RUTH-ANNE RICHTER BSc (Hon), DVM, MS FAEP COUNCIL PAST PRESIDENT rrichter@brandonequine.com
ADAM CAYOT DVM adamcayot@hotmail.com
The arrival of spring means our busy season has begun once more! With the veterinary workforce crisis, the equine field has seen a decline in veterinarians. Those of us in the industry are pushing harder than ever – with increased workloads – to care for the equines around us and manage our clients. Sometimes, we may find ourselves overextended. It is my hope that we will utilize what we learned in the last issue exercise clear communication with our clients about our abilities and time constraints. If you are ever struggling, please reach out to the FVMA/FAEP, and we will help connect you with valuable resources.
Topically, this issue of The Practitioner features information on placentitis, foals, and managing difficult clients.
SALLY ANNE DENOTTA DVM, PhD s.denotta@ufl.edu
As always, I look forward to seeing you all at our flagship equine conference, Promoting Excellence Symposium (PES), to be held Oct. 19-22, 2023, in West Palm Beach, FL, at the Hilton West Palm Beach. Offering world-class continuing education, PES 2023 features renowned speakers and a wet lab that will provide comprehensive instruction and lead participants in hands-on learning.
Kind regards,
COREY MILLER DVM, MS, DACT cmiller@emcocala.com
Armon Blair, DVM Ocala Equine Hospital FAEP Council President abeqdoc@gmail.com
ANNE L. MORETTA VMD, MS, CVSMT, CVA maroche1@aol.com
JACQUELINE S. SHELLOW DVM, MS FVMA PRESIDENT jackie@shellow.com
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Dr. Taylor McLendon grew up in Saint Augustine, FL, where her interest in horses first began. Keeping to her Florida roots, she received both her bachelor's degree in animal biology and doctorate in veterinary medicine from the University of Florida (UF). During her time at the UF College of Veterinary Medicine (UFCVM), Dr. McLendon served as class president all four years and as the president of UF’s chapter of the Student American Veterinary Medical Association (SAVMA). Continuing her love for learning and leadership, Dr. McLendon is currently enrolled in the FVMA’s Power of Ten program, which is designed to develop skills in leadership and entrepreneurship for Florida veterinarians. She is also a member of the AVMA, AAEP, FAEP, and FVMA.
Her love for horses began as a child while competing in Western performance events. This is where her passion for the equine athlete began and why she has devoted her career to this field. Her practice largely focuses on lameness and sports medicine of the performance horse.
Dr. McLendon currently owns and operates Mandarin Equine Veterinary Service in Jacksonville, FL. During her
fourth year of veterinary school, she accepted a position working at the practice, which was then owned by her lifelong mentor, Dr. Peggy Fuller. While most recent graduates start their career with an internship, Dr. McLendon went straight into field work at the practice. After three years working as an associate, she purchased the practice in July of 2022 and is now the sole practice owner and only practitioner. Dr. McLendon has big goals for her business and is looking to expand and grow the practice.
She hopes to expand Mandarin Equine to a three-doctor practice, while keeping the focus on sports medicine and lameness. Her five-year plan includes adding to the ambulatory services and increasing the staff size. Her goal is to continue to offer innovative diagnostic and treatment options that will best serve the performance horse. She is heavily involved in continuing education opportunities and is an advocate for advancing veterinary medicine and techniques in her field.
Dr. McLendon is very interested in the business side of the veterinary industry as well. She enjoys running her practice and working on the financial and management side of the business rather than just focusing on practicing veterinary medicine.
Dr. McLendon is a truly family-oriented individual – and she brings that into her work as much as possible. One of her sisters, Adison, works as the practice manager at Mandarin Equine and her youngest sister, Meghan, is currently in her second year of veterinary school at UF. Meghan is also focused on veterinary medicine and plans to join Dr. McLendon's practice after graduating in 2025. Dr. McLendon is even going to be coating Meghan at her White Coat Ceremony.
“This [coating Meghan] will absolutely be a core memory that stays with me forever. There is nothing that means more to me than being a part of her journey into the best profession,” said Dr. McLendon.
Dr. McLendon is married to her husband, Josh. They have a two-year-old son, Grady, and recently welcomed their daughter, Evan Shea, in March 2023. She loves that her job allows her to work with her family daily and is thankful to have a career that allows her to have a work-life balance, especially while starting her family.
When asked what advice she would give to someone who is just starting their career in veterinary medicine, Dr. McLendon said:
“Your career does not have to (and should not) consume your entire life. This profession has so much to offer and can be incredibly rewarding. However, it’s entirely possible to have a work-life balance. I think the current mindset is that in order to be an exceptional vet, you must make personal sacrifices, and I could not disagree more. I run a very successful practice, I have close personal relationships with many of my clients, and (even more importantly) I do everything in my power to be the best mother and wife that I can be. Being an excellent vet does not mean working yourself to the point of burnout. It means taking care of yourself first so that you are healthy and strong enough to serve your patients.”
Over the last three decades, research on equine placentitis has undoubtedly provided great insights into this frustrating problem. This article will review the pathogenesis, diagnosis, and treatment of placentitis. Recent findings on therapeutics, with a special focus on the prolonged nature of antibiotic administration, will open a discussion on how this arm of multi-modal placentitis therapy impacts One Health.
After expending considerable time in establishing pregnancy in the sub-fertile mare, it is imperative that she be adequately monitored to detect complications in the later part of gestation. The most likely complication to arise during the last third of gestation in the sub-fertile mare would be placentitis. Timely identification of placentitis is crucial for multi-modal therapy to be successful. Other potential reproductive causes of high-risk pregnancy such as intrauterine growth retardation and cord abnormalities might also be identified.
