History
A 1-year-old 24.0-kg (52.8-lb) primiparous gravid Nigerian Dwarf doe was presented to the University of Pennsylvania, School of Veterinary Medicine, New Bolton Center approximately 2 hours after being found trapped under a wooden transport pallet and with a large red swelling protruding from the vulva. The doe was believed to have been at approximately 130 to 135 days of gestation.
On physical examination, the doe appeared anxious and alert and was ambulatory, tachycardic (152 beats/min; reference range, 70 to 110 beats/min), tachypneic (104 breaths/min; reference range, 15 to 40 breaths/min), and normothermic (rectal temperature, 38.9°C [102.0°F]; reference range, 38.5°C to 39.5°C [101.5°F to 103.5°F]). The doe's mucous membranes were tacky and pale and had a capillary refill time of approximately 3 seconds. A spherical, maroon, fluid-filled mass (approx 30 cm in diameter at its widest point) and a hyperemic piece of tissue (approx 12 × 5 × 6 cm) protruded from the doe's vulva (Figure 1). Initial hematologic and plasma biochemical analyses revealed that the doe had a clinically normal PCV (28%; reference range, 22% to 38%), low total plasma protein concentration (3.9 g/dL; reference range, 6.0 to 7.5 g/dL), and high plasma creatinine concentration (2.1 mg/dL; reference range, 1.0 to 1.8 mg/dL).
Presurgical image of a sedated 1-year-old primiparous Nigerian Dwarf doe (approx 130 to 135 days of gestation) that the owners found trapped under a wooden transport pallet and with a large red mass protruding from the vulva. The doe is in right lateral recumbency, with its head toward the upper right corner of the image.
Citation: Journal of the American Veterinary Medical Association 256, 9; 10.2460/javma.256.9.991
Question
What are the differential diagnoses for protrusion of such vulvar masses in a late gestation doe? Please turn the page.
Answer
Differential diagnoses are prolapse of the vagina, uterus, or bladder; parturition; or neoplasia of the reproductive tract.
Results
The doe was sedated with midazolam hydrochloride (0.30 mg/kg [0.14 mg/lb], IV). Manual examination of the vagina revealed a dorsally located rupture of the vaginal wall and prolapse of the body of the uterus and cervix through the defect (Figure 2). Placentomes, fetal fluids, and fetal membranes were palpable through the wall of the exteriorized portion of the uterus, and transabdominal ultrasonography with a 5-MHz probe revealed the presence of at least 1 live fetus in the intraabdominal portion of the uterus.
Same image as in Figure 1 (A) and a closer presurgical image of the ventral aspect of the doe's perineal area (B). The larger mass protruding from the doe's vulva is the body of the doe's gravid uterus (asterisk; A and B) that prolapsed without invagination through a vaginal rupture. Both uterine horns, with 1 fetus in each, are retained intra-abdominally. The smaller, more hyperemic tissue visible ventral to the prolapsed gravid uterus is the cervix (arrow; A and B).
Citation: Journal of the American Veterinary Medical Association 256, 9; 10.2460/javma.256.9.991
In preparation for surgery, a 16-gauge IV catheter was placed in the doe's left jugular vein, and the doe was administered thawed caprine plasma (300 mL total delivered as a 10.0 mg/kg [4.5 mg/lb], IV bolus, followed by 3.0 mL/kg/h [1.4 mL/lb/h], IV infusion) and penicillin G procaine (22,000 U/kg [10,000 U/lb], IM). The doe underwent general anesthesia for left paralumbar fossa exploratory laparotomy. In addition to surgical site preparation, the prolapsed tissues and perivulvar region were aseptically prepared and routinely irrigated with sterile saline (0.9% NaCl) solution. During surgery, the presence of 2 fetuses (1 in each uterine horn) was confirmed, as was a dorsally located rupture (approx 10 cm long) in the vaginal wall, through which the uterine body had prolapsed. A hysterotomy incision (approx 12 cm long) was made in the left uterine horn, and 1 live but nonviable premature kid was delivered. A similar hysterotomy incision was made in the right uterine horn, and a stillborn kid was delivered. The hysterotomy sites were closed with 2-0 poliglecaprone 25 suture in a double-layer Cushing pattern, and the uterine horns were placed back into the abdomen. Initial attempts to reduce the prolapsed section of uterus were unsuccessful. Therefore, a stab incision in the exteriorized portion of the uterus was made with a No. 10 blade to drain the fetal fluids. Afterward, the stab incision was closed with 2-0 poliglecaprone 25 suture tied in a single cruciate pattern. Moderate manual manipulation was then used externally and intra-abdominally to guide the uterus and cervix back through the vaginal rupture and into correct position. The location of the vaginal rupture within the pelvic canal, however, prevented primary closure of the wound. The abdominal cavity was thoroughly lavaged with sterile saline solution, and the peritoneum, abdominal muscles, and skin of the laparotomy incision were closed routinely in 3 layers with 3-0, 3-0, and 2-0 polyglactin 910, respectively, each in a simple continuous pattern. A Penrose drain was placed in the subcutaneous space of the incision. A Buhner stitch was placed around the vulva to help prevent recurrence of uterine prolapse. The doe was recovered from anesthesia without complication.
