Surgical Management of Pre-cervical Uterine Torsion and Prolonged Gestation with Standing Caesarean Section Approach - A Clinical Study of Three Cows.
Uterine torsion is an important maternal reason for dystocia during parturition in cows, bitches, queens, ewes, does and mares, but rarely in sows (Robert, 1986). The post-cervical torsion (combined uterine and vaginal torsion, torsio uteri and vaginae) is more commonly diagnosed than intra-cervical or pre-cervical torsion. Torsion to the left occur more frequently than to right. Clinical symptoms clearly vary depending on degree of torsion. The frequency in relation to all parturitions is described as between 0.5 and 1 percent, whereas the percentage of uterine torsions presented to the Veterinarian as a reason for dystocia varies between 2.7 and 65 percent. The pathogenesis of uterine torsion remains unclear; however, general agreement exists that cow is predisposed to uterine torsion due to its anatomy (Erteld et al., 2012). The instability of gravid uterus is certainly the most important predisposing factor in bovine uterine torsions. Each uterine horn is supported in a dorsolateral direction by broad ligaments, which are attached to ventral surface of uterus. The greater curvature of uterus is dorsal and in advanced pregnancy, uterus is positioned beyond the relatively stable area of attachment, resting on abdominal floor and being supported by rumen, viscera and abdominal wall (Sloss, 1980). In addition, the manner in which the cow lies down, with the forequarters going down first and rises, by elevating the hindquarters first, implies that each time the cow lies down or rises, the gravid uterus is suspended in abdominal cavity. Therefore a sudden slip or fall could cause torsion of unstable gravid uterus. However, there must be some contributory factors in addition to instability that occur during first stage labor, otherwise uterine torsion would also be seen frequently in late gestation, which is not the case (Arthur et al., 1996).
The present study describes successful surgical management of pre cervical uterine torsion with standing cesarean section approach in cows.
Materials and Methods
The present study was conducted on an adult Holstein Fresian crossbred cow of 10 years and two Jersey cows of age between 4-5 years which were presented with history of prolonged gestation for about fifty days which was earlier treated by allied staff. Anamnesis of all three cases revealed, full development of udder, however which gradually reduced nearing gestation (at the stage of completion of gestation i.e. 182 days).
Clinical examination was conducted on all three cows and all animals were found to be of normal appetence, temperature, heart rate and respiration rate. Per rectal examination revealed, no foetal movements, very feeble fremitus, tensed uterus with meager foetal fluid. The stretching of broad ligaments revealed twisting of uterus on right side. On per-vaginal examination, cervical os was tightly closed with no vaginal involvement.
Depending on the clinical signs, the cases were suspected for pre-cervical uterine torsion and hence were approached for caesarean section in a standing position with left flank mid ventral oblique incision.
The animals were restrained besides the travis in a standing position to facilitate more access to the surgical site. After sedation with Diazepam @ 0.25 mg/kg b. wt. intravenously, the surgical site was completely washed and scrubbed with Povidone Iodine and local infiltration was done at the operative site with 60-80 ml of 2% lidocaine.
After appropriate restraining and taking proper aseptic measures, an incision was taken and skin was incised and separated from subcutaneous layer. The muscles were then incised ligating all bleeding vessels (Fig. 1 and Fig. 2). After separation of muscles by blunt dissection, the peritoneum which is a glistening white layer was opened by first making a nick with a scissor and then guiding the cut by a finger placed underneath the peritoneum. The attachments of muscles below peritoneum were cut by using the ventrolateral approach. The uterus was located and brought to operative site by holding uterus over the foetal leg. The uterus was packed on the sides by surgical drapes. The uterus was incised away from cervix over the greater curvature avoiding cotyledons (Fig. 3).The foetus in all three animals were removed as quickly as possible and margins of uterus were washed with sterile Normal saline (Fig. 4 and Fig. 5). Removal of parts of necrosed/ischemic uterus is suggested for the rest of uterus to regain normal function (Singh et al., 2006). Further, the placenta was removed. The uterus was sutured using absorbable suture material (chromic catgut 1 or 2) employing lambert and cushing suture pattern as described for cattle. Further, the uterus was replaced back in the abdomen after thorough washing. Shreds of tissue debris and contaminants that were entering the peritoneum were removed by infusing the peritoneal cavity with normal saline diluted with 5% Povidone iodine and scooping out the contents manually or by using suction apparatus. The muscle and peritoneal layers were sutured using the same suture material and employing continuous suture pattern. The antibiotic powder was sprinkled between the suture layers especially while removing an emphysematous fetus. The skin was sutured employing mattress sutures using surgical nylon.
