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Endometritis - Horse (view source)

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==Introduction==
 
==Introduction==
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Endometritis is an '''infection of the uterine endometrium''' [[Image:Endometritis.jpg|thumb|right|200px|Endometritis,Copyright RVC 2008]]
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[[Image:Endometritis.jpg|thumb|right|200px|Endometritis,Copyright RVC 2008]]
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Endometritis is an '''infection of the uterine endometrium'''.
    
Endometritis is a common cause of '''poor fertility''' in the mare. It occurs following '''uterine contamination''' during '''covering''', [[Artificial Insemination - Anatomy & Physiology|artificial insemination]], '''reproductive examination''', [[Parturition Behaviour - Mare|'''parturition''']] and as a result of '''poor conformation'''.
 
Endometritis is a common cause of '''poor fertility''' in the mare. It occurs following '''uterine contamination''' during '''covering''', [[Artificial Insemination - Anatomy & Physiology|artificial insemination]], '''reproductive examination''', [[Parturition Behaviour - Mare|'''parturition''']] and as a result of '''poor conformation'''.
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[[Equine Viral Arteritis|Equine Viral Arteritis]] (EAV) and [[Equine Herpesvirus 3|Equine Herpes Virus 3]] (EHV-3) are also classified as venereal infections however they do not cause endometritis or prevent conception.
 
[[Equine Viral Arteritis|Equine Viral Arteritis]] (EAV) and [[Equine Herpesvirus 3|Equine Herpes Virus 3]] (EHV-3) are also classified as venereal infections however they do not cause endometritis or prevent conception.
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Detailed guidelines on the diagnosis, treatment and prevention of all these infections can be found in the [http://codes.hblb.org.uk/|Codes of Practise] which are followed by Thoroughbred breeders in the UK.  
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Detailed guidelines on the diagnosis, treatment and prevention of all these infections can be found in the [http://codes.hblb.org.uk/|Codes of Practice] which are followed by Thoroughbred breeders in the UK.  
    
===Non-venereal Infectious Endometritis===
 
===Non-venereal Infectious Endometritis===
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==Diagnosis==
 
==Diagnosis==
 
* '''Clinical examination''' may reveal '''vulval discharge''' or '''matted tail hairs'''.
 
* '''Clinical examination''' may reveal '''vulval discharge''' or '''matted tail hairs'''.
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* '''Vaginal''' '''examination''' should identify any '''discharge''' and '''increased vascularity''' of the tissue. Conformational abnormalities such as pneumovagina and urovagina may be evident.
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* '''Vaginal''' '''examination''' should identify any '''discharge''' and '''increased vascularity''' of the tissue. Conformational abnormalities resulting in e.g. pneumovagina and urovagina may be evident.
 
* '''Ultrasound''' examination of the uterus - '''more than 2 cm of fluid with abnormal character''' suggests endometritis.
 
* '''Ultrasound''' examination of the uterus - '''more than 2 cm of fluid with abnormal character''' suggests endometritis.
 
* '''Clitoral''' and '''endometrial swabs''' should be taken for '''culture and sensitivity'''. Clitoral swabs should be taken if a chronic venereal infection is suspected. Guarded endometrial swabs should be taken during oestrus to identify either acute venereal infections or the causative organism of other endometrial infections and evidence of inflammation. A high level of neutrophils is indicative of endometritis. The mare should be confirmed as not pregnant before taking an endometrial swab.
 
* '''Clitoral''' and '''endometrial swabs''' should be taken for '''culture and sensitivity'''. Clitoral swabs should be taken if a chronic venereal infection is suspected. Guarded endometrial swabs should be taken during oestrus to identify either acute venereal infections or the causative organism of other endometrial infections and evidence of inflammation. A high level of neutrophils is indicative of endometritis. The mare should be confirmed as not pregnant before taking an endometrial swab.
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A combination of multiple therapies should be used to collectively resolve the inflammation within the uterus and treat existing infections:
 
A combination of multiple therapies should be used to collectively resolve the inflammation within the uterus and treat existing infections:
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'''(1) Uterine lavage''' with copious amounts of fluid. This is beneficial because it:
 
'''(1) Uterine lavage''' with copious amounts of fluid. This is beneficial because it:
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:removes contaminants such as bacteria and purulent material
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- removes contaminants such as bacteria and purulent material
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:stimulates uterine contractions to aid clearance
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:causes mechanical irritation to the endometrium aiding healthy neutrophil recruitment
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- stimulates uterine contractions to aid clearance
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- causes mechanical irritation to the endometrium aiding healthy neutrophil recruitment
      
'''2-3 litres of saline or lactated ringers''' solution should be administered using a '''uterine flushing catheter''' and then '''drained''' back into the bag and '''inspected'''. Dilute Povidone iodine can also be used as a cheap alternative.
 
'''2-3 litres of saline or lactated ringers''' solution should be administered using a '''uterine flushing catheter''' and then '''drained''' back into the bag and '''inspected'''. Dilute Povidone iodine can also be used as a cheap alternative.
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'''(2) Antibiotics (intrauterine or systemic)'''. Antibiotic type should be guided by culture and sensitivity and activity of the drug in the uterus where possible. The length of the treatment should be proportional to the severity of infection.
 
