the efficiency of medical treatment of pyometra

LITHUANIAN UNIVERSITY OF HEALTH SCIENCES VETERINARY ACADEMY

Faculty of Veterinary Medicine

Alex-Sander Myhre

Canine pyometra:

the efficiency of medical treatment of pyometra

Šunų piometra:

piometros medikamentinu gydymo efektyvumos

MASTER THESES

Integrated Studies of Veterinary Medicine

Supervisor: Doc.Dr.Gintaras Zamokas

TABLE OF CONTENT

Summary ... 2

Santrauka ... 3

Introduction ... 4

Keywords ... 5

Abbreviations ... 6

1 Literature Review ... 7

1.1 Background ... 7

1.2 Pathogenesis ... 7

1.3 Clinical Signs ... 9

1.4 Treatment ... 10

1.4.1 Surgical treatment ... 10

1.4.2 Uterine drainage/lavage ... 10

1.4.3 Pharmaceutics ... 11

1.4.3.1 Prostaglandin F

... 11

1.4.3.1.1 Side effects of prostaglandins ... 13

1.4.3.2 Cloprostenol... 13

1.4.3.3 Aglepristone ... 13

1.4.3.4 Aglepristone and intrauterine antimicrobials ... 14

1.4.3.4.1 Side effects of Aglepristone ... 15

1.4.3.5 Cabergoline ... 15

2 Material and methods ... 17

2.1 Animals ... 17

2.2 Data collection ... 17

2.3 Variables in the material ... 17

2.4 Clincal examinations ... 18

3 Results ... 20

3.1 Treatment protocols... 21

3.2 Clinical signs ... 23

3.3 Bacterial evaluation... 25

3.4 Outcome and ovariohysterectomy (OHE) findings in the material ... 25

3.5 Side effects of the medical treatment ... 27

4 Discussion ... 28

5 Conclusions ... 31

6 Suggestion ... 32

7 Acknowledgments ... 33

References... 34

Annex ... 37

SUMMARY Canine pyometra:

the efficiency of medical treatment of pyometra Alex-Sander Myhre

Master Theses

Uterus inflammation, pyometra in the female dog is a very common disease.

The disease can potentially be life threatening if no treatment is done or the uterine wall are ruptured, leading to peritonitis, sepsis, and possibly also DIC.

The disease is caused by the influence of hormones on the uterus, in

combination with the presence of a bacterial infection. It is regarded that the hormone progesterone plays a major role in the development of the disease.

Treatment of choice is most often by performing an ovariohysterectomy (OHE), but there are several medical options available for the treatment of pyometra. With that kind of treatment it will maintain the fertility of the female, possibility to avoid surgery and anaesthesia.

For medical treatment of pyometra the drugs that is available is progesterone receptor antagonist, dopamine and prostaglandin agonists.

In this study the main focus have been on using the natural prostaglandins (PGF 2 ) available under the marketing name Dinolytic Vet. Zoetis 5 mg/ml.

The drug is sold in Norway with the following indications: Horse: Oestrus synchronization, prolonged oestrus interval. Cattle: oestrus synchronization, induction of labour prolonged pregnancy. Chronic metritis. Uterine inflammation.

Pigs: Induction of labour-prolonged gestation (www.veterinærkatalogen.no Norway) In combination with the hormone treatment it has also been given antimicrobial treatment.

The study has been done retrospectively on the journals from Kaunasvet and Fredrikstad Animal Hospital. Included in the study there are ten females that did receive medical treatment and one that had OHE.

The outcome and success rate of the study have been to see clinically healthy status at the end of the treatment period.

After treatment 10/11 had successful result, 1/11 had recurrence within one year

SANTRAUKA Šunų piometra:

piometros medikamentinu gydymo efektyvumos Alex-Sander Myhre

Master Theses

Gimdos uždegimas, piometra yra dažni kalių susirgimai. Liga gali būti potencialiai pavojinga gyvūno gyvybei, nes savalaikiai nesuteikus kvalifikuoto gydymo, gali plyšti gimdos sienelė, prasidėti peritonitas, sepsis ir galbūt taip pat DIK.

Ligą sukelia hormonų poveikis į gimdą, kartu esant lytinių takų bakterinei infekcijai. Laikoma, kad hormonas progesteronas vaidina svarbų vaidmenį ligos vystymesi. Dažniausiai pasirenkamas operacinis gydymo būdas, atliekant

ovariohisterektomiją (OHE), tačiau yra ir kiti galimi piometros gydymo pasirinkimai.

Pasirinkus kitus galimus gydymo metodus yra išsaugomas kalės vaisingumas, išvengiama operacijos ir anestezijos. Pasirinkus medikamentinį piometros gydymo būdą, vartojamas progesterono receptorių antagonistas, dopaminas ir prostaglandinų agonistas.

Šiame tyrime, pagrindinis medikamentas gydant kalių piometras, buvo natūralus prostaglandinas (PGF 2 ), kuris rinkoje žinomas kaip Dinolytic VET. Zoetis 5 mg / ml.

Šis vaistas yra parduodamas Norvegijoje nurodant indikacijas, kaip:

kumelėms: rujos sinchronizacija, ilgai trunkanti ruja;

karvėms: rujos sinchronizacija, abortui ar veršiavimuisi sukelti, lėtinis metritas, piometra; kiaulėms: paršiavimuisi sukelti (www.veterinærkatalogen.no Norvegija).

Skiriant hormoninį gydymą, kartu turi būti skiriami ir antimikrobiniai preparatai.

Tyrimui duomenys buvo renkami Kaunasvet ir Fredrikstad Animal Hospital klinikose. Tyrimui buvo atrinkta dešimt kalių, kurioms buvo taikytas medikamentinis piometros gydymas ir viena, kuriai buvo atlikta OHE.

