Pyometra
TEXTBOOK OF VETERINARY INTERNAL MEDICINE
Client Information Series; written by Dr Autumn P. Davidson

Pyometra is a progesterone-mediated uterine disorder in bitches and queens.

Progesterone is the female hormone that works to maintain pregnancy. All normal female dogs are naturally exposed to tremendous concentrations of progesterone during the 45 to 75 days that follow the period of breeding (the period called diestrus).

Progesterone places the nonpregnant uterus at risk for bacterial infection. These bacteria are normally found in the vagina but have infected the uterus by migrating through the cervix. A bacterium called Escherichia coli is the most common cause of pyometra in bitches. An increased incidence of pyometra is associated with oestrogen administration in the bitch. Therefore, oestrogen should not be used as a treatment for "mismate" in dogs. Administration of progesterone to queens can also precipitate pyometra.

Pyometra can occur with or without vaginal discharge, depending on the ability of uterine contents to flow through an open (patent) or closed cervix. Closed cervix pyometra is more serious because some of these dogs become ill before an owner realizes there is a problem. In contrast, dogs with "open cervix" pyometra can be recognized as having a problem earlier because they usually have an obvious, malodorous, pus-coloured vaginal discharge before they become seriously ill.

Dogs with closed cervix pyometra may suffer from uterine rupture, which can be as critical and life threatening as when people have a ruptured appendix. In addition to the vaginal discharge, the classic clinical signs of pyometra include partial to complete loss of appetite, fever, lethargy, weight loss, an unkempt appearance, vomiting and diarrhoea, and excessive thirst and urination. Blood and urine tests are consistent with infection and may indicate involvement of other organs that can be harmed by this severe disease. Abdominal x-rays and ultrasonography can be useful in confirming the diagnosis. Although it is rare, pyometra can occur in one uterine horn with pregnancy in the other.

The best, least expensive, most reliable, quickest, and easiest treatment for pyometra, after stabilization of your dog with intravenous fluids and antibiotics, is the spay (ovariohysterectomy). This would not be the first and best treatment only if your pet is younger than 6 years of age and a valuable breeding bitch.

Medical treatment of open cervix pyometra, using prostaglandin F2c. (PGF2cy) and appropriate antibiotics, has been successful in both the bitch and queen. Antibiotics alone are almost never successful in completely resolving pyometra.

PGF2 causes emptying of uterine contents and a lowering of blood progesterone levels. The presence of live foetuses should be ruled out by use of ultrasonography before treatment because the drug causes abortion and because the treatment is not usually successful if there are any remnants of previous pregnancies in the uterus. Those dogs should be spayed, as should any dog that is extremely ill. The PGF2c. treatment should never be used for an extremely ill dog.

Bitches may need to be hospitalised for the PGF2~ treatment to enable administration of adjunct supportive care, such as intravenous fluids and antibiotics, and to permit monitoring of adverse effects and outcome of treatment. The treatment protocol includes 5 to 7 days of injections. Most can be treated on an outpatient basis because dogs treated with PGF2~ should never be critically ill.

Predictable physical reactions that occur after the administration of this drug include restlessness, panting, salivation, vomiting, diarrhoea, urination, and dilatation of the pupils (bitch and queen) and grooming, lordosis, and kneading (queens). These reactions usually resolve within 5 to 60 minutes. After each subsequent injection, the reactions diminish in severity and duration. Reactions are rarely considered severe enough to warrant discontinuation of the drug.

A successful short-term response, defined as resolution of the signs of pyometra, may not be evident at the completion of PGF2(~ treatment. At the time of release from the hospital, bitches and queens should have an improved appetite and normal rectal temperature. However, the abnormal vaginal discharge may be completely gone or may persist for another 5 to 10 days.

Re-examinations should be scheduled for 7 and 14 days after completion of treatment. At 2 weeks after treatment, there should be little or no vaginal discharge and the pet should be otherwise healthy. Abdominal x-rays or ultrasonography can be used to evaluate reduction in uterine size compared with that on previous examinations.

Persistence of problems suggests that re-treatment be considered. A second series of injections for recurrent pyometra can be successful and may be considered if the condition of the bitch or queen permits. A successful long-term response is defined as a return to normal oestrous cycles and, if bred, conception and carrying a litter to term. Breeding at the next oestrus is recommended to avoid potential complications after progesterone's effects on a nonpregnant uterus. Prostaglandins do not resolve underlying uterine wall disease. The overall successful conception rate after PGF2L. Treatment has been reported to be 40 to 82 per cent in bitches.

Pseudocyesis (False Pregnancy) in Dogs
By Roger Ross, DVM

False pregnancy is a condition in which a female exhibits behaviour that resembles pregnancy. This is caused by the influence of hormones produced by the ovaries. During false pregnancy, the female seems restless and tends to "mother" toys, shoes, or other articles. She may attempt to build a nest with torn paper or blankets. Her abdomen may seem larger than normal, and the mammary glands may actually produce milk.

