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CASE REPORT

Complete uterine prolapse without uterine mucosal eversion in a queen E. Bigliardi, F. Di Ianni, E. Parmigiani, A. M. Cantoni and C. Bresciani Department of Veterinary Science, University of Parma, Parma, Italy

A five-year-old female cat weighing 3 kg was presented by the owner after noticing a large pink, bilobed mass protruding through the vulva during labour. The cat was in good condition, with appropriate lactation, and the newborn kittens were nursing normally. The uterus was not reverted or invaginated at examination, and there was rupture of the mesovarium, mesometrium and uterine-vaginal connection around the cervix. Manual reduction of the prolapsed uterus was not possible because of torn ligaments. A coeliotomy was performed to remove the ovaries, and the apex of the uterine horns was passed by the vaginal route. The remaining part of the mesometrium was disconnected, and the prolapsed uterus was removed. The queen and kittens were discharged from the hospital on the second day after surgery. An unusual feature of this case is that the prolapse was complete, without eversion of any part of the uterus through a vaginal tear.

Journal of Small Animal Practice (2014) 55, 235–237 DOI: 10.1111/jsap.12190 Accepted: 3 December 2013; Published online: 12 February 2014

INTRODUCTION Uterine prolapse, which rarely occurs in domestic cats, has been reported both in primiparous and multiparous queens (Vaughan & McGuckin 1993, Nothling et al. 2002). Although uterine prolapse can occur at any time during prolonged labour and up to 48 hours after delivery, it can also occur during normal parturition (Roberts & Straw Rodney 1988). Prolapse of the uterine body and one or both uterine horns has been previously reported (Egger 1978). The possible causes include excessive relaxation and stretching of the pelvic musculature, extreme dilation of the cervix, uterine atony due to metritis, incomplete separation of the placental membranes, severe tenesmus and rupture of the mesovarium and mesometrium. Typically, these mechanisms all occur under the powerful contractions induced by oxytocin, which is released during labour (Roberts & Straw Rodney 1988) and intensifies in early lactation. Diagnosis is made according to history and inspection of the prolapsed organ. A queen with a prolapsed uterus has one or two tubular masses protruding from the vulva. The clinical signs of uterine prolapse vary and include varying degrees of systemic illness or severe shock, septicaemia, haemorrhage and/or incarceration of the abdominal organs within the prolapsed tissue (Roberts & Straw Rodney 1988, Mostachio et al. 2008). For uncomplicated cases, the suggested therapeutic option is manual reduction. However, if reduction is not possible, the uterus is amputated, and the stump is reduced, followed by immediate ovariectomy by coeliotomy. Journal of Small Animal Practice



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Uterine prolapse usually occurs with complete or partial endometrial eversion. However, in the case presented, the prolapse was complete, without eversion of any part of the uterus.

CASE HISTORY A five-year-old, 3 kg female domestic cat was presented to the veterinary teaching hospital of Department of Medical Veterinary Science, University of Parma (Italy) because the owner had noticed a large pink, one-lobed mass protruding through the vulva during labour and after delivery, two tubular masses were present. The reproductive history showed that the queen was multiparous; the current labour had begun 9 hours prior to admission. The queen had given birth to 5 healthy kittens within 5 hours and was in good clinical condition, with appropriate lactation, and the newborns were nursing normally. A bilobed mass, 15 cm long and 5 cm thick, protruded through the vulva, without endometrial exposure (Fig 1). During examination, the uterus was not reverted or invaginated, though rupture of the mesovarium, mesometrium and uterine-vaginal connection around the cervix was present (Fig 2). The queen and kittens were hospitalised for surgery. The uterus was washed with sterile saline and 1% povidone-iodine solution (Betadine®); a blood sample was collected from the jugular vein for haematological and biochemical analyses. Maintenance fluid therapy was initiated using 50 mL/kg/day lactated Ringers intravenously (iv) through a cephalic vein

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FIG 1. Complete prolapsed uterus: note the right and left uterine horns

FIG 3. Right uterine horn removal through the vagina

FIG 2. Prolapsed uterus: note the laceration of the uterine-vaginal connection

FIG 4. Complete uterine horns isolation

catheter (24 G), and an antibiotic injection of amoxicillin clavulanate (Synulox®; Pfizer) was administered intramuscularly (im). Five hours later, the queen was sedated with 0·2 mg/kg butorphanol (Dolorex®; MSD Animal Health), followed by general anaesthesia induced with 4 mg/kg propofol (Rapinovet®; Schering-Plough Spa) and maintained with 1·5% isoflurane (Isoflo®; Esteve) in oxygen. Manual reduction of the prolapsed uterus and repositioning was not possible because of the torn ligaments, and a coeliotomy was performed for ovariectomy. The ovarian pedicles were ligated with EP 3·5 absorbable polyfilament polyglactin 910 (Vicryl®; Ethicon Inc.). The ovaries were isolated and removed, and the apex of the uterine horns was then removed by the vaginal route (Fig 3). Subsequently, the remaining part of the mesometrium was disconnected, and the prolapsed uterus was completely removed (Fig 4). Before closure of the abdominal wall, the vaginal tearing was closed by placing a continuous pattern suture with EP 2-0 absorbable polyfilament polyglactin 910 (Vicryl®). The surgery was performed for 30 minutes. The