After surgery, the doe was hospitalized and received broad-spectrum antimicrobials (potassium penicillin G [22,000 U/kg, IV, q 6 h] and gentamicin sulfate [8.8 mg/kg {4.0 mg/lb}, IV, q 24 h]), analgesics (flunixin meglumine [1.1 mg/kg {0.5 mg/lb}, IV, q 12 h] and morphine sulfate [0.10 mg/kg {0.05 mg/lb}, IM, q 8 h]), a gastroprotectant (pantoprazole [1.5 mg/kg {0.7 mg/lb}, IV, q 12 h]), and fluid therapy (lactated Ringer solution). Before administration of gentamicin, the owners were informed that the drug was not approved for use in food animals and that there was an 18-month meat withdrawal interval if gentamicin was administered. The owners agreed that this animal would not enter the food chain.
Discussion
Typically, uterine prolapse occurs postpartum when a previously gravid uterine horn invaginates and protrudes from the vulva.1 Uterine prolapse usually occurs within a few hours of parturition and has been associated with dystocia, hypocalcemia, and increased parity.2 In contrast, the doe of the present report had a portion of the body of a gravid uterus prolapse through the vaginal wall without inversion. Similar to the doe in the present report, prolapse of a gravid uterus through a vaginal rupture was reported in a goat with chronic vaginal prolapse3; however, with that goat, the fetuses were palpable in the exteriorized portion of the uterus, and the goat died after hysterotomy and vaginal rupture repair. In contrast, the prognosis for the doe of the present report was improved by the owner promptly seeking veterinary care and by the doe's gravid uterine horns being retained in the abdomen (preventing prolapse of the entire uterus through the vaginal rupture) and plugging the vaginal rupture (limiting the amount of further abdominal involvement and contamination).
Although spontaneous vaginal rupture has been reported in sheep,4 underlying causes of vaginal ruptures can be multifactorial. Often, some irritating source (eg, vaginal prolapse) causes the vagina to become edematous or friable, making it more susceptible to damage (eg, with tenesmus or dystocia). Vaginal ruptures occur in various species; however, because of the uncommon nature of both vaginal rupture and uterine prolapse, prognosis for fertility can be difficult to determine. A study3 of sheep shows that 2 of 3 affected and treated ewes were rebred in the following years and delivered viable twins, suggesting potential for good reproductive health after recovery, compared with a study5 in cattle that shows poor prognosis for fertility after uterine prolapse.5 For instance, 18 of 72 (25%) cows with uterine prolapse were culled for infertility, compared with 8 of 144 (5.6 %) cows in the control group, and of the cows bred in the subsequent breeding season, 30 of 40 (75%) cows in the prolapse group conceived, compared with 106 of 132 (80.3%) cows in the control group.5 Also, in that study,5 the mean interval from calving to conception was longer for cows in the prolapse group (156 days), compared with the control group (106 days).
In women, vaginal ruptures generally occur in the cranial vagina, particularly in the fornices,6 and clinical signs vary depending on the severity. The mainstays of treatment include hemostasis, surgical repair, and antimicrobial treatment. Ideally, vaginal ruptures are repaired with primary closure, either per vaginum or via laparotomy. However, the small size of some animals can make surgical access to the site of vaginal rupture difficult, as was the situation in the doe of the present report. In such situations, treatment involves allowing for second-intention healing and closely monitoring the patient for complications. Antimicrobials are recommended because of the high risk for abdominal contamination and peritonitis; however, not all vaginal ruptures penetrate the peritoneum and enter the abdominal cavity.
With uterine prolapse, major complications include hemorrhage, shock, peritonitis, and death. The condition of a prolapsed gravid uterus is a true reproductive emergency. The longer the uterus remains outside of the abdomen, the poorer the prognosis becomes. The patient should be restrained where found to prevent further damage to the uterus and reduce risks of rupturing large vessels of the uterus. Prompt treatment is recommended because exteriorized uterine tissue becomes progressively edematous and friable. In addition, persistent straining by the affected animal leads to further prolapse and increases tension on uterine vessels, thereby increasing the risk of hemorrhage. Epidural anesthesia can be administered to ease patient straining and thereby facilitate correction of the prolapse after it has been cleansed and inspected. If a prolapsed gravid uterus cannot be manually corrected, cesarean section is warranted, and cesarean section in a small ruminant before day 138 of gestation is unlikely to result in a viable fetus.7 Preoperative fetal ultrasonography may help determine whether the fetus is alive or dead; however, fetal viability is greatly decreased if the dam is not close to term. If uterine tissue is compromised and the dam is not used as a production animal, ovariohysterectomy should also be considered. Thus, veterinarians need to know the priorities of the owner as to whether the life of the dam versus that of the fetus is more important and whether the dam will or will not need to have future production potential. The owners of the doe in the present report expressed that the doe was a beloved pet and elected to proceed with surgery at the risk of losing the fetuses.
Medical treatment after correction of uterine prolapse generally includes administration of an appropriate antimicrobial because metritis is a common sequela. For an animal in which its nongravid uterus has been returned to position, treatment with oxytocin may be considered to induce myometrial contractions and aid in uterine retention. Further, hypocalcemia is a common predisposing condition, and treatment of such, if present, will also aid in uterine contraction.
Outcome
The doe recovered well, and its PCV and plasma total protein concentration stabilized at 24% and 4.2 g/dL during hospitalization. A fecal egg count was performed, and results were negative for intestinal parasites. The day after surgery, fluid therapy was discontinued. Three days after surgery, the Buhner stitch was loosened and morphine administration was discontinued. Seven days after surgery, the fetal membranes were expelled and all other medications were discontinued. The doe was discharged in good health 8 days after surgery and was reported by the owner to have been in excellent health 6 months later.
Acknowledgments
The authors declare that there were no conflicts of interest.
References
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