Edmondson

2. Signalment/Clinical Presentation/History • 4 year-old female, entire Simmental/Angus cow • Presented on Saturday, November 9th, 2013 • History: • dystocia of 3 hour duration • Owner attempted to pull calf with chains with no success • Bred to a Simmental/Angus clean-up bull • 2 previous calvings without incident *Photos Permission and Courtesy of Owner

3. Presentation to AU Large Animal Teaching Hospital • Cow Bright, Alert, Responsive (BAR) and ambulatory • Per vaginal palpation, calf orientation: caudal longitudinal presentation, dorsosacral, hind limbs extended • Hind limbs protruded from vulva and calf deceased • Fracture of the left rear distal metatarsus 3

4. TIME OUT • Dystocia = abnormal or abnormally difficult birth • Eutocia = normal or physiologic parturition • A detailed history is always VERY important • Vocabulary: • Presentation: the direction in which the long axis of the calf is oriented. • Position: relationship of fetal back to maternal pelvis • Posture: relationship of extremities – extended vs. retained/flexed.

5. Normal Calf Orientation 910’s calf presentation Cranial longitudinal (anterior), dorsosacral, head and forelimbs extended Caudal longitudinal (posterior), dorsosacral, hind limbs extended http://www.hoards.com/E_animalhealth/ah12 http://www.drostproject.org/en_bovrep/4-14/itemtop17.html

6. Initial Plan • Vaginal Palpation • Arms width of clearance between thorax of fetus and pelvis of dam • Attempt to pull • Lubricant placed within the cervix and uterus • Lidocaine epidural • Reduce cow straining • Chains placed on calf’s limbs • Another attempt to pull the calf – student powered • Unsuccessful • Re-palpated vaginally by another student • Flexed front limb • Two heads?

7. Plan • Twins suspected • Two options: • Fetotomy • Cesarean section • Consult with owner • Elected for initial fetotomy • Cesarean section if fetotomy unsuccessful

8. Fetotomy • “A cutting of the unborn.” • Goal: Rapid reduction of fetal size to facilitate delivery per vaginum • Utilize obstetric wire to cut the fetus into smaller pieces within the vagina/uterus to then be delivered.

9. Our Plan • Detruncate and manipulate. • Dam went down into right lateral recumbency • Detruncation attempted • Placed obstetrical wire around the thorax of the fetus • OB wire could not be placed past the xyphoid • Communication with owner • Based on inability to properly detruncate the fetus, ventral line cesarean section elected

10. Cesarean Section • Considerations: • Calf alive or dead? • Calf malformed? • Uterine contents septic or fresh? • Physical condition of the dam-can she stand for 2 hours? • Environment • Availability of assistants • *Preference and experience of the surgeon

11. Cesarean Section • Several approaches • Ventral Midline • Best surgical exposure • Best opportunity to exteriorize the uterus • Least abdominal contamination (emphysematous calf, septic uterus) • Disadvantages to consider: • Restraint • Failure of ventral midline suture = catastrophic • Dorsal recumbency (respiratory compromise)

12. Preparation • Hobbled and cast into right lateral recumbency • Rolled into dorsal recumbency onto a mat, fore/hindlimbs extended with ropes • Surgical site shaved and prepped • Line block: • Lidocaine • On midline, from sternum to the mammary glands, coursing around umbilicus

13. Surgery • Procedure: • Incision along ventral midline extending 5 inches cranial to the mammary gland, around the umbilicus, extending three inches cranial to umbilicus • Greater omentum reflected • Uterus located within the abdomen

14. Surgery continued • Once uterus located, dam began to struggle, resulting in a tear in her omentum due to exteriorization of her abomasum • 1mL of acepromazine administered intravenously • Abomasum and omentum returned to abdomen • Uterus located and attempted to exteriorize to minimize contamination • After multiple attempts, unsuccessful

15. Entering the Uterus • Uterus incised along the greater curvature • Rule of thumb: length of incision into uterus should = distance from fetus’s hock to hoof • Feti exposed after removal of hindering placenta • Administration of a tocolytic (epinephrine) to decrease uterine contractions

16. After much manipulation, palpation, and examination, it was discovered the feti were…

17. Exteriorizing the feti • Chains placed on two of the carpi and both heads extended out of the uterus • Revealing twins conjoined from manubrium to xyphoid along the sternum. • A four inch tear in the uterus occurred along the incision line.