Placentitis has been reported to be responsible for 9.8, 19.4, 24.7, and 33.5%1, 2, 3, 4 of abortions, stillbirths, and perinatal losses in horses. Bacterial infections are responsible for 53% of these losses; Streptococcus equi subsp. zooepidemicus (S. zooepidemicus) was isolated in 28% of these cases.3 Other bacteria frequently identified were Escherichia coli, Leptospira spp., Crossiella equi, Pseudomonas spp., S. equisimilis, Enterobacter spp., Klebsiella spp., α-hemolytic streptococci, Staphylococcus spp., and Actinobacillus spp.3 Infection was localized to the cervical star in 95% of cases, supporting the argument that ascension of aerobic bacteria through the vagina and cervix is the most frequent route of infection (Fig. 1A).5 Clinical signs include vulvar discharge, udder development, prenatal lactation, and premature delivery or stillbirth. Abortions can occur from 75 days to term,5 although
the majority of clinical cases are presented to practitioners during the third trimester. In a survey of 200 fetal membranes with infective placentitis, 36% of those with bacterial infections were recorded to have had premonitory signs, compared to 63% of those with fungal infections.5
A notable exception to the transcervical ascension of pathogens is focal mucoid placentitis (“nocardioform placentitis”) caused by actinomycetes (Fig. 1B). Most isolates have been C. equi, 6 although other species have been identified, including Amycolatopsis spp., Streptomyces spp., and Cellulosimicrobium cellulans. Although sporadic cases of nocardioform placentitis have been reported in South Africa, Florida, and Italy,7-9 most reported cases are from Kentucky. Inflammation of the chorion extends from the cranial ventral uterine body, usually at the base of the gravid horn, with an adherent tan to brown mucoid exudates.10 Precocious udder development is occasionally observed with nocardioform placentitis, but vaginal discharge is uncommon. The majority of abortions occur during the ninth and tenth month of gestation. Interestingly, other non-nocardioform bacteria have been isolated from lesions that are grossly indistinguishable from nocardioform placentitis,11 so perhaps the gross appearance of this form of placentitis is unique to its distribution pattern rather than the causative agent.
Ultrasonography is a key diagnostic modality for diagnosing disturbances of the feto-placental unit and for monitoring the progression of fetal viability and placental changes. Evaluations are made both transrectally and transabdominally and are best performed when the mare is restrained in stocks in a quiet environment. Mare agitation or anxiety can produce fetal tachycardia without concomitant fetal movements. Sedation is also to be avoided, due to the associated fetal bradycardia. Hormonal profiling can provide crucial information and is complimentary to the information gained by ultrasonography. Other modalities that can be used include centesis of fetal fluids, and echocardiography. Ultrasonography replaced fetal echocardiography to monitor fetal heart rate.
Transrectal Ultrasonography – For transrectal examination, a 5.0- to 7.5-MHz linear-array transducer is positioned just cranial to the junction of the cervix and the uterine body. Small lateral movements are made until a vessel on the ventral border of the uterus is located. This vessel is variably described in anatomy texts, but most commonly is designated as the uterine branch of the vaginal artery, which is a branch of the internal pudendal artery. Several measurements are taken from the leading edge of the allantoic surface to the leading edge of the blood vessel
and averaged. An increase in the combined thickness of the uterus and placenta (CTUP), especially with concomitant accumulation of echogenic fluid between the endometrial and chorionic surfaces, is characteristic of placentitis (Fig. 2). If serial monitoring is anticipated, it is beneficial to consistently measure the CTUP at the same distance from the cervix during each examination. Upper limits of the normal CTUP have been established;12 finding increases in the CTUP of >8 mm during the ninth month, >10 mm during the tenth month, and >12 mm after day 330 signals that placental failure and abortion may occur.13, 14 Certain circumstances can lead to CTUP values being greater than is considered normal in the absence of placentitis. Episodes of high fetal and uterine activity, especially when the fetus becomes positioned in the caudal uterine body, can produce CTUP values that are above the normal range for that stage of gestation. Apposition of the amnion with the allantois produces a slight increase in the CTUP. Allantoic fluid is hypoechoic in comparison to amniotic fluid with small hyperechoic foci (“vernix”) suspended in the anechoic medium. Vernix is also present in the amniotic fluid, but it is somewhat less obvious due to the overall greater echogenicity of amniotic fluid compared to allantoic fluid. This hypoechogenicity of the allantoic fluid persists until parturition nears, while the amniotic fluid gradually increases in echogenicity during the last month of gestation.12 Increased echogenicity of the allantoic fluid coincided with the first day of recovery of bacteria from allantoic fluid with experimental infection.15 Edema of the chorioallantois at term
is normal and simply indicates impending parturition. Edema of the chorioallantois, or a discernible difference in the echogenicity of the uterine wall and the chorioallantois at other times, should be considered as an indicator of potential premature delivery. Chorioallanotic edema was seen with experimentally induced placentitis in the 24 hours preceding abortion.16 Fetal presentation is easily confirmed by identifying the presence (anterior) or absence of (posterior) the fetal orbit.
