Tuesday, June 24, 2014

1388. Myanmar Seminar - Video; Closed and open pyometra


Recent Advances in Veterinary Practice No.3
Myanmar Veterinary Association, July 5, 2014

GUIDELINES ON TREATMENT OF PYOMETRA CASES
IN DOGS AND CATS

Dr Sing Kong Yuen, BVMS (Glasgow), MRCVS
Founder of Toa Payoh Vets, Singapore. 
www.toapayohvets.com, judy@toapayohvets.com

Pyometra is an infected uterus filled with pus. The uterine lining becomes cystic and hyperplastic due to the effects of oestrogen and progesterone. Bacteria from the vagina enter the cervix to invade the uterine lining leading to inflammation and pus formation.  

If the cervix remains closed, the pus accumulates in large quantities inside the uterus (closed pyometra). If the cervix is open, the pus is discharged via the vagina (open pyometra).  (VIDEO & IMAGES)

If there are ovarian remnants after spay, the animal may develop pyometra of the stump of the uterus (stump pyometra) any time after ovariohysterectomy.  (IMAGE CAT STUMP PYOMETRA X 2)

In Singapore, almost all apartment cats are spayed to prevent anti-social noises of caterwauling and so pyometra in cats is uncommon.  However, many dog owners do not spay their dogs for reasons such as cruelty and therefore pyometra is more frequently seen in veterinary practice.

Yangon appears to have a higher incidence of pyometra in cats and dogs as they have been treated with the synthetic progesterone (Depo-M or Contracep)  IM every 3-4 months to suppress the heat cycle.   (IMAGE OF DEPO-M & CONTRACEP). However, client education has led to more owners opting for ovariohysterectomy (IMAGE OF DOG BOMA).   

This paper shares my experiences with the treatment of pyometra for the last 40 years after my graduation from Glasgow University in1974.  My guidelines are as follows:

1. A correct diagnosis is important.
1.1 History of estrus. Do a thorough physical examination including weighing the dog, taking rectal temperature and checking for false pregnancy or mating.

TIP. Always ask the owner when the vomiting intact female dog has the last estrus.  Pyometra occurs usually 1-12 weeks after estrus. Pyometra may co-exist in pregnancy (20-24 days after ovulation) but it is rare.

1.2 Clinical signs. Important ones are fever, polydipsia, polyuria, abdominal swelling, vaginal discharge. Many owners give false information saying that the vomiting dog was fed a wrong type of food and had diarrhoea. I had a case when the vet misdiagnosed the closed pyometra as acute gastroenteritis (IMAGE OF HUSKY). The dog died of septicaemia and shock when the owner consulted me. Some owners say that the dog does not have polydipsia but has polyuria.

2. Uterine palpation (large uterus for closed pyometra). Abdominal pain or discomfort (dog bites) may be present in a swollen abdomen.

3. Vaginal discharge (serosanguinous or mucopurulent) is seen in open pyometra. VIDEO.

4. CBC/Biochemistry. Leucocytosis and neutrophilia, anaemia, thrombocytopenia, high serum BUN and creatinine, low haematocrit.

TIP. Always advise a blood test to screen the health of the dog and possible kidney damage to determine the anaesthetic risks and prognosis. Some closed pyometra cases may have permanent kidney damage and will continue to vomit even after spay as in one case of a Miniature Schnauzer whose owner’s father procrastinated surgery. The owner was satisfied that the vomiting was due to kidney damage rather than from the surgery as I had interpreted the high serum BUN and urea to her from the blood test.  Without this blood evidence, some owners blame the vomiting on the vet doing an incompetent spay.   

5. Imaging. 
5.1 Survey radiography may show large distended uterus or loops.
5.2 Ultrasonography shows thickened uterine wall (cystic endometrial hyperplasia and intraluminal fluid (pus). Normal uterine wall cannot be detected.

6. Client Education & Informed Consent Form.
6.1. Pyometra is a medical emergency. Prognosis depends on the health of the dog as shown in the blood test results of CBC/Biochemistry.
6.2  Informed consent for anaesthesia and surgery explaining the high risks involved esp. for old dogs.
6.3  Financial costing explained. VIDEO.






PRE-OP STABILISATION
1. Immediate I/V fluid therapy, antibiotics, pain-killers for 1-2 days as inpatient case.

ANAESTHESIA & SURGERY
1.  Use 25-50% of the calculated dosage for I/V sedation depending on the health of the dog.. Intubate and maintain with isoflurane + oxygen gas. I use only isoflurane + oxygen gas anaesthesia in very old or sick dogs as this will be much safer to ensure survival. 

1.1 My calculated dosage is: For a young 10-kg dog, Domitor + Ketamine IV = 0.4 ml + 0.5 ml respectively.

1.2. For very old (over 10 years) dogs and in poor health, I use only isoflurane + oxygen gas.

2. Clipping and cleaning to be done before sedation outside the operating room.

3. Make a long incision carefully. The full bladder may be just below the skin and may be incised spilling urine into the peritoneum.

