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Sheila WilsonAdvised By: Dr. Misty Edmondson 910s Double Trouble A Bovines Obstetrical StruggleSignalment/Clinical Presentation/History4 year-old female, entire Simmental/Angus cowPresented on Saturday, November 9th, 2013History: dystocia of 3 hour durationOwner attempted to pull calf with chains with no successBred to a Simmental/Angus clean-up bull 2 previous calvings without incident

*Photos Permission and Courtesy of Owner

Presentation to AU Large Animal Teaching Hospital Cow Bright, Alert, Responsive (BAR) and ambulatoryPer vaginal palpation, calf orientation: caudal longitudinal presentation, dorsosacral, hind limbs extendedHind limbs protruded from vulva and calf deceasedFracture of the left rear distal metatarsus 3

TIME OUTDystocia = abnormal or abnormally difficult birthEutocia = normal or physiologic parturition

A detailed history is always VERY important

Vocabulary:Presentation: the direction in which the long axis of the calf is oriented. Position: relationship of fetal back to maternal pelvisPosture: relationship of extremities extended vs. retained/flexed.

Normal Calf Orientation910s calf presentationCranial longitudinal (anterior), dorsosacral, head and forelimbs extendedCaudal longitudinal (posterior), dorsosacral, hind limbs extended

http://www.drostproject.org/en_bovrep/4-14/itemtop17.html

http://www.hoards.com/E_animalhealth/ah12Important to note that this is also a normal presentation, many calves are born this way not requiring assistance. But it can present challenges. 5Initial PlanVaginal PalpationArms width of clearance between thorax of fetus and pelvis of dam Attempt to pullLubricant placed within the cervix and uterus Lidocaine epiduralReduce cow strainingChains placed on calfs limbsAnother attempt to pull the calf student poweredUnsuccessfulRe-palpated vaginally by another studentFlexed front limbTwo heads?

6PlanTwins suspectedTwo options:FetotomyCesarean sectionConsult with ownerElected for initial fetotomyCesarean section if fetotomy unsuccessfulAt this point we thought we were probably dealing with two calves that were tangled cranial to our arms reach preventing the presenting calf from being delivered. Our two options were to perform a fetotomy or a C-section. After consult with the owner, the plan was to pursue a fetotomy and resort to a C-section if the fetotomy was unsuccessful 7FetotomyA cutting of the unborn.Goal: Rapid reduction of fetal size to facilitate delivery per vaginumUtilize obstetric wire to cut the fetus into smaller pieces within the vagina/uterus to then be delivered.

So what is a fetotomy?A cutting of the unborn. In which the goal is to rapidly reduce fetal size to facilitate delivery per vaginum.

8Our PlanDetruncate and manipulate.

Dam went down into right lateral recumbency

Detruncation attemptedPlaced obstetrical wire around the thorax of the fetusOB wire could not be placed past the xyphoidCommunication with ownerBased on inability to properly detruncate the fetus, ventral line cesarean section elected

We werent satisfied with making the cut at the level of the xyphoid since we knew our problems preventing delivery lied cranial to that. Dr. Edmondson contacted the owner, explained the situation and communicated that we were likely dealing with a set of tangled up twins with a less likely possibility of being a fetal monster. The owner agreed to the C-section with the instructions to take pictures if its something neat.9Cesarean SectionConsiderations:Calf alive or dead?Calf malformed?Uterine contents septic or fresh?Physical condition of the dam-can she stand for 2 hours?EnvironmentAvailability of assistants*Preference and experience of the surgeon

A few considerations when performing a C-section. 10Cesarean SectionSeveral approachesVentral MidlineBest surgical exposureBest opportunity to exteriorize the uterus Least abdominal contamination (emphysematous calf, septic uterus)

Disadvantages to consider:RestraintFailure of ventral midline suture = catastrophic Dorsal recumbency (respiratory compromise)

There are several approaches to a Caesarean section, but a ventral midline was our best choice. 11PreparationHobbled and cast into right lateral recumbencyRolled into dorsal recumbency onto a mat, fore/hindlimbs extended with ropesSurgical site shaved and preppedLine block:LidocaineOn midline, from sternum to the mammary glands, coursing around umbilicus The cow had risen since becoming recumbent during the fetotomy so she was hobbled and cast into right lateral recumbancy. Then rolled into dorsal recumbency onta a mat and secured with fore and hind limbs extended with ropes. She was then tilted to the right about 30degrees

12SurgeryProcedure:Incision along ventral midline extending 5 inches cranial to the mammary gland, around the umbilicus, extending three inches cranial to umbilicusGreater omentum reflected Uterus located within the abdomen

Surgery continuedOnce uterus located, dam began to struggle, resulting in a tear in her omentum due to exteriorization of her abomasum 1mL of acepromazine administered intravenously Abomasum and omentum returned to abdomenUterus located and attempted to exteriorize to minimize contamination After multiple attempts, unsuccessfulAfter multiple attempts the uterus was too heavy and could not be fully exteriorized14Entering the UterusUterus incised along the greater curvature Rule of thumb: length of incision into uterus should = distance from fetuss hock to hoof Feti exposed after removal of hindering placentaAdministration of a tocolytic (epinephrine) to decrease uterine contractions

After much manipulation, palpation, and examination, it was discovered the feti wereExteriorizing the fetiChains placed on two of the carpi and both heads extended out of the uterusRevealing twins conjoined from manubrium to xyphoid along the sternum. A four inch tear in the uterus occurred along the incision line.

