Postpartum Complications

Ahmed AliMS, PhD

Dept. Theriogenology, Assiut Univ., Assiut, Egypt

Postpartum period (Puerperium)

AI Birth AI Birth

Pregnancy Postpartumperiod

Pregnancy

12 m

Changes occur during the Puerperium

1. 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)

Most important postpartum complications

1. Perineal rupture2. Retained placenta3. Uterine prolapse4. Uterine and vaginal rupture5. Postparturient paraplegia6. Postparturient uterine atony7. Postparturient straining8. Bacterial puerperal diseases9. Puerperal intoxication10. Puerperal infection11. Septic metritis12. Puerperal tetani13. Puerperal vaginitis and vulvaitis

Perineal Rupture

Causes:1. Spontaneous, during the second stage of labor (vigorous straining)2. Extreme traction of an oversized foetus3. Predisposition include a hypoplastic vulva 4. Mares with Caslick operation

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 toaspiration 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

Surgical correction:1. The patient is confined in stanchion in the standing position2. Cleaning the perineal region3. Light epidural anesthesia4. The tail is tied to one side 5. Tampon placed in the rectum6. Exposure the operative area by placing tension suture in the perineal skin7. The free edge of the shelf is incised to a depth of 3 cm and extended laterally and caudally on each side8. 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.

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.

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 fetus5. 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.

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 Causes1. 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 wall6. In allergic cases.7. Advanced involution of the placentomes.8. Hyperemia of the placentomes.9. Placentitis and cotyledonitis.

Direct causes1. Infection of the uterus during gestation2. Brucella abortus, tuberculosis, Vibrio fetus, mold infection3. Infection of the uterus immediately after partuition Strept., E. Coli, Staph., Cory. pyogenes.4. Abortion and premature birth5. Uterine inertia (primary or secondary)6. Endocrine disorder7. Mechanical prevention

Indirect causes1. Stress 2. Transportation, short dry period, change of locality, management problem4. Deficiency of vitamins and minerals, Carotene, vitamin A, iodine, selenium and vitamin E, imbalance in calcium and phosphorus5. Hereditary factors

Incidence:

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

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 illness3. About 20% may exhibit moderate to sever symptoms of metritis and septic metritis4. 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 involution8. Increase day open

Treatment:Manual treatment1. 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.

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.

Therapeutic treatment without manual removalOxytocin: 20-50 I.U., within 24h after birthEstrogenic substances: 5-20 mg stilboesterolErgot preparation: 1-3 mg of ergonovineCalcium gluconateBroad acting antibiotic: 2-4 gm terramycine 

No treatmentUncomplicated cases required no treatment

Prophylaxis:Balanced nutrition for pregnant animalLarge animal boxesDaily outletAvoidance of transportSufficiently extended dry periodAvoidance of bacterial infections and parturition hygiene.Injection of 2 million IU of vitamin A 4-8w antepartumInjection of 50-100 IU oxytocin immediately after parturition

Postpartum Paraplegia

The animal fail to raise after parturition

 Causes:Metabolic and nutritional disturbances1. Hpocalcemia 2. Grass tetany 3. Ketosis 4. Debility 5. Vitamin E and Selenium deficiency Traumatic injuries1. Paralyses of the obturator, perineal, gluteal femoral or brachial nerves2. Dislocation of the hip joint.3. Fracture of the leg and pelvis4. Exhaustion after dystocia 5. Hemorrhage, anemia, or shock due to rupture of uterine or pelvic vessels

Infectious diseases1. Septi metritis 2. Septic mastitis 3. Peritonitis4. Acute laminitis 5. Septic Arthritis 

Diagnosis1. Examining the locomotor system, especially the hind limbs2. 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 udder4. Infectious cases usually accompanied with fever

Treatment1. Each case must be treated on its merits2. Tray to rise the animal with a brief application of electric goad3. Place the recumbent animal on ample, soft, clean and dry bedding

Uterine and vaginal Rupture

Causes1. Prolonged dystocia with fetal emphysema2. Uterine torsion3. Improper manipulation and traction of the foetus4. Forced traction of the fetus in abnormal p.p.p.5. Fatigue of the operator6. An accident in foetotomy operations7. In mare with the foetus of long extremities (spontaneous)8. Poorly dilated cervix9. Administration of oxytocin while the cervix is closed

Symptoms and prognosis

Depend on:1. Animal art 2. Portion of the genital tract 3. Size of the rupture4. 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 peritonitisAnorexia, lack of rumination and rumen contraction, restlessnessCold extremitiesNormal or subnormal body temperature

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.

TreatmentIn 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 

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 sutureOxytocin

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.

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 cervixHypocalcemia 

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

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 vulvaLong standing dystociaPneumometraBleeding from the genital tractPhlegmone of vaginal tissue

SymptomsThe pains may persist for 4-7 days after birthContinuos or intermittent straining, arched back, sunken eyes and depressionFrequent defection, diarrheaThere is great tendency for prolapse of the vagina or rectumUterine contractions are stronger TreatmentGeneral sedativeEpidural anesthesiaLocal antibiotic within the uterusTreat the original cause

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 lochiaTreatment: 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

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 tenseTreatment: see before

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

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

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.

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