3.1  I use the 3-haemostat method to clamp the blood vessels of the ovary and uterus. I ligate  the clamped grooved area vacated by the middle of the 3 haemostats.  For the uterine body, I usually ligate in two areas. In big canine breeds, I use the inverting continuous suture to close the stump to prevent pus leaking and contaminating the abdomen.






I note that some vets use 2 haemostats and ligate below the haemostat while they cut off the tissues between the 2 haemostats.  In this method, the ligature may slip off causing bleeding.

4. Sutures. For medium to large breed dogs, I use 2/0 braided absorbable sutures (Polysorb). For small breeds I use 3/0 sutures. My associate vets like the monofilament absorbable sutures (Monosyn).

5. I used Anti-sedan IM to reverse and abolish the effects of Domitor sedation. The dog usually is awake within 5 minutes of the injection.






POST-OP NURSING

6. The dog is hospitalised around 3 days to lower the medical costs. She goes home with antibiotics for another 10 days and an Elizabeth collar. Tolfedine pain-killers are given for the first 4 days.



7. Outcome. If the dog is not extremely ill, she recovers very well from the surgery. The blood test is useful in client education on the permanent kidney damage (high serum BUN and creatinine and phosphous).

8. Practise evidence-based medicine by doing blood tests, urinalysis and radiography. Some 10 years ago, in one case, the dog kept vomiting and died despite being spayed. I did not do the blood test as the owner wanted the cheapest medical cost. This owner or her family members sent mass e-mails to everyone in Singapore advising them to avoid me. Nowadays, they use Facebook or pet forums anonymously to bad-mouth any vet who did not perform to their expectations.

8.1 AMA (Against Medical Advice). Nowadays, I give the owner a written record that he did not want blood tests, X-rays or lab tests as advised by me.

SURGERY FOR STUMP PYOMETRA
Make a long incision to access the ovary caudal to the kidney area. The remnant ovary is usually cystic and enclosing the sutures. (IMAGE).

MEDICAL TREATMENT FOR VALUABLE BREEDING FEMALE DOGS & CATS
1. PGF2alpha is an effective pregnancy terminating drug. Causes uterine contractions to expel the pus. In closed pyometra, the uterus may rupture. In Singapore, a senior vet had one successful case. He incised the linea alba to access the swollen uterus. He passed catheters into the uterine horns to suck out the pus and pumped normal saline and antibiotics to irrigate the uterus. The Pekinese gave birth to one pup at the next cycle.    

Video of one case of pyometra,  produced as educational video as follows:
http://www.youtube.com/watch?v=J9WJqmVPfw8. A 14-year-old X had closed and open pyometra. This video will be screened.





Written notes about the video:

When the vet (myself) said that the dog had a very low chance of survival on the operating table and the medical costs were high in this closed-open pyometra case, the owner probably felt that it would not be justified paying for such a high risk anaesthesia.  He decided to bring the dog home to die.

But I noticed that there was this 12-year-old boy who cried his heart out. Some vets don't follow up as the owner had decided and they had no time to "solicit" for business and risk being rejected..

But this little boy loves this 14-year-old dog very much as tears streamed down his face when the father decided on no operation. He knew the outcome would be death from septicaemia (leucocytosis, neutrophilia, thromobocytopenia in the blood test).

I phoned the father (owner) the next morning. The dog was still passing bloody vaginal discharge and had become lethargic.

I reduced the surgical costs to give this high anaesthetic risky canine patient a chance to live.

Time was running out on her as she became sick again. Her serosanguinous vaginal discharge flowed out like a burst dam.

If she survived the operation, the little boy would get his companion back to health and that was what mattered to me in this case.

 "Don't wait till you have finished work this evening to bring the dog down," I advised the father. "Bring her down now while she still has a fighting chance to live. Time is running out."

Dr Daniel operated immediately in the afternoon. The dog was warded one night. The little boy was most happy to have his companion back home the next day with his mother. "Are you happy now?" I asked him as he carried his friend carefully into the car. "Yes," he beamed to me his best smile..

This is a case where a vet can make a difference if he makes time to follow up before time has run out for a little boy's best friend. Happiness in the boy's face when the dog went home the day after surgery would be hard to describe. "Are you happy now?" I asked him as he sat at the back of the car with this old dog. "Yes," he nodded vigorously while his mummy was most happy too..

Time was running out as the bacterial toxins would cause permanent kidney damage. The father's decision to operate  saved the dog's life. .

Now, as at Jun 25, 2014, around 2 months after spay, the 14-year-old dog is normal.

This case encourages the vet to care for the sick pyometra dog by following up with the owner the next day. Reducing the medical costs would be needed in some cases where money was a concern.

OTHER VET EDUCATIONAL VIDEOS FOR REFERENCES OR AS A BACK UP AS THERE IS NO TIME FOR SCREENING.
http://www.youtube.com/watch?v=C7EyNdXES6I. A Golden Retriever has open pyometra.  Not for screening owing to lack of time.

http://www.youtube.com/watch?v=7c_QNAHP3wY. Enactment by 2 interns. A Maltese has closed pyometra. Part 1.


http://www.youtube.com/watch?v=P54Q6NZgK7w. Enactment by 2 interns. A Maltese has closed pyometra. Part 2.

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