Uterine ClosureUterus palpated for tears and sparesLavaged then closed using #2 catgut, Utrecht pattern. Uterus appeared grossly healthy Utrecht suture patternModified Cushing (slanted)InvertingNo exposure to suture material which could lead to adhesionsGoal: PREVENT LEAKAGEhttp://www.drostproject.org/en_bovrep/guide.htmlSurgical Closure Omentum18 inch tear Repaired with #2 catgut (absorbable), simple continuous pattern and replaced in abdomenLinea#3 Supramid (non-absorbable), interrupted vest over pants patternTacked edge with simple continuous = increased securitySubcutaneous tissue#2 catgut, simple continuous pattern to reduce dead spaceSkin#3 Supramid, continuous horizontal mattress pattern

Linea: working from outward in towards middle of incision19Cow 910

Image Courtesy of Dr. EdmondsonPost-operative CareMedical (immediately post-op):Flunixin meglumine (Banamine): 15mL IV for inflammationFlorfenicol (Nuflor): 100mL SQ on both left and right side of neck, broad spectrum antibioticOxytocin: 1mL IM, promote uterine clearance HusbandryF/C HWM6# soy hull pellets BIDOffer haylageKeep stall clean

Treatments and Monitoring Physical Exam every 6 hoursMonitor incision siteMonitor vaginal dischargeMonitor eating/drinkingPalpate as needed to monitor uterine involutionMonitor for indications of peritonitisFlunixin meglumine: 15mL IV every 12 hours as needed

Post-operative CareSunday, Nov. 10thMonday, Nov. 11thQAR; hunched appearance and increased heart rate indicating pain15mL Banamine administered IV in the morningIncision site: slightly swollen with small amount of blood drippingAnorectic, no signs of drinking waterRumen contractions present but weakAll other physical parameters WNLContinue to monitor feed/water intake, F/C HWM, Banamine as needed (15mL) once dailyBARSubcutaneous emphysema noted along left ventral thoraxAte readily when haylage moved to the ground from hay rack Soy hull pellets offeredMonitoring and treatments same Post-operative CareTuesday, Nov. 12th3 days post-opBARAte silage and soy hull pellets overnight; readily ate more when offeredBased on good mentation, incision healing and good appetite, ready for discharge on November 13th, 4 days post-opDischargeInstructions for Owner:Kept in dry pasture Monitor incision daily-swelling, purulent discharge Monitor for depression, loss of appetite or vaginal dischargeSuture removal-11/29/13 by rDVM

PrognosisFor recovery: Fair to guardedFor rebreeding: fair to guarded if she does not develop peritonitis and adhesionsThoraco-omphalopagus Conjoined TwinsBothBull calves of fair body condition scoreCongested CerebrumConnected by markedly thickened cranial sternumLungs diffusely dark purple and collapsedTwo hearts enclosed within a single, enlarged pericardium Continuous Peritoneum Livers fused, hypolobulated and diffusely mottled dark red to tanNegative for Bovine Viral Diarrhea Virus by ear notch ELISAWeighed 125lbs

Image Courtesy of Dr. EdmondsonNecropsy Pictures

Pictures Courtesy of Dr. Joanna HylandAbnormalitiesTwin 1Twin 2The one presented vaginallyFractured left rear distal metatarsus 3Small intestines exteriorized through a 5-6cm rent in ventral abdomenBody wall adjacent to the rent diffusely dark red to blackIntestinal tract diffusely pink to dark redVentricular septal defect: 5cm diameter opening connecting the right ventricle to the left ventricleRent

Image Courtesy of Dr. Edmondson

http://www.hoards.com/E_animalhealth/ah12

Image Courtesy of Dr. Joanna HylandThe rent was caused by pulling on the calf in an attempt to deliver it. The calves were connected at the level of the xyphoid so every time we pulled they were caught on the cranial aspect of the pubis and eventually the skin tore. 29So what happened?TwinningIn cattle, natural twinning: 2-3%Dizygotic: twins arising from two ova, derived from two separate ovarian follicles, each fertilized by separate spermatozoa during a single breeding cycle. Monozygotic: arise from a single ovum fertilized by a single spermatozoon. Cattle occurrence: 0.1% or approx. 10% of same sex twins

