Vaginal varicose veins

Keywords: veins, varicose, equine, vagina, hemorrhage

In older mares, varicose veins occasionally develop in the vagina during pregnancy. The reason for their presence is obscure because there is no effect of gravity on vaginal veins. However, weakening of the veins with age, increased blood flow to the genitalia under the influence of estrogens and retrograde pressure due to abdominal filling during advanced pregnancy, may all be contributing causes. Under the effect of Laplace's law, these vessels grow larger with time.

Occasionally vaginal veins may rupture and become a source of hemorrhage, seen at the vulvar lips. Hemorrhage is seldom severe but it can provoke suspicions of impending abortion. Dried blood on the vulvar lips may also attract flies.

The vagina of this postmortem specimen has been everted to demonstrate the affected vessels.

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Smaller varicose veins are visible below; in the lateral wall of the vaginal vestibule in a Standardbred mare.

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Vaginal varicose veins can be up to 4 or 5 mm in diameter and are usually seen in the vestibule rather than the cranial vagina.

Numerous treatments have been described including cryotherapy, ligation and vasocontricting medications such as Preparation H ® which contains Phenylephrine in some (but not all) countries. Varicosities shrink after foaling and treatment is not required in most cases.

Ultrasonography of intra- and extrauterine hemorrhage.

Keywords: ultrasound, hemorrhage, uterus, mesometrium, equine

1. A hematoma seen in the mesometrium (Me) at the time of foal heat breeding.  Like the majority of mares with mesometrial hematomas, this mare showed no outward symptoms at the time of foaling. The structure was clearly palpable per rectum; hence the ultrasonograph.

2. A similar hematoma to that described above but older, more consolidated and more echogenic.

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3. Intra uterine (IU) hemorrhage in a mature mare presented because of a foul smelling vaginal discharge at 35 days post foaling. The mare was systemically normal but ultrasonography and a glove hand examination of the uterus revealed masses of clotted blood, seen here on ultrasound in the left uterine horn. This was hemorrhage was presumed to be due to a severe partial thickness endometrial tear, sustained during parturition. The hooves of foals can cause these tears.

Most of the clotted blood was removed by hand then the uterus was flushed with saline. Antibiotics and tetanus toxoid were administered. The uterus appeared to be normal on ultrasonography at the time of discharge but the mare was lost to follow up.

4. Two images of an unusual intra-endometrial (IE) multilocular cyst at the approximate time of foal heat. Its contents were not consistent with the non-echogenic fluid usually seen in endometrial lymphatic cysts. However, this mare was known to have endometrial lymphatic cysts before she conceived. Therefore it is possible that this was a group of cysts that was traumatized during foaling, causing hemorrhage within the cysts.

Reference

Dolente, B.A. et al. 2005. Mares admitted to a referral hospital for postpartum emergencies: 163 cases (1992-2002). J.Vet.Emergency and Critical Care 15: 193-200

Mesenteric hemorrhage associated with foaling

Keywords: hemorrhage, foaling, equine, mare, intestine

A mature Standardbred mare that died suddenly immediately after foaling.  Her mucous membranes were extremely pale upon presentation and postmortem examination revealed that she had suffered from an extensive intra-abdominal hemorrhage. Contrary to expectation, the hemorrhage did not arise from a rupture of the uterine artery (prev. middle uterine artery). Instead, hemorrhage originated from one of the major vessels in the spleno-colic ligament. Bleeding extended into the mesentry and peritoneal cavity.

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Despite an adequate worming program on this stud farm, the presiding pathologist suggested the mare could have experienced verminous arteritis and by extension, arterial rupture because of hypertension during foaling. However, some doubt  has been leveled at that suggestion, based on the fact that verminous arteritis due to S. vulgaris is still well controlled by current anthelmintics and cases of arteritis are no longer common in this geographical area (N.E. Canada). Instead, it has been suggested that the trauma seen here may have been sustained by the foal during parturition. The accompanying review substantiates that idea.

Reference: 
Dolente, B.A. et al. 2005. Mares admitted to a referralhospital for postpartum emergencies: 163 cases (1992-2002). J.Vet.Emergency and Critical Care 15: 193-200

Hemorrhage after endometrial biopsy

Keywords: biopsy, endometrial, hemorrhage, equine

The approximate site for biopsy is shown relative to the cervix (is framed within the green rectangle in the inset image).  Large, deep and penetrating biopsies can occur, causing mild to severe hemorrhage but this is rare and to the author’s knowledge has never been reported to be fatal.  Nevertheless, owners should be warned of this possibility, noting that blood may appear on the vulvar lips within one or two days of the biopsy being taken.

This image shows the dorsal surface of the endometrium and two sites (green arrows) where biopsies were taken 24 hours earlier. A large blood clot can be seen adjacent to the biopsy site that is lowest in this image. The upper biopsy site appeared to be less traumatic.  In this case, the mare did indeed show a small amount of blood on her vulvar lips the morning after the biopsy was taken.

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Usually, there is far less hemorrhage than this after uterine biopsy. The image below, also taken 24 hours after biopsy shows a more typical appearance (note the small lymphatic cysts; a very common finding in older mares):

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Biopsy sites heal very quickly in mares and within 48 hours, the site of a biopsy is barely visible. Therefore biopsies can be taken from mares during the first few couple of days of estrus and can be inseminated at the time of ovulation, three or four days later.

Urethral hemorrhage in a gelding.

Keywords: hemorrhage, urethra, gelding, blood

A seven year old Icelandic gelding was presented with a history of severe but sporadic hemorrhage from his urethra. An episode of hemorrhage also occurred during examination.

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The owners reported that large volumes of "pure blood" had been discharged from the penis, not associated with urination.  Dried blood was also present on both hind legs, suggesting that more hemorrhage may have occurred than that seen by the owners.

Endoscopic examination revealed the presence of blood in the urethra (subset image 1) close to the ischial arch. Shortly after the first image was obtained, a column of blood was projected toward the endoscope (subset image 2). Advancing in the direction of the bladder, the urethra was flushed with saline and group of varicose veins was seen (subset image 3 on the left side of the image). No points of hemorrhage could be demonstrated on the surface of these veins, therefore it was impossible to state unequivocally that they were the source of hemorrhage. Just caudal to the bladder (subset image 4) pooled blood was seen ventral to the colliculus seminalis.

Hemorrhage can occur from many sources in the proximal genital tract. These include mucosal tears in the urethra, urethritis, inflammation and neoplasia of the accessory glands and so on. Circumstantially however we concluded that fragility of urethral varicose veins was the source of hemorrhage.

It was with some reservation that yunnan baiyao; a chinese herbal remedy was used to treat this horse. The usual dose recommended for exercise induced pulmonary hemorrhage is “one bottle of powder in the morning and one in the evening”. This is clearly unscientific because the powder has more than 20 ingredients and standardization is therefore virtually impossible. Only a single treatment was used.

Recent contact with the owner revealed that sporadic hemorrhagic episodes occur at three to five day intervals but the gelding remains bright, alert and responsive.  The condition may remain untreated. In similar cases in mares where vaginal varicosities have bled intermittently, the author has recommended ligation or cautery of the vessels but surgical intervention is neither safe nor feasible in this case.

Note: Fatal air embolism has recently been linked with urethral endoscopy. The chance for this is thought to be remote. However, because of this possibility, urethral endoscopy should probably be done only if there are strong indications to do so.