Tyrimo metu gydymas buvo laikomas sėkmingu, jei gydymo laikotarpio

pabaigoje buvo stebimas pilnas gyvūno pasveikimas . Gydymas buvo sėkmingas 10/11 kalių, vienai kalei 1/11 susirgimas atsikartojo po vienerių metų po gydymo.

Vienai kalei 1/11 buvo atlikta OHE be medikamentinio gydymo išskyrus

INTRODUCTION

Pyometra in the intact female dog is a potential life threatening condition, and the treatment of such a diagnosis is of great importance for the dog. The different methods to choose from for the veterinarian are limited to two options.

One is surgical and the other one is medical treatment. In this paper I will focus on the efficiency of medical treatment of pyometra in the female dog.

In the Scandinavian countries there is a mainly intact population of dogs, this also due to the legislation in some countries, for example Norway where it is forbidden to neuter a dog without medical reason (1).

This may explain the reason for the higher incident of pyometra disorder in comparison with other countries where there is more normal to neuter both the male and females in a younger age (2). Analysis of survival rates in Swedish dogs indicates that, on average, about 24% of female dogs will develop pyometra by the age of 10 years (3).

The pathogenesis of pyometra is not fully investigated, and the full mechanism of action that takes place is not completely understood. But the hormonal influence of oestrogen and long time presence of progesterone is in combination with naturally occurring bacterial flora in the uterus is believed to have a great part in developing the disease.

Bacterial invasion, presumably from the vaginal flora, is an important trigger.

Escherichia coli is the most common organism isolated from female dogs with pyometra (3).

There is a six fold increased risk of pyometra in nulliparous females, compared to primiparous and multiparous animals (3).

Ovariohysterectomy (OHE) is the treatment of choice for pyometra and is considered safe and effective (4). Downside with surgical treatment are the increased risk with

anaesthesia and that the female becomes sterile, and will not be able to produce offspring (5).

Medical treatment should be considered for:

Breeding female dogs, with excellent confirmation

Females in very poor condition or old dogs, in whom anaesthesia would be dangerous.

Cases where owners have a limited economical budget

Before surgery, if the general condition of the female is poor (5).

The aim of this study is to assess the efficiency of medical treatment of canine

pyometra based on clinical records and from small animal clinics in Kaunas, Lithuania and in Norway.

My objectives for this study has been:

1. Enhance my own knowledge and competence related to the given area of study. And in the same time develop a scientific approach to a given hypothesis and work systematically with sources and material.

2. To identify if canine pyometra should be considered an emergency problem, with need of urgent surgical treatment.

3. To describe alternative treatment compared to surgical.

4. To compare some of the medical options available.

KEYWORDS

Pyometra, Cystic endometrial hyperplasia, Prostaglandin F 2 , Aglepristone, Female dog

ABBREVIATIONS

OHE Ovariohysterectomy

CEH Cystic endometrial hyperplasia h Hour

im Intramuscular iv Intravenous sc Sub cutaneous

DIC Disseminated intravascular coagulopathy MD Missing data

NAD Nothing abnormal detected

PAD Pathological anatomical diagnosis PGF 2 Prostaglandin F 2

Po Per os Temp Temperature

WBC White blood cell count CXCL8 Interleukin-8

KVET Kauno veterinarijos praktika

FAH Fredrikstad Animal Hospital

1 LITERATURE REVIEW

1.1 Background

Pyometra, literally meaning pus in the uterus, is a common disease of intact female dogs. Canine pyometra is a disease of the uterus in intact sexually mature female dogs usually diagnosed 4 weeks to 4 months after oestrus (6).

Pyometra can be open, with vaginal discharge, or closed, with small or no amount of vaginal discharge, depending on the function of the cervix.

Other names to describe the condition have been purulent metritis, hypoplastic endometritis, chronic cystic metritis and cystic hyperplasia-pyometra complex (7,8) (9).

Cystic endometrial hyperplasia (CEH) was generally present in pyometra uteri, but CEH could also be found in many older female dogs without any signs of pyometra (8).

Dow (7) (8) also found that the cystic hyperplasia-pyometra complex could be divided into four groups, after his studies of 100 cases histologically.

More recent research suggests that CEH and pyometra should be separated as two different entities (10). In that study it was also determined that CEH and pyometra can develop independently of each other (10).

1.2 Pathogenesis

The most common bacteria that are isolated from uterine content in female dogs with pyometra are Escherichia Coli (11), (12).

It is in general thought that CHE is considered a predisposition in the female dog to develop pyometra, but recent studies indicate that these two conditions may develop independently (13), (10).

Most frequently pyometra develop in the diestrus phase of the hormonal cycle of the female dog, although it is also diagnosed the disease in anoestrus (14). It has also been suggested that the pro-inflammatory chemokine Interleukin-8 (CXCL8) is present and elevated in pyometra, and may be a good predictor and useful complement for existing laboratory tests and clinical signs to diagnose the disease.

CXCL8 has a fundamental role in inflammation; it promotes migration of the

neutrophils and activation of these, including the full pattern of responses for these cells (15).

Pyometra is developed as a result of complex etiological factors. These include

hormonal influence on the uterine environment, virulence of the infecting bacteria, general

ability of the female dog to combat the infection and the individual sensitivity to bacterial and

Fig. 1

Conceptual and generalized model of factors involved in the pathogenesis of canine pyometra (16).

The presence of progesterone during the oestrus cycle is used to describe one of the most important factors resulting in the development of pyometra in the female dog, this in combination with a bacterial infection (17).

Recent studies gives the indication that it is not the concentration in circulation that is of most importance, but the number of progesterone receptors and the sensitivity to the hormone stimulation that play the role of the pathogenesis of the disease (18).

Hormonal influence Open cervix

Bacteria in the uterus

Immune

response CEH

Suitable uterine environment Bacterial viru-

lence attributes

Established infection

Pyometra

Bacterial endotoxin

10

Fig. 1. Conceptual and generalised model of factors involved in the pathogenesis of canine pyometra.

