Postpartum Complications

1. Postpartum Complications Ahmed Ali MS, PhD Dept. Theriogenology, Assiut Univ., Assiut, Egypt

2. Postpartum period (Puerperium) AI Birth AI Birth Pregnancy Pregnancy Postpartum period 12 m

3. Changes occur during the Puerperium • Return of normal ovarian activity (3-4 weeks) • 2. Shrinkage of the uterus (25-35 d) • 3. Regeneration of the endometrium (50-60 d) • 4. Elimination of bacterial contamination (4-5 weeks)

4. Most important postpartum complications 1. Perineal rupture 2. Retained placenta 3. Uterine prolapse 4. Uterine and vaginal rupture 5. Postparturient paraplegia 6. Postparturient uterine atony 7. Postparturient straining 8. Bacterial puerperal diseases 9. Puerperal intoxication 10. Puerperal infection 11. Septic metritis 12. Puerperal tetani 13. Puerperal vaginitis and vulvaitis

5. Perineal Rupture Causes: 1. Spontaneous, during the second stage of labor (vigorous straining) 2. Extreme traction of an oversized foetus 3. Predisposition include a hypoplastic vulva 4. Mares with Caslick operation

6. Symptoms: 1. In cow, the tearing begins at the dorsal commissure, as the head of the fetus approaches the vulvar cleft, and extended dorsally and cranial. 2. In mare, the initial injury in perforation of the vaginal roof by the fetal forelimb, the limb then perforate the rectum to tear the anal sphincter. 3. Such lesion destroy the sphincter effect of the vulva, lead to aspiration of air into the vagina. 4. laceration may extend and destroy the anal sphincter, thus creating a cloaca through which faces fall into the terminal vagina. Complication: Pneumovagina Bacterial contamination of the genital tract. Infertility

7. Surgical correction: 1. The patient is confined in stanchion in the standing position 2. Cleaning the perineal region 3. Light epidural anesthesia 4. The tail is tied to one side 5. Tampon placed in the rectum 6. Exposure the operative area by placing tension suture in the perineal skin 7. The free edge of the shelf is incised to a depth of 3 cm and extended laterally and caudally on each side 8. Synthetic non-absorbable suture and a No. 2 or 3 half circle cutting edge needle are used in the modified vertical suture pattern after the method of Goetze, starting at the deepest part. 9. The two ends of each suture are left long (8 cm) and are tied together at their ends to aid in identification of each knot during removal. 10. The suture must not penetrate the rectal mucosa. 11. The perineal skin is closed with vertical mattress suture.

8. Retained Placenta Definition: In cattle the fetal membrane are expelled within 12h after parturition. Retention of the placenta for longer period must be considered pathological.

9. The Loosing Process in Placentomes: 1. In the last month of pregnancy: The connective tissue of the placentomes become progressively collagenized up to the time of birth. The maternal epith. Of the crypts become flattened. Many phagocytic cells are manifested. 2. With the onset of parturition and following hormonally induced imbibition, the tissue of the placentome become loose. 3. During uterine contraction, the attachment of the villi in the crypts becomes impaired. 4. During fetal expulsion, caruncles are pressed against the fetus 5. After fetal expulsion and rupture of the umbilical cord no blood is pumped in the fetal villi and they shrink in size due to a reduced blood supply, and the maternal crypts dilate. 6.The postpartum uterine contraction complete the process of detachment of the membrane.

10. Etiology: It is basically due to failure of the villi of the fetal cotyledon to detach themselves from the maternal crypts of the caruncle. Basic Causes 1. Immature Placentomes. 2. In non-infectious abortion and premature birth. 3. Edema of the chorionic villi. 4. Following cesarean section and uterine torsion. 5. Necrotic areas between chorionic villi and the cryptal wall 6. In allergic cases. 7. Advanced involution of the placentomes. 8. Hyperemia of the placentomes. 9. Placentitis and cotyledonitis.

