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A Twist of fate

A Twist of fate. #52’s Case of a Uterine Torsion. By: Amy Sanders Advised by Dr. Jenna Bayne. Case presentation of #52. March 28 th , 2014 7 years old Charolais Approximately 1000 lbs BCS 5/9 Full term Owner rectally palpated: Uterus felt twisted

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A Twist of fate

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  1. A Twist of fate #52’s Case of a Uterine Torsion By: Amy Sanders Advised by Dr. Jenna Bayne

  2. Case presentation of #52 • March 28th, 2014 • 7 years old • Charolais • Approximately 1000 lbs • BCS 5/9 • Full term • Owner rectally palpated: • Uterus felt twisted • Fetus still was presumptively alive

  3. What is a “twisted uterus”? • Usually occurs at the termination of gestation (Gestation length 280 days) • Prolonged Stage I Parturition • No clear age or season predisposition • Multiparous > Primiparous • Commonly Reported Breeds: Brown Swiss, Holstein, and Charolais is a high-risk breed. • Can be twisted CLOCKWISE or COUNTERCLOCKWISE • Can range from 180-720

  4. What is a “twisted uterus”? • Instability of the gravid uterus Small non-gravid horn • Excessive fetal weight • Broad ligament: Body vs. Horns • When a cow lies down gravid uterus is suspended in abdominal cavity. a sudden slip or fall could cause the gravid uterus to twist • Increased fetal movements during 1st-stage labor • Decreased amounts of uterine fluid • Flaccid uterine wall • Confinement in stables for long periods can contribute • FUN FACT: TWINS can PREVENT torsion

  5. Do the twist • Counter Clockwise (twisted to the LEFT) MORE COMMON • Normal Presentation • Clockwise (twisted to the RIGHT)

  6. Clinical Signs of Uterine Torsion • Fever • Tachycardia • Tachypnea • Anorexia • Straining • Vaginal Discharge

  7. How to diagnose What was found with #52 • VAGINAL EXAM • Twist will be caudal to cervix • CORKSCREW EFFECT • Torsion <360 may be possible to reach the cervix • #52 had a 180 twist • Fetal limb could be felt through the cervix: • Upon stimulation of the limb there was no reaction from the fetus • RECTAL EXAM • Feel Broad Ligaments • The Right Broad Ligament was stretched= COUNTER CLOCKWISE TWIST

  8. How to untwist • Manual Detorsion via Vagina • Rolling the cow • Detorsion Rod • Cesarean Section

  9. NON-SURGICAL CORRECTION:“PLANK IN DA FLANK” • COUNTERCLOCKWISE TORSION • Lay in LEFT lateral and roll LEFT 360 • CLOCKWISE TORSION • Lay in RIGHT lateral and roll RIGHT 360  Roberts, Stephen J and Hillman, Robert B. An Improved Technique for the Relief of Bovine Uterine Torsion.

  10. NON-SURGICAL CORRECTION:DETORSION ROD • Place chains as far up the limbs you can reach as possible • Place chains through one eye on the bar • Push into cow between calf limbs and start to hand twist until tight • Place a bar in the outside eye and rotate.

  11. Surgical Options:Cesarean section • Uterus cannot be corrected by rolling • Cervix does not dilate to sufficiently deliver the fetus • Fetal proportion or anomalies prevent delivery of the fetus • APPROACHS: • RECUMBANT LEFT FLANK • VENTRAL MIDLINE • OBLIQUE PARAMEDIAN • STANDING LEFT FLANK

  12. Pros and cons of Standing Left Flank • PROS • The cow is standing so more comfortable for the surgeon • Closure Simplified • CONS • Less exposure • Cow can go down • Peritoneal contamination

  13. Left flank c-section steps • Pre-Op Treatment: • Epinephrine 10 mL IM injection • FlunixinMeglumine (1.1 mg/kg) 15 mL IV injection • Florfenicol (6 ml/100lbs) 90 mL Subcutaneous injection • Inverted “L” block with 250 mL 2% Lidocaine • Incision midway between last rib and the wing of the ilium ending approximately ten inches vertically, individually incising through: • Skin • External Abdominal Oblique • Internal Abdominal Oblique • TransversusAbdominus • Peritoneum

  14. Left flank c-section steps • Palpate the uterus, pull limb • If forelimb: • Carpus to toe pulled out of incision site • If hindlimb: • Hock to toe pulled out of incision site • Make vertical incision through uterus and placenta • Remove calf and uterine fluid

  15. closure • Uterus • Utrect Pattern • Want an INVERTING pattern for luminal seal • Chromic Gut #2 • Cleansed with Sterile Saline solution around the incision site to reduce the chance of infection and reduce uterine fluid in the abdominal cavity • IMPORTANT • Place uterus back into CORRECT position • The uterus was pulled to the left so then the uterus was pushed back into the abdominal cavity placing the right horn into the right abdominal space

  16. closure • Peritoneum, TransversusAbdominus, Internal Abdominal Oblique • Simple Continuous • Chromic Gut #2 • External Abdominal Oblique • Simple Continuous • Chromic Gut #2 • Skin • Fords Interlocking Pattern • Appositional • Nylon 3 ply

  17. unexpected “TWIST” • Dead • Male • Weighed approximately 100 lbs • Fetal-maternal mismatch

  18. The fate of the cow • Can be good- worsens with time • Depends on: • Severity of torsion • Systemic compromise • Complications of the C-section can include: • Retained Placenta • Metritis • Incisional edema • Peritonitis • Infertility • Adhesions

  19. FATE OF #52

  20. REFERENCES • Pearson H. Uterine Torsion in Cattle: A review of 168 cases. Veterinary Record 1971:597-603. • Noakes DE. Fertility and Obstetrics in Cattle. 2 ed. Cambridge, MA: Blackwell Science, 1997. • SchonfelderAMaS, Axel. Cesarean Section and Ovariohysterectomy After Severe Uterine Torsion in Four Cows. Veterinary Surgery 2006;35:206-210. • Roberts, Stephen J and Hillman, Robert B. An Improved Technique for the Relief of Bovine Uterine Torsion. Cornell Vet. 1973, 63:111-116 • Youngquist RS. Current Therapy in Large Animal Theriogenology. Philadelphia, PA, 1997. • ZaborskiReview Factors affecting dysotcia in cattle • http://www.vin.com/members/proceedings/proceedings.plx?CID=WVC2002&PID=1051&O=VIN • http://www.vet.uga.edu/lam/teaching/mueller/FemaleBovUrogen.swf • http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2275340/#!po=60.9375 • http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1687017/?page=1 • http://books.google.com/books?id=DYGUFOLiGWkC&pg=PA50&dq=uterine+torsion+in+cow&hl=en&sa=X&ei=cVxHU4eMMYnu2QWU2IHoCw&ved=0CCsQ6AEwAA#v=onepage&q=uterine%20torsion%20in%20cow&f=false

  21. A GREAT BIG “WAR EAGLE” THANKS • God • My Amazing Family • Friends all over the country • Dr. Jenna Bayne • All the Large Animal Clinicians • Food Animal Block Crew “You pick me up when I fall” • Radiology Rotation • Trimac Farm • Sebastian and Colby

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