Uterine torsion in cattle--a study of 16 referral cases.
Uterine torsion, rotation of pregnant uterus on its longitudinal axis was first reported in 1766 by Boutrolle (Fleming, 1930). It has been reported in all domestic animals, but is most prevalent as a cause of dystocia in cattle. The cattle dystocia handled under field conditions or presented to referral hospitals report uterine torsion incidence as 3-11 percent and 4-28 percent, respectively (Frazer et al., 1996; Laven and Howe, 2005). It's commonly associated with advanced pregnancy and process of parturition. Among referred cases of torsion, pregnancy period is generally complete in 77-100 percent cattle (Frazer et al., 1996; Srinivas et al., 2007). It generally occurs during late 1st stage or early 2nd stage labor, but there are some reports of prepartum uterine torsions (Frazer et al., 1996). The instability of gravid uterus is certainly the most important predisposing factor in bovine uterine torsion. Many authors suggest that increased fetal movements during 1st stage labor may be the precipitating parturient factor. Other factors that have been mentioned are decreased amounts of uterine fluid, flaccid uterine wall, small non gravid horn and excessive fetal weight. About 66-96 percent torsions are post-cervical in which twist of rotated uterus extends caudal to cervix and involves anterior vagina in rotation (Noakes et al., 2001). In Bos taurus cattle, 59-75 percent torsions are towards left (Aubry et al., 2008) and about 57-80 percent torsions at referral hospitals are of 180[degrees]-270[degrees] (Aubry et al., 2008). Survivability of calves delivered from torsion affected bovines presented varied between 4-56 percent. Both duration and degree of torsion appear to influence calf survivability, while dam survivability is dependent on time elapsed between onset of parturition and correction of torsion (Prabhakar et al., 1995).The purpose of this analysis was to evaluate referred cases of uterine torsion and their clinical management to compare various diagnostic and treatment options and maternal and fetal outcomes.
Materials and Methods
Cases of uterine torsion in dairy cattle referred during January to December' 2013 were investigated in the study. The stage of gestation, duration of condition, type, degree and direction of torsion, method of diagnosis and correction, cervical dilatation following detorsion, viability of calf, fetal gender and weight, dam and fetal survivability were analyzed. Estimate of duration of torsion was based on behavioral history provided by owner. Degree of torsion was determined by number of twists present on body of uterus and tightness of spiral folds in vagina. Direction of torsion was assessed by diagonal stretching of broad ligaments on rectal palpation and direction of spiral folds in vagina. Four different methods of correction like manual, rolling of dam, Schaffer's method or caesarean section were judiciously employed as per duration, severity of torsion and condition of cow, uterus and fetus.
Except for one, all animals presented were pluriparous. No cases occurred prior to term or overdue and all were presented at due date (289 [+ or -] 10 days). More than half were estimated at 12-24 hrs (56.25%). Three cases (18.75%) were presumed to have been presented between 6-12 hrs, with another two (12.5%) being 24-48 hrs of duration. In two cases (12.5%), torsion was suspected of lasting for atleast more than 48 hrs. No cases of pre-cervical torsion were presented before 12 hrs. Four were presented after more than 24 hrs and one between 12 and 24 hrs. Only two cows were bright and alert on presentation, while remaining was depressed (8/16) or recumbent (6/16). There was no evidence of vaginal discharge in 75 percent of cases. A bloody discharge was noticed in three cases and fetid, serosanguinous discharge in one case. Only in one cow, the vulvar lips were deviated in direction of twist.
Two third of torsions (11/16) were diagnosed by vaginal examination alone, whereas in remaining cases, both vaginal and trans-rectal examination only confirmed torsion. All pre-cervical torsion were confirmed only by both vaginal and transrectal examination. Vaginal involvement was not noticed in any of pre-cervical torsion and external os of cervix was accessible, though it lacked normal consistency.
The direction of torsion before correction could be properly diagnosed in all post-cervical cases, whereas in pre-cervical cases, it was correctly diagnosed in nearly half the cases only. The proportion of clockwise (7/16) and counter clockwise direction of torsion (9/16) was nearly identical. In over half the cases (62.5%), uterus was rotated between 1800 and 3600. The next prevalent severity (18.75%) was between 90[degrees] and 180[degrees]. Only one case had a torsion lesser than 90[degrees], while in two cases, it was greater than 360[degrees]. The duration, direction, diagnosis, location and degree of torsion in study is presented in Table 1.
Successful vaginal delivery after manual correction was possible only in two cases (12.5%). Twelve cows were rolled with (n=8) or without a plank (n=4). All cases that were rolled with plank were successfully detorted, compared with 3 of 4 cases where rolling without plank was attempted. Only in three cows (25%), successful vaginal delivery was possible after correction was accomplished with rolling with or without plank. Seventy percent of cows (9/12) that had uterine torsion and successfully corrected by rolling subsequently required caesarean section for fetal removal because of incomplete cervical dilatation. In two cases (12.5 %), caesarean section was performed as first choice (Table. 2 and 3). Altogether, caesarean section was performed to resolve 68.75 percent (11/16) of referred cases of uterine torsion in this study.
As far as fetal disposition is concerned, only 12.5 percent (2/16) of fetuses were in posterior presentation and 87.5 percent (14/16) were in anterior presentation. Many of these were either in dorso-pubic or dorso-ileal position. Only four calves were delivered live (25%) and condition of dead fetuses ranged from fresh to autolytic, with two being emphysematous. A greater number of male (75%) than female fetuses (25%) were present.
The uterine wall was found to be severely compromised in two cases having torsion 360[degrees] of which one died within 2 hrs of surgery and other within 24 hrs. One case in which fetus was removed per vaginum following detorsion by rolling, intense bleeding and vaginal tear occurred which was managed by suturing and pressure pack. One cow that underwent caesarean due to incomplete cervical dilatation also died within 24 hrs of surgery. On a week's review of cows discharged from hospital, the survivability was found to be 75 percent (12/16).
It was observed in this study that greater the degree of torsion, poor the survivability of calves and dam (Table 4). Also, it was noticed that more the duration from occurrence of torsion and correction of torsion, lesser the survivability of calves and dam (Table 5).
The most striking aspect of bovine uterine torsion is that they almost invariably occur at term and although the exact cause remains controversial, there is general agreement that most of bovine uterine torsions occur in association with first stage labor. This is based on the fact that in most cases a variable degree of cervical dilation will be noted prior to or immediately after detorsion (Nanda and Sharma, 1986). All animals in this study were presented at term that supports the observation made by Frazer et al. (1996) and Srinivas et al. (2007) that pregnancy period is complete in 77-100 percent of referred cases of uterine torsion in cattle. Also, varying degrees of cervical dilatation observed in this study following detorsion supported the hypothesis that uterine torsion is a complication of first stage of labor in cattle.
Regarding the time elapsed since occurrence of uterine torsion and presentation, maximum number of cases presented in current study was between 12 and 24 hours (56.25 %). The logistics for referral of cases meant that no cases were presented within 6 hours of onset of torsion. This is in accordance with the study by Frazer et al. (1996) who reported percentage of torsions presented in 6 hrs, 6-24 hrs, 24-48 hrs, 72-96 hrs and 96-168 hrs after onset of torsion as 5, 55, 16, 17 and 7 respectively.
Most frequently, torsion extends caudally beyond cervix such that vaginal wall is involved in rotation (Roberts, 1986; Noakes et al., 2001). In our study, vaginal involvement was obvious in most cases, consistent with the fact that two-thirds of torsions were diagnosed by vaginal examination alone. In all other cases, rectal examination was performed, in addition to vaginal examination, emphasizing observation by Frazer et al. (1996) that presence of uterine torsion should not be ruled out unless transrectal palpation has been performed.