'''(2) Antibiotics (intrauterine or systemic)'''. Antibiotic type should be guided by culture and sensitivity and activity of the drug in the uterus where possible. The length of the treatment should be proportional to the severity of infection.
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'''(3) Administration of ecbolics''' to stimulate uterine contractility and clearance of infection - oxytocin and prostaglandin analogues
 
'''(3) Administration of ecbolics''' to stimulate uterine contractility and clearance of infection - oxytocin and prostaglandin analogues
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'''(4) Hormonal therapy'''- Oestradiol Benzoate and PG can be used to aid the clearance of infection. They are more effective during oestrus.
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'''(4) Hormonal therapy'''. Oestradiol Benzoate and PG can be used to aid the clearance of infection. They are more effective during oestrus.
         
In the cases of venereal infections additional treatment may be required:
 
In the cases of venereal infections additional treatment may be required:
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:'''Acute infections''': Repeated antibiotic clitoral irrigation and reintroduction of normal flora. A clitorectomy may be considered.
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'''Acute infections''': Repeated antibiotic clitoral irrigation and reintroduction of normal flora. A clitorectomy may be considered.
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:'''Chronic/carrier infections''': Repeated clorhexidine clitoral irrigation and reintroduction of normal flora.
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'''Chronic/carrier infections''': Repeated clorhexidine clitoral irrigation and reintroduction of normal flora.
      
==Management of Susceptible Mares==
 
==Management of Susceptible Mares==
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==Prevention==
 
==Prevention==
 
* Employment of strict hygiene measures during breeding, reproductive examinations and parturition
 
* Employment of strict hygiene measures during breeding, reproductive examinations and parturition
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* Adherence to the [http://codes.hblb.org.uk/| Codes of Practise]
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* Adherence to the [http://codes.hblb.org.uk/| Codes of Practice]
 
* Surgical correction of any existing conformational abnormalities
 
* Surgical correction of any existing conformational abnormalities
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The prognosis of this [[Healing and Repair - Pathology#Repair in the Genital Tract|condition]] vary according to the '''type''', '''severity''' and '''chronicity''' of the infection and the '''age''' of the mare.
 