Multiorgan effects

Systemic inflam- matory response

Immune response

Endotoxic shock

During the oestrus cycle the levels of progesterone and estradiol vary.

Progesterone increases the endometrial epithelium secretions, and inhibits relaxing of the cervix (7).

Progesterone levels in the bitch can be used to establish the stage of the oestrus cycle (Table 1).

Table 1 The progesterone and estradiol levels during the oestrus cycle (10).

Progesterone ng/mL Estradiol-17 pg/mL

Anoestrus < 0,5 < 25

Proestrus < 1 > 25

Oestrus > 1 > 25

Metestrus > 0,5 < 25

The relationship between CEH and pyometra is still not fully understood, the studies of De Bosschere (10) support that the two diseases is separate entities and that they can develop independently. CEH do not have to be followed by pyometra, and that pyometra may occur without the presence of previous CEH (10).

The clinical value for distinguish the CEH from pyometra is of more importance in case of emergency situations. For example the diagnose of a false pyometra that really is a

CEH/mucometra will not have a negative consequence for the patient, except that the female will not be able to be breed from.

More serious is the diagnose of false CEH/mucometra that is not treated as an emergency (19).

1.3 Clinical Signs

Clinical signs most often occur during dioestus or in early anoestrus. With the female been in season 4-8 weeks earlier. It may be presence of vulvar discharge, in case of open cervix pyometra.

Other clinical signs are not exclusive for pyometra, like lethargy, anorexia and vomiting. Polydipsia-polyuria may also be present in the female dog (3).

Physical examination often reveals dehydration, uterine enlargement. If no vaginal discharge the cervix is closed and it is classified as closed cervix pyometra (20).

Blood sampling most commonly show that when the female is affected by pyometra

neutrofilia with a left shift, monocytosis, leucocytosis, and anaemia (17).

1.4 Treatment

Surgery is considered the best treatment of pyometra, either open or closed; this is also according recommendations in literature (1).

In the survey done by Rootwelt-Andersen (1) 98% of the 116 participating veterinarians answer that surgery is treatment of choice.

Medical treatment is known and there have been several researches about the different protocols (21), (22), (23) (24).

Still there is a majority of veterinarians that does not consider this as option in the treatment of pyometra (1).

Use of uterine drainage for the treatment of canine pyometra is not well described in literature, there is a clinical case study done with good results by De Cramer (25).

This paper will evaluate the efficacy of medical treatment, so that the surgical treatment and drainage/lavage will be only described briefly.

1.4.1 Surgical treatment

OHE is the recommended treatment of choice for canine pyometra, according literature (1), (3). The method is associated with low mortality rate and fast recovery.

The most common method is to remove both the uterus and the ovaries (1).

Complications may come be stump pyometra from residual ovarian tissue, and the same complications associated with elective OHE, peritonitis, septicaemia and endotoxemia (26).

1.4.2 Uterine drainage/lavage

Surgical drainage of the uterus without OHE is not recommended in the literature (26), but in the clinical case study from 2010 (25) it shows good results.

The corpus lutea is removed; each horn lavage and suctioned, drains are placed through the cervix to allow daily lavage with diluted antiseptics (26).

In the study by De Cramer the uteri were flushed with 5% povidone-iodine and saline mixture in combination with systemic antimicrobial treatment.

The vaginal discharge stopped by day 4 in all 7 of the 8 females. The last one had discharge until day 12 of treatment.

All of the females had subsequently normal oestrus, and all except one was mated and

produced puppies with normal litter size (25).

1.4.3 Pharmaceutics

There are various medications used for treatment of canine pyometra, not all of the different products are registered for that use, so off label protocols have been developed.

The most common therapeutics will be described.

1.4.3.1 Prostaglandin F 2

One option for treatment of pyometra in female dogs with conservative protocol is the use of prostaglandins. Prostaglandins are hydroxyacids derived from the fatty acid

arachidonate with a variety of actions in the body (27).

PGF 2 has luteolytic effect, when it is used it results in contraction of the

myometrium, increased cervix relaxation, and reducing serum concentration of progesterone (21). PGF 2 is not registered for use in small animals, but it is indicated for treatment of oestrus synchronization, abortion, and treatment of pyometra in pigs, cattle and horses (dinoprost, Dinolytic vet. Zoetis, Veterinærkatalogen Norway).

There have been a number of studies regarding the use of prostaglandins in treatment of pyometra in the female dog. I will make a short review of the main and most relevant findings. In an early study from 1982 Burke with PGF 2 treatment of females dogs.

They were given a dose of 22, 110, 220, or 441 g/kg and the two lowest doses were found ineffective. PGF 2 were given once a day during two following days and had a positive outcome. Later the treatment protocol were adjusted and the dose were given at 250 g/kg sc every 24 h for 3 to 10 days, additional dose were administered at day 3 and 5 after vaginal discharge were last observed. Two of the females were diagnosed with metritis post mating and were treated for three and four days respectively, both gave birth to healthy puppies at the expected time. Follow up data show that five of nine females had puppies after the first or second oestrus after treatment with PGF 2 .

Side effects reported were vomiting, salivation, loose faeces, ataxia, hyperpnoea and constriction or dilatation of pupil (27).

In 1986 another study of 10 female dogs treated with PGF 2 were described. They

were treated at a dose of 500 g/kg (n=8) or 250 g/kg (n=2) sc dinoprost once daily for three

days, in combination with antimicrobials during four weeks. In this study the success rate was

100%. All ten females were mated on the following oestrus; only two of them produced

puppies. Four out of the ten females produced puppies during the first year following

treatment and five out of nine of the females were followed up more than one year.

The recurrence rates during the first year were 40% (4/10), they were treated repeatedly with the same protocol and all had another recurrence. Of the females that were followed up more than one year the recurrence rate were 77% (7/9).