18. Uterine Closure • Uterus palpated for “tears and spares” • Lavaged then closed using #2 catgut, Utrecht pattern. • Uterus appeared grossly healthy • Utrecht suture pattern • Modified Cushing (slanted) • Inverting • No exposure to suture material which could lead to adhesions • Goal: PREVENT LEAKAGE http://www.drostproject.org/en_bovrep/guide.html

19. Surgical Closure • Omentum18 inch tear • Repaired with #2 catgut (absorbable), simple continuous pattern and replaced in abdomen • Linea • #3 Supramid (non-absorbable), interrupted vest over pants pattern • Tacked edge with simple continuous = increased security • Subcutaneous tissue • #2 catgut, simple continuous pattern to reduce dead space • Skin • #3 Supramid, continuous horizontal mattress pattern

20. Cow 910 Image Courtesy of Dr. Edmondson

21. Post-operative Care Medical (immediately post-op): Flunixinmeglumine (Banamine): 15mL IV for inflammation Florfenicol (Nuflor): 100mL SQ on both left and right side of neck, broad spectrum antibiotic Oxytocin: 1mL IM, promote uterine clearance Husbandry F/C HWM 6# soy hull pellets BID Offer haylage Keep stall clean Treatments and Monitoring Physical Exam every 6 hours Monitor incision site Monitor vaginal discharge Monitor eating/drinking Palpate as needed to monitor uterine involution Monitor for indications of peritonitis Flunixinmeglumine: 15mL IV every 12 hours as needed

22. Post-operative Care Sunday, Nov. 10th Monday, Nov. 11th QAR; hunched appearance and increased heart rate indicating pain 15mL Banamine administered IV in the morning Incision site: slightly swollen with small amount of blood dripping Anorectic, no signs of drinking water Rumen contractions present but weak All other physical parameters WNL Continue to monitor feed/water intake, F/C HWM, Banamine as needed (15mL) once daily BAR Subcutaneous emphysema noted along left ventral thorax Ate readily when haylage moved to the ground from hay rack Soy hull pellets offered Monitoring and treatments same

23. Post-operative Care • Tuesday, Nov. 12th • 3 days post-op • BAR • Ate silage and soy hull pellets overnight; readily ate more when offered • Based on good mentation, incision healing and good appetite, ready for discharge on November 13th, 4 days post-op

24. Discharge • Instructions for Owner: • Kept in dry pasture • Monitor incision daily-swelling, purulent discharge • Monitor for depression, loss of appetite or vaginal discharge • Suture removal-11/29/13 by rDVM

25. Prognosis • For recovery: Fair to guarded • For rebreeding: fair to guarded if she does not develop peritonitis and adhesions

26. Thoraco-omphalopagus Conjoined Twins • Both • Bull calves of fair body condition score • Congested Cerebrum • Connected by markedly thickened cranial sternum • Lungs diffusely dark purple and collapsed • Two hearts enclosed within a single, enlarged pericardium • Continuous Peritoneum • Livers fused, hypolobulated and diffusely mottled dark red to tan • Negative for Bovine Viral Diarrhea Virus by ear notch ELISA • Weighed 125lbs Image Courtesy of Dr. Edmondson

27. Necropsy Pictures Pictures Courtesy of Dr. Joanna Hyland

28. Abnormalities Twin 1 Twin 2 The one presented vaginally Fractured left rear distal metatarsus 3 Small intestines exteriorized through a 5-6cm rent in ventral abdomen Body wall adjacent to the rent diffusely dark red to black Intestinal tract diffusely pink to dark red Ventricular septal defect: 5cm diameter opening connecting the right ventricle to the left ventricle