11. Direct causes 1. Infection of the uterus during gestation 2. Brucella abortus, tuberculosis, Vibrio fetus, mold infection 3. Infection of the uterus immediately after partuition Strept., E. Coli, Staph., Cory. pyogenes. 4. Abortion and premature birth 5. Uterine inertia (primary or secondary) 6. Endocrine disorder 7. Mechanical prevention

12. Indirect causes 1. Stress 2. Transportation, short dry period, change of locality, management problem 4. Deficiency of vitamins and minerals, Carotene, vitamin A, iodine, selenium and vitamin E, imbalance in calcium and phosphorus 5. Hereditary factors

13. Incidence: More common in dairy than in beef cattle The average incidence for all calving 11% The incidence after normal calving 8% The incidence after dystocia 25-50% Retention increase with parity

14. Clinical feature: 1. A portion of fetal membranes hang from the vulva 12h or more after calving. Occasionally the FM may be not hang but entirely within the vulva and uterus. 2. About 80% of cases show no marked illness 3. About 20% may exhibit moderate to sever symptoms of metritis and septic metritis 4. In severely affected animals RFM may be associated with mastitis, perimetritis or peritonitis, sever straining, necrotic vaginitis, parturient paresis and acetonemia. 5. A fetid odor is usually produced. 6. Mortality 2% and morbidity 55% 7. Delay uterine involution 8. Increase day open

15. Treatment: Manual treatment 1. One day after parturition under aseptic condition without injury to the maternal caruncle. The trial should not exceed 10 minutes/day. 2. The veterinarian twist the postcervical part into a bulky rope, which he hold in one hand at the vulva. With the other hand he gently follows the rope through the cervix to the cotyledonary attachment of the uterus. He squeezes gently the base of the maternal caruncle so as to open the crypts on its convexity, the thumb is lightly passed over the periphery of the caruncle in order complete the separation of the released villi. 3. Succeeding cotyledons are approached in a circumferential order. 4. Continuos steady traction and rotational force are applied with the other hand.

16. 5. Regardless of the outcome, 2-4 gm terramycine is deposited in the uterus. 6. This treatment should be repeated on days 3, 6 and 9 postpartum, when necessary, in addition to manual trial of loosening the afterbirth. 7. In all cases as much as possible of the uterine exudate should be removed by siphonge.

17. Therapeutic treatment without manual removal Oxytocin: 20-50 I.U., within 24h after birth Estrogenic substances: 5-20 mg stilboesterol Ergot preparation: 1-3 mg of ergonovine Calcium gluconate Broad acting antibiotic: 2-4 gm terramycine No treatment Uncomplicated cases required no treatment

18. Prophylaxis: Balanced nutrition for pregnant animal Large animal boxes Daily outlet Avoidance of transport Sufficiently extended dry period Avoidance of bacterial infections and parturition hygiene. Injection of 2 million IU of vitamin A 4-8w antepartum Injection of 50-100 IU oxytocin immediately after parturition

19. Postpartum Paraplegia The animal fail to raise after parturition Causes: Metabolic and nutritional disturbances 1. Hpocalcemia 2. Grass tetany 3. Ketosis 4. Debility 5. Vitamin E and Selenium deficiency Traumatic injuries 1. Paralyses of the obturator, perineal, gluteal femoral or brachial nerves 2. Dislocation of the hip joint. 3. Fracture of the leg and pelvis 4. Exhaustion after dystocia 5. Hemorrhage, anemia, or shock due to rupture of uterine or pelvic vessels

20. Infectious diseases 1. Septi metritis 2. Septic mastitis 3. Peritonitis 4. Acute laminitis 5. Septic Arthritis Diagnosis 1. Examining the locomotor system, especially the hind limbs 2. In cases of recumbency due to physical inability to rise, the affected animal usually has good appetite, its temperature and pulse are unaffected. 3. Examining the uterus and udder 4. Infectious cases usually accompanied with fever

21. Treatment 1. Each case must be treated on its merits 2. Tray to rise the animal with a brief application of electric goad 3. Place the recumbent animal on ample, soft, clean and dry bedding

22. Uterine and vaginal Rupture Causes 1. Prolonged dystocia with fetal emphysema 2. Uterine torsion 3. Improper manipulation and traction of the foetus 4. Forced traction of the fetus in abnormal p.p.p. 5. Fatigue of the operator 6. An accident in foetotomy operations 7. In mare with the foetus of long extremities (spontaneous) 8. Poorly dilated cervix 9. Administration of oxytocin while the cervix is closed

23. Symptoms and prognosis Depend on: 1. Animal art 2. Portion of the genital tract 3. Size of the rupture 4. character of rupture while regular or irregular, vertical or horizontal 5. Nature of the uterine contents In mare fatal peritonitis usually develops rapidly In cow rupture due to emphysema rapidly produce peritonitis Anorexia, lack of rumination and rumen contraction, restlessness Cold extremities Normal or subnormal body temperature

24. In infected material released into the abdominal cavity, acute, sever septicemic symptoms develop rapidly. Shock, prostration and death usually occur in 1-2 days. In small rupture of the uterus, when no infection is present and the rent is in the dorsal half some cattle have survived. In sever cases, the prognosis is poor and slaughter is advised. Even if recovery take place, future breeding life is questionable. Rupture of the vagina is not serious as uterine rupture and the prognosis is much better.

25. Treatment In small uterine rupture Repeated doses of oxytocin Parental and intrauterine Antibiotic Fluid therapy Close observation of the animal In large uterine rupture Suturing the uterus through the birth way Prolapsing the ruptured uterus and suturing it Suturing the uterus through laparotomy

26. Under no circumstances should fluids be injected into the ruptured uteri, nor should manipulations of retained placentas take place. Rupture of the cervix: Cervical forceps can be used to draw it to the cervix to the vagina and vulva and suture Oxytocin Rupture of the vagina: Simple rupture in the lateral or dorsal wall need not to be sutured Recto-vaginal fistulas should be changed into cloaca and repaired after granulation.

27. Postparturient Uterine Atony The uterus is abnormally large, roomy, flabby and without contraction directly after birth Causes: Uterine inertia (primary and secondary) Over-thinning of the uterus (twins, hydropsy) Rupture of the uterus or cervix Hypocalcemia

28. Clinical findings: In rectal examination, the uterus found descended in the abdominal cavity, the uterus lack any contraction and filled with lochia The cervix is dilated with small amount of lochia discharged from the vulva. Secondary retention of placenta Treatment: Oxytocin: 50-100 IU, within 24h after birth Methergin: 5-10 mg i.m. Siphonage of the uterine content Calcium gluconate Local and systemic antibiotic

29. Postparturient Straining There is a persistent strong uterine birth pains for one or more day after birth Causes: There is irritant to the vagina or vulva Long standing dystocia Pneumometra Bleeding from the genital tract Phlegmone of vaginal tissue

30. Symptoms The pains may persist for 4-7 days after birth Continuos or intermittent straining, arched back, sunken eyes and depression Frequent defection, diarrhea There is great tendency for prolapse of the vagina or rectum Uterine contractions are stronger Treatment General sedative Epidural anesthesia Local antibiotic within the uterus Treat the original cause

31. Bacterial puerperal Infection Disease: Puerperal bacterial intoxication Cause: Saprophytic bacteria Pathogenesis: Putrefaction of the uterine contents produce toxins which absorbed through the uterine endometrium to circulate in the blood with general intoxication. Symptom: Fever, indigestion, exhaustion, little edema in the genital tract, abnormal lochia Treatment:Local antibiotic,Oxytocin, Siphoning the uterus, Supportive treatment, Antihistaminic, Calcium gluconate, Good green pasture, Systemic antibiotic, Epidural Anesthesia, Ice packs in case of laminitis in mare

32. Disease: Puerperal bacterial infection Cause:Saprophytic bacteria Pathogenesis: Bacterial activities are intensive. Bacteria tend to act locally in the uterus Symptom: Fever, Depression, edema of the soft birth way, abdomen is tense Treatment:see before

33. Disease: Septi metritis Cause: Coliform,C. Pigeons, Streptcoccen and Micrococcen Pathogenesis: The difficult form of the non-specific Puerperal infection Symptom:Fever, reddish watery fetid vulvar discharge, peritonitis, arthritis, laminitis Treatment:see before

34. Disease: Puerperal necrosis Cause:F. nechrophorum Pathogenesis: Necrotic bacteria get entrance to the uterus from the claws Symptom:General health disturbances, liver painful in palpation, the mucus membrane yellowish. Treatment:Local and systemic Antibiotic, supportive treatment

35. Disease:Puerperal tetanus Cause:Cl. tetani Pathogenesis: m.o. enter the uterus through injury in the endometrium. Symptom:Muscular cramps and stiffness. Treatment:Anti-tetanic serum, supportive treatment.

36. Disease: vaginitis and vulvitis Cause:Saprophytic Bacteria, F. nechrophorumPathogenesis: Narrow birth way result in trauma and laceration + m.o. Symptom:Swollen vulva and vagina, fetid odor, diaphteretic inflammation. Treatment:Oily bland antiseptic Antibiotic, Epidural Anesthesia.