Post-operatively, the cow was treated with Inj. Oxyteracycline @ 10mg/kg b.wt, Inj. Metronidazole, Inj. Meloxicam ([Melonex.sup.a]) @ 0.5 mg/kg b.wt. and Inj. DNS 1000 ml I/V for 5 days. Inj. [Tribivet.sup.a] (Vitamin [B.sub.1],[B.sub.6] and [B.sub.12]) 10 ml I/M and Inj. Intavita [H.sup.a] (Vitamin A, [D.sub.3] and E) 10 ml I/M, on alternate days of two injections and the wound was cleaned and dressed with Povidone iodine solution. The skin sutures were removed on fifteenth post operative day and animal recovered uneventfully.
In all three animals, colour of uterus was highly cyanotic with fibrinous adhesions. On opening the uterus, dark brown coloured fluid oozed out. Fully developed dead male foetus was removed from uterus. After removal of foetus, attempt was made to relive the torsion of uterus on right side about 180[degrees], however torsion could not be relieved manually due to extensive adhesions. All three cases showed an uneventful recovery, with no milk production in subsequent lactation. After one month of caesarean section, all three animals were showing normal activity.
Pre-cervical torsion is more detrimental to cervix due to severe ischemia of cervical tissue compared to post-cervical torsion (Honparkhe et al., 2009). Cervical dilation failure is commonly observed, subsequent to correction of uterine torsion and is considered a major obstacle in vaginal fetal delivery (Prabhakar et al., 2007) especially in the presence of a dead fetus. Most uterine torsions do not warrant surgical intervention and caesarean section is never performed as the first choice. Delayed uterine torsion (>72 hours) should be directly subjected to caesarean operation in order to avoid undue stress of rolling (Prabhakar et al. 1995). Nanda et al., 1991 and Singh et al., 1978 also suggested caesarean operation to be preferable, in cases of uterine torsion that fail to be corrected by rolling or in long standing cases where fetus is dead and uterine adhesions/ruptures are likely.
Uterine torsion during pregnancy at parturition or post-partum is one of the complicated cause of maternal dystocia, both in cows and buffaloes culminating to death of both the foetus and the dam if not treated early. The early diagnosis and the right treatment reduces the fatality and improve the quality of recovery.
The standing approach for caesarean improves the success rate due to the drainage of the peritoneal secretions and discharges due to the gravitational force. The innovative approach can be a boon and can be practically applicable under field conditions in docile and cooperative crossbred animals (Kanakapur et al., 2006 and Murty et al., 1999).
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S.V. Gaikwad (1), G.S. Khandekar (2), A.H. Ulemale (3), M.S. Rajhans (4) and S.D. Tripathi (5)
Teaching Veterinary Clinical Complex K.N.P. College of Veterinary Sciences Maharashtra Animal Fishery Sciences University (MAFSU) Shirwal Dist. Satara - 412801 (Maharashtra)
(1.) Hospital Registrar
(2.) Associate Professor, Department of Veterinary Surgery and Radiology, BVC, Mumbai and Corresponding author. E-mail:
(3.) Associate Professor
(4.) Ph.D. Scholar, Veterinary Surgery and Radiology, BVC, Mumbai
(5.) Assistant Professor
(a) - Brand of Intas Animal Health, Ahmedabad
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|Title Annotation:||Clinical Article|
|Author:||Gaikwad, S.V.; Khandekar, G.S.; Ulemale, A.H.; Rajhans, M.S.; Tripathi, S.D.|
|Date:||Jul 1, 2017|
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