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Periparturient Problems in Mares and Neonatal foals

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Periparturient Problems in Mares and Neonatal foals Powered By Docstoc
					           Presentation at BVA Congress
                     27-
                     27-29 September 2007
                     Belfast, North of Ireland



PLEASE NOTE:
 While this presentation may be quoted
 from it cannot be reprinted in full without
 the permission of the author and the BVA




Periparturient Problems in Mares
       and Neonatal foals




            Hugh Dillon MVB,MRCVS,Cert ESM
                     Troytown Hospital




                                                 1
 Neonatal Foal : birth to7 days




      Induction of Parturition
Never use for convenience
Reserve for high risk pregnancies
Gestational age at least 335 days
Adequate pelvic ligament + cervical relaxation
Udder development + good colostrum
Milk :Ca > 10 mmol/ltre, crossing K + Na
60 iu in 1 litre saline over 45 mins.
Low dose ;2.5 iu --- only work if mature foetus
5 iu in 20 mls saline iv every 15 mins
Dinoprost 10mg




                                                  2
Induction of Parturition




      Parturition




                           3
               Parturition
              Emergencies

Red bag presentation
Recto-Vaginal injury : leg through anus
Vaginal laceration + herniation of intestine
Dystocia
Uterine inertia




               Parturition
Hygiene very important
Epidural (Xylazine 30 mg+2.5 ml intraepicaine )
Lubrication
Walking mare / stomach tube in trachea
Avoid prolonged dystocial manipulations
Field anaesthesia
Embryotomy
Cesarean section




                                                  4
         Cesarean Section




            Resuscitation
Clear Airway
Stimulation
Ventilate oxygen
Cardiovascular support
Warmth
Medication




                            5
Normal Parameters post partum
Gest.      315-
Gest. age 315-365
               60-
Time to suck: 60-180 mins
Time to stand:<2 hours
Temp : 99 – 102
             60-
Heart rate : 60-80 bpm
Resp rate: 60 for 15 mins
then 30per min
Urination within 8 hours
Meconium within 12 hours




Neonatal maladjustment syndrome:
           Category 1
Usually Full term(>320
days)
Normal delivery
Normal behaviour post
foaling (except suck
reflex)
Onset 6 – 24 hours
Better prognosis
Natal or Post Natal
aetiology




                                   6
       Neonatal Maladjustment
            Category 2
Poorer Prognosis
Prenatal aetiology
Abnormal delivery
Abnormal placenta
Abnormal behaviour
immediately
Very weak
Often Septic
Multiple organ involvement
Requires very intensive
therapy




           Behavioural signs
Chewing and over reactive to stimuli
Abolition of suck reflex
Wanders aimlessly / Disorientation
Blindness
Barker ??
Recumbency
Convulsions
Coma




                                       7
   NMS Post mortem findings
Ischemic cerebral necrosis
Cerebral and spinal oedema and
haemorrhage
Lung atelectasis and pneumonia
Liver pathology
Other organ pathology associated with
sepsis




NMS Therapy and Management:
Diazepam(0.5mg/kg) tid
Midazolam infusion
                  then0.3-
0.1mg/kg loading then0.3-
0.6 mg/kg/hour ( up to
2mg/kg/hour )
Detomidine(0.1-
Detomidine(0.1-0.3mg)
Phenytoin(10mg/kg
                    tid)
followed by 5mg/kg tid)
Phenobarbitone(10mg/kg
                    tid)
followed by 5mg/kg tid)
Dexamethasone(4mg tid) tid)
DMSO (1 g/l bid)




                                        8
NMS Therapy and Management:
Oxygen
Colostrum
Prophylactic Antibiotics
Prevent hypothermia
Restraint
Feeding
Help to brisket or stand
        hypoglyaemia,
Control hypoglyaemia,
hypokalaemia,
hypokalaemia,
hypomagnesaemia and
hyponatraemia




              NMS Prognosis
Category 1 better than
category 2
Clinical signs can change
rapidly
Recovery can be slow over
a number of days
Survey: 50% mortality if
no improvement by 4 days,
100% mortality if no
improvement by 6 days.
Usually stands first and
suck reflex last.




                              9
Seizures Differential diagnosis
Colic
Septicaemia (Bacterial
meningitis)
Tetanus
Botulism (shaker foal)




  Referral to Specialist Centre
Not always best option
Is care at home an option?
Cost : UK quote £1000 for
first 24 hours then approx
£300 per day
Is there a realistic chance
of survival ?
Is the foal insured ?
Discuss with centre before
deciding




                                  10
 Troytown neonatal foal referrals
          2006 / 2007
2006 : 127 foals
       91 % survival
       10.5 % went to Goffs / Tatts foal
        average price 61,800
        top price 260,000
        23 % entered for Goffs / Tatts Yrl
2007 : 150 foals
         87.6 % survival




       Neonatal septicaemia
Sepsis : First on list of differential diagnosis
High risk foal ?
Colostrum intake ? (measure IgG)
Lethargy
Overt clinical signs ( temp., diarrhoea, swollen
joints, umbilical infection)
Heamatology : low wbc
Biochemistry : raised fibrinogen, low blood
glucose




                                                   11
               Sepsis Score
             Each category 0-4
History : high risk (3); <300 (3); >331 (0)
Clinical: >39(3) Diarrhea(4)
Haematology: wbc< 2(4); 2-4(3);4-8(2)
Biochemistry: fibr g/l: >6 (3), 3-4 (1)
                glucose mmol/l <3 (2),>4.5(0)
                IgG g/l <2(4) ; >8 (0)
Score > 11 indicates 90 % septic.




          Neonatal septicaemia
              Treatment
400 ml Colostrum every 2
hours three times
1 litre high quality immune
plasma
Supportive care
Antibiotics:
First 7 days almost 100 %
        negs.
gram negs.
E.Coli, Actinobacillus,
E.Coli, Actinobacillus,
               spp.,
Enterobacter spp.,
klebsiella.
klebsiella.
50% cases mixed
infections




                                                12
              Antibiotic regimes
              for neonatal foals
                         qid)                       sid)
 Penicillin(30,000iu/kg qid) +Gentamicin(6.6mg/kg sid) ----
 hydrate first!!
                       tid)
 Ampicillin (30 mg/kg tid) + Amikacin (25mg/kg)
 Cefquinome (Cephaguard 1mg/kg bid)
 Ceftiofur (5mg/kg i/m bid )
 Enrofloxacin care re joints
 Potentiated Sulfonamides (15 mg/kg)
                            t.i.d.
 Flucloxacillin ( 7.5mg/kg t.i.d. orally )
 Ticarcillin / Vancomycin / Imipramine (responsibility of
 using these questionable)
 Cefuroxime ( Zinnat 240 mg/kg/day given qid) bacterial
                                            qid)
 meningitis




          2. Bladder Rupture
Uroperitoneum
Males mainly, present
2-7 days of age
Depressed,
abdominal distension
Urination – variable,
may be dysuria, may
manage stream of
urine
Pain – mild if any




                                                              13
  Diagnosis – Ultrasound Best




         Abdominocentesis
                  Only after ultrasound
                  Omentum often makes full
Teat cannula            drainage difficult
                  May cause omental hernia




                                             14
             Bladder Repair
Electrolyte problems –
hyperkalaemia,
hyponatraemia,
hypochloraemia and
acidosis ( use Normal
saline for hydration)
Surgery – tears usually
dorsal
Complications
Non-septic – good
prognosis, otherwise
guarded




  Urachal
  Necrosis
Present as
ruptured bladder
Differentiate at
surgery
Can cause
bacterial spread
to abdomen




                              15
    Bladder Rupture – Re-rupture
       2 days after first surgery




 Straining in meconium impaction cases?




           3. Umbilical Problems
• Umbilical abscesses
  (extra abdominal)
• Septic omphalophebitis,
  (or omphaloarteritis),
  sequalae of septicaemia,
  peritonitis, liver
  abscesses, septic arthritis
• Patent urachus
• Umbilical herniation




                                          16
    3. Umbilical
     Problems
CASE REPORT
• 3 day old colt foal
• Swollen umbilicus and
  also suspicion of
  scrotal hernia
• Progressive oedema of
  umbilicus and sheath




     Umbilical             3 day old
     Problem
DAY 3: PALPATION
• Can feel right sided
  inguinal hernia
TREATMENT
• Rest, ketoprofen sid,   8 day old
  ceftiofur bid im
DAY 8 IMPROVED
• External umbilicus
  still thickened