Transabdominal Ultrasonography – For transabdominal ultrasonography, a 3.5- to 5.0-MHz sector-array transducer is preferred. In very late gestation or in heavy breed mares, a 2- to 2.5-MHz sector-array transducer may allow for greater access to the fetus. Transabdominal ultrasonography is useful for assessing fetal heart rate (FHR), fetal activity, fetal presentation and position, character, and depth of fetal fluids, as well as increased CTUP in cases of placentitis not due to ascension through the cervix (e.g., nocardioform placentitis or hematogenous infection). For single transabdominal evaluations, the hair of the ventral abdomen should be cleaned of all dirt and debris, and alcohol and ultrasound coupling gel applied liberally. In patients for whom
serial examinations are anticipated, clipping of the abdomen is recommended, followed by application of alcohol and coupling gel. If the abdomen has been clipped, then scanning can be performed in either a caudalto-cranial or cranial-to-claudal direction. If the belly was not clipped, then scanning in a cranial-to-caudal direction avoids “ruffing up” the hair, which increases air interference and reduces image quality. Scanning should begin at the ventral midline, evaluating in parallel parasagittal planes from the mammary gland to the umbilicus or sternum depending on the stage of pregnancy.
Baseline FHRs in the last weeks of pregnancy are 60–75 bpm with a range of 40–250 bpm. Low or high FHRs are cause for alarm if they are persistent with no accelerations or decelerations or accelerations that are unaccompanied by fetal movement.17
Fetal activities (e.g., movement, breathing, swallowing, sucking) should be noted and either scored subjectively or quantified as the number of movements in a given time period. Fetal presentation is confirmed based on the orientation of the fetal thorax relative to the maternal pelvis. In addition to flexion and extension of the extremities, other more extreme motion patterns can sometimes be observed: rotation on the short axis (spinning) or long axis (rolling) and whole body shifting vertically or horizontally (translation). The fetus is able to change presentation through the first eight months of gestation. Since cases of nocardioform do not have vulvar discharge or increases in the CTUP of the caudal uterine segment, transabdominal ultrasound has the best chance of making a diagnosis. Unfortunately, it can be difficult to locate the area of separation of the chorioallantois from the endometrium, so false negative results are commonly encountered.
Identification of cord abnormalities such as long cord/cord torsion may on occasion be detected with transabdominal ultrasonography, especially with the use of Doppler technology. Unfortunately, only short segments of the cord can usually be imaged at a time, which lessens the likelihood of detecting cord abnormalities prior to abortion. Likewise, assessment of in-utero growth retardation (small for gestational age) can be estimated by measuring the fetal aortic diameter, which is significantly correlated with neonatal foal weight. Fetal aortic diameter is measured during systole from leading edge to leading edge as
Figure 2. Transrectal ultrasonography of the caudal uterine segment demonstrates measurement of the combined thickness of the uterus and placenta. Measurements of the CTUP (dashed line) and the depth of exudate accumulation (dotted line). Image courtesy of Sara K. Lyle.
it emerges from the heart. Fetuses with substantial deviations from the mean aortic diameter for the stage of gestation may be small for gestational age;18 however, this may not be a very reliable predictor of in-utero growth retardation.
Allantocentesis/Amniocentesis – Although amniocentesis is commonly used by physicians to diagnose chorioamnionitis in women and assess fetal maturity, allantocentesis is rarely used in cases of suspected placentitis in the mare either to document infection in the fetal fluid compartments or to ascertain readiness for birth. Lecithin to sphingomyelin ratio (L:S) and lamellar body count in amniotic fluid have been used in human medicine to predict the presence of phosphatidylglycerol, a marker for fetal lung maturity.19 The L:S and lamellar body count in amniotic fluid in healthy equine term neonates have been measured;20 however, neither the L:S nor the percentage phosphatidylglycerol were found to provide useful antepartum predictors of fetal maturity from day 292 to term. 21 In experimental models of placentitis, PGF2α and PGE2 15, 22 and cortisol 23 were found to be elevated prior to pre-term delivery. Because PGF2α and PGE2 are labile and require strict and cumbersome sample handling to avoid analyte degradation, measurement of prostaglandins in fetal fluids is not practical. Elevated cortisol concentrations in fetal fluids signal that the fetal hypothalamic-pituitary-adrenal axis has been prematurely activated and that delivery may be impending. Until reliable markers for fetal maturity and for infection are identified, the use of allantocentesis in the diagnosis and management of placentitis should be undertaken with caution. Continued research is needed to identify reliable indicators of equine fetal maturity. In mares with suspected hydropic pregnancy, the concentrations of creatinine and chloride are useful in determining whether hydrops allantois or hydrops amnii is present. During the last four months of pregnancy, chloride is significantly higher in amniotic than in allantoic fluid (112.3 - 0.5x and 37.3 + 0.3x mM respectively, where x is the days prepartum), while creatinine is significantly lower in amniotic than in allantoic fluid (12.796 + 0.26x + 0.0008x 2 and 1000.96 + 2.574 +x + 0.014x 2 mg/dl respectively, where x is the days prepartum). 24 Calcium was significantly increased in both fetal fluid compartments with impending term parturition; however, calcium was decreased in pregnancies following intrafetal betamethasone administration, questioning the usefulness of fetal fluid calcium concentration as a determinant for readiness for birth in preterm pregnancies. 24
Hormonal Profiling and Biomarkers – Several hormones in the maternal circulation may be useful to monitor during high-risk pregnancies. Total progestins are commonly measured in pregnant mares, although single samples probably are not as informative as serial samples. Total maternal plasma progestins (as measured by cross-reactivity with a progesterone assay) are low (2-12 ng/
mL) until the last 15-21 days of gestation, climb substantially, and then fall abruptly within 24 hours of parturition. 25, 26 Precocious increases in progestins prior to day 315 may be seen with placentitis; acute declines in progestagens are associated with fetal demise and impending abortion. 27, 28 It is crucial that samples be submitted to a laboratory that has established values for progestins in the late-term mare. Each progesterone assay has different cross-reactivities with the various progestagens, so it is not possible to compare values from one laboratory with ranges established by another laboratory, which uses a different assay. Estrone sulfate can be used to monitor fetal well-being, but it is not sensitive in detecting the early stages of placentitis. From day 150 to 310, total estrogens (predominately conjugated estrogens) are greater than 1000 pg/mL, falling to 500 pg/mL by day 340; mares with total progestins greater than 15 ng/mL and total estrogens less than 500 pg/mL between days 150 and 280 aborted, while those with progestins less than 8 ng/mL and total estrogens greater than 1000 pg/mL during this same time frame delivered live foals. 29 Relaxin is produced by the placenta, and it has been found to be decreased in mares with placentitis or signs of endophyte-infected fescue toxicosis.30 Unfortunately, at this time no commercial assay is available for relaxin. Recently the concomitant profiling of progestins, estrogens (predominately estradiol 17-β), and foal outcome were reported with the following cutoffs to distinguish healthy and foal loss groups for different timeframes of days 240 to term.31 See Table 1.