It's crucial that direction of twist is correctly determined prior to attempts at correction as rotation in incorrect direction will worsen problem. The amount of tension on broad ligaments helps to establish severity of torsion. Determining direction of torsion by vaginal palpation alone can sometimes be difficult and palpating taut broad ligaments and uterine artery per rectum reduces risk of misdiagnosing precervical torsion (Pearson, 1971; Roberts, 1986). Counter clockwise torsions are reported to be more frequent than clockwise torsions (Pearson, 1971; Frazer et al., 1996). A counter clockwise torsion would be found mostly in cases of right horn pregnancy, as gravid horn rotates over non gravid horn, in line with reported frequency of 60-68 percent right horn pregnancy in dairy cattle (Pearson, 1971; Noakes, 2001). But in our present study, the proportion of clockwise and counter clockwise torsions were almost equal, probably from equal proportion of left and right horn pregnancies and small sample size.
In general, torsion of 90[degrees]-180[degrees] is common, but a marked difference exists between referral and field cases of uterine torsion. Almost all referral cases are torsions of at least 180s with about 25 percent of these being greater than 270[degrees] (Pearson, 1971; Frazer et al., 1996). The higher proportion of torsions between 180[degrees] and 360[degrees] (62.5%) obtained in this study agrees with observations by Pearson (1971), Frazer et al. (1996) and Aurby et al. (2008) who reported about 57-80 percent of torsions between 180[degrees] and 270[degrees] at referral centres.
Many authors have reported success rates of manual correction varying between 24 and 96 percent, with rate being higher when correction per vagina is attempted as a first choice in field cases (Pearson, 1971; Frazer et al., 1996). Success rate with manual correction was only 12.5 percent in this study, as most torsion referred was of higher degree and fetus was not accessible. Detorsion following Schaffer's method was successful in all attempted cases as against one failure in rolling method. Rolling the cow has been reported to be successful in 34-100 percent of cases (Sloss and Dufty, 1980). Schaffer's method for rolling the cow with plank appeared more successful than without plank as reported by Roberts and Hillman (1973). Also, some cows need to be rolled more than once before torsion is corrected and according to Roberts (1986), rolling should be attempted 4 or 5 times before failure is admitted and another technique is tried. However, the method of correction was more personal preference of attending clinician, availability of assistance and convenience of location to roll the cow.
Duration of torsion has significant role in likelihood that cervix will completely dilate subsequent to detorsion. Also, uterine contractions induced by live fetus help to achieve complete dilatation of cervix (Ghuman, 2010). Pearson (1971) and Frazer et al. (1996) observed that cervix is incompletely dilated following 20-52 percent of successful detorsions and cesarean section has to be performed. In this study, cervix failed to dilate in 75 percent of cases following detorsion and required caesarean section to recover fetus. This higher incidence may be due to non-viability of fetuses and delayed presentation of case. Moreover, pre-cervical torsion is more detrimental to cervix due to severe ischemia of cervical tissue compared to post cervical torsion. The higher number of pre-cervical torsions in referral situation like this, than those diagnosed in field condition may be responsible for less probability of cervical dilatation following detorsion. As per Frazer et al. (1996), it's advisable to proceed immediately to cesarean section when vaginal delivery of dead fetus is impossible because of an undilated cervix and if fetus is alive, one may elect to wait a few hours, but not more than three hours, to see if labor will naturally proceed to 2nd stage.
Survivability of calves delivered from torsion in his study was 12.50 percent only (2/16), which agrees to observations by Pattabiraman et al. (1979) and Prabhakar et al. (1994) that survivability of calves varied between 4-56 percent at referral hospitals. The low calf survivability obtained in this study is in agreement to finding that both duration and degree of torsion influence calf survival rate as reported by Prabhakar et al. (1994) and Frazer et al. (1996). Calf survival can be as high as 44-58 percent if there is timely diagnosis and correction of torsion. Delay in diagnosis can cause fatal hypoxia due to placental separation even in presence of intact water bags (Sloss and Dufty, 1980). The delay in presenting case at a referral place similar to this has resulted in poor calf survival rate.
Main factor determining survivability of dam is time elapsed between onset of parturition and correction of torsion. Survival rate in torsion affected bovine declines linearly from 87-43 percent with increase in duration of torsion. Furthermore, dam survival rate in pre-cervical torsion is lower than post cervical torsions (Prabhakar et al., 1997). Also, degree of torsion and thus vascular compromise influence development of uterine edema and ischemic necrosis that leads to endotoxic shock (Sloss and Dufty, 1980). Survivability of dams that are first rolled and thereafter subjected to caesarean in 36 hrs and 36-72 hrs of occurrence of torsion is 100 and 50 percent, respectively (Srinivas et al., 2007).
Upon judicious handling in this study, survivability of dam presented in 24 hrs, 24-48 hrs, 48 hrs were 91.66 percent, 50 percent and 0 percent, respectively. The low range of survivability in each point of time are those that are first handled in field, then subjected to detorsion at referral hospital, followed by caesarean owing to incomplete cervical dilatation. Moreover, most pre-cervical torsions were not judiciously diagnosed in field leading to delay in case presentation. Two cases of torsion 360[degrees] died from a compromised uterus and endotoxic shock.
In conclusion, prognosis and future fertility of dam as well as fetal outcome depends on severity and duration of uterine torsion and methods of handling. Diagnosis of condition, particularly pre-cervical torsions is a dilemma for Veterinarians. However, judicious diagnosis and timely intervention can reduce calf mortality as well as dam mortality, significantly. As torsion of uterus frequently occurs during parturition, any abnormal sign at the time of parturition requires due attention and rectal examination in addition to vaginal examination is mandatory.
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C. Jayakumar (1), G. Sudha (2), T.R. Lakshmikanth and S. Kantharaj
Department of Veterinary Gynaecology and Obstetrics Veterinary College Karnataka Veterinary, Animal and Fisheries Sciences University (KVAFSU) Hebbal Bangalore--560024 (Karnataka)
(1.) Corresponding author. E-mail: firstname.lastname@example.org
(2.) Assistant Professor
Table 1: Details of Uterine Torsion in reported cattle Total cases Location of torsion referred Pre- Post cervical cervical 16 05 11 Percent 31.25 68.75 Total cases Duration of torsion (hrs) referred 6-12 12-24 24-48 [greater than or equal to] 48 16 03 09 02 02 Percent 18.75 56.25 12.5 12.5 Total cases Degree of torsion referred [less than or 90-180 180-360 equal to] 90 16 01 03 10 Percent 6.25 18.75 62.5 Total cases Direction of torsion referred [greater than or Clock wise Anti equal to] 360 clock wise 16 02 07 09 Percent 12.5 43.75 56.25 Total cases Diagnostic Method referred Vaginal Method Vagina and trans-rectal 16 11 05 (All precer-vical) Percent 68.75 31.25 Table 2: Successful detorsion method Total Manual Rolling Schaffer's Primary C-Sec 16 02 04 08 02 Percent 12.5 25.0 50.0 12.5 Table 3: Cervical dilatation following detorsion Total Cervical Improper cervical dilatation dilatation & & extraction extraction of fetus of fetus by C-section per-vaginum 12 03 09 Percent 25 75 Table 4: Degree of torsion and survivability of dam and fetus Degree of torsion Total Fetus Dam Live Dead Live Dead [less than or equal to] 90 01 01 -- 01 -- 90-180 03 01 02 03 -- 180-360 10 -- 10 08 02 [greater than or equal to] 360 02 -- 02 -- 02 Total 16 02 14 12 04 Percent 12.5 87.75 75 25 Table 5: Duration of torsion and survivabilty of fetus and dam Duration Total Fetus Dam (hrs) Live Dead Live Dead 6-12 03 02 01 03 -- 12-24 09 -- 09 08 01 24-48 02 -- 02 01 01 [greater than 02 -- 02 -- 02 or equal to] 48 Total 16 02 14 12 04 Percent 12.5 87.75 75 25
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|Title Annotation:||Clinical Article|
|Author:||Jayakumar, C.; Sudha, G.; Lakshmikanth, T.R.; Kantharaj, S.|
|Date:||Jul 1, 2014|
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