Sire of Twins*Photo Permission and Courtesy of OwnerThere are two mechanisms from which twinning can result. 30Formation of Tissues Fertilization in cattle: Ampulla/Isthmus junctionProduces a zygoteCleavage: cell divisions producing a hollow ball of cells = blastocystAbout 1 week following fertilization2 groups of cells within blastocyst:Outer layer/trophoblast = placentaInner cell mass = embryonic body Fertilization produces a single cell, or zygote, that contains the diploid number of chromosomes (60 in cattle). The cell divisions called cleavage produce a hollow ball of cells called a blastocyst about one week after fertilization. The blastocyst has two groups of cells with very different fates. The outer layer, or trophoblast (cotyledon of placentome), will produce the placenta that nourishes the developing embryo. The inner cell mass will form the embryonic body. 31Embryologic DevelopmentInner cell mass Embryonic shieldTwo epithelial layersUpper: ectoderm Lower: endodermPrimitive Streak:Region where superficial cells migrate between the ectoderm and endoderm, forming an intermediate layer of mesoderm.

Inner cell mass is only about 1 mm in length after approximately 2 weeks of development. The region of embryonic development, called the embryonic shield, consists of two epithelial layers-an upper ectoderm and an underlying endoderm. At a region called the primitive streak, superficial cells migrate between the ectoderm and endoderm, forming an intermediate layer of mesoderm. Ectoderm: epidermis and epidermal derivatives of the integumentary system, lining of the mouth, salivary glands, nasal passageways, and anus, teeth, and endocrine system. Mesoderm: lining of pleural, pericardial, and peritoneal cavities, muscular, skeletal cardiovascular and lymphatic systems. Kidneys, portion of the urinary tarctEndoderm: most of the epithelium of the digestive tract, exocrine glands, liver and pancreas. Respiratory system, portions of urinary and reproductive systems. 32Monozygotic Twins

Possible in 3 stages of embryological development:Formation of two blastocysts within a single zona pellucidaEach giving rise to a separate individual with its own fetal membranes

McGeady, T. A., P.J. Quinn, E.S. FitzPatrick, and M.T. Ryan. Veterinary Embryology. Oxford: Blackwell Pub., 2006. Print.Monozygotic TwinsInner cell mass stage Duplication of inner cell massSeparate amnions but with a shared yolk sac and chorionDivision of blastocyst as it emerges from zona pellucida

McGeady, T. A., P.J. Quinn, E.S. FitzPatrick, and M.T. Ryan. Veterinary Embryology. Oxford: Blackwell Pub., 2006. Print.Monozygotic TwinsEmbryonic Disc stage: formation of two primitive streaksEach giving rise to separate individualsShare a common amnion, yolk sac and chorion

McGeady, T. A., P.J. Quinn, E.S. FitzPatrick, and M.T. Ryan. Veterinary Embryology. Oxford: Blackwell Pub., 2006. Print.Development of two primitive streaks within a single embryo35Conjoined Twins

Results from anomalous incomplete separation of two primitive streaksIncidence of conjoined twins in cattle:Higher than in other farm animals1 in 100,000 births1 in 400 in monozygotic twins

McGeady, T. A., P.J. Quinn, E.S. FitzPatrick, and M.T. Ryan. Veterinary Embryology. Oxford: Blackwell Pub., 2006. Print.Image Courtesy of Dr. Edmondson36Freemartinism in Cattle Different mechanismFemale born co-twin to a maleFused chorioallantoic membranes = vascular anastomosisAnti-Muellerian hormone crosses from male to female twinIntersex sterile animal, phenotypically female

Owner Update910 recovered but never returned to the breeding herd

Sold at auction Dec. 16, 2013 for $0.50/poundDocked for swelling on ventral midline

No other calves from this bull with abnormalities

ReferencesMcGeady, T. A., P.J. Quinn, E.S. FitzPatrick, and M.T. Ryan. Veterinary Embryology. Oxford: Blackwell Pub., 2006. Print.Ball, P J. H, A R. Peters, and A R. Peters. Reproduction in Cattle. Oxford, UK: Blackwell Pub, 2004. Print. Noakes, David E. Fertility and Obstetrics in Cattle. 2nd ed. Oxford: Blackwell Science, 1997. Print.Dr. Morrison, Formation of Germ Tissues. Class Notes. Fall 2011. Maxwell, Fetotomy, C-section. Class Notes. Fall 2013. Carson, Bovine Obstetrics. Class Notes. Fall 2013. http://www.hoards.com/E_animalhealth/ah12http://www.drostproject.org/en_bovrep/4-14/itemtop17.htmlhttp://www.drostproject.org/en_bovrep/guide.hthttp://www.hoards.com/E_animalhealth/ah12http://en.wikipedia.org/wiki/Conjoined_twins

39Thank YouGodFamilyDr. EdmondsonDr. MorrisonDr. Newton, Dr. HylandLauren Smith and seniorsOwnerFriendsClass of 2015