                                       17
Day 8 schedule
surgery: urachal
   resection




        Umbilical Resection




                              18
  Bladder suture – size 3 PDS




Culture from urachal stump - neg




                                   19
  Marsupialization of Infected Vein
• For infected vein
  which could not be
  resected
• Soft pliable
  catheter placed
• Lavaged gently
  twice daily
• Successful
  outcome in 2 cases




 Post-operative – restrict for 4 weeks




                                         20
         Neonatal Isoerythrolysis
•   Differential diagnosis:
•                             Equine Herpes virus
•                             Neonatal septicaemia
•   Normal at birth
•   Lethargy, Anaemia, Jaundice after 12 hours
•   Normal temperature
•   PCV can drop to 5%
•   Cross match mares colostrum with foals rbc




          Neonatal Isoerythrolysis
                Treatment
• PCV > 15% Conservative incl. muzzle foal
• PCV < 15% ------ clinical picture
•   Transfusions ( 1-3 litre ) may help
•   New cells only last 3 days
•   Danger of further cross reactions
•   Stressful for foal
•   Transfusion reactions
•   Increased icterus




                                                     21
             Differential Diagnosis
            Foal with colic symptoms
  •   Retained Meconium
  •   Inguinal hernia
  •   Intussusception
  •   Atresia coli
  •   Enteritis (rota virus)
  •   Gastric ulceration
  •   Seizures
  •   Ruptured bladder




  1. Colic and Meconium Impaction
• Meconium is
  digested amniotic
  fluid, glandular
  secretions, mucous,
  bile and epithelial
  cells
• Green, black/brown
• Tarry consistency
• Start passing within
  3 hours after birth




                                       22
 1. Colic and Meconium Impaction
SIGNS:
• First day usually
• Restlessness, attempt
  to defacate, tail
  swishing, tail
  elevation, straining
• Colic, lying down,
  getting up, rolling, lie
  upside down
• Appear to be trying to
  urinate                    13 hours old




  1. Colic and Meconium Impaction

VIDEO 1
• Straining to
  defaecate
• Tail swishing
• Appears to be
  trying to pass
  urine




                                            23
     1. Colic and Meconium Impaction

    VIDEO 2
    • More severe
      signs of colic
    • Rolling, leg
      waiving in air
    • Lying on back




     1. Colic and Meconium Impaction
• Males, narrowed pelvis
• Low – pelvic inlet
• High – large colons
                                2 day old
• Discomfort associated        dysmature
  with passage
• Pain is not related to
  time of passage
        OTHER FOAL
          MEDICAL
         PROBLEMS




                                            24
  1. Colic and Meconium Impaction

DIAGNOSIS
• Digital rectal
  examination, often
  cannot feel
• Confirm no other
  colic by ultrasound
  scan
• Radiography less
  useful




Foal colic – Abdominal Ultrasound




                                    25
    Abdominal Ultrasound – Small
        Intestine Distension




    Meconium Impaction Treatment
Enemas
• Soapy water, gravity flow,
  flexible tube
• Acetyl cysteine 4%
• Per os – liq paraffin
  150mls, castor oil 60 mls
Hydration status – iv fluids
Analgesia / Sedation
• ketoprofen, valium,
  xylazine, butorphanol, GA




                                   26
             Colic - Analgesics
                   Dose         Analgesia          Duration
Xylazine       Upto 1 mg/kg Good              30-45 mins
Detomidine     Upto 40μg/kg Excellent         45 mins-1 hr

Buscopan -     5 mls          Poor            2-3 hours
dipyrone
Phenylbutazone 4mg/kg         Poor            3-6 hours
Ketoprofen     1-2 mg/kg      Good            8-10 hours
Flunixin       1 mg/kg        Excellent       10-12 hours
meglumine
Turbugesic     1-5 mls        Good            1-2 hours




   Colic – Why not to use Flunixin!
   • Powerful analgesic, long duration of action
   • May “mask” signs of a surgical colic:
      – Delays onset of toxaemia
      – Keeps pulse rate low
      – Real pain of surgical lesion is not seen
   • It’s indiscriminate use leads to the death of
     horses and foals which might otherwise be
     saved by timely surgical intervention
   • Litigation problems?