Considerable effort has been made in identifying a biomarker, either in the allantoic fluid or the systemic circulation, which might provide an early diagnosis of placentitis. Serum amyloid A, lactate, α-fetoprotein, lactate, and metabolomics profile have all failed to be sensitive and specific for providing an earlier diagnosis in comparison to ultrasonographic examination.
Table 1The exact list of therapeutic agents needed for an individual mare will vary depending on the reason for the high-risk status. Historically a few agents are commonly used in many highrisk mares: altrenogest, flunixin meglumine, pentoxifylline, and antibiotics. To provide supplemental progestagen support, the usual dosage of altrenogest is 0.044 mg/kg po q24h. In high-risk mares, increasing the dosage to 0.088 mg/kg q24h is thought to provide improved tocolytic activity (decreased uterine contractions). Long-acting injectable progesterone has become popular to avoid the need for daily altrenogest administration. Caution is urged following the report of a one-month retention of a fetus following death.32 Injectable clenbuterol is a potent tocolytic agent but is not available in the U.S. Debate exists on
whether oral clenbuterol (200 µg/kg) produces significant reduction in uterine contractions. Flunixin meglumine, a cyclooxygenase inhibitor, prevents the production of prostaglandins stimulated by endotoxemia; it must be given in endotoxemia to avoid luteolysis, which in early pregnancy would lead to abortion. Later in pregnancy, endotoxemia can directly compromise the fetoplacental unit resulting in abortion. Recent evidence indicates that firocoxib (Equioxx®) successfully suppresses prostaglandin and cytokine production in mares with placentitis, which provides a safer alternative when prolonged NSAID treatment is indicated.33 Pentoxifylline (8.5 mg progestagens and NSAIDs) appears to delay pre-term delivery in cases of placentitis.33 Vulvar discharges from mares with suspected placentitis are typically contaminated with commensal microbiota making isolation of the causative organism difficult. Broad-spectrum antibiotics (trimethoprim sulfa, ceftiofur, or penicillin and gentamicin) are indicated in these instances8,34 until identification and sensitivity are confirmed. Unfortunately, the potential efficacy of trimethoprim sulfa combinations35 and ceftiofur36 have recently been challenged. Enrofloxacin, when administered at 7.5 or 15 mg/kg for 14 days starting at 280 days gestation, had no effect on advanced imaging, biomechanical testing, or gene expression of the foal cartilage at 30 days of age.
Placentitis hinges on early recognition of infection. Unfortunately, the clinical symptoms of placentitis are not consistent, but a combination of serial ultrasonography and maternal hormonal profiling may allow for the earliest identification of mares with an abnormal feto-placental unit. Sub-fertile mares, or those with a history of previous ascending placentitis, should have serial examinations beginning no later than the start of the last trimester. In some cases, monitoring from mid-gestation onward would be prudent. Further research on biomarkers for identifying infection of the allantoic fluid prior to changes in the CTUP and the use of biologics for reducing the dependence and length of treatment with antibiotics will aid in improving outcomes of cases with placentitis and reduce the impact on OWOH.
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2. Hong CB, Donahue JM, Giles RC, Jr, Petrites-Murphy MB, Poonacha KB, Roberts AW, et al. Etiology and pathology of equine placentitis. J Vet Diagn Invest; 1993;5(1):56-63.
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4. Hong CB, Donahue JM, Giles RC, Jr, Petrites-Murphy MB, Poonacha KB, Roberts AW, et al. Equine abortion and stillbirth in central Kentucky during 1988 and 1989 foaling seasons. J Vet Diagn Invest; 1993;5(4):560-6.
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20. Poggi SH, Spong CY, Pezzullo JC, Bannon PZ, Goodwin KM, Vink J, et al. Lecithin/sphingomyelin ratio and lamellar body count. What values predict the presence of phosphatidylglycerol? J Reprod Med; 2003;48(5):330-4.
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27. Ousey JC, Houghton E, Grainger L, Rossdale PD, Fowden AL. Progestagen profiles during the last trimester of gestation in Thoroughbred mares with normal or compromised pregnancies. Theriogenology; 2005;63(7):1844-56.
