HISTORY
A 9 years old Female West Highland White terrier presented as an emergency from one of our member practices. She had been quieter than usual for a week, with polyuria, polydipsia, and the owner’s main concern was that she started vomiting that morning. There was no recent change in her diet, not known exposure to any poison, she was not a scavenger nor she used to chew toys.
PHYSICAL EXAMINATION
On arrival she was ambulatory, quiet but alert and responsive, with some purulent vaginal discharge that started the same day. Some moderate skin tent was noted. Her abdomen was distended -this fact was confirmed by her owner having noticed that today- and painful on palpation, which limited its manipulation in the consult. Her body condition score was 5.5/9, and she was 9.30kg. The remainder of the clinical examination was unremarkable.
Open pyometra Hydrometra Mucometra Concomitant conditions: gastrointestinal disorder, pancreatitis, renal disorder.
INVESTIGATION
As this patient was seen referred by her practice as their Out Of Hour’s provider, there was no clinical records of this patient and no access to her history. That limited the clinical information to what the owner could report.
The investigation was both extremely limited and challenged due to financial constraints. The presence of vulva discharge was a pathognomonic symptom for any of the reproductive related differential diagnostics. Pyometra was singled out as the most likely diagnosis due to the bloody, purulent aspect of the discharge. Surgical removal of ovaries and uterus was strongly recommended, which cost was already over the owner’s budget. Therefore, the owner was adamant to perform a pre-anaesthetic blood test and/or abdominal ultrasound on both uterine horns.
TREATMENT OPTIONS
The owner was presented with three main options:
l Immediate surgical removal of ovaries and uterus
l Initial treatment with injection of antibiotics and pain relief, hospitalization and fluid therapy, and transfer to her own practice the next day
l Medical treatment with an oral course of antibiotics, strongly advising booking an appointment to her own vet the next day
The first option was initially declined for the said financial reason. Medical options were discussed, stressing that the chances of success by starting on a course of oral antibiotics was very small, and providing it would work chances were very high that the problem reappear during or after her next season. An initial approach of a single injection of amoxicilline with clavulanic acid, symptomatic treatment for her pain and sickness, and overnight fluid therapy was a most advisable option, focused on performing the recommended surgery at her own practice. Cost-wise it was likely to be more economic, though the risks would be higher and the prognosis was guarded. Plans and estimations for each options were presented. Owner was considering discharge against veterinary advice soon after surgery, to save the overnight hospitalization. Finally, the owner agreed with the surgical option, reducing the cost to a minimal medical treatment and hospitalization. As a requirement, the estimation included one hour of surgical time maximum, with no post-op hospitalization, and no oral medication to take at home. It was agreed the cost would not be over the fixed estimation cost that was calculated. The owner was committed into booking an appointment at his own veterinary practice early the following morning.
SURGERY
Prior to surgery, she was given a single subcutaneous injection of amoxicillin and clavunate acid (Synulox, Zoetis). Once the owner opted for the surgical approach, she was premedicated with buprenorphine (Buprecare, Animalcare) and acepromacine (ACP injection, Novartis), using an intravenous bolus of propofol (PropoFlo Plus, Abbott ) as induction to general anaesthesia, which was mainteined with sevofluorane (SevoFlo, Abbott) and oxygen. After the routine preparation to surgery, a midline incision through the linea alba was performed, without significant blood loss. Both uterine horns were exteriorized with the help of two wet abdominal swabs, using sterile saline. The left uterine horn was very distended and with obvious fluid content on palpation. The right uterine horn also had some fluid content, but it was roughly half the side of the left one. None of them presented rupture, and no peritoneal contamination was detected macroscopically. Each ovary artery was clamped with its ligament, and the vessels were double ligated with braided absorbable suture (Vicryl 0, Ethicon). Ovarian ligaments were clamped, so that the ovarian pedicles could be monitored and found at any time, in case a bleeding was detected. The uterine horns and body were also removed, ligating the vessels on each side of the uterine neck with the said material, closing the stump and covering it with omentum once checked there was no bleeding or discharge. No abdominal flushing with warm sterile saline was performed because there was a very low risk of abdominal contamination during the surgery at the time the uterus and ovaries were removed, no uterine rupture or spillage was detected, and this step had not been included in the initial plan.