Side effects during treatment were salivation, restlessness, panting and defecation (12).

One study used dinoprost at a low dose of 20 g/kg im three times per day for

maximum of eight days, combined with antimicrobials for four weeks, to treat 10 female dogs with pyometra. (24). On the 8 ^th day uterus were still enlarged in 3 dogs, and they were

decided surgical treatment with OHE. Of the other females had any recurrence during follow up of 10 months after treatment. Five of the females were mated and produced litters.

No side effects were reported (24).

In a retrospective study on 40 female dogs that were treated with dinoprost and/or luprostiol (a synthetic PGF 2 analogue) at the dose of 26,8 to 258 g/kg 1 to 3 times a day, with the duration of treatment varied from 2 to 26 days. Broad-spectrum antimicrobials were used until the females did not show any clinical symptoms. The treatment protocol were successful in 87% (33/38) of the females. With the follow up for 1 to 5 years post treatment show that 25% (5/20) had not been able to reproduce, and that 45% (9/20) had produced at least one litter. In 6 of the cases no follow up data were available. Recurrence of pyometra- metritis did occur in 10% (2/20) and 10% (2/20) had to have OHE due to complications after the treatment. The authors advice not to use high doses and start the treatment with low dose in dogs with cardio-pulmonary lesions, and be careful and observe before increasing the dose, because of the bronchospastic effect of dinoprost (28).

In 1999 Gábor et al. did a study with 17 female dogs with diagnose of pyometra or metritis. The dose of 150 g/kg PGF 2 were given intravaginal, once or twice per day in combination with amoxicillin or gentamicin im injections. The duration of the treatment was 3 to 12 days. In that period 88% (15/17) of the females had recovered, two of the females had been treated surgically with OHE because of reduced general health. There were no observed recurrences at the next oestrus within 12 months post treatment. They did not comment any side effects from the treatment (29).

More recent study were done by Jena et al. in 2013, they treated seven females with dinoprost in the dose of 100 g/kg sc once every day for seven days. All of the females recovered and six came in oestrus, where there were four that did get pregnant. The

recurrence rate was 42,9%. During treatment the reported side effects like vomiting, panting,

In another study it is suggested to divide the treatment protocol according to the phase of the oestrus cycle the bitch are in (31). Arnold at al. describe that treatment during anoestrus (when last heat were more than 2,5 months ago) is recommended at a dose of 20-30 g/kg im for a period of 5-8 days. Ultrasound examination one week after starting the treatment, for control of the evacuation of pus from the uterus, and to check the size of the uterine horns.

If the bitch is in metestrus (within 2,5 months from last heat) a combination with aglepristone (Alizin Vet.) is recommended. The protocol suggested is the same dose of prostaglandins, but with the addition of aglepristone 10 mg/kg sc 2 x 24h apart.

This to ensure that the cervix is open and that the pus in the uterus has a way out. In addition a broad-spectrum antibiotic are given po for up to 3 weeks (31).

From the different studies that have been studied it show a clear and high success rate with the use of prostaglandins in treatment of pyometra in the female dog, the only downside is the reported side effects. To overcome the effect of the side effects it have been reported that walking the dog after the injection will have a beneficial effect, and reduce the side effects dramatically (32).

1.4.3.1.1 Side effects of prostaglandins

There have been reported side effects when administering prostaglandins. The type of side effects is vomit, panting, restlessness, defecation, urination, ataxia, hyperpnoea and salivation (12), (27), (30).

As described before, side effects may be both reduced and eliminated by walking the dog after the injection of PGF 2 (32).

1.4.3.2 Cloprostenol

Cloprostenol is a synthetic prostaglandin, and in comparison to natural prostaglandins it is much more effective in causing luteolysis and maintaining uterotonic action (33).

It is been advised that only females without kidney and/or liver dysfunctions should be treated with cloprostenol (18).

The use of clopostenol is mainly in combination with other therapeutics as for example with aglepristone or cabergoline. (21), (33).

1.4.3.3 Aglepristone

Aglepristone is a steroid sex hormone that binds competitively to the progesterone

receptors with high affinity. Alizin Vet. From Virbac, France is the registered aglepristone

product for veterinary use. It is registered with indication for abortion in the female dogs up to

Treatment of pyometra is also described effective with this therapeutic. (17).

Aglepristone has been shown effective as treatment of both open and closed cervix pyometra (34), (18). This is also supported by the study done by Trach et al (35), where 7 out of 8 female dogs were treated with aglepristone and antimicrobial successfully, none of them had any recurrence for at least one-year post treatment. Another study done in 2010 showed similar results in 12 bitches with closed cervix pyometra, which was treated with aglepristone and antimicrobial, and all had recovered by the 14 ^th day after treatment (36).

Aglepristone is also used in combination with cloprostenol, this to reduce the side effects of the drug (18). There are several studies of this combination, (5), (18), (21).

In the study by Fieni from 2006 the comparative study with the use of aglepristone (at the dose of 10mg/kg on day 1,2 and 8 and if necessary also on day 14 and 28 with

aglepristone (same dose as previous group) combination with cloprostenol (at the dose of 1 g/kg daily on day 3 to 7). The success rate at day 90 was 60% (12/20) and 84% (27/32) respectively.

In total 54,5% of the 33 female dogs hade side effects like nausea (12/33) and

vomiting (6/33). Follow-up data were available in 23 female dogs of which 13% (3/23) had a recurrence of pyometra 7 to 12 months later. 19% (4/21) had recurrence at 19 months after treatment. Five females were mated at the first oestrus after treatment and four gave birth to normal litter. Three of the females were followed for 6 years without any recurrence and with normal oestrus cycle (18).

Gobello et al in 2003 did a similar study and the combination of aglepristone and cloprostenol were evaluated in a study with 15 female dogs.

The dose used in this study was aglepristone (10 mg/kg on day 1,3,8 and if necessary day 15) and cloprostenol (1 g/kg were either given 3 and 8, or on day 3,5,8,10,12 and 15 if necessary). The success rate were 100% (all 15 females recovered), after 15 (n=10) or 29 (n=5) days. No side effects were observed. Recurrence rate at the next oestrus were 21%

(3/14), one of the females had been mated and had puppies (21).

1.4.3.4 Aglepristone and intrauterine antimicrobials

In one study from 2005 by Gürbulak et al, 24 female dogs they found no statistical

significant difference in the recovery rate in females with open or closed cervix pyometra,

treated only with aglepristone (6/13 recovered). But it was found that there were significantly

higher recovery rate in female dogs with closed cervix pyometra treated with aglepristone in

1.4.3.4.1 Side effects of Aglepristone

In many studies there is reported no side effects observed in the female dogs with pyometra and treated with aglepristone (21).

However there has been reported side effects when using aglepristone in the treatment of termination of pregnancy, such as anorexia 36%, weight loss 5%, polydipsia 5% and local swellings 9% (37).

1.4.3.5 Cabergoline

Cabergoline (Galastop vet. Ceva Animal Health) is a prolactin inhibitor, which acts directly on the anterior pituitary gland (38)

The way cabergoline function in the brain is schematic described here (Fig. 2).

Fig. 2

Schematic drawing of the inhibition of nursing/nesting behaviour, and the inhibition of lactation and development of the milk glands (38).

Cabergoline have mainly been used for milk suppression in dogs, but as prolactin has a role in the latter half of the luteal phase as a luteotropic hormone, makes it a useful

pharmaceutical in inhibiting the luteal action of progesterone and thus makes it useful also for the treatment of pyometra and mammary tumours, in addition to pregnancy termination (21).

In a study made in 2013 it were seven female dogs that received treatment with a

combination of cabergoline (at the dose 5 g/kg po once daily) and cloprostenol (at the dose 1 g/kg once daily) for seven days. All seven females recovered and all came later in oestrus,

Cabergoline

Based on this study we can say that cabergoline in combination with cloprostenol has a good success rate and seem to be a good treatment option.

The same positive results were also given in the study from 2006, when 29 female dogs

where treated with the combination of cabergoline and cloprostenol, where the goal was to

reduce the dose of prostaglandin agonist to reduce the amount of side effects previously

reported for the use of prostaglandins (33)

2 MATERIAL AND METHODS

2.1 Animals

A retrospective study was performed with the help of Dr.Saulius Laurusevičius at KVET small animal clinic in Kaunas, Lithuania. With the use of data of 8 females admitted at this clinic with symptoms of pyometra.

In addition two females were referred to small animal clinic in Norway, Fredrikstad Animal Hospital (FAH), with vaginal discharge and diagnosed with canine pyometra from the referring clinic (Annex 1).

All females have been treated medically with prostaglandins (PGF 2 ) and/or

aglepristone (Alizin Vet ^® Virbac), in combination with amoxicillin/clavulanic acid (Synolux Vet. Zoetis) One female was only treated with Synolux Vet.

One female with clinical signs of pyometra that were decided to make surgical treatment is also included in this paper. Data are collected in the period from January 2014 until November 2016, treated females with the diagnosis of pyometra and treated medically in this period. (n=11).

2.2 Data collection

Search in the journal system of the small animal clinic was done using the search for pyometra, mucometra or OHE. All data the results are based on were reported in the journals.

No direct contact with the animal owner has been done. The three cases from FDH the author were responsible for the two females that were given medical treatment under

supervision of clinic veterinarian.

The third case from FDH the author was assisting the on duty veterinarian.

The found data were adopted into a excel file and then adopted to fit into tables.

2.3 Variables in the material

Clinical data are based on the written journal, and the anamnesis collected from the owner during the time before first visit to the clinic. Clinical examination data are based on the veterinarian´s physical examination of the female on the day admitted to the clinic.

Only a few of the journals had blood test results included, so only the data written in the journal are included in the analysis. In case bacterial culture has been done this is commented.

Side effects are based on information given from the owner of the female and included by the

Variables can be present regarding the long time outcome as this is based on the fact that the treated animals not have been in contact with the clinic in a later time with the same clinical signs.

It is considered as a positive result of the treatment when the female is clinically healthy after the treatment was finished.

2.4 Clincal examinations

The clinical examination of the patients have been done in each of the journals, the author has made clinical examination of four of the patients in the study material.

When conducting the clinical examination the female dog is checked starting from the nose, checking the mucous membranes colour, capillary refill time, and palpation of the lymph nodes. Further distally palpation of the abdominal cavity to investigate perception of pain, and check if there is possible to feel increased size of the uterine horn/s.

Checking the vulva and evaluation of the discharge, if that is present. It is also important to consider the general appearance of the dog, if it felt dehydrated and lethargic.

When the first general examination is done, the ordering of the special examinations may start. At this point it is taken blood samples if it is considered needed. For

haematological investigation, blood biochemistry results and in some cases also hormone assay. Rectal temperature is always taken at this point, and if it is wanted a sample of the vaginal discharge for bacteriological culture this is done.

When all this initial examinations are done, the next step will be ultrasonography examination. We have not performed radiological examination in any of the cases.

Example of the ultrasound examination that has been done, pictures courtesy of Dr. Brigita

Grigalevičienė (Fig. 3, Fig. 4).

Fig. 3 ID 1

Measure of the diameter of the uterine horn.

This female was diagnosed with pyometra.

Fig. 4 ID 1

Measure of the diameter of the uterine horn.

Marginally increased size.

3 RESULTS

Eleven females have been identified with vaginal discharge and treated in clinic, all was given diagnose of canine pyometra. Ten has been treated medically.

