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Date:   08 July, 2011  
Focus: Small animals - dogs, cats, hamsters, guinea pigs & rabbits
 
Pyometra in two Golden Retrievers & five management tips
Dr Sing Kong Yuen, BVMS (Glasgow), MRCVS
Case written:  29, June 2008 Date:   08 July, 2011  
toapayohvets.com 
Be Kind To Pets
Veterinary Education
Project 2010-0129

CASE 1 IN 2008. PYOMETRA IN A 12-YEAR-OLD GOLDEN RETRIEVER

Sunday, June 29, 2008

"Flies just would not go away when I swat them," the 65-year-old grandmother with a fair 5-year-old grandson came to the surgery. She was surprised at the tenacity of flies: "They just swarm onto the dog's vaginal discharge."

This was not good news. Flies are attracted to decaying flesh as moths are to candle light. Kamikaze flies who just cannot resist necrotic flesh.

The 12-year-old Golden Retriever had some vaginal discharge 2 months ago. The grandmother attributed it to the dog having heat. In the last 4 days, the dog passed out thick glue-like mucus from her vagina. She stopped eating for 2 days and had vomited.

"Your dog had a severe womb infection. She vomited because toxins could have damaged her kidneys and internal organs, " I did not give much hope of survival for this dog. "Why didn't you spay the dog after the breast tumour operation?"

My past procedure was to remove the breast tumour first and then spay the female dog later. In this way, hormones feeding any new breast tumour would not be available after removal of the ovaries.

The slim and fair grandmother laughed: "You said that Rover would not survive 9 months as her cancer could have spread to her body. Can you recall? breast cancer was as large as a tennis ball!"

I checked my records. It was September 2005 when the large breast tumour was removed. It was a solitary gigantic lump as large as a tennis ball. Now, in Jun 2008, the dog had a long scar where the tumour was. There was a small breast tumour around 2 cm in diameter.

My 'prediction' of 9 months' of life for this Golden Retriever had been way off the mark. It was now 33 months after tumour removal. Why would I give a definite 9 months, I cannot remember. Why not 3 months or any other number? No vet can foresee the future. But I did not argue as the grandmother had a sharp memory.

Now the dog was very sick. She had fever of 40.5 degrees C. She was not eating. She yelled in protest of great pain on the operating table when I stretched her legs to see the long 15-cm scar of the tennis-ball-sized breast lump.

She was now in poor health. If flies just zeroed into her vaginal discharge, it indicated that her womb tissues had rotted. Flies are suicidal and sticky when the tissues and discharges stink a lot. They seem to appear from nowhere and are large bodies flies from the vegetation near the house.

Pyometra in old Golden Retrievers. Singapore. Toa Payoh VetsThe grandmother understood the big risk of dying on the operating table. I boarded the dog one day to give her antibiotics, anti-fever and drips. The dog felt good 24 hours later and ate a full meal after canned food was added.

Now I had to decide. To operate 36 hours after admission or wait another day? The infected womb might rupture anytime as it was decaying. Her temperature had dropped to 37.5 degrees C, one degree below normal. She was sleepy and lethargic. This was a life and death situation. If the surgery was delayed another day, she would die due to toxic blood infusing her whole body. If the surgery was performed, she might die on the operating table as chances of survival were deemed below 50%. So, which decision to make?

The dog was given just gas anaesthesia and intubated. Her large thin-walled uterus and ovaries were removed. The reddish brown pus was copious. Bacterial toxins had seeped into the blood system by permeating past the uterine walls. The uterine horns were purplish in colour when the normal ones would be light pink.

The dog survived the surgery. After waking up, she vomited a big mass of food on the operating table. I had taken out the endotracheal tube some 2 minutes ago.

This was an abnormal event as she had been starved >12 hours prior to surgery and should not vomit anything. This indicated that the stomach was not moving the food along the gut. Another abnormal feature was the dark bluish black blood of her omental blood vessels. Normally they would be reddish.

Such negative signs were not good for the dog. I phoned the grandmother to come to see the dog after surgery which was completed around 11 am. I assessed that this dog would not survive and it would be good for the grandmother to see her. She was the dog that brought newspapers to the grandmother every morning and kept her company. However the grandmother's two adult sons needed her at the airport - one going abroad and one returning to Singapore.

