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Before an endometrial swab is taken, the nonpregnant status of the mare must be confirmed because the swabbing could lead to termination of a pregnancy see Pregnancy Determination in Horses.
The perineum is cleansed with povidone-iodine scrub, rinsed, and dried. The operator dons a sterile sleeve or clean examination sleeve with the hand encased in a sterile glove. A water-soluble lubricant free of bacteriostatic chemicals is placed on the back of the hand and lower arm. When obtaining an endometrial swab sample, the vestibule, vagina, and cervix must be passed. Care must be taken to avoid contamination of the swab by microorganisms in the structures caudal to the uterus that would hinder accurate interpretation of the culture results.
A double-guarded occluded uterine swab is gently guided through the cranial end of the cervix. Once inside the uterine body, the inner guard is advanced from the outer guard, and the swab is exposed to the uterine lumen for 30—60 sec. The swab tip is withdrawn into the inner guard, which is then withdrawn into the outer guard before the entire swabbing instrument is removed from the uterine body.
The swab tip is carefully placed into a transport system, which is vital to maintain viability of the organisms from the time of sample collection until aerobic culture in the laboratory.
Stuart's carrier medium may maintain microorganisms for as long as 72 hr if stored at ambient temperature. A second endometrial sample may be taken immediately after the first or simultaneously with a uterine swab or cytology brush. This sample is then evaluated cytologically by rolling it onto a glass microscope slide, fixing and staining with a Romanowsky-type stain, and viewing it microscopically for evidence of neutrophils, debris, and microorganisms.
A low-volume uterine lavage can be performed in mares with negative culture results despite obvious clinical signs of endometritis. Sterile saline 60— mL is infused into the uterus using a closed system with a small uterine catheter. Oxytocin 20 IU, IV is administered to enhance uterine evacuation. The effluent is collected by gravity flow into a sterile centrifuge tube and then centrifuged.
The pellet is then swabbed, placed into transport media, and submitted for aerobic culture. A second swab can be made of the pellet for cytologic examination after staining.
In most cases, the mixed growth of a few miscellaneous microorganisms is not significant. A heavy growth of any microorganism should be considered significant unless obvious contamination has occurred. Clinical signs must be correlated with culture results to determine clinical significance and to develop a therapeutic plan. Isolation of an organism transmitted venereally, such as Taylorella equigenitalis requires a special culture system and certain strains of Pseudomonas and Klebsiella spp, is considered a significant finding.
Occasionally, microorganisms causing a pyometra may not be detected on aerobic culture, because products of the inflammatory reaction prohibit their growth. Aerobic culture results of the endometrial swab should be used as a diagnostic adjunct and not as the sole determinant in diagnosing a uterine infection. A positive culture result must be accompanied by evidence of inflammation for the diagnosis of endometritis to be made. Mares exhibiting clinical signs of infection uterine fluid as seen on ultrasonographic examination per rectum, tail matting or uterine discharge, and the presence of inflammatory cells seen on a stained smear from a uterine sample with a positive endometrial swab are likely to have endometritis.
Inflammation seen on histologic evaluation of the endometrium confirms the diagnosis of endometritis. In these cases, the culture results are useful in determining the sensitivity of the causative microorganism and developing an antimicrobial treatment plan.
The following antibiotics see Table: Intrauterine Antibiotics for Use in Mares have been used for daily 3—7 days uterine infusion by diluting with sterile saline to an infusion volume of 60— mL. Systemic administration of antibiotics may be considered if the microorganism, management situation, and ease of treatment indicate.
Two doses of long-acting ceftiofur crystalline free acid 6. Gentamicin sulfate diluted with 20 mL sodium bicarbonate and 20 mL saline. An endometrial biopsy sample is usually obtained immediately after the endometrial samples have been procured.
It should be kept in mind that manipulation of the endometrium can quickly cause a neutrophilic response in the endometrium. Preparation for biopsy is the same as for taking a swab see above. The basket of the biopsy instrument should be kept closed during positioning to prevent accidental procurement of vagina, cervix, or examination glove. The instrument is manually guided with the gloved hand through the caudal genital tract into the uterine lumen.
While keeping the instrument in place within the uterus with the nongloved external hand, the gloved hand is carefully withdrawn from the genital tract and inserted into the rectum to allow positioning of the basket of the biopsy instrument at the ventral luminal surface of the base of a uterine horn.
The instrument jaws are then opened, the uterine wall is pressed into the side of the basket, and the jaws are closed. The jaws should be kept closed while the instrument is withdrawn from the genital tract.
It is not unusual for a small amount of uterine bleeding to occur after biopsy. The biopsy procedure is not detrimental to fertility, and a mare can conceive from a breeding that occurred during an estrus when biopsy was performed. The luminal contents may indicate the presence of uterine fluid or exudate.
Epithelial cell height is related to hormone status; cells are cuboidal during anestrus and low to tall columnar during the breeding season. Transepithelial cells may indicate active inflammation. The pattern, character, and location of inflammation indicate the chronicity of response—neutrophils indicate an acute reaction, and lymphocytes and plasma cells indicate a chronic reaction. Focal or diffuse cellular distribution pattern, frequency of inflammatory cells, and degree of infiltration slight to severe relate to severity of inflammation.
Histologic evidence of significant inflammation, combined with a report of growth of microorganisms from aerobic culture of endometrial swab and the presence of clinical signs of infection uterine fluid, uterine discharge , support the decision that an endometrium would benefit from therapy to decrease inflammation.
Knowledge of the pattern of distribution and severity of periglandular fibrosis is prognostically useful. Periglandular fibrosis may interfere with endometrial gland function and may be a factor causing early embryonic death. Glandular distention normally develops during pregnancy, but widespread cystic glandular distention in the nonpregnant mare is undesirable. Cystic glandular distention is often associated with periglandular fibrosis and may result from an accumulation of gland secretions proximal to the occlusion of the endometrial gland by periglandular fibrosis.
Endometria are classified in four categories that attempt to predict ability to carry a foal to term. Category I indicates no significant changes are present in the endometrium, and no treatment is required. An endometrium with any notable periglandular fibrosis cannot be classified as Category I. Category II is a broad category that includes most mares. Often, therapy may improve the state of the endometrium by reducing inflammation, cystic glandular distention, and lymphatic lacunae.
Improvement in the endometrium may allow for better classification at a later date. There is no effective treatment to decrease the severity of periglandular fibrosis.
Category III is the poorest classification, and these endometria have widespread, severe changes that include periglandular fibrosis or inflammation. A widespread pattern of distribution of slight to moderate changes may be more deleterious than more severe changes that are infrequent and only involve individual glands.
The estimated foaling rate of a Category III endometrium is During interpretation of the findings on histologic evaluation of an endometrial biopsy sample, the extent of normal, unaffected endometrium is more significant than the presence of any particular lesion.
In barren mares with a Category I or IIA endometrium, other reproductive abnormalities or poor breeding management should be investigated as the cause of infertility. The perineum is cleansed, rinsed, and dried before the visual vaginal examination via speculum.
The vulvar lips are separated, and the speculum is advanced cranially at a dorsal angle so as to pass over and through the transverse vestibulovaginal fold of the vagina. Resistance against the speculum by this fold of tissue indicates good tone and function.
A bright light is necessary to adequately view the cervix and vaginal wall. The character of the cervix reflects the hormonal status of the mare. As the speculum is being withdrawn, it should be noted whether the vestibulovaginal fold occludes the vagina.
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