The 11 females is of the following breeds:

One Pug, one Newfoundland dog, one Boxer, two Dachshunds, one mix breed, one Chow Chow, one American Akita, one Tibetan Terrier and two Finnish Lapphunds.

The age range of the patients was from 2 years old to 13 years old when the treatment started (Fig. 5), with mean average 9 years.

The weight range of the treated patients were from 4,5 kg to 56 kg (Fig. 6).

The diagnosis was based on anamnesis, clinical examinations and laboratory findings.

Ultrasound was used to identify fluid in the uterus in most cases. Some of the cases were diagnosed based only on clinical signs, physical condition and general condition of the female. All were in for control ultrasonography during treatment and after treatment was finished.

The treatment has been evaluated as successful if the patient has returned to normal health without any clinical symptoms.

Fig. 5

Statistical representation of the age of the patients in the study.

0 2 4 6 8 10 12 14 16

1 2 3 4 5 6 7 8 9 10 11

Ag e in y ea rs

Number of female patients

Age of treated females

Fig. 6

Statistical representation of the weight of the patients in the study.

3.1 Treatment protocols

The nine females that were treated with PGF 2 (Dinolytic Vet. Zoetis 5mg/ml) were given a dose of 150-200 µg/kg pr day, the injections were done sc and divided into 3x pr day.

Treatment had a period from 5 to 22 days with an average of 10.6 treatment days (Table 2)

Some of the females were also treated with aglepristone (Alizin Vet. ^® Virbac 30mg/ml) to promote opening of the cervix for emptying of uterine content (Table 3).

The doses used for this were 10 mg/kg sc, on day 1 and 2. If needed, further injections were done with same dose.

All treatment was in combination with the administration of systemic antimicrobials, drug of choice in all cases has been amoxicillin/clavulanic acid (Synolux Vet. Zoetis).

The duration of antimicrobial treatment is according (Table 4).

The average treatment period for prostaglandins (Dinolytic Vet) were 11,55 days, and the average treatment period with antimicrobials (Synolux Vet.) 10,2 days.

In one of the females it was not considered necessary to start hormonal treatment, and she were treated with the combination of antimicrobials (Synolux Vet.) and anti-inflammatory meloxicam (Metacam Vet.Mixture 1.5 mg/ml).

Duration of treatment with meloxicam was 5 days (Table 4)

0 10 20 30 40 50 60

0 2 4 6 8 10 12

Weig th in k g

Number of female patients

ID Days treated

1 12

2 22

3 5

4 8

5 8

6 17

7 18

8 7

9 7

Table 2 Period of treatment Dinolytic Vet.

(PGF 2 )

ID Times treated

1 0

2 Day 1, 2 & 12

3 0

4 0

5 Day 1

6 Day 1

7 Day 1, 2 & 8

8 0

9 0

Table 3 Period of treatment Alizin Vet

ID Days treated

1 10

2 22

3 8

4 8

5 8

6 12

7 14

8 7

9 5

10* 8

Table 4 Period of treatment Synolux Vet ^TM

* Also treated with meloxicam

(Metacam Mix 1.5mg/ml)

3.2 Clinical signs

From the journal it is not possible to get information regarding the clinical observations made by the owner. But since they did contact veterinary assistance it is most likely that they have observed many of the same symptoms as were presented when they first come to the clinic. As many as 27% (3/11) of the females show symptoms of still be in oestrus, and the result from the progesterone test confirm this. Six of the females had vaginal discharge before medical treatment were started, so they had open cervix pyometra diagnose. Four had no discharge and the width of the uterus was evaluated by ultrasound, which confirmed that there were fluids in the uterus and enlarged size. These four females were in addition treated with aglepristone (Alizin Vet ^® ). 64% (7/11) were evaluated with a good general condition, the other 36% (4/11) were evaluated with a moderate general condition.

Inappetence were noted in 45% (5/11), polyuria in 45% (5/11), polydipsia in 55%

(6/11), abdominal pain in 30% (3/10) one here with missing data (Fig. 7).

No female with signs of vomit or diarrhoea, 33% (3/9) show mild to severe signs of dehydration, 2/11 missing data. 33% (3/9) of the females with temperature 39 ^o C or above.

With blood cell count was in 27% (3/11) over the reference range and evaluated as high, but here as much as 73% (8/11) was missing data.

Table of all the clinical examination data are listed in (Table 5).

Fig. 7

Results of clinical examination in statistical representation.

45% 45%

55%

33% 33%

0%

10%

20%

30%

40%

50%

60%

Inapp PU PD Dehydr Temp

Repre sent ed in %

Clinical signs at examination

Clinical signs

Table 5 Schematic information regarding the clinical status of the females when first presented at the clinic ID Age Weight Inapp PU PD Vomit

Diarrhoe

a Temp Deh Abd.pain Muc WBC Last heat Prog. GC

1 7 22 No Yes Yes No No 38,5 No Yes NAD MD 9 5,32 Good

2* 5 24 No No No No No MD MD MD NAD MD 4 - Good

3 9 8 No Yes Yes No No 38,5 No No NAD MD MD 0,09 Good

4 12 4,5 Yes No No No No 39,3 Mild No NAD H MD 2,28 Mod

5 13 8,3 No No No No No 38,6 No No NAD H 0 24 Good

6 9 39 Yes Yes Yes No MD 37,5 Yes Yes NAD MD 0 25 Mod

7 3 56 No Yes Yes No MD MD MD No NAD MD 0 12,42 Good

8 9 7,9 Yes No No No No 38,7 No No NAD MD MD 3,1 Good

9 3 37 Yes Yes Yes No No 39,3 Mild Yes NAD H 6 - Mod

10 3 18 No No Yes No No 39,4 No No NAD MD 11 - Mod

11 2 8,7 Yes No No No No 38,7 No No NAD MD MD - Good

Explanation 1

Age= years, Weight= in kilograms, Inapp=innapetence, PU=Polyuria, PD=Polydipsia, Temp=Rectal temperature in C ⁰ ,

Deh=Dehydration, Abd.pain=Abdominal pain when palpated, Muc=Mucus membranes, WBC=White Blood Cell count, H=High,

MD=Missing Data,

3.3 Bacterial evaluation

In the presented material there is little or no information regarding culture of bacteria and resistance control. In two of the cases there is written bacterial sampling is done with sterile swab from the cranial part of vagina. With the result given after antimicrobial treatment had started, result was presence of Escherichia Coli in the purulent discharge.