All this is fairly common in dogs and cats. Dogs have fairly high levels of progesterone for a couple of months after heat whether they get pregnant or not and if the progesterone level is high enough, it will stimulate uterine enlargement, mammary enlargement and production etc.  Progesterone is the hormone that human pregnancy test kits detect, but in dogs these tests are unreliable because progesterone levels are often high even if not pregnant.

Treatment
In most animals, no treatment is necessary, because the affected female will "cycle" out of the false pregnancy on her own. This usually takes 2 months; the same as a normal pregnancy in dogs.

Surgical removal of the ovaries and uterus (spaying) may be advisable in females that have severe or repeated false pregnancies.

If your pet is especially uncomfortable, you can provide some relief with warm compresses, bag balm, and Benadryl, Rimadyl, or similar products. (Please consult your Vet before administering any medication for their advice and dosage rates).

Your vet may also prescribe some steroid anti-inflammatories if needed.

The big worry here is either uterine infection and/or mastitis.

Mastitis in Dogs and What to expect when you take your Dog to the vet
(Of course, your veterinarian may treat this problem a little differently)
By Roger Ross, DVM

Mastitis refers to swelling, inflammation, and infection of the breast...one of the many things that can go wrong during the pregnancy, birth, and nursing process.  Having babies is a fairly high risk venture in all species, and of all the potential problems that can occur, mastitis is usually fairly easy to treat ...but not always: this disease can be deadly.  Yet another reason to recommend spaying female pets unless you really want a litter and are willing to take on the responsibility and expenses of when things go wrong.

Some Basics:
Mastitis refers to the swelling, inflammation, and infection of one or more mammary glands (breast tissue)...a problem that sometimes occurs while nursing puppies or kittens. 

Think about it; the spongy glands of the breasts have been recently stimulated by hormone changes to swell and produce milk and colostrum...full of nourishing fats and sugars...A NEAR PERFECT situation for bacterial growth.  All a bacteria has to do to gain entrance into the milk enriched gland is find a way up the teat canal...which very likely might be swollen and raw from being suckled and gnawed on by greedy little infants.

If the bacteria can't make it up the nipple, it can possibly gain entrance from the blood; after all, it's common to have an extra high bacteria count in the uterus, the vagina, and the near-by urinary tract for a few weeks after delivery...AND NOT ONLY THAT, but the mum's immune system is often out of whack during the massive hormone changes of pregnancy and nursing.  So, bacteria might gain entrance into the blood stream, evade the immune system's defences...and settle happily into the milky goo of the mammary glands.

To top it off, the intestinal system...the number one source of bacterial invasion into the blood stream...is more likely to be raw and inflamed during nursing.  Why?  Because the hormones of pregnancy stimulate intestinal worms to come out of dormancy and feast on the intestinal tract...AND...GI upset (inflammation) is very common post delivery due to the mom eating all those nasty placentas, cleaning up all that vaginal discharge, and licking all those puppy butts.

After reading the above, you might not be surprised to know that ALL (100%) nursing dogs get bacteria in their breast tissue.  Luckily, most of the time, the immune system is successful at keeping the bacteria numbers low enough so as not to cause obvious disease needing medical treatment.  But sometimes the immune system is not up to par...often due to poor nutrition, poor parasite control, or poor vaccination protection...and sometimes due to poor dental care. (Inflamed gums are a major source of bacterial entry into the blood stream)  Sometimes the immune system is simply over-whelmed:

This article is about what to expect if your pet happens to get an infection of the breast tissue during nursing...a disease known as MASTITIS

Symptoms: 
The most obvious symptom is a swollen mammary gland (breast, tit, etc) that is either more red, discoloured, painful, firm, or lumpy than the other breasts on the pet.

The breast may discharge pus...or milk that looks different from the other breasts.

Other symptoms might include:

    Fever (rectal temperatures greater than 103 F in both dogs and cats)

    No or poor appetite

    Dying pups

    Poor energy level

Note: the above symptoms are not exclusive to mastitis; they could be caused by other or additional problems.

What to Expect When you go to the Vet:

A good exam.  It's tempting to simply look at an obviously infected breast and make

the diagnosis of mastitis...and start treatment.  But it's not that simple.  There are usually multiple problems and a good vet will go over the entire pet checking out all the major body systems to see what we're up against.  Here are some examples of problems that are often associated with gross infections of the mammary glands:

High fever and all the secondary vascular changes that can occur with high fevers such as blood clots.

Dehydration

Toxic Shock and Sepsis

Stress, bacterial invasion, and resulting dysfunction of the liver, kidney, and lymphatic systems.

Toxic Milk

Gangrene (from gas producing organisms)

Moderate to severe Intestinal upset and inflammation resulting from the fever and infection...or as mentioned in the introduction above...as the cause of the problem.