At 7 p.m, the Golden Retriever just passed away quietly due to heart failure. Her gums and tongue were cyanotic. We informed the grandmother. She came around midnight.

5 days later, the grandmother came to pay the bills. "My daughter said there would be nobody in your surgery during lunch-time," grandmother said. "But there ought to be somebody."

The grandmother was correct. I had just returned from visiting abalone farms in Xiamen, China.

The grandmother was sad in her heart. Every dog's death is sadness for everyone involved. I asked grandmother to sit down and we reminisced in the consultation room. Just to know more about Rover.

Grandmother said, "Rover dog behaved strangely the night before going to the vet. She dog walked around the house and went to the back garden to stroll by herself."

"Does Rover not wander around usually?" I asked as the bungalow would have ample garden for her to roam.

"No," grandmother said. "Rover does not go to the back garden by herself at night."
"She also went to my daughter's bedroom to sit and wait patiently."

"Why would she do it?" I asked.

"She waited till my daughter gave her a second piece of Pokey biscuit. My daughter said to her 'You are permitted only one Pokey biscuit. Go away. Mommy will scold me,'" the daughter told Rover off.

"But Rover would not go away. My daughter gave her a second Pokey biscuit stick and after eating it, Rover left."

Was the dog saying good-bye to the family members and the house? It is hard to explain such unusual canine-human interaction. As if there was a farewell communication between old companions.  Some animals might know that their life would be ending soon and wanted to say good-bye.

The grandmother stoically said to me: "My grandson keeps asking when Jesus will bring Rover back." The 5-year-old was too young to understand that death was permanent.

Would spaying her when she was younger prevent pyometra and prolong her life? Without the womb, she would not have pyometra and therefore would live to a ripe old age of another year or two? It is hard to say. Anaesthesia in dogs older than 8 years are high risk.

No vet can be assured of 100% survival in such cases. Sometimes it is best to pass such high risk cases to other vets. The daughter still grieved her loss daily for the past 5 days. "I guess she would be angry with me," I said to the grandmother. No comment from her.

The grandmother was stoic. Her friend had just got a stroke. She was widowed some 2 years ago and had now fortified herself.

"This dog was adopted as a puppy when there was a newspaper advertisement in the Straits Times looking for homes for the puppies to be given free," grandmother recalled. "I saw the advertisement when the newspapers were delivered at 5 am. Usually papers come at 7 am. So I went with my two sons and the owner gave us Rover. Rover used to bring the newspapers into the house every morning."

The grandmother had lots of work to do with so many dogs and children. "At one time, I looked after 8 dogs. Friends asked me to care for them for a while. They just did not come back for the dogs. I have 3 children to cook for and look after."

What an active energetic life, grandmother must have had. Though she was now 65 years of age, she looked much younger and trimmer than a 50-year-old. Usually grandmothers look matronly but she was a model for the slimming saloons.

"I cured one terrapin with enlarged closed eyes just by researching the internet," the grandmother said to me. That was great news. Most Singapore women of her age would not touch the computer.

"I can remember important dates and do calculations fast," the grandmother reminisced. "I would tell my children the price per kg for things they bought. But lately, I am not able to calculate so well."

It was good that she came during lunch time as we had some time to talk about the dog. "I can't stay long to chat," grandmother suddenly saw that time had passed so fast. "I have to go to Hong Kong,"

"Why do you have to rush to Hong Kong?" I appreciated the grandmother taking the trouble to pay the bills without being asked to do so.

"To look after my grandson for a week while my son and his wife had to go on holidays" she said. "There are two maids looking after him too."

All grandsons must surely love her very much but the one who loved her the most was the 5-year-old boy who stayed with her in Singapore. This 5-year-old boy came with the grandmother during the consultation and later around midnight to see the dog. A fair-looking boy with big eyes. He asked his grandmother for the past days with questions the grandmother told me, such as:

"Why Jesus take away Rover?"
"Why Rover has not come home?"
"Only one (pre-school) classmate knows when I said that Rover had gone to see Jesus."

The grandson had come with the grandmother during consultation as his pre-school had closed due to the presence of hand-foot-and-mouth disease prevalent in Singapore at this time.