This made no changes in the choice of treatment of the female dog. Sensitivity testing has not been done.

3.4 Outcome and ovariohysterectomy (OHE) findings in the material

Treatment was defined as successful when the female returned to clinically health status at the end of the treatment. The longest follow up time is from February 2015 until writing of this rapport, with one female. She has been in heat several times post treatment without recurrence of pyometra, she has not been mated or had puppies after the treatment with Dinolytic Vet.

In 82% (9/11) no contact have been made with the clinic post treatment, this is

considered as successful outcome since it is very likely that the owner would brought the dog back for treatment if same symptoms would have occurred again.

9% (1/11) had successful treatment and the dog was healthy until the next heat, then the symptoms came back and it was decided to do OHE (Fig. 8).

Fig. 8

82%

9%

9%

Results

Clinically healty

OHE after 1 year

OHE directly

9% (1/11) the only female in this study that did not receive medical treatment, that dog is included for illustration of the importance of making the correct diagnosis before deciding to make surgical treatment. Female with ID 11 was admitted to FDH, referred from another small animal clinic. Preliminary diagnose pyometra, without vaginal discharge. Ultrasound examination was done with minor enlargement of uterus. Cytology sampling was done from the cranial part of vagina; microscopy evaluation done by the author was evaluated to mid/late pro-oestrus with predominant superficial cells present and lack of neutrophils.

Despite any clear clinical signs it was decided to make exploratory laparoscopy with OHE. Pathological examination of the uterus and ovaries post surgery display the presence of cyst on the ovaries and blood in the uterus. No pus or fluids present (Fig. 9).

Fig. 9 ID 11

Green arrow=Ovaries Red arrow=Cysts

White arrow=Uterine blood consistent of pro-oestrus

3.5 Side effects of the medical treatment

The noted side effects are the same as mentioned in the literature (12), (27), (30).

Some of the females had a stronger reaction than the others. All show les side effects after each administration of PGF 2 .

In this study the author has observed by him self the adverse reactions in two of the treated females. The others are described based on journal and interview with clinic

veterinarian. Restless, increased salivation, panting was observed after the first injection in both the females. Directly after injection of PGF 2 the owner were asked to walk with the dog for about 20 minutes.

The side effect only lasted between 10-20 minutes. With the second injection the side effects were reduced to slight increase in salivation, no panting or restlessness.

By the third injection no side effects was observed. Directly after injection the owner

should walk with the dog for approximate 20 minutes.

4 DISCUSSION

This study is based on ten female dogs that were diagnosed with pyometra and treated medically with PGF 2 , in addition one that was treated surgically.

The success rate is high, based on the criteria that the aim is for the dog to show no clinical signs after the treatment period is over. 100% (10/10) female dogs responded very well to the treatment and recovered.

The study material is limited to two different clinics, but the end result for all patients treated has been similar. Since some of the cases are quite new the long-term outcome is difficult to address.

If a different definition of successful treatment had made, perhaps this would have made a difference. If for example the definition would be that the female dog were able to produce puppies at a later time, or if the recurrence of pyometra would not occur.

But this was not the case and the objectives for this study.

In a study done by Gilbert et al. in 1989 (28) they had a success rate of 87%, and Meyers- Wallen et al (12) had a 100% success rate in their study from 1986.

These results are consistent with the results from this study.

It has been one argument that treatment of pyometra medically is not considered as good treatment practice since “all” get recurrence at the next time of heat.

It is clear from many retrospective studies (5), (22), (33) that this hypothesis is not valid.

From the material studied in this study only 1/10 did get recurrence within one year after the treatment and it were decided to do OHE.

Regarding differences in the results from other studies, this could also be depending on the initial health status of the female dog. If the female dog were very reduced before starting treatment the outcome would possibly be worse.

As (Table 5) show in this study all the female dogs were in relatively good condition when presented at the clinics.

Verstegen et al. (14) gives reference to an unpublished study done by them in 2008,

where they have an incidence-based case study. With 57 previously treated dogs with

pyometra and a control group of 256 dogs not been presented with pyometra earlier.

As such when treatment is done and uterine regeneration is made, the probability for the female dog to develop pyometra again is the same as the probability of a female dog of the same age that never had any incidence of pyometra earlier to develop this condition (14).

The economical situation of the owner is also an important part of the discussion and something that has to be dealt with by the practicing veterinarian.

Based on this study the cost will depend very much if the cervix is open or closed, with a closed pyometra the medical cost would reach approximately the same as with surgical treatment. It is important to inform the owners of all possible outcomes and what the risks would be, regardless of treatment of choice.

The example is made of a female dog of 20 kg weight with no predispositions that would make her unfit for either surgery or medical treatment (Table 6).

Treatment period and calculations is based on the use of medications during a 7-day treatment protocol, compared to making an OHE in normal clinic hours. If emergency OHE would be done during off hours, that would increase the surgical cost.

Table 6 Comparison of medical versus medical treatment, in €uro.

Medical Surgical

Consultation 20 20

Blood test 30 30

Ultrasound (US) 15 15

Operation 150 ^*

Alizin (aglepristone) 105 ^**

(5,2 pr ml) PGF 2 (prostaglandin) 4,2

(1,2 pr ml)

Progesterone 15

Synolux Vet.