29. Rent http://www.hoards.com/E_animalhealth/ah12 Image Courtesy of Dr. Joanna Hyland Image Courtesy of Dr. Edmondson

30. So what happened? • Twinning • In cattle, natural twinning: 2-3% • Dizygotic: twins arising from two ova, derived from two separate ovarian follicles, each fertilized by separate spermatozoa during a single breeding cycle. • Monozygotic: arise from a single ovum fertilized by a single spermatozoon. • Cattle occurrence: 0.1% or approx. 10% of same sex twins Sire of Twins *Photo Permission and Courtesy of Owner

31. Formation of Tissues • Fertilization in cattle: Ampulla/Isthmus junction • Produces a zygote • Cleavage: cell divisions producing a hollow ball of cells = blastocyst • About 1 week following fertilization • 2 groups of cells within blastocyst: • Outer layer/trophoblast = placenta • Inner cell mass = embryonic body

32. Embryologic Development • Inner cell mass • Embryonic shield • Two epithelial layers • Upper: ectoderm • Lower: endoderm • Primitive Streak: • Region where superficial cells migrate between the ectoderm and endoderm, forming an intermediate layer of mesoderm.

33. Monozygotic Twins • Possible in 3 stages of embryological development: • Formation of two blastocysts within a single zonapellucida • Each giving rise to a separate individual with its own fetal membranes McGeady, T. A., P.J. Quinn, E.S. FitzPatrick, and M.T. Ryan. Veterinary Embryology. Oxford: Blackwell Pub., 2006. Print.

34. Monozygotic Twins • Inner cell mass stage • Duplication of inner cell mass • Separate amnions but with a shared yolk sac and chorion • Division of blastocyst as it emerges from zonapellucida McGeady, T. A., P.J. Quinn, E.S. FitzPatrick, and M.T. Ryan. Veterinary Embryology. Oxford: Blackwell Pub., 2006. Print.

35. Monozygotic Twins • Embryonic Disc stage: formation of two primitive streaks • Each giving rise to separate individuals • Share a common amnion, yolk sac and chorion McGeady, T. A., P.J. Quinn, E.S. FitzPatrick, and M.T. Ryan. Veterinary Embryology. Oxford: Blackwell Pub., 2006. Print.

36. Conjoined Twins • Results from anomalous incomplete separation of two primitive streaks • Incidence of conjoined twins in cattle: • Higher than in other farm animals • 1 in 100,000 births • 1 in 400 in monozygotic twins McGeady, T. A., P.J. Quinn, E.S. FitzPatrick, and M.T. Ryan. Veterinary Embryology. Oxford: Blackwell Pub., 2006. Print. Image Courtesy of Dr. Edmondson

37. Freemartinism in Cattle • Different mechanism • Female born co-twin to a male • Fused chorioallantoic membranes = vascular anastomosis • Anti-Muellerian hormone crosses from male to female twin • Intersex sterile animal, phenotypically female

38. Owner Update • 910 recovered but never returned to the breeding herd • Sold at auction Dec. 16, 2013 for $0.50/pound • Docked for swelling on ventral midline • No other calves from this bull with abnormalities

39. References • McGeady, T. A., P.J. Quinn, E.S. FitzPatrick, and M.T. Ryan. Veterinary Embryology. Oxford: Blackwell Pub., 2006. Print. • Ball, P J. H, A R. Peters, and A R. Peters. Reproduction in Cattle. Oxford, UK: Blackwell Pub, 2004. Print. • Noakes, David E. Fertility and Obstetrics in Cattle. 2nd ed. Oxford: Blackwell Science, 1997. Print. • Dr. Morrison, “Formation of Germ Tissues.” Class Notes. Fall 2011. • Maxwell, “Fetotomy”, “C-section”. Class Notes. Fall 2013. • Carson, “Bovine Obstetrics.” Class Notes. Fall 2013. • http://www.hoards.com/E_animalhealth/ah12 • http://www.drostproject.org/en_bovrep/4-14/itemtop17.html • http://www.drostproject.org/en_bovrep/guide.ht • http://www.hoards.com/E_animalhealth/ah12 • http://en.wikipedia.org/wiki/Conjoined_twins

40. Thank You • God • Family • Dr. Edmondson • Dr. Morrison • Dr. Newton, Dr. Hyland • Lauren Smith and seniors • Owner • Friends • Class of 2015