Uterine torsion

Uterine torsion in bovines and farm animals

1. UTERINE TORSION (VGO-603) LALA LAJPAT RAI UNIVERSITY OF VETERINARY AND ANIMAL SCIENCES HISAR Submitted to: Dr Gyan Singh Submitted by : Amit Kumar

2. Torsion of the uterus, or part of it, is seen as a cause of dystocia in all domestic species. However, there is a wide variation in its frequency between species, which is due to differences in suspension of the tubular genital tract that affect the 'stability' of the gravid tract.

3. Definition Rotation of the uterus on its longitudinal axis is called as uterine torsion .

4. Most commonly observed in dairy cattle, buffaloes Occaionaly seen in beef cattle,dogs ,cats,mare,sheep and goat Rarely seen in sow Breed - more in surti than other buffalo breeds due to wallowing habit. More common in pluriparous animals.

5. Predisposing factors Mare-true since dorsally attached ligament prevent uterine torsion Multiparous animal specific segment of gravid hornor only one gravid horn is involved In uniparous species less common in animal as compared to to multiparous species More common in stallfed animals Uniparous animal both horn are involved Oversize of fetus Hilly region. MaInutrition- causes weakness of ligaments and lack of uterine tone. More common in pluriparous animal due to decrease in uterine and mesometrial tone is caused by multiple birth.

6. Etiology Lack of tone of uterus lack of fluids Flaccid uterine walls Small non gravid horn long flaccid amesometrium Deep capacious abdomen Violent fetal movements

7. Why cattle is more susceptible ?

8. Due to these reasons Broad ligament attachment to uterus Broad ligament attachment in abdominal cavity Narrow Ovarian end Attachment of amnion Method of sitting and standing Swimming also more common in buffaloes (walllowing)

9. Degree of torsion Degrees Rotation of uterus 1st degree 90 2nd degree 180 1/2 3rd degree 270 3/4 4th degree 360 complete

10. Continued.... If the twist is of 90-180°, Discharge comes from vagina Water bag may come out and limbs of the foetus may be in the pelvic cavity. If the twist is of 360° the vaginal passage becomes narrower and the cervix cannot be palpated through vagina.

11. Direction of torsion Clockwise or right side torsion Anti-clockwise or left side torsion

12. Site of torsion : Pre-cervical (posterior part of uterine body). Post-cervical (anterior vagina).

13. Symptoms of torsion at the time of parturition Uterine torsion is a complication of late first stage or early second stage labour. The first sign may be noted towards the end of the first stage of labour, which is prolonged and the cow shows signs of mild discomfort (uneasy, restless, colic, kicking and switching its tail). Tenesmus or abdominal straining characteristic of the second stage of labour but it is either absent or mild in uterine torsion High respiration rate Tachycardia Anorexia The patient may adopt a "rocking horse" stance so that dorsal surface of her spine is concave and the fore limbs and hind limb are held respectively forward and backward than normal (ewe)-Peritonitis ,intussusception or volvulus

14. If mild (45-90°) - No symptoms. If 180° or more : Abdominal pain Anorexia Constipation Lack of rumination Rapid pulse rate. Symptoms of torsion during gestation period:

15. Late pregnancy and severe case : Complete anorexia Foetid diarrhoea Suspended rumination Rapid pulse rate Normal to sub-normal temperature Difficulty in micturition due to involvement of urinary bladder Foetus dies and becomes emphysematous Shock, collapse and death may occur within 24-72 hours.

16. colic traumatic gastritis indigestion, pyelonephritis intestinal intussusception.

17. By history By symptoms By per vaginal examination By per rectal examination Clinical pathology Blood component Liver and renal functions

18. Per Vaginal examination If the hand is inserted into vagina, it cannot be passed easily towards cervix. Twisting of hand indicates whether torsion is clockwise or anti-clockwise. Intensity of twisting or stenosis of birth canal indicates severity of torsion.Birth-canal is narrow and stenosed in the region of anterior vagina. If the torsion is greater than 180°, it is usually impossible to pass the hand through the twisted portion of the birth canal. If the torsion is less than 180°, the obstetrician's hand may be passed through the birth canal to palpate the foetus. Dorsal commissure of the vulva is pulled forward and left in case of left torsion and forward and right in case of right torsion (270 to 360 ).

19. Per Rectal Examination Where the site of the twist is precervical, the vagina is much less involved and diagnosis is assisted by palpating the uterus per rectum On rectal examination, the twisted uterine horn can be felt and the broad ligament on the side of torsion is rotated downwards sometime palpable under the uterus and the ligament on the opposite side is tense and stretched and crossing to the opposite side The positive diagnosis of uterine torsion should thus, be based on the location of broad ligaments palpated per rectum. The position of fetus indicate degree of torsion

20. Clinical pathology Limited arterial perfusion and venous outflow in the twisted uterus leads to ischemia, hypoxia and cell death causing irreversible damage to the endometrium, myometrium and ultimately death of the fetus. Continued failure of blood supply results in loss of uterine wall elasticity and viability, and hence the uterine wall becomes necrosed, brittle, fragile and prone to rupture. Inflammatory changes can cause adhesions of uterus with surrounding abdominal tissues. Macroscopically, following rotation of the uterus, the color of the uterine wall changes from rose-pink to blue-purple to grey; indicating the progressive metabolic deterioration of the uterus

21. Continued... Congestion,edema and hematoma are present in the uterine ligaments, mesovarium and ovaries The damage to uterine tissue and its regenerative potential following the rotation of uterus can be accessed from plasma indicators, viz. haptoglobin and creatine kinase, which increase further following correction of torsion by the rolling of the dam