                                                              27
   Meconium Impaction - Treatment




Meconium Impaction: Acetyl Cysteine Enema
• 8 gms acetyl
  cysteine, 200mls
  water, 20 gms
  baking soda
• Enema
  administered by
  Foley catheter,
  leave balloon
  inflated 30 mins
• Repeat 2-4 hours




                                            28
    Meconium Impaction Surgery

TO BE AVOIDED
  IF POSSIBLE
• Distended large
  and small colons
• Meconium often
  inaccessible in
  pelvic / caudal
  abdomen




       Foal Colic – Atresia Coli




                                   29
              Septic Arthritis
 • Often lethargy day
   before
 • Acute onset severe
   lameness
 • Synovial distension
 • Periarticular
   distension
 • Assume present unless
   proven otherwise




 CASE REPORT – 16 day old foal

HISTORY
• Lame for 1 week,
  been treated with
  penicillin, gentamicin
  5 days, then E & R
  for 2 days
• No improvement




                                 30
   Case Report – 16 day old foal
• Lame at walk and
  grade 3 out of 5 lame
  at trot on right
  forelimb (head nod to
  left on weight bearing)




     Palpation and Radiography




                                   31
          Septic Elbow - Treatment
• Lavage through and
  through, 3 litres
  Hartmann’s, with
  150ml ozone + 100mg
  amikacin sulphate
  medication
• Systemic antibiotics –
  gentamicin and
  ceftiofur
• Ketoprofen – 1mg/kg
• Box Rest




     Septic Elbow – Treatment contd
 • Initial WBC 70 x109/l
 • Repeat flush day 3 –
   WBC 34 x109/l
 • Further medication of
   joint with ozone and
   amikacin sulphate




                                      32
   Monitoring Response to Treatment

• Degree of
  lameness
• Joint WBC count
• Degree of effusion
  or swelling




      Intra-articular Administration
                       Administered following
                       conventional lavage of
                       joint and ozone is left in
                       situ




                                                    33
    Intravenous regional Perfusion
• 50mg Amikacin
• 50 mg gentamicin
• Ceftiofur
• 10 mls saline slow
  infusion
• Leave 30 mins
• Usually repeat every
  other day




                                     34
    Mare Periparturient Problems




        Differential Diagnosis
Last Trimester of Pregnancy:
  Abortion
  Uterine Torsion
  Large Colon Impaction
  Incarceration of small intestine through a
  mesenteric rent (usually at proximal jejunum)
  Pre-
  Pre-pubic tendon rupture
  Hydrops
  Endotoxaemia associated with a dead foetus




                                                  35
                 Differential Diagnosis
Colics at or close to parturition:
  Partuition/dystocia
  Arterial Rupture of middle uterine artery
  Haematomas of the uterine wall or within the pelvic canal
  Uterine Rupture
  Endotoxaemia associated with retained foetal membranes &
  Inversion of the tip of a uterine horn
             gas-                          caecum)
  Rupture of gas-distended viscous (tip of caecum)
  Peritonitis
  Entrapped bowel between pelvis and uterus
  Rupture of bladder
  Mesocolon tear with ischaemic necrosis of small colon
  Uterine prolapse
  Rectal prolapse




                Differential Diagnosis
  Colics in mares in first two months post-
   partum:

  • Colon torsion

  • Colon displacement

  • Laminitis

  • Post-partum eclampsia




                                                              36
   Diagnosis based on a combination of:

   History

   Clinical signs

   Investigative procedures

   Review of differential diagnosis for stage
   of pregnancy




Troytown Survey January ’03 – April ‘03

45 Periparturient Colics:

  30 Post Foaling

  29 Surgical

  16 Medical




                                                37
              Condition          No    Post      Surgical   Medical     Mare        Foal     Survival
                                      Foaling                          Survived   Survived    Rate
Colon Torsion                    7       7          7          0          3         ----      42%
Uterine torsion                  3      ----        2          1          2          2        66%

epiploic foramen entrapment      4      ----        4          0          2          2        50%
Mesenteric tear                  3       1          3          0          3          3       100%

Ruptured stomach                 3       3          3          0          0         ----       0%

Peritonitis                      3       1         ----        3          3          0       100%

Intestinal bruising at foaling   4       4          3          1          1         ----      25%

Uterine tear                     3       0          1          1          1          2        33%