28. Morris S, Kelleman AA, Stawicki RJ, Hansen PJ, Sheerin PC, Sheerin BR, et al. Transrectal ultrasonography and plasma progestin profiles identifies feto-placental compromise in mares with experimentally induced placentitis. Theriogenology; 2007;67(4):681-91.
29. Ousey JC. Hormone profiles and treatments in the late pregnant mare. Vet Clin North Am Equine Pract; 2006;22(3):727-47.
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31. Ryan PL, Christiansen DL, Hopper RM, Bagnell CA, Vaala WE, Leblanc MM. Evaluation of systemic relaxin blood profiles in horses as a means of assessing placental function in high-risk pregnancies and responsiveness to therapeutic strategies. Annals of the New York Academy of Sciences2009. p. 169-78.
32. McAfoos JL, Ellerbrock RE, Canisso IF. Fetal death associated with premature mammary gland development and lactation in a mare treated with weeky injections of longacting progesterone. J Eq Vet Sci, 2019;81:102783.
33. Shikichi M, Iwata K, Miyakoshi, Murase H, Sato F, Korosue K, Nagata S, Nambo Y. Abnormal pregnancies associated with deviation in progestin and estrogen profils in late pregnancy mares: A diagnostic aid. Theriogenology; 2017;98:75-81.
34. Macpherson ML, Giguere S, Pozor MA, Burden CA,
Berghaus LJ, Berghaus RD, Varner JC, Hayna JT, Benson SM, Randell SA, Lyle SK, Kelleman AA, Hart KA, Mallicote MF, Horohov DW. Evidence for anti-inflammatory effects of firocoxib administered to mares with experimentally induced placentitis. A J Repro Immunol, 2021;86(1):1- 13.
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36. Ferrer MS & Palomares R. Aerobic uterine isolates and antimicrobial susceptibility in mares with post-partum metritis. Eq Vet J, 2018;50(2):202-207.
37. Mapherson ML, Giguere S, Pozor MA, Runcan E, Vickroy TW, Benson SA, Troedsson MHT, Hatzel JN, Larson J, vandenBerg E, Kelleman AA, Sanchez LC, LeBlanc MM. Pharmacokinetics of ceftiofur sodium in equine pregnancy. J Vet Pharmacol Ther;2017;40(6):656-662.
Sara K. Lyle, DVM, MS, PhD, DACTDr. Sara Lyle received her veterinary degree from the University of Florida, followed by a combined residency and master's program in theriogenology. She is a diplomate of the American College of Theriogenologists. While on faculty at Louisiana State University’s School of Veterinary Medicine she completed a PhD focused on immunologic and endocrinologic aspects of infective pre-term delivery (placentitis) in mares. Currently, she is an associate professor of theriogenology at North Carolina State University’s College of Veterinary Medicine and the past president of the American College of Theriogenologists. She has authored numerous peer-reviewed articles and book chapters on equine and small animal reproduction. Her main clinical and research interests are in infectious infertility, highrisk pregnancy in the mare, contraceptive measures for wild and companion animal populations, assisted reproductive technologies, and non-invasive instrumentation for reproductive research.
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Abdominal pain is a relatively common problem encountered in the foal. Accurate and prompt diagnosis is critical to successful management, but it comes with unique challenges. Colic in a foal may look like the classic cockroach on its back or might present as dull and obtunded. To complicate evaluation, some routine diagnostics performed in an adult are not feasible in foals and, unlike adult horses, the degree of pain exhibited by a foal does not often correlate to the severity of the underlying lesion. Ultimately, similar decision-making criteria is required to determine the need for exploratory surgery in the neonate versus the adult horse. Common differentials, diagnostic techniques, and treatment options will be discussed further in this article.
Signalment and history are invaluable when narrowing differentials for colic in the neonatal foal. For example, complications due to congenital abnormalities are often observed within the first few hours of life, while colic secondary to meconium retention or uroperitoneum usually presents within 24-48 hours of life. A thorough foaling history can raise suspicion of foaling injuries, which may present like colic pain, and a complete farm history may suggest infectious enterocolitis.
Physical examination is helpful to further differentiate causes of abdominal pain in the foal. Observation of the colicky foal can be extremely important as certain types of colic in the foal have a more typical outward appearance. Foals with gastric ulcers commonly lay on their back with their legs in the air, while a hunched-up position may indicate a caudal impaction. Foals which park out and appear straining could be trying to urinate
Tiffany L. Hall | DVM, DACVIM, DACVECC Equine Medical Center of Ocala Nimet Browne | DVM, MPH, DACVIM Hagyard Equine Medical Institute Abdominal pain in foals can mimic the signs of Neonatal Maladjustment. Image courtesy of Dr. Tiffany L. Hall.or indicate an urge to urinate associated with omphalitis or to relieve the weight of sand impaction. A complete physical examination includes vital parameters as well as auscultation of the thorax for typical “clicks” of a rib fracture or murmur of congenital cardiac abnormalities. Rib fractures can also be identified via palpation or imaging. As heart rate is influenced by several parameters, its value as a prognostic indicator is not as great in the foal compared to the adult. Nasogastric intubation can provide important information as in adult horses, but severe gastric distension can make intubation more challenging. Digital rectal examinations will replace the abdominal palpation per rectum and can provide information about meconium retention or the presence of diarrhea.
Occasionally meconium impactions may be palpated externally via deep abdominal palpation. Complete blood count, serum biochemistry, and immunoglobulin G concentrations should be performed to help identify the cause of abdominal pain and help rule out comorbidities.