22. Ultrasonography of cow affected with Torsion

23. Liver and renal functions Following uterine torsion and after its correction by detorsion or surgical treatment, the activities of aspartate amino transferase (AST), alanine amino transferase ALT), glutamate dehydrogenase (GLDH), creatine phosphokinase (CK) and gamma glutamyl transferase (GGT) are increased, which usually becomes stabilized within 10 days after surgical treatment of uterine torsion The increase in plasma AST and muscle specific CK is attributed to great muscular exhaustion produced by strong abdominal contractions following uterine torsion At the time of presentation of a uterine torsion case, a substantial increase in plasma urea and creatinine indicates poor prognosis . In uterine torsion, ureters lying in the broad uterine ligaments are constricted; thus, the urine output reduces and renal functions may be affected Moreover, the presence of a stress induced decrease in blood flow to kidneys, shock, dehydration and nephropathy resulting from toxic substances liberated by dead fetus may cause acute or chronic renal insufficiency, leading to decrease in the urea and creatinine elimination

24. Blood components Blood components: Clinical studies on the hematology and blood biochemistry of torsion affected buffaloes have shown marginal differences . Normocytic normochromic anaemia (decrease in the RBCs, Hb and PCV) due to accumulation of metabolic waste products or relatively large loss of blood during abnormal parturition lymphocytopaenia, neutrophilia and monocytosis in association with eosinopenia , which continuestill the third day postpartum in surgically corrected cases of uterine torsion. A huge decrease in the total plasma proteins and albumin liver malfunction and negative nitrogen balance because of reduced protein intake leads to hypoproteinemia Occurrence of torsion of the uterus is a highly stressful event as revealed by the huge increase n plasma cortisol, which increases further by 15-30% following detorsion of uterus through the rolling of dam Stress axis cortisol increased gluconeogenesis Hyperglycemia Ketone level increased

25. Treatment: (1) Rolling of dam (2) Schaffer's method (3) Rotation of foetus and uterus through the birth canal (4) Abdominal ballotment (5) Stimulation of vigorous foetal movement (6) Laparotomy (7) Caesarean section

26. Rolling of dam • Sedative (Siquil 5 ml IM) should be administered. • Ascertain the side of torsion. • Cast the animal in lateral recumbency on the same side as the direction of the torsion. • The front and the hind limbs are secured separately. • Keep hand in birth canal and grasp the foetal part (if cervix is dilated). • Roll the cow in the same direction of torsion. • After the cow has been rolled through 180°, her body must be pushed slowly over the legs and sternum to bring back the same position to continue the rolling in the same direction.

27. Continued.... • Examine the vaginal passage to find out whether rolling is effective or not. If the rolling is effective, the spiral folds and stenosis of birth canal starts to disappear. If the rolling is in wrong direction, vaginal folds become more tight. • After each two or three rapid rotations of the cow's body, the birth-canal should be examined. • Occasionally, there may be a rush of foetal fluids from the uterus as the torsion is relieved. • After correction of uterus, the foetus should be pulled out by applying forced traction as soon as possible because the cervix

28. Schaffer's method It is a modification of rolling method. The cow is casted on the same side as the direction of torsion.The legs are tied in the same manner as in the above method.

29. Continued... • A plank 9 to 12 feet long and 8 to 12 inches wide is placed over the abdomen while the other end of plank should be on the ground.

30. Continued... An assistant stands on the lower end of the plank and the cow is slowly rolled in the same direction of the torsion.

31. Continued... Determine the torsion by placing the hand in the birth canal,whether the torsion is being relieved or not.

32. Rotation of foetus and uterus through the birth canal • This method is only possible if obstetrician's hand can pass through the cervix. • Epidural anaesthesia should be given. • Lubricate the birth canal, if it is dry. • The foetus is grasped by a convenient prominence such as elbow, sternum or thigh. • Rock the uterus side to side and then with a sudden strong twist, uterus is lifted and then pushed downwards on the side opposite to the direction of torsion. • Instead of hand, Cammerer's torsion fork may be used. • The method is easier in the smaller breeds of cattle.

33. Torsion of the uterus-rolling of the foetus and uterus per vaginum

34. Stimulation of vigorous foetal movement: • This method helps other manual methods of correction of torsion. • The hand is passed in the uterus, and eye ball of the foetus is pressed firmly. This results in strong reflex movement of the foetus that may aid in manual correction of the torsion.

35. Laparotomy • If the case cannot be corrected by either of the above methods, a laparotomy should be performed on the standing cow through the left or right sublumbar fossa. • Caesarean section may be required if after correction of torsion, the cervix remain closed. Therefore, left flank approach is preferable.

36. Caesarean section: It is indicated when correction by laparotomy or other means fails or cervix is insufficiently dilated.

37. Abdominal ballotment • This method helps in correction of torsion through birth canal as described in the above method. • Left torsion: An assistant on the left side pushes the upper left flank region downward and inward whereas the other assistant on the right side pushes the lower right flank region upward and inward. • Right torsion: Upper right flank - Push downward and inward.Lower left flank - push upward and inward. • Both the assistants should push alternatively at regular intervals in quick succession which causes the uterus to roll from side to side and this helps the operator working via birth-canal.

38. Sequelae Rupture of the uterus with pertonitis Internal bleeding due to rupture of large uterine vessels Retained placenta Septic metritis Perimetritis

39. References Veterinary Reproduction and Obstetrics 9 th edition-David E. Noakes,Timothy J. Parkinson and Gary C.W. England Veterinary Obstetrics and Genital Diseases 2nd Edition- Stephen J. Roberts) APPLIED VETERINARY GYNAECOLOGY AND OBSTETRICS-Pardeep kumar Wikipedia Internet Review paper