Elective Caesarean Operation in the Bitch Using Aglepristone Before the Pre-Partum Decline in Peripheral Progesterone Concentration

Proliferation and apoptosis studies of interplacental areas after aglepristone treatment for planned cesarean section in pregnant bitches

Background and Aim

Progesterone (P4) is the main hormone for pregnancy maintenance, occurring approximately 62-64 days after ovulation in bitches. Progesterone acts by binding to specific receptors. Aglepristone is a progesterone receptor (PR) antagonist with a higher affinity for PR binding. There are no published studies on cell proliferation and apoptosis in the canine uterus at the time of parturition. Therefore, this study aimed to determine the local effects of aglepristone on cell proliferation and apoptosis of interplacental uterine tissue during planned cesarean section (C-section) in bitches.

Materials and Methods

In this study, 13 client-owned French bulldogs were examined. Bitches were divided into treatment (n = 8) and control (n = 5) groups. Ovulation timing was predicted based on the serum P4 level on 62-64 days post-ovulation for parturition. Serum P4 levels were measured before (on 60-day post-ovulation) and on C-section day (on 61-day post-ovulation). Aglepristone (Alizine®), 15 mg/kg subcutaneously (SC), was administered on 60 days post-ovulation in the treatment group. A C-section was planned 20-24 h later, and interplacental uterine areas were collected from both groups during the C-section. Immunohistochemistry based on Ki-67 and TUNEL assay was used to evaluate cell proliferation and apoptosis in four different interplacental uterine tissue layers (epithelium, stroma, glandular epithelium, and myometrium). Data are reported as mean ± standard deviation. Kruskal-Wallis test was used for comparisons of more than two independent groups. P value of 0.05 was considered statistically significant.

Results

One bitch in the treatment group was excluded due to emergency C-section 8 h after aglepristone administration. Serum P4 levels (ng/mL) at 20-24 h before and at C-section were 6.09 ± 2.72 and 4.32 ± 2.2 in the treatment group (n = 7) and 5.45 ± 1.28 and 3.67 ± 1.89 in the control group (n = 5), respectively. Proliferation (PI) and apoptotic (AI) indices were <5% and >45%, respectively, in both the treatment (n = 5) and control (n = 3) groups. PI and AI were detected at interplacental areas.

Conclusion

There were no significant differences in serum P4 levels or PI and AI indices between the groups. The PI <5% and AI was higher than 45% in both groups. Aglepristone did not have a direct effect on the serum P4 levels in both groups. These results correlated with the natural physiology of parturition preparation. Aglepristone 15 mg/kg SC injected 20-24 h before parturition had no effect on the P4 level, nor were any harmful effects observed for a planned C-section in pregnant bitches.

Canine Cesarean Section: Emergency and Elective

Canine Cesarean Section (CS) is primarily performed to increase survival of newborns and less commonly to save the life or reproductive future of the dam. Conducting proper ovulation timing to accurately predict the due date will allow a planned, elective CS as an excellent alternative to a high-risk natural whelping, and possible dystocia, for certain breeds and situations. Techniques for ovulation timing, anesthesia, and surgery tips are provided.

Incidence and concomitant factors of cesarean sections in the bitch: A questionnaire study

Dystocia in the canine species is a common problem, and elective cesarean sections (C-sections) have become more frequent in breeds that are at risk. The aim of this study was to evaluate the incidence of C-section and contributing factors and to compare data on elective and emergency C-sections (e.g., regarding stillbirth). Using a questionnaire, a total of 423 bitches of 80 breeds and their 899 litters were included. The mean number of litters per bitch was 2.1 ± 1.1 litters. The overall rate of stillbirth was 6.7%. Of all litters, 194 were born via C-sections (21.6%), of which 35 were declared as elective and 159 as emergency due to dystocia. Significantly more C-sections were performed in either small litters (1-2 pups) or large litters (&gt;12 pups) (p &lt; 0.001). Bitches that have had prior C-sections had a 4-fold increase in the risk of successive C-sections (RR = 4.54 (95%CI 2.56–7.70; p &lt; 0.001). Furthermore, primiparous bitches of advanced age had a significantly higher incidence of emergency C-sections (p = 0.004). Stillbirth was significantly higher in emergency C-sections compared with that in elective C-sections (p = 0.003). Also, timing of intervention had a significant impact on stillbirth in emergency C-sections (p = 0.025). Within a breed-specific evaluation, significant differences were observed between breeds regarding incidence of C-section and stillbirth. Lesser-known breeds were represented in the population, and the results showed that the Norwich Terrier had the highest (51.6%) and the Gordon Setter had the lowest (4.8%) incidence of C-section (p &lt; 0.001). The inclusion and evaluation of lesser-known breeds regarding incidence of C-section is of importance as it shows that certain breeds without phenotypical traits such as brachycephaly may also have an increased incidence of emergency C-section and stillbirth. We further conclude that more importance may be given to the age at first parturition concerning the occurrence of dystocia and the decision making regarding possible elective C-sections.

Molecular studies on oestrogen α and progesterone receptors and histomorphometric analysis of canine uteri following aglepristone treatment

Aglepristone, a competitive progesterone antagonist, is successfully used in various progesterone-dependent conditions. This study investigated uterine histomorphometric analysis, and expressions of the oestrogen α receptor (ERα) and progesterone receptor (PR) in uteri of bitches following the single dose of aglepristone treatment. Twelve client-owned healthy diestrous bitches were used in the study. The single dose of aglepristone (Alizine^® , 10 mg/kg) was injected subcutaneously 5 days before ovariohysterectomy in the treatment group (n = 6); bitches without treatment served as a control group (n = 6). Uteri were collected for histomorphometric analysis, ERα and PR gene, and protein expressions studies. The mRNA expressions of ERα and PR were determined by RT-qPCR. Immunohistochemical analysis was used to evaluate the ERα and PR protein expressions using an H-score in five parts of the uterus. The results demonstrated glandular epithelium height significantly decreased (p < .05) and ERα mRNA increased (p < .01) in treated dogs. Of the treated bitches, lower expression levels of ERα were observed in the luminal epithelium, crypt and glandular epithelium, with higher expression in the endometrial stroma and myometrium (p < .05); however, PR expression decreased in the luminal epithelium, crypt and glandular epithelium (p < .01). In conclusion, reduction of the uterine glandular epithelium and ERα mRNA upregulation together with changes in ERα and PR expressions were observed in the treated bitches. However, changes in uterine ERα and PR expressions in the treated bitches depended on tissue layers. The treatment had no effect on serum oestradiol and progesterone levels.

Towards scheduled pre-parturient caesarean sections in bitches

Elective caesarean section (CS) is the safest means of delivering the litter in bitches in specific situations. Timeously performing elective pre-parturient CSs at a fixed time would be convenient and prevent emergency CSs and foetal demise. This review proposes a method of performing elective pre-parturient CSs which is safe for both the bitch and puppies. Brachycephaly, small litters and large litters, preceding litter delivered by CS and trial of labour after a preceding CS are identified as factors increasing the need for CS whereas emergency CS is identified as factor increasing foetal demise. The first day of cytological dioestrus more precisely predicts the day of onset of spontaneous parturition than the first day of the LH surge or the dates during oestrus on which progesterone (P4) first exceeds 6 nM or 16 nM. Foetal biparietal diