Introduction
Fetal maceration is characterized by fetal death and incomplete abortion to occur as a result of uterine inertia and intrauterine infections [1]. The most common cause is infection when, bacteria enter the uterus via the cervix after fetal death, causing putrefaction and autolysis of the soft tissues, leaving fetal bones within the uterus [2]. After bacterial contamination, fetal emphysema begins within 24–48 hours and, maceration occurs within 3–4 days [3]. The fetus or fetuses are putrefied and autolyzed to different degrees according to the pathogenicity of the bacteria. If maceration occurs after bone formation, autolysis could continue until all fetal soft tissues become autolyzed thus only bones remain [4]. Bone fragments remaining in the uterus could be embedded into the uterine wall [5] leading to chronic endometritis or severe damage of endometrium. Fetal maceration has been described in cattle [4], sheep [6], goat [7], dogs [8], and mare [9], while the incidence is quite low in bitches [10]. Moreover, in the majority of cases, the absence of general signs in the bitch leads to misinterpretation of the diagnosis [11]. This case report describes an isolated and rare case of canine fetal maceration with retained bones and its successful surgical management.
Maceration can be graded as: grade 1, characterized by skin slippage and peeling which occurs more than 8 hours after fetal death, grade 2 is characterized by extensive skin peeling, red serous effusions in chest and abdomen occurring 2–7 days after fetal death while a 3rd grade is characterized with yellowish-brown liver, turbid effusion, and the fetus may be mummified thus occurring more than 8 days after fetal death. Management of Foetal Maceration includes the administration of pharmaceuticals, for example, prostaglandin E1 analog mifepristone, misoprostol in early pregnancy loss [12,13] transcervical removal [14,15], and the Surgical Management—Hysterotomy, Hysterectomy, or ovariohysterectomy.
Case Management
History and clinical examination
A 1½-year-old dwarf Russian Shepherd bitch weighing 16.6 kg was presented to the small animal clinic of the Veterinary Teaching Hospital, University of Jos, with a chief complaint of inappetence and weakness. History revealed that the bitch was artificially inseminated over 60 days ago and has been passing out brown vaginal discharges about 3 days prior to presentation. It was also known that the bitch had earlier been presented to the SAC about 8 months prior with vaginal prolapse which was appropriately managed. Clinical examination revealed a rectal temperature of 38.6°C, pulse rate of 70 beats per minute, and respiratory rate of 24 cycles/minute. Upon further examination, there was a slightly congested ocular mucous membrane, enlarged superficial (submandibular, prescapular, and popliteal) lymph nodes, soiled perineum with dark brown vaginal discharges with an unpleasant smell, enlarged mammary glands with milky secretions, rough hair coat/epilation and the bitch was slightly lethargic (Fig. 1).
Figure 1.
The patient on the day of presentation (A); the soiled perineum (B).
Management
Laboratory examinations conducted
A blood sample was collected through the cephalic vein to be used for complete blood count according to the method described by Robinson et al. [16] (Table. 1) and parasitological examination, while a vaginal swab was taken for microbiology culture and sensitivity (Table. 2).
Table 1.
Patient’s haemogram.
| Parameters/Units | Patient values | Reference values |
|---|---|---|
| PCV (%) | 55 | 35–57 |
| Total WBC (×109/l) | 5.3 | 5.0–14.1 |
| Seg. Neutrophils (×109/l) | 1.8 | 2.9–12.0 |
| Band neutrophils (×109/l) | 1.1 | 0–0.45 |
| Lymphocytes (×109/l) | 1.7 | 0.4–2.9 |
| Monocytes (×109/l) | 0.2 | 0.1–1.4 |
| Eosinophils (×109/l) | 0.5 | 0–0.13 |
| Basophils (×109/l) | 00 | 0–0.14 |
MSD (2022)
Table 2.
Microbiology result.
| Organism | Sensitive | Resistant |
|---|---|---|
| Escherichia coli | Amikacin ceftriaxone | Gentamicin, Penicillin and Sreptomycin, Enrofloxacin, and Oxyteracycline. |
| Streptococcus species | Amikacin, ceftriaxone | Gentamicin, Penicillin and Sreptomycin, Enrofloxacin, and Oxyteracycline. |
Laboratory results
Haemogram
Parasitology results
- No haemoparasite was seen on a thin blood smear stained with giemsa.
- No ova/oocyst was seen on simple flotation and sedimentation techniques.
Radiography
The bitch was subjected to a radiographic examination, which revealed the presence of some fetuses within the uterus (Fig. 2).
Figure 2.
Laterolateral abdominal radiograph of a 1½-year-old Russian Shepherd bitch.