Haemorrhage                      5       5         ----        5          4         ----      80%

Volvulus                         1       1          1          0          1         ----     100%

Large colon displacement         2       2          2          0          2         ----     100%

Impaction                        1       1         ----        1          1         ----     100%

Necrotic bladder                 1       1          1          0          0         ----       0%

CMA                              1       1         ----        1          1         ----     100%
Mesodiverticular band            1       1          1          0          1         ----     100%
Spasmodic                        2       2          0          2          2         ----     100%
Uterine inertia                  1       0          0          1          1          1       100%
                                 45   30 (66%)   29 (64%)   16 (36%)   28 (63%)    66%




           Periparturient Haemorrhage

           • Middle Uterine Artery

           • Intra-mural or intra-luminal

           • Pelvic Wall




                                                                                                        38
      Clinical Signs
              •   Severe Pain
              •   Shock
              •   Tachycardia
              •   Pale Mucous Membranes
              •   Weakness
              •   Perineal Oedema




Diagnosis
            Rectal Palpation
            Transabdominal Ultrasound
            Peritoneal Tap
            Haematology




                                          39
                     Treatment
• Quiet Environment
• Analgesics
• Corticosteroids
• Acetylpromazine
• Blood Transfusion/Fluids
• Naloxone (8 – 32mg) – pressor & analgesic effect
• Aminociproic Acid (10mg/kg slow IV)
• Oxytocin
• Antibiotics
• Intravenous formaldehyde (15ml 10% Formalin
  in 1L saline)
• Oxyglobin (7.5 – 10ml/kg)




                     Prevention
    • Avoid Stress

    • Copper Status

    • Limit roughage towards end of gestation.




                                                     40
          Uterine Torsion




   Last Trimester of Pregnancy
• Intermittent mild or moderate colic

• Diagnosis by rectal palpation

• Surgical or non-surgical correction




                                        41
             Large Colon Torsion
• Most common cause of severe colic in post-parturient mares.

• Occasionally seen in pre-parturient mares

• Strangulated (>360o torsion)

• Non-strangulated (90o – 360o)

• Fatality rate for strangulated large colon torsion is 72%
  (Equine Gastroenterology, T.Mair)




                                                                42
43
         Predisposing Factors
 • Anatomy of Colon
 • Foaling
 • Lactation
 • Feeding
 • Previous Displacement
 • Electrolyte & Mineral Imbalance




      Clinical Signs & Diagnosis
• Acute, violent colic with progressive abdominal
  distension

• Poor response to painkillers

• Shock & rising heartrate

• Severely gas-distended large colon per rectum

• Needs immediate referral or surgery




                                                    44
  Flunixin




Dead Intestine




                 45
Mare due to foal in 3 days
Low-grade colic reported for
Low-
                                Uterine Tear
previous 18 hours
Received 40cc Finadyne during
this period
On arrival, dull, sweating,
dehydrated
Puse 60 bpm
Mucous membranes pale
PCV 14
Fluid on abdominal scan
Cervix closed
On rectal, very prominent leg
palpable




 Necrotic Bladder




                                               46
Caecal Rupture




                 47
              Peritonitis Case (i)
• Nine-year old thoroughbred mare
• Foaled normally at 12:00 p.m.
• Found in the field the following day at 4:00 p.m. in sternal
  recumbency
• Depressed
• Heart rate 80 bpm
• No gut sounds
• Toxic
• No evidence of Colic
• Uterine flush – Clear
• Sore to palpate right horn of uterus
• Administered fluids, antibiotics, NSAID’s and oxytocin




Peritonitis Case




                                                                 48
               Retained Placenta
•   Retained > 3 hours
•   Tie up placenta
•   Oxytocin drip
•   Repeated i/m injections
•   Gentle traction
•   Antibiotics / Nsaids
•   Uterine lavage
•   Examine Placenta for torn
    tip of horn




         Prepubic tendon rupture




                                   49
                          Hydrops




                                             With Thanks to

                                             Warren Schofield,
                                                     Sadlier,
                                             Michael Sadlier,
                                             and the Staff of
                                             Troytown Equine
                                             Hospital.

          that’                  Clinic’
Ooh wait, that’s perfect for the Clinic’s
home page!! – just stretch it out a little
further…        more…
further… little more….




                                                                 50

				
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