As the equine neonate tends to be more demonstrative about pain than its adult counterpart, the vast majority of equine colic is non-surgical despite the severity of discomfort they may display. Ultrasound of the foal’s abdomen provides information regarding gastrointestinal distension and motility, but may also identify the
presence of fluid, gas, or meconium within the gastrointestinal tract, increased free abdominal fluid (with or without evidence of a ruptured bladder) as well as parasitism (older foals). Radiographs can be beneficial in determining gas distension and the presence of meconium impactions. Contrast studies using barium enemas delivered by gravity can be diagnostic for atresia coli or meconium impaction in the small colon, while barium administered by nasogastric tube can identify pyloric or duodenal strictures. Abdominocentesis is slightly more challenging in the foal and should be performed with caution. Due to the relatively thin bowel wall, enterocentesis is more likely and can result in septic peritonitis, especially in the face of bowel distension. When performed, a blunt cannula should be used, and the fluid obtained submitted for testing which may include cytology, culture, and creatinine analysis.
Specific conditions that cause acute abdominal pain in the neonate are widespread and encompass some of the same differentials that are seen in the adult. Disorders of the stomach, small intestine, and large colon are all seen in foals, but more unique disorders include meconium impactions, gastroduodenal ulcer syndrome, and uroperitoneum. A brief discussion of common conditions and field therapy, where appropriate, follows.
Atresia ani is confirmed through physical examination of the perineum; atresia coli may be confirmed through contrast radiography; and congenital aganglionosis is suspected based on breed and phenotype.
Enterocolitis accounts for approximately 40% of colic in foals presenting to referral institutions. As enterocolitis may appear similar to strangulating intestinal lesions depending on the individual’s pain response and is in a gray zone on diagnostic evaluation, we often initiate a period of therapy and assess response rather than moving immediately to surgery. Ideal therapy includes a period of gastrointestinal rest, antimicrobials, and supportive care. The identification of gas within the intestinal walls on ultrasound is a poor prognostic indicator.
Meconium impactions are one of the most common causes of colic in the equine neonate and are typically seen within the first 24 hours post-foaling. Normal passage of meconium should occur within the first few hours and may continue for 24-48 hours post-foaling. The administration of phosphate “Fleet” enemas within the first 12 hours can help prevent meconium impactions of the small colon. Meconium retention occurs in
Analysis of peritoneal fluid obtained via abdominocentesis may be used to assess intestinal health and/or confirm the diagnosis of uroabdomen. Image courtesy of Dr. Tiffany L. Hall.the rectum, small colon, transverse colon, or large colon. Medical treatment is generally successful, but surgical intervention should be considered in cases of uncontrollable pain, peritoneal fluid abnormalities, and/or signs of bowel inflammation.
Medical management of impactions includes the administration of warm soapy water enemas by gravity feed using very soft tubing; however, clients must know not to administer serial enemas without consulting their veterinarian. Repeated enemas can result in mucosal irritation and associated “straining” in the absence of persistent impaction. I recommend not exceeding two enemas within 24 hours without veterinary intervention. If additional enemas are required, acetylcysteine is recommended.
Enemas with acetylcysteine can be effective in breaking up impactions but can also cause tissue inflammation. Liquid acetylcysteine is available commercially as a 20% can be mixed with 160 ml of water and 20g of NaHCO3 to obtain a concentration of 4% and a pH of 7.6. Foals typically require sedation with midazolam, butorphanol, and/or xylazine for proper positioning in lateral recumbency. Elevation of the hind quarters can also help maintain fluid retention. The procedure requires introduction of a 30 Fr. Foley catheter with a 30 ml bulb approximately 2.5-5 cm into the rectum. The balloon is gently inflated until the anus and rectum are occluded. One hundred to 200 ml of 4% acetylcysteine is then administered by gravity flow and retained for approximately 30-45 minutes. The procedure can be repeated up to three times (one every 12-24 hours). Retrospective studies have shown this procedure to reduce the requirement for surgery in almost all cases.
The prevalence of equine gastric ulcer syndrome (EGUS) in neonatal foals is estimated to be approximately 25% to 50%. The four clinical syndromes seen in foals are subclinical, clinical, perforating, and outflow obstruction with a pyloric stricture. Clinical signs include lethargy, colic, bruxism, ptyalism, unthriftiness, frequent recumbency, and rolling into dorsal recumbency. Affected foals are typically two to six months of age; however, gastric ulceration is common in neonates presenting for concurrent disease (e.g., gastrointestinal, sepsis, maladjustment). The pathophysiology of gastric ulceration in foals includes physiologic stress, hypoxia, delayed gastric emptying, prolonged time between feedings, small meal size, and prolonged recumbency. NSAIDs inhibit the production of protective prostaglandins and therefore predispose the equine neonate to glandular ulceration. In addition, illness increases the risk of ulceration by decreasing gastric mucosal defenses secondary to decreased blood flow.
Ultrasound image of intussusception in a five-day-old foal. The parts of the intussusception are as follows: redundant mucosa within lumen (green arrow), intussusceptum (orange), intussuscipiens (yellow).
Image courtesy of Dr. Tiffany L. Hall.
Ultrasound image of distended amotile small intestine which may be observed in foals presenting with colic secondary to enterocolitis or strangulating obstruction. Image courtesy of Dr. Tiffany L. Hall.
Omeprazole is not recommended for use in neonates as ill neonates often have increased gastric pH; sucralfate administration is recommended instead.
Foals may develop uroperitoneum secondary to traumatic bladder rupture, septic necrosis of the bladder wall, leakage or rupture from the internal urachus, congenital abnormalities of the ureters, or urethral rupture. Foals may present with frequent posturing to urinate, abdominal distension, or obtundation depending upon the severity of electrolyte derangements. Diagnosis may be suspected based upon identification of free peritoneal fluid on ultrasound and confirmed by laboratory analysis of blood and peritoneal fluid. Surgery is often recommended; however, some foals may be managed medically with an indwelling urinary catheter.
In Florida, it is not uncommon to see neonates and older foals present for colic or diarrhea associated with pica, particularly ingestion of sand. These foals often display signs of colic through posturing as if to urinate and occasionally have significant abdominal distension. Diagnosis is confirmed via radiography and treatment involves supportive care and prolonged psyllium administration. Oral administration of psyllium may be accomplished by mixing a concoction of psyllium, yogurt, and applesauce. Surgery is rarely required, and recurrence is prevented through controlled management of the environment. Foals will often grow out of this habit within the first few months of age.
Neonatal colic is common, and the degree of pain demonstrated is often not indicative of the severity of the underlying cause. Both gastrointestinal and extra GI causes must be considered, and possible in many cases; however, consideration of owner capabilities and the proclivity of foals to decline rapidly should be taken into account. Indicators for referral include the presence of gastrointestinal reflux, lack of nursing, moderate abdominal distension, refractory pain, intestinal distention, or free fluid on ultrasonography, and/or altered mentation.
1. Bohanon TC. Colic in the Equine Neonate. Proceeding NAVC North Am Vet Conf 2005:129–131.
2. Camacho-Luna P, Buchanan B, Andrews FM. Advances in Diagnostics and Treatments in Horses and Foals with Gastric and Duodenal Ulcers. Vet Clin North Am - Equine Pract 2018;34:25–38.
3. Cribb NC, Coté NM, Bouré LP, et al. Acute small intestinal obstruction associated with Parascaris equorum infection in young horses: 25 cases (1985-2004). N Z Vet J 2006;54:338–343.
4. Furr M. Part VII Diagnosis of Colic in the Foal - Signalment and History. In: The Equine Acute Abdomen.; 2017:413–417.
5. Lewis S. Gastric ulceration in an equine neonate. Can Vet J 2003;44:420–421.
6. McAuliffe SB. Abdominal ultrasonography of the foal. Clin Tech Equine Pract 2005.
7. McClure S, Faber N, Mealey R. Diagnosing and correcting an intussusception of the small colon in a foal. Vet Med 1995:177–981.
8. Neal HN. Foal colic: Practical imaging of the abdomen. Equine Vet Educ 2003.
9. Nielsen MK, Donoghue EM, Stephens ML, et al. An ultrasonographic scoring method for transabdominal monitoring of ascarid burdens in foals. Equine Vet J 2016;48:380–386.
A period of gastrointestinal rest supported by continuous rate fluids and parenteral nutrition can be beneficial in neonates presenting with colic.
Image courtesy of Dr. Tiffany L. Hall.
10. Pilati N, Masciarelli AE, Werner LA, et al. Small colon obstruction by an ovarian pedicle as an acquired condition in a foal. Equine Vet Educ 2013.
11. Reef VB. Equine diagnostic ultrasound. Philadelphia, USA: W. B. Saunders Company.; 1998.
12. Russell CM, Wilkins PA. Evaluation of the Recumbent Neonate. Clin Tech Equine Pract 2006.
13. Slovis NM. Gastrointestinal failure. Clin Tech Equine Pract 2003.
Dr. Tiffany Hall is an internist and criticalist with the Equine Medical Center of Ocala. Originally from Kentucky, she is a graduate of North Carolina State University College of Veterinary Medicine. Dr. Hall completed her internal medicine residency training at the University of California, Davis followed by a fellowship in emergency and critical care at a private practice in Texas before moving to Florida in 2013. She completed training in acupuncture at the Chi Institute in December 2018. Dr. Hall enjoys the challenge of emergency and critical care medicine and the evaluation of poor performance with a focus on the respiratory, cardiac, and neuromuscular systems. For Tiffany, the most satisfying part of her veterinary career is the long term relationships she has developed with area veterinarians since moving to Ocala.
Dr. Nimet Browne studied veterinary medicine at University of Tennessee, graduating in 2010. Following veterinary school, Nimet went on to complete an internship in a private practice in Illinois, then a large animal internal medicine residency at Virginia Tech. During that time, she also obtained a masters in public health with a focus on infectious disease. Following her residency, she completed a yearlong fellowship at Hagyard Equine Medical Institute. In 2016, she took a faculty position in the equine internal medicine department at North Carolina State University but returned to Central Kentucky in 2018. Her interests include neonatal medicine, gastrointestinal disease, infectious disease, and public health. She is currently working on manuscripts regarding infectious causes of diarrhea in neonates as well as the use on enrofloxacin in neonates.
Image courtesy of Dr. Tiffany L. Hall.
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Excellent client communication improves patient outcomes and quality of care and also protects veterinarians from legal and licensure complaints. Conversely, difficult clients make our ability to provide great veterinary care more challenging and more time-consuming. Let’s unpack the reasons behind client communication challenges and difficult client expectations and how to manage those situations more effectively.
There is a growing body of literature that shows a relationship between quality of communication and outcomes for both patient and practice health. Diagnostic accuracy requires accurate history taking and missed diagnoses often result from breakdowns in history collection (56% of cases in one study).
Studies of doctor-client visits show significant differences in how clients and doctors ask questions, speak, and listen. These differences affect the quality of data collected during the interaction. Improved communication also results in improved client/patient adherence. Several studies have shown that when trust is not established, less information is collected from clients, and follow-up care is not sought. Third, breakdowns in care team communication can compromise the quality and efficiency of patient care.
Ineffective team communication was the root cause for ~66% of reported human medical errors in JCAHO data (1995-2005). Poor communication can result in an increased risk of formal patient complaints and liability suits. Up to 82% of formal complaints and malpractice cases are due to client perceptions of misinformation or disrespect, lack of informed consent or detailed explanations for a procedure, or a client feeling that their opinion did not matter.
First impressions are incredibly important. Success in this small step requires proactively organizing the ‘welcoming ritual’. Most Americans wish to be addressed by name and want the clinician to introduce themselves. Appropriate touch — often a handshake — is expected and eye contact should be maintained. These two non-verbal components of the introduction are most likely to contribute to a client’s assessment of connectedness.
Nonverbal awareness is key to properly interpreting the client’s response to discussions. About 80% of communication between
Image courtesy of Camva.individuals is nonverbal, and these behaviors are generally involuntary. This means that important information that cannot be hidden is being exchanged at all times — from client to veterinarian and from veterinarian to client. If the client has a concern with veterinary care, it will be signaled in the nonverbal channel, even if they verbally agree with the treatment offered. Luckily, using nonverbal communication does not require extra time; the doctor can simply notice and respond to those messages as the interaction proceeds.
How we communicate can influence diagnostic accuracy, often by allowing the client the opportunity to tell their story. Failure to get the story, by using a narrow data gathering process, is a missed opportunity for complete diagnostic information. Open-ended questions are key to success in this area, and veterinarians are not always patient enough to do this well.
Active listening presents an opportunity to both get a complete understanding of the case and build rapport with the client. Focus on the client and communicate your attention with nonverbal methods. Reflect back on what the client says by both directly restating key facts and summarizing back the information that has been communicated. Further, the clinician can demonstrate an appreciation of what the experience was like for the client with empathy statements. Empathy is most useful when the client is having an emotional response to information about their pet’s situation. Empathy is the single most important skill in building client relationships, yet it is commonly absent. In one veterinary study, empathy statements were expressed in only 7% of appointments.
About half of all client-veterinarian encounters end with the client unable to repeat the plan of action for their animal. It is key to ensure that the client agrees with and understands the plan, thus tools for ensuring client understanding are essential. One technique to "close the loop" is the Ask-Tell-Ask Method:
1. Ask the client to describe his/her current understanding of the issue, then;
2. Tell the client in straightforward language what you need to communicate — the bad news, treatment options, or other information — while avoiding medical jargon. Then finally;
3. Assess the client’s understanding. To do this, ask the client to restate what was said in their own words to ensure they fully processed what was said.
Many challenging client communication scenarios center on discussions of “bad news” — whether that be a poor prognosis, an
unexpected outcome, treatment failure or recurrence of disease, need for expensive treatment, and even medical errors. Ultimately, bad news is any information likely to be perceived by the client as distressful, unwanted, and/or unexpected. Particularly when delivering bad news, communication is the veterinarian’s responsibility. It is an essential task that should not be delegated and can have lasting effects on the client and patient. The good news is that effective delivery of bad news can strengthen the client-veterinarian relationship, and clinicians who develop skills for this task will have less stress and burnout.
In one study, about 20% of physicians said that they experienced strong emotions when they had to tell a patient that their medical condition would lead to death. The stress clinicians experience when they give bad news has a different course than the distress patients experience (Shaw et al., 2013). The clinician’s stress peaks during the encounter when the bad news is delivered, whereas the patient’s stress peaks after the encounter as the implications of the bad news are better understood. This mismatch in stress and distress is important to be aware of when delivering bad news to a client. At the very moment a clinician is breathing a sigh of relief (because they successfully delivered bad news), the client is still increasing in stress level.
As already discussed, the use of open-ended questions, reflective listening, and sharing empathy can all help to build rapport with clients. These skills should be again deployed when planning how to deliver bad news. Orient clients to the plan for your encounter when delivering bad news, so that they are prepared for what the conversation will cover. While it is useful to provide a warning that bad news is about to be shared, clients have also been shown to appreciate direct delivery of bad news instead of starting with a long introductory period of information sharing.
Image courtesy of Camva.Communication is always a two-way interaction and a series of verbal procedures. Like other veterinary procedures, there are degrees of difficulty in various communication procedures, and our clinical skills will improve with deliberate practice. While we cannot change the need to communicate about difficult situations and with difficult clients, the way we communicate can make the process easier for clients and ourselves.
Much of this content is sourced from the IHC Veterinary Communication Project modules. For more information, visit the Institute website at www.healthcarecomm.org and click on Veterinary Communication.
Dr. Martha Mallicote completed her undergraduate work at the College of Charleston in South Carolina, completed a master of business administration degree at the University of Florida and is a 2006 graduate of the University of Tennessee College of Veterinary Medicine. Since graduation, she has worked in both ambulatory and referral hospital settings, including an internal medicine fellowship at Rood and Riddle Equine Hospital. In 2012, Dr. Mallicote completed her residency in large animal internal medicine at the University of Florida and joined the faculty. She was appointed to the Weeks Endowed Professorship in Veterinary Medicine in 2018 by colleagues at the University of Florida. Her professional interests include endocrinology, neonatology, and veterinary business management.
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