Follow up consultation

& US

20-30 x 2 Removing stiches is normally included in the

price of the operation

Total 104,2 - 124,2 (no Alizin)

209,2 – 229,2 (with Alizin) ^**

* Surgery is done in normal 215 hours

Explanation 2 All numbers is from Kaunas vet and LSMU VA Dr. L.

Kriaučeliūno smulkiųjų gyvūnų klinika.

The differences in the pricing for the medical treatment is depending on what kind of protocol that must be done. In this study it has been given aglepristone (Alizin Vet) to four of the treated females, with closed cervix pyometra. Aglepristone is a progesterone receptor antagonist, the efficacy has been demonstrated to induce parturition and pregnancy

termination, and the lack of uterotonic effect makes it very good choice with closed cervix pyometra (5).

The result is relaxation of the uterus and cervix, and opening of the cervix without the risks of uterine rupture.

Aglepristone is quite expensive and the need of using this in the treatment increases dramatically the cost of the medical treatment protocol.

It has been reported that the used of medication to treat pyometra in the female dogs should be avoided if the patient is having kidney and liver dysfunction (18).

In addition it is important to be cooperate with a dedicated owner who is willing to follow the treatment plan and closely monitor the symptoms from the dog.

When comparing the different protocol that is available for medical treatment I have in this study evaluated the one with the use of PGF 2 , natural prostaglandins, with the additional use of aglepristone to induce opening of the cervix to empty the uterine content in the cases that was needed.

My aim has been to investigate and evaluate the efficacy of this kind of treatment compared to the most common first choice of OHE; surgery.

On one side the efficacy of performing an OHE is unquestionable, it removes the problem and the recurrence rate is 0% if done correctly.

If surgery would be the treatment of choice it is still a very good reason to stabilize the patient with IVFT to avoid dehydration, and if there is a closed cervix pyometra, to make two injections (with 24h between) with aglepristone (Alizine Vet.) to induce relaxation of the cervix, discharge of purulent pus and the conditions for making the surgery two days later is much better. The overall health status of the patient is most likely better, and the risk of peritonitis or rupture of uterine horn is much less probable.

One other major factor to ensure optimal results from medical treatment of pyometra is

the general recommendations for care of the female. It is not found in any paper, only

observed by the author during practice that the use of Elizabethan collar is highly

recommended. By doing this we avoid that the female dog wash herself and therefore

ingesting the pus from the vulva.

5 CONCLUSIONS

My objectives for this study has been:

1. Enhance my own knowledge and competence related to the given area of study.

And in the same time develop a scientific approach to a given hypothesis and work systematically with sources and material.

This study and the approach to the learning materials have increased my ability of critical thinking, I have achieved an increased knowledge it the area of this study and I also feel that working with the thesis has given me valuable experience in academic writing that will benefit my future career.

2. To identify if canine pyometra should be considered an acute problem, with need of urgent surgical treatment.

By doing this study and learn from the veterinarians that have treated the patients that I have studied; it has become clear to me that this should not be treated as an acute surgical case. But that it is critical that the dog get treatment also during of-hours, and the importance of making the correct diagnose to provide the correct treatment plan.

3. To describe alternative treatment compared to surgical.

I have been able to investigate in depth the different medical and non-surgical option available, and to establish a broad knowledge in the area.

4. To compare some of the medical options available.

In one study done in Sweden 2014, it were evaluated use of aglepristone together with antimicrobial treatment for canine pyometra, in this study the use of antimicrobial drugs were up to 53 days with an average of 22 days (17).

In this study the average duration of antimicrobial treatment were 10,2 days, with the longest duration were 22 days.

Based on the policy of reducing the antimicrobial drugs in both veterinary and human

medicine it seems that a treatment protocol with the use of PGF 2 is advantageous compared

to the use of aglepristone treatment protocol with much less use of antimicrobials and for a

shorter period of time.

6 SUGGESTION

It is my suggestion that canine pyometra should not be considered as a medical emergency patient with an acute need of surgical treatment.

It is also in many cases a lot more economical for the owner compared to OHE surgery.

Many owners have second thoughts regarding OHE also because of the changes that occur in the female post-op, with changing of the texture of the coat, and some of the female dogs also exhibit a change in character.

There is also the situation if anaesthetics would like to be avoided for some reason, that

medical treatment with prostaglandin PGF 2 is a good option.

7 ACKNOWLEDGMENTS

I would like to thank DVM, PhD Saulius Laurusevičius, at Kaunasvet for providing me with the material for the study, always willing to answer all my questions related to the writing of this thesis. Without his knowledge about this subject I would had much more difficulty with the preparation.

I will also used the opportunity to thank my supervisor Doc dr. Gintaras Zamokas at LSMU

VA Dr. L. Kriaučeliūno smulkiųjų gyvūnų klinika, always willing to give help and support

during the work with the study.

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ANNEX

Annex 1 ID in

study

Breed Name Age Clinic treated First consultation Outcome

1 Finnish Lapphund Navdi 7y KVET 25.02.2015 healthy, no recurrence

2 Chow Chow Inara 5y KVET 20.03.2015 Recurrence <11 months, OHE

3 Dachs hound Sampa 9y KVET 23.04.2014 healthy, no recurrence

4 Mixbreed Pupse 12y KVET 11.06.2014 healthy, no recurrence

5 Dachs hound Smilga 13y KEVT 31.07.2014 healthy, no recurrence

6 Boxer Rina 9y KVET 03.07.2015 healthy, no recurrence

7 New Foundlanddog Milte 3y KVET 08.02.2016 healthy, no recurrence

8 Pug Sirle 9y KVET 26.02.2016 healthy, no recurrence

9 American Akita Inka 3y FAH 06.09.2016 Healthy after treatment

10 Finnish Lapphund Tuli 3y FAH 06.11.2016 Healthy after treatment

11 Tibetian Terrier Chanti 2y FAH 10.10.2016 OHE