A thorough revision with sterile dry swabs was done prior to removing the clamps that were holding each ovary ligament, and closing the abdomen. The peritoneum was sutured with simple interrupted stitches, using a monolifament absorbable material (PDS 0/2, Ethicon). A second layer of continuous suture in the submucose, and intradermal stitches reinforced with four outer simple interrupted ones. A non-woven adhesive wound dressing was placed over the incision (Primapore, Smith&nephew), and the recovery from the general anaesthesia was uneventful.
The final operational time was 40 minutes, which reduced the cost significantly, allowing the veterinary surgeon to keep the patient hospitalized for 12 hours for monitoring, continuing the fluid therapy, and dispense oral antibiotic of amox (Noroclav tablets 250mg, Norbrook) and oral pain relief of tramadol (Tramadol hydrochloride 50mg capsules, Accord) as a more economic option.
PROGRESSION
She was quiet, alert and responsive within 30 minutes after surgery. Her recovery was uneventful overnight, except some burping 3 hours after eating a bland diet, and was transfer in the morning to her normal practice by her owner.
DISCUSSION
The fact that the owner eventually agreed with the surgical treatment was partially due to the thorough discussion of the pros and cons for each options, their prognosis and the owner private discussion with other members of the family over the phone requesting their second opinion. Exceptionally, in this case it was agreed with the owner that the cost would not exceed the given estimation at all, despite the practice policy and admission forms stress that there is an agreement that the cost might exceed up to 20% over the given estimation to cover unexpected complications. Financial issues were extremely important to the client, greatly restricting options. A second medical treatment option with aglepristone (Alizin, Virbac) was not considered due to the rate of recurrences, and the use of an off-licensed drug when other options were available. The controversy of using Alizin to treat pyometras (Fieni et al, 2014) considers both open and close pyometras, bitch’s age, antibiotherapy, or planning having a litter in her next season (Ros et al, 2014). The author’s experience using Alizin in three previous cases was not positive, as both bitches presented with another pyometra within three months after being treated, and a third one presented a close pyometra that was diagnosed at the time she was being neutered, also within the three months after treatment. In regards to cost, it would not be much reduced if we include neutering after treatment, which would have been strongly advisable .Therefore, the owner was not offered Alizin as an optional treatment. As for the medical treatment, the risks of inducing antibiorresistance by using a common broad spectrum antibiotic without any culture and sensitivity test would compromise the success of this treatment (Bassessar et al, 2013). Providing that this most economical option would initially succeed, the fact that an ovaryhysterectomy was still advisable, made the owner also reconsider performing surgery urgently, rather than trying antibiotherapy first.
The veterinary surgeon was aware of the higher risks of performing this surgery without a pre-anaesthetic blood test, on an elderly bitch, even more so after her actual status were considered as unstable. The lack of haematology and biochemistry information was taken in consideration when making therapeutic decision. In particular, using a non-steroidal antiinflammatory drug was avoided because the renal function in the patient was not assessed. Other drugs that were considered and dismissed were medetomidine or ketamine use in the premedication protocol. As it was found, during the surgery, that one of the uterine horns was remarkably more enlarged than the other, could lead to argue whether a medical treatment would have been successful, or if the fact that one of the uterine horns might have retained its content, negatively interfering in a potential medical treatment. Additionally, a follow-up abdominal ultrasonography would have detected the retained fluid or confirmed that the more enlarged uterine horn had finally got its content discharged. Word count: 1489
References
Ros, Linnea; Holst, Bodil Ström; Hagman, Ragnvi (2014). A retrospective study of bitches with pyometra, medically treated with aglepristone. Theriogenology. December 2014 82(9):1281-1286
Fieni, F; Topie, E; Gogny, A. (2014). Medical Treatment for Pyometra in Dogs. Reproduction in Domestic Animals. June, 2014; No 49; pag 28-32.
Bassessar, Varun; Verma, Yamini; Swamy, Madhu (2013). Antibiogram of bacterial species isolated from canine pyometra. Veterinary World. August 2013, Volume 6 Issue 8, p546-549.
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