How to NOT Miss a Closed Pyometra

This week I had another pyometra. Pyo Queen strikes again!


This particular dog was an almost 11-year-old doodle. The key thing is that I looked at her file prior to presentation and she was listed as an unaltered female. This means she still has a uterus.


Presenting Complaint:


Our patient presented to the ER due to a slight decrease in appetite over the past 4 days, not feeling herself, and then had an episode of vomiting.


I immediately put pyometra on the top of my differential diagnoses, because she was an intact female.


When my patient presented, I had two other veterinarians around me. I did my physical examination, and other than maybe some mild abdominal splinting, she had a fever of 39.8 degrees Celsius. For those that do not know, the normal dog temperature per rectum is 38-39 degrees.


I get on the phone with the owner and tell them that an intact female has a pyometra until I can prove it otherwise. I would like to do an A-FAST (an abdominal ultrasound, quick assessment) and blood work to see if there is an elevation in white blood cells. We have blood work from 4 months ago to compare to as her normal. The owner gave me the go ahead, and I had the staff shave some of her abdomen so that I could get a better look.


Sure enough, I see fluid filled cystic structures inside her abdomen, consistent with pus in the uterus.


Our new graduate says, I think I would have missed that she was a pyo.


My answer to that is, I missed one - and now I never miss one! Did I pigeon-hole the case? Yes, absolutely. But keep in mind that for any vomiting dog, blood work and an A-FAST is actually a good start to get some information on your patient!


Now, remember, not all veterinary clinics have an ultrasound, sadly. I love ultrasonography - it's why I did my Master's in it! I am fortunate that my new clinic has a better ultrasound machine!


In the absence of an ultrasound machine, you can take an x-ray of the abdomen. As you may recall, I wrote a blog post about this as well!


So, I guess my post is just that... How do you not miss the closed pyometra?


Tips:


1) Ensure you know your signalment. Remember that any intact female that is presenting with any symptom of not feeling well could have a pyometra.


2) Don't forget to take a temperature - and take it rectally. All of my cases of pyometra have had a fever. The aural temperature is not as accurate in our patients.


3) Remember that a pyometra requires surgical correction! This is not a matter of does your patient need surgery or not. It is a matter of are you going to cut today or tomorrow, or the next day? You have to use your clinical judgement with the patient. If they are stable, they can wait until tomorrow or even the next day. If they are in septic shock, showing those signs of shock such as tachycardia, hypoglycemia, or even low normal glucose in a clearly stressed or sick patient, you may want to go in sooner rather than later.


Remember that a chance to cut is a chance to cure!


4) You can start IV antibiotics prior to cutting. It's a good idea to get your patient on IV fluids prior to surgery. Get them settled, ensure that their vitals are doing well. It also doesn't hurt to have some dextrose on hand for these patients, especially the smaller ones.


5) Take your time in surgery. The last thing you want is to try to rush and have the uterus rupture or disintegrate in your hands. Now I know, even if it does. Don't panic. Soak up what you can, and flush what you can.