The prognosis of this [[Healing and Repair - Pathology#Repair in the Genital Tract|condition]] vary according to the '''type''', '''severity''' and '''chronicity''' of the infection and the '''age''' of the mare.
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{{Learning
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|flashcards = [[Equine Reproduction and Stud Medicine Q&A 12]]
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}}
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=Cattle Endometritis=
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==References==
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Cattle endometritis  is a '''common''' condition that is known by the layman as ''''whites''''. It occurs '''three weeks or more''' '''after calving''' and should not be confused with the more severe condition of metritis which occurs immediately post-partum. The main consequence of endometritis is '''poor fertility'''. Therefore it has a '''major economic impact''' by '''increasing calving interval''', '''services per conception''' and '''cull rates''' and by '''decreasing milk yield'''. It is reported to have an incidence of between '''ten and fifteen percent''' in dairy herds (however it is very variable from herd to herd), with the total cost of '''£160 per case'''.
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[http://codes.hblb.org.uk/| '''Codes of Practice'''] (2011) ''Horserace Betting Levy Board (HBLB)''
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==Aetiology==
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The normally '''sterile''' uterus is '''contaminated by environmental microorganisms during parturition''' or '''immediately postpartum'''. The main bacteria involved in endometritis is '''''Actinobaccillus pyogenes''''' however numerous '''gram-negative anaerobes''' may also be involved. The presence of this opportunist bacteria can '''delay return to service''' and '''cyclical activity''', '''prevent fertilisation''' and cause '''early embryonic death''' by producing a hostile uterine environment. It is also reported that it increases incidence of '''ovarian cysts'''.
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==Signalment==
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Endometritis can occur in any cow post-partum however incidence is increased by the following '''predisposing factors''':
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* Retained foetal membranes
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* [[Dystocia]]
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* Caesarian section or assisted calving
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* Induced parturition
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* Still Birth
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* Twins
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* Unhygienic calving environment - includes seasonal effect as indoor calving has higher endometritis rates
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* Ovarian inactivity
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* Parity
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* Concurrent disease and nutrition - [[Fatty Liver Syndrome|fatty liver disease]] and [[Hypocalcaemia|hypocalcaemia]] are reported to increase endometritis rates
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Multiple defense mechanisms exist to prevent opportunistic infection of the uterus. The '''vulva''' and '''cervix''' provide a '''physical barrier''' to opportunist bacteria; '''resident bacteria''' in the vagina '''prevents''' the '''colonisation''' of harmful bacteria; '''involution''' and '''caruncle sloughing''' expel contaminants and tissue debris; a '''higher pH''' during '''oestrus''' prevent bacterial growth and various '''immunological mechanisms''' also act to prevent infection of the uterus. Following parturition endometritis may still occur, especially is one or more of the mentioned predisposing factors is present.
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==Clinical Signs==
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'''Mucopurulent vaginal discharge''' should be evident on vaginal exam '''21 days or more post-calving'''. Discharge is relatively odourless (dependant on severity) and '''white''' in colour, hence the name 'whites'. The discharge should not be confused with '''lochial discharge''' or '''vaginitis'''. Rectal palpation should reveal a '''poorly-involuted''', '''oedematous uterus'''. On a individual or herd level there may be a history of '''subfertility'''.
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==Diagnosis==
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Diagnosis should be based on the '''calving history''' and '''clinical signs''' following '''vaginal''' and '''rectal''' exam. Vets may use a '''scoring system''' to categorise the '''colour''' and '''odour''' of the vaginal discharge which indicates how '''severe''' the infection is and whether '''treatment''' is necessary. Measurements of the '''uterine''' and '''cervical''' '''diameter''' may be included in the scoring system. Definitive diagnosis can only be achieved by '''endometrial biopsy''', however this is rarely indicated.
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== Treatment ==
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'''Greater success''' is achieved with '''milder cases''' of endometritis. Treatments available include [[Antibiotics|antibiotics]], '''hormones''' and '''intrauterine antiseptics''':
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'''(1) Antibiotics'''
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Various factors should be considered when selecting an antibiotic for the treatment of endometritis.
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'''Criteria for antibiotic''':
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* appropriate efficacy in infected uterine environment
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* appropriate efficacy against the causal bacteria
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* no inhibition of natural uterine defense mechanisms
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* appropriate concentration and duration of action in the infected uterine lumen
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* little or no milk withdrawl period
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* cost effective
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* no detrimental effect on fertility
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Generally a '''broad spectrum antibiotic''', active against '''''Actinobaccillus pyogenes''''' and '''gram-negative anaerobes''' should be used. Ideal antibiotics are [[Cephalosporins|cephalosporins]] and [[Tetracyclines|oxytetracycline]] as they match the majority of criteria listed above. Some resistance to oxytetracyclines is reported and additonally some formulations cause irritation to the endometrium, therefore '''intrauterine cephalosporin''' should be considered the '''most effective antibiotic treatment'''.
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[[Sulphonamides|Sulphonamides]], [[Aminoglycosides|aminoglycosides]], nitrofurazones and [[Penicillins|penecillins]] have decreased activity as a result of the uterine environment and bacteria present. [[Nitroimidazoles|Metranidazole]] and [[Chloramphenicol|chloramphenicol]] should not be used as they are banned from use in food-producing animals.
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Some antibiotics are rapidly absorbed and distributed throughout the body, and in these cases it may be of more use to administer them parenterally.
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'''(2) Hormones'''
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'''Oestrogens:''' controversial treatment bases on the knowledge that the uterus is more resistant to infection during oestrus. It is not licensed in the EU for use in cattle.
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'''Prostaglandins:''' PGF2a or analogues can be administered parenterally. They should be considered the '''treatment of choice if a corpus luteum is present'''. The administration of prostaglandins removes the inhibitory effect of progesterone on the uterus and induces oestrus, which both of these actions '''improve the uterine defense mechanisms'''. They may have an additional beneficial '''ecbolic effect''', aiding clearance of the lumenal contents. There is '''no milk withdrawl period''' for prostaglandins, making them ideal for use in dairy cattle.
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These are mainly used in chronic cases.
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'''(3) Antiseptics'''
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'''Chlorhexidine''' and '''metakresol sulphonic acid''' (Lotagen) antiseptic administered '''intrauterine''' are reported to be a effective alternative to antibiotic treatment, however few studies have been carried out to confirm this and detrimental effects on fertility are reported.
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==Prognosis==
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Prognosis is '''dependant on the severity of infection and the effectiveness of treatment'''. Greater success is seen with mild cases of endometritis
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=References=
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[http://codes.hblb.org.uk/| '''Codes of Practise'''] (2011) ''Horserace Betting Levy Board (HBLB)''
      
Pycock, JF (1997) '''Self-Assessment Colour Review Equine Reproduction and Stud Medicine''' ''Manson''
 
Pycock, JF (1997) '''Self-Assessment Colour Review Equine Reproduction and Stud Medicine''' ''Manson''
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RVC staff (2009) '''Urogenital system''' RVC Intergrated BVetMed Course, ''Royal Veterinary College''
 
RVC staff (2009) '''Urogenital system''' RVC Intergrated BVetMed Course, ''Royal Veterinary College''
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Andrews, Blowey, Boyd & Eddy (2004) '''Bovine Medecine - Disease and Husbandry of Cattle''' (2nd edition) ''Blackwell''
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{{Learning|flashcards = [[Equine Reproduction and Stud Medicine Q&A 12]]}}
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{{review}}
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[[Category:Reproductive Disorders]][[Category:Parturition]][[Category:Uterus - Pathology]]
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[[Category:Reproductive Disorders]][[Category:Uterus - Pathology]]
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[[Category:To Do - Reproductive]][[Category:To Do - Major]]
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[[Category:Reproductive Diseases - Horse]]
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[[Category:Reproductive Diseases - Cattle]]
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[[Category:Expert Review - Horse]]
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[[Category: To Do - Siobhan Brade]]
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[[Category:To Do - Manson review]]
 
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