It is extremely high risk to operate on toxemic pyometra and old dogs. If the owner had returned to get the dog spayed one or two months after the breast tumour removal in 2005, this dog might still be alive. She might have died during the spay surgery too but the probability of her dying on the operating table when she was 10 years old would be much lower.

Singapore owners generally have not reached a high level of awareness stage that the dog must be spayed after removal of the breast tumour. They just forget about the spay once the tumour is removed. It is not prudent to remove the breast tumour and spay at the same time in old dogs as the prolonged anaesthetic time increases the risk of death on the operating table and so I do not perform dual surgeries at the same time as some vets would do so. The risks of deaths are simply too great for the older dog. 

My present procedure would be to spay the dog first. If the owner did not return to get the breast tumour removed 2-4 weeks later, the female hormones feeding and growing the tumour would be removed as the ovaries would be taken out during the spay. Ideally, spay and mammary tumour removal should be done at the same time. But the surgery would take a long time and at the end of the long surgery, the dog might die on the operating table.

No family member can forgive or forget a death on the operating table. So it is best not to take foolish risks.
 


CASE 2 IN 2011. PYOMETRA IN A 6-YEAR-OLD GOLDEN RETRIEVER
July 7, 2011

I have been searching the internet (googled "pyometra in old dogs") for my past cases of pyometra in a Golden Retriever as I had one case recently. This Golden Retriever was passing pus in large amounts and was not eating. The dog was operated on it late at night as the floor was flooded with more vaginal discharge of pus.

I intended to wait and see after giving an antibiotic and anti-fever injection and drip in the morning to bring down the fever. The dog's temperature had dropped to below normal and she was lethargic again. Another IV drip was given and she was operated as an emergency. I had not phoned the owner prior to surgery on that night. I had informed the owners that the dog needed to be operated on within 7 days in the morning.

The next evening, I sent her home when the owners arrived to visit. She vomited on Day 3 and I asked the owner to bring the dog back for review and treatment just to be sure that there was no post-operation complications.

At the surgery, the dog was alert and normal. After one day of hospitalisation, she went home and there were no more complaints as at today (5th day after surgery).

The reason I write this case is to advise other vets of my experience in this case when I asked the owner to come back for review when he complained that the dog had vomited. It was a remark made by one angry lady in her 30s who said: "How would my old mother know what you show her? For all I know, it could be intestines! This implied that I had been dishonest to show some pig intestines which are easily available for sale at the wet markets.        
 
I had said that the dog was suffering from a womb full of pus and had performed an emergency spay. It was my fault for not phoning first before the surgery. I did not make any excuse. I had to bear the responsibility of what the family members would want to do as a consequence including financial compensation. 

The big sausage-like uterine horns were kept on a plate and covered up. When the  mother and her adult son came the following evening, they were shown the plate and asked if they wanted to see the womb covered up by paper. They declined. In retrospect, I should not have the plate covered up so that the mother and the adult son really saw the womb of their dog.

To improve Toa Payoh Vets' veterinary services, there are 5 tips for vets as regards the management and client communications in pyometra in dogs:

1. It was best not to release the dog home 24 hours after surgery as was my decision in this case. I thought the dog would be better cared for at home in this case. Poor judgments do occur. 

2. Also, every attempt must be made to phone the owner prior to any emergency surgery even though the owner had consented to the surgery to be done soon.

This is to prevent misunderstandings and anger from some family members who were not present at the first consultation. This Golden Retriever is OK but if she had died on the operating table, repercussions would be terrible for me as I should have waited till phone consent was given. An informed consent form should be signed in all cases of surgery and hospitalisation to protect the vet.

3. Phone the owners immediately after surgery. This may not be practical advice but it is best done as soon as possible.

4. Send written reminders or phone the owner and record this down in the case card, after breast tumour removal, to ask the owner to get the female dog spayed as well (to prevent pyometra or more tumour formation).

5. Show the infected womb without covering it up with papers, but know that some clients do not want to see the blood and the gore. 

P.S
For interested readers, the google search result for "pyometra in old dogs" was my blog at:
 http://veterinarymedicinesingapore.blogspot.com/2008/06/3-pyometra-in-old-female-dogs-to-spay.html

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