Treatment
On analysis of the radiographic result, it was then concluded that there were autolyzed fetuses that were not able to be aborted and so hysterotomy was indicated. Consent was sought and surgical preparations began immediately.
Ethical statement
This case management is a part of the University of Jos Veterinary Teaching Hospital’s routine clinical case management; therefore, ethical approval for animal care and welfare was not required. Informed consent for surgery and publication was sought from the client along with permission from the head of the clinic unit.
Surgical procedure
Standard preoperative preparations for hysterotomy were followed. Preanaesthetic agent consisting of 1mg Atropine sulfate 0.02 mg/kg, intravenous injection (Amopin® XierKangtai Pharmo. Co., Ltd. Yanzhou, China) at 0.02 mg/kg, was administered which was followed by the Anaesthetic agents which constituted of 20 mg Xylazine 1 mg/kg, intravenous injection (Xylased® Biaveta, ivanovice, Czech Republic) at 1 mg/kg and Inj. 50 mg Ketamine 11 mg/kg, IV (Jawa® Swiss Parenterals Ltd, Qujarat, India, at 11 mg/kg). A vertical incision was done on the left abdominal flank while the muscular layers were dissected along the direction of their fibers. When an incision was made into the uterus (Fig. 3a), uterine tissues were examined and the diagnosis was confirmed to be a case of maceration due to the presence of the macerated fetuses and the macerated fetuses were delivered (Fig. 3a and b).
Figure 3.
A. Delivery of macerated fetus B. Macerated fetuses.
The abdominal cavity and other structures were washed with sterile 0.9 % NaCl saline solutions. Uterine closure was done with chromic catgut, size 1 suture (Anhui Kangning Ind., Co., Ltd, Tiangchang, Anhui, China), size 1 suture. The peritoneal and muscular closure was done with polyglactin 910 suture (Agarycryl® Huaian Angel Med. Ins. Co., Ltd, Jiangsu, China), size 1 suture, Subcutaneous layer closure with size 1 polyglactin 910 and routine skin closure with nylon (Anhui Kangning Ind., Co., Ltd, Tiangchang, Anhui, China), size 0 suture.
Post surgically, the bitch was confined to an area to restrict movement. Based on the microbial culture and sensitivity result, the bitch was managed post surgically using:
- Injection 100 mg Ceftriaxone. 15 mg/kg (2.5 ml), IV × 5/7.
- Injection 10 mg Piroxicam. 0.3 mg/kg (0.5 ml), IM, × 2/7, Q48 hours.
- Injection Vitamin C. (3 ml), IV, ×3/7.
- Bolus 500 mg Oxytetracycline (2 boluses), IU (after uterine lavage).
- Use of Elizabethan collar until healing is complete.
Discussion
Fetal maceration is a pregnancy pathology occurring as a result of intra-uterine fetal death. It occurs when the fetus fails to abort and decomposition occurs in-utero leaving the fetal bones. The brown discharges observed were the vaginal drainages from the intra/extra fluids resulting from fetal death that would have accumulated in the uterus leading to sepsis, this helped in preventing sepsis in the bitch, this is related to the report of [17,18]. The foul smelly vaginal discharge is also characteristic of maceration and septicemia, this has been reported by [1,19] who reported foul fetid vulval discharges from animals with fetal maceration.
The fetal death and inability to complete abortion during the late stage of gestation as reported by the client with the history of mating 60 days ago observed in this case may have been as a result of uterine inertia and intrauterine infections [16]. Surgical intervention was indicated in this case as against the use of medications such as progesterone antagonists and PGE1 as suggested by Schreiber et al. [12] who reported that medications could be used in fresh cases of maceration where the fetal bones are not embedded within the uterus because this same bitch was presented earlier with a case of uterine prolapse in the previous pregnancy, coupled with the size of the bitch that she was a dwarf, she was unable to be mated naturally, based on history, the bitch was mated via artificial insemination, so to avoid any further complications, surgical intervention was concluded. On a general note, it has been advised that surgical intervention (ovariohysterectomy or hysterotomy) should be the best bet for handling maceration cases [14].
The vaginal sample taken for culture and sensitivity incriminated Escherichia coli and Streptococcus spp having been isolated from the samples. These organisms have been reported to be seen in a lot of maceration cases [13,15] and so the bitch was treated using the antibiotic that the isolated organisms showed sensitivity.
The client was advised not to use the bitch for mating purposes to avoid further complications due to the bitch’s pelvic anatomy and reproductive tract, as this plays a major role during mating and parturition, any deformity in this could lead to dystocia leading to the eventual death of puppies and even the dam if not handled properly and in good time.