And remember...nursing is a time when multiple problems can happen together: Milk Fever (Calcium-phosphorus imbalances), protein deficiencies, post delivery diabetes and other blood sugar irregularities, as well as immune system suppression, greatly increased parasitism, and to some extent hormone induced depression.

The take home message: a good professional exam by a veterinarian is important even though it's usually not difficult to determine that your pet has mastitis.

Lab work your vet might recommend:
As you might gather from reading the above...lab work isn't usually needed to make a diagnosis of mastitis.  But lab work might very well be needed to determine how badly the rest of the body is faring.  Also:  Many mastitis cases require anaesthesia and surgical draining and debridement (cutting away of dead, putrid, and damaged tissue).  Therefore, to minimize the risk of anaesthesia and surgery, your vet may recommend:

Blood Work:  (usually a CBC and Blood Chemistry).  These common tests flag sepsis, diabetes, anaemia, kidney, liver, and pancreatic diseases, dehydration, and electrolyte problems.

Fluid analysis with microscopic evaluation of the milk or any discharge.  What the vet will be looking for is a high white blood cell count of the milk, free or encapsulated bacteria, and a type of white blood cell called degenerate neutrophils. Milk pH might also be considered as different antibiotics work better at differ pH levels.

Aspirate (inserting a needle and syringe to remove a sample of material) and cytology of solitary masses

Bacterial culture and sensitivity of the fluid to allow better choice of antibiotic

Bacterial culture of the blood if sepsis is suspected

Urinalysis: useful anytime a patient acts weak and sick as a screening test for dehydration, diabetes, debilitation, and kidney function.

TREATMENT
Treatment options will depend on how sick the patient is in general and how extensive the local damage to the breast tissue.  Mastitis can be a minor, inexpensive nuisance or a major, life threatening disease requiring a big commitment.

Probable treatments will include:

Antibiotic injections followed by oral antibiotics

Some type of anti-inflammatory medication to reduce swelling.  This usually means some sort of short acting steroid...our most effective treatment...but also one with potential problems that needs to be monitored.

Lancing and draining of the infected breast...either without anaesthesia for minor cases or as part of a major surgical procedure involving debridement and surgical drains.  Sometimes complete surgical removal of the breast is needed.

Topical wound cleaners, compresses, ointments, wound healing enhancers, and various soothing remedies  (each vet seems to have their favourites)

Supportive care of the whole patient if needed:  IV Fluids, antioxidants, electrolytes, pain meds, etc.

Knowing when and how aggressive to get with supportive care for each different case is where experience and the practice art become so important.  Too little and the patient suffers or dies.  Too aggressive and we waste your money and lose your respect for making a mountain out of a molehill.

Time to heal and good home treatment by the pet owner.  Once bacteria gets established in such a perfect growth media as a milky breast it won't be easy to kill it off...It's critical that you administer the pet's antibiotics faithfully for at least 10 days.

Even if your vet does everything right, mastitis is a potentially fatal disease and there's a fair chance that the initial medical treatment won't be entirely successful and more aggressive treatment and/or surgery will be needed.  You can greatly increase your chance of initial success by making sure you give the prescribed meds even if difficult or inconvenient to do so.

Clean bedding.  A pet with a draining breast shouldn't be lying on wet, urine soaked, filthy bedding.  Nor should the bedding be irritating.

Recheck/follow up exam if not obviously all better.  Some people seem to think that the vet somehow failed if a treatment plan doesn't go perfectly.  Hey...this is a serious disease with lots of complicating factors.  A certain percentage of cases will need additional work.

Some Other Treatments or Things that your vet may consider:
Early weaning of the pups to allow the mammary glands to dry up or to prevent death of the babies.  Sometimes we recommend total separation (different buildings) so that the bitch can't smell or hear their babies which stimulates lactation.  Another reason for early weaning is if the bitch is simply too weak to both fight off her mastitis and nurse.  There are negatives to early weaning too...so the decision will be based on each case like so many other situations in medicine.

Supplemental feeding of the puppies or kittens.  A sort of compromise of early weaning.

Shaving the hair from around the teats and clipping the toenails of the puppies or kittens.

Manual milking of the infected breast to keep it draining.

Herbal and other "Alternative" treatments. 

Caution: Disorders that might be confused with mastitis include:
Insect or snake bite wounds to the breasts.  This is, technically, still mastitis, but treatment would also include antihistamines etc.

Mammary gland enlargement caused by advanced pregnancy, lactation or pseudo-pregnancy. Sometimes there is an excessive accumulation (galactostasis) of milk in the glands, and they may become warm and somewhat painful. In other words...just because the breasts are firm and tender doesn't necessarily mean they're infected.

Mammary hypertrophy is a benign growth of the mammary tissue causing a firm swelling.

Mammary gland tumours are fairly common in older animals and could be confused with mastitis especially if they are draining.

This information has been kindly supplied by the Roger Ross, DVM, Animal Pet Doctor and the FoxNest Veterinary Hospital.  Please visit their website for more interesting articles on pet health.