abdominal wall reconstruction was performed according to the standard technique; 20 mg/kg of amoxicillin and clavulanic acid was administered twice daily and the cat was maintained on 40 mL/kg/day iv fluid therapy. The queen was nursing her neonates 30 minutes after surgery. No haemorrhage or vaginal discharge was observed. On the second day after surgery, the queen and kittens were discharged from the hospital; 1 week later, the owner reported that the queen had recovered completely. After surgical excision, the uterus was macroscopically evaluated, measured for width and length, and fixed in 10% neutral buffered formalin for 3 days. Once fixed, the uterine horns were sliced in several transversal sections approximately 0·5 cm thick for histological evaluation. All the sections were routinely dehydrated, paraffin embedded, microtome sectioned (5 µm) and stained with haematoxylin and eosin. The slides were observed using a Nikon Eclipse E800 microscope with a Nikon PLAN APO lens (Nikon), and images were acquired using a DS Camera Control Unit DS-L2 (Nikon). Diffuse neutrophilic infiltration

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DISCUSSION

FIG 5. Uterine wall: endometrium and glandular layer; trophoblastic and syncytiotrophoblastic cells and epithelial debris (arrow)

FIG 6. Uterine wall: endometrium and the placental junctional zone (arrow); endometrial glands, H&E, ×4

of the perimetrium, interstitial oedema of the myometrium and hyperaemia of the vascular structures with cellular diapaedesis were observed in the histological sections. In the endometrium, residues of the glandular layer of the foetal-maternal tissue were found, which appeared to be characterised by the junctional zone of the placenta. This residual tissue showed lamellar structures covered with trophoblast cells that were occasionally multinucleated. Trabecular and villous structures were covered by trophoblast and syncytiotrophoblasts (Figs 5 and 6). Cellular infiltrates (neutrophils), multifocal areas of necrosis and cellular debris were present in the junctional zone, in association with congestion and vascular occlusion (thrombosis).

Journal of Small Animal Practice



Vol 55



April 2014



Uterine prolapse in cats is considered a rare finding (Egger 1978, Ozyurtlu 2005). To date, some authors have described uterine prolapse with invagination and eversion of the mucosa. However, in the present case, the uterine prolapse was the consequence of the laceration of the uterine-vaginal connection, without invagination and eversion of the uterus. As previously reported, there are many causes of uterine prolapse (Roberts & Straw Rodney 1988, Ozyurtlu et al. 2005), and the suggested therapeutic options depend on whether the prolapse can be reduced. In either case, it is advisable that an ovariohysterectomy be performed, either immediately or some time later (Ozyurtlu et al. 2005). In this case, a rupture of the vaginal wall allowed a progressive “expulsion” of the entire uterus through the tear around the cervix, and, as mentioned above, the causes of this undesirable event can be due to multiple factors. In this case, the prolapse was most likely a result of the powerful uterine and abdominal contractions and excessive oxytocin stimulation, with a strong pressure of the first- and secondborn kittens, inducing vaginal rupture. In this case, the accurate clinical and manual examination of the two tubular masses was fundamental. By examining their origin to assess whether this was a case of complete uterine prolapse through a vaginal tear without the invagination of both horns, time was saved by not attempting manual repositioning of the organ (involving animal restraint and manipulation of the tissue of the prolapsed organ). The main risk to the animal during this condition is that the broad vaginal tear increases the risk of retroperitoneal/abdominal bacterial contamination and should be closed as soon as possible. It is important that practitioners are aware of this condition in order to be able to quickly recognise it, make an appropriate diagnosis and correctly approach this rare clinical condition in feline obstetrics. Acknowledgements The authors acknowledge Giuseppe Bertaccini for technical collaboration. Conflict of interest None of the authors of this article has a financial or personal relationship with other people or organisations that could inappropriately influence or bias the content of the paper. References Egger, E. L. (1978) Uterine prolapse in a cat. Feline Practice 8, 34-37 Mostachio, G. Q., Vicente, W. R. R., Cardilli, D. J., et al. (2008) Uterine prolapse in queen and uterine retroflexion in bitch. Ciencia Animal Brasileira 9, 801-805 Nothling, J. O., Knesl, O., Irons, P., et al. (2002) Uterine prolapse with an interesting vascular anomaly in a cheetah: a case report. Theriogenology 58, 1705-1712 Ozyurtlu, N. (2005) Unilateral uterine prolapse in a cat. Turkish Journal of Veterinary and Animal Sciences 29, 941-943 Roberts, D. & Straw Rodney, C. (1988) Uterine prolapse in a cat. Compendium Small Animal 10, 1294-1296 Vaughan, L. & McGuckin, S. (1993) Uterine prolapse in cats. Veterinary Record 132, 568

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Complete uterine prolapse without uterine mucosal eversion in a queen.

A five-year-old female cat weighing 3 kg was presented by the owner after noticing a large pink, bilobed mass protruding through the vulva during labo...
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