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      Date:   06 June, 2010  
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Pyometra in 3 female dogs
Three cases involving 8-year-old dogs

Dr Sing Kong Yuen, BVMS (Glasgow), MRCVS
First Written: 19 September, 2008
Upd
ate:  06 June, 2010
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Be Kind To Pets
Veterinary Education
Project 2010-0129
Case 1. A veterinarian's "stop at 8" spay policy

"A  veterinarian refused to spay any dog over 8 years old," she said.  Her dog had vaginal discharge but was eating. The dog had been licking her private parts to clear the discharge. Could she be suffering from  pyometra or not?

"Why did Vet 1 say to 'stop at 8'" I asked the young lady as this was the first time I encountered such a statement. She shook her head Vet 1 did not elaborate.

"Most likely older dogs are high anaesthetic risks," I said. "Therefore the older they are, the chances of them dying on the operating table are much higher. So Vet 1 stops doing spays of dogs older than 8 years."

In the case of the young lady's 9-year-old dog, blood tests were normal. The lady could feel two small hard breast nodules in this dog. Spaying would remove the oestrogen hormones that encourage the breast tumours to grow bigger.

At 3.20pm, I started the surgery. A routine spay that I had done so many in the past 2 decades of practice. No problem but still I had to be careful in view of the "stop 8 policy" mentioned.

Blood tests done at another veterinarian requested by the young lady some weeks ago indicated that the dog had no liver and kidney trouble.

So, this should be a simple routine spay. Man proposes, God disposes if you are religious as illustrated by this case.

I gave the dog gas anaesthesia using a mask. As she was a quiet dog, she went to sleep soon without fear or struggle. 

Intubation means the insertion of the endotracheal tube into the lungs. The tube delivers oxygen and isoflurane anaesthetic case for surgery. It also provides a means to deliver emergency oxygen when necessary. The gas mask anaesthesia is used when the dog cannot be intubated. The Lhasa Apso had 2 X-rays before the surgery to determine whether she had pyometra.

By 3.40 pm, I had ligated the uterine blood vessels and put the stump into the abdomen. Closing up the muscle and skin layers would take 10 minutes and the surgery would be completed by 3.50 pm.

I checked the dog's tongue and breathing rate. Just as the uterine stump was put into the abdomen and disappeared, the dog's tongue turned cyanotic. The breathing rate slowed considerably. This was not good.

Was the "8-year no-spay prohibition" by the other vet casting a spell on this Lhasa Apso? Turning cyanotic indicated that the blood had insufficient oxygen. There was no time to reflect on the spell of the other vet.

Emergency resuscitation and oxygen were given. The dog breathed normally again and the tongue turned pinkish blue. It was time to stitch up the muscle layers. Then the nightmare of all veterinary surgeons doing spay occur. Bright red blood appeared in the abdomen. Flowing non-stop. Like a waterfall or a flash flood in a storm. Non-stop.

The uterine blood vessels were ligated twice in two areas. The resuscitation procedures had increased the blood pressure and now the vessels leaked blood. The blood vessels are more fragile during the period of heat as in this dog.

What to do? Where was the source of bleeding? From the ovarian blood vessels further cranial or the uterine blood vessels? The ovarian stumps were also double ligated and further cranial. The forceful bleeding indicated that the source was the uterine stump. There was no choice but to extend the skin and muscle incision much longer to find the uterine stump. I fish it out with the artery forceps and clamped the stump. The short stump was ligated and put back into the abdomen. Bleeding stopped immediately.

Dogs over 5 years old. High anaesthetic risk. Gas mask. Toa Payoh Vets Dogs over 5 years old. High anaesthetic risk. Intubation for emergency oxygen. Toa Payoh Vets
Early pyometra - nothing can be seen on the ventral views of the X-ray. X-rays had shown a bigger womb and therefore I made a bigger incision than normally done during a spay so as to get the womb out easily. Pain on lower 1/3 abdomen near the bladder area indicates cystitis+/- pyometra.
Before spay. Lhasa Apso. Pyometra and proestrus now. Toa Payoh Vets After spay. Lhasa Apso. Uterine walls thickens and starts to bleed. Toa Payoh Vets
Proestrus uterus. Lhasa Apso 9 years. Toa Payoh Vets No skin scar visible 9 days after spay and during stitch removal. Toa Payoh Vets
Lhasa Apso 9 years, 2 very small breast tumours. Toa Payoh Vets Prettied the Lhasa Apso for the vet? Toa Payoh Vets
  Cystitis, periodontal disease and breast tumours to be monitored. Toa Payoh Vets

Maybe the other vet was wise enough as to avoid spays of female dogs from 8 years of age.  He might have a premonition and had rejected this case earlier.

Now the dilemma is whether the owner should get dental work done for the dog as there is always an anesthetic risk involved.

As at Sep 18, 2008, the Lhasa Apso was all right some 2 months after the spay. She had some vaginal bleeding a few days after spay, attributed to pro-estrus/estrus bleeding of heat. Later she passed blood in the urine. But now she was all right.

This dog in 2008 was 9 years old and had thick deposits of tartar in her back molars. Should she just brush her teeth, go to a groomer who does dental work without the need to use anaesthesia or goto the veterinarian who will use anaesthesia for dental work? Only the owner can make the decision and accept the risk. Dental work is important in the dog because the bacteria in the mouth spreads to infect the heart valves and other organs as time goes by. Mouth ulcers and tumours do form in a dog that had periodontal disease over the years.

So, there is a benefit of living a longer life when older dogs don't get foul-breathing infected teeth and gums. There is the worry of death under anaesthesia and this risk is always there, even in old people. 
 

UPDATE IN JUNE 2010
The dog is OK and well cared for. 

Case 2. An 8-year-old Chihuahua stopped eating for 2 weeks

"My friend's Chihuahua has not been eating for the past 2 weeks," the expressive lady in her late forties said. "So I asked her to see the vet." The friend took out the 8-year-old female Chihuahua with a long coat from her sling bag.

The Chihuahua had passed large blobs of blood two weeks ago instead of the usual fresh watery blood of heat. After that the dog just had no appetite. "Not even the table food," the friend said. I had seen this dog 2 years ago and had advised spaying her as she had false pregnancy.

"Why didn't you get the dog spayed in 2006?" I asked the quiet lady owner in her 40s. Now she has a fever due to an infection of the womb."

I palpated the lower abdomen with my left hand. The Chihuahua winced in pain and cried softly whenever I felt the lower abdomen. The lady owner could see the dog arching her back as I pressed the lower abdomen. The dog's soft cries of discomfort were heard in this small consultation room of 7 sq metres.

This case of pyometra was easy to diagnose based on the history of dirty blobs of blood passed after the heat period, lethargy, anorexia and fever and lower abdominal pain.

The owner said: "My friends advise me not to get the dog spayed. Too dangerous. My dog will die on the operating table."

Such fears are common and must be appreciated from the owner's point of view.

So, what to do now?

"Antibiotics will likely cure this dog. Most owners will forget about my advice to spay the dog after she recovers from the fever. She will be normal and active. But she will suffer the same problems of passing sticky dirty brown tissues of blood at the next heat."

My advice was to get the dog spayed one month later when the dog is healthy and normal.

"It is a high risk anaesthetic case now that the dog is 8 years old. Your dog may die on the operating table since she is much older than 2 years ago. Giving antibiotics every time she has pyometra is not a solution. The dog will keep licking her private parts to get rid of the continuous vaginal discharge and thereby infecting her womb and bladder after some years."

The quiet lady's eyes turned reddish. This dog is family. She has to decide in one month's time. Alternatively, she could wait for the same clinical signs and repeat the whole process of antibiotics and waiting for a month to spay. Blood samples were taken from the dog.

After a 100-ml IV drip of dextrose saline, the dog looked bright and energetic.

I cannot understand why this quiet lady would not see the vet when her dog was not eating or had poor appetite for 2 weeks. The intervention of her good friend to get the dog examined probably saved the dog's life for the time being.

Bacterial toxins from the womb would poison the dog and affect the kidneys if the dog was left untreated. Blood tests showed a very high white cell and neutrophil count.

This indicated that the dog had a severe bacterial attack, provoking an extremely high number of white blood cell production. The white blood cells increase to fight the bacterial infection.

Presently, this dog had no vomiting and therefore the kidneys and liver are unlikely to be affected.

When a dog is not eating for 2 weeks, do not delay veterinary attention.

The most likely reason that the quiet lady did not consult the vet was that she feared that the vet might advise spay. When her dog is operated, she may die.

One moment the dog is alive. The next moment, the vet says she has died. So, she does not want to visit the vet.  This is just my conjecture but it is a common worry of old dog owners.

In any case of pyometra, it is best for the vet not to do immediate surgery to reduce the risk of anaesthetic death and a lot of unpleasantness associated with deaths of a beloved pet, not forgetting damage to a professional reputation built up with sweat and tears over many years.

As for owners of female dogs, it is best to spay them when they are young as they are healthy and able to take anaesthesia generally.

Pyometra is a common condition of old female dogs. Spaying the female dog early prevents pyometra and a lot of expenses and worries about deaths on the operating table. 

UPDATE IN JUNE 2010
The dog is OK and well cared for. 

Case 3. An 8-year-old dog died on the operating table

Recently the Chinese press printed a case of an 8-year-old dog dead after visiting a veterinarian for spay and dental treatment. I did not read this report and do not know the other side of the story from the veterinarian involved.

A pet shop operator told me on Sep17 2008 when she sent her Golden Retriever for spay about this case. She said the complainant was  quoted $500 for spay (probably due to pyometra) and dental work for the 8-year-old Jack Russell. However, the vet presented a bill of $1,200 on the death of the dog. 

Another person told me that the vet had justified saying that expensive drugs were used to revive the dog.

When a dog dies on the operating table, there is so much unpleasantness from uneducated dog owners and sensationalism from tabloids.

Conclusion

As I review the above 3 cases that occurred recently, it seems that the dogs were coincidentally 8 years of age.

Is the "stop at 8" spay policy from a vet (Case 2) a wise policy?

It may be wise for a vet to reject spaying and pyometra if the dog is 8 years and above to avoid unnecessary bad mouthing and unpleasantness from uneducated dog owners. Some vets lose money as they don't charge if the dog dies in such a situation. Overall, it is not a good situation to be in.

I read the comments in an internet forum regarding this case. This time the forum moderators were more responsible as they did not permit mention of the name of the veterinarian or the veterinary surgery in Singapore. There were more balanced comments than in a previous writing of dog anaesthetic death at the surgery. There were readers asking for the name of the surgery and one writing about never spaying her dog.
 
To avoid unpleasantness due to poor clinical outcomes, maybe it is wise to pass the case to other veterinarians. Reputations are hard to build and with an uneducated pet owner suffering from such situations, reputations are demolished in an internet forum in no time.      

In old dogs, it may be wise for the vet not to combine spay and dental work so as to reduce the anaesthetic time and therefore reduce the risk of anaesthetic death. It is possible that the owner will not come back for dental work after the spay, but then so much unpleasantness is avoided and damage to professional reputation.

BE KIND TO OLDER DOGS & CATS --- GET TUMOURS REMOVED EARLY --- WHEN THEY ARE SMALLER.  More case studies, goto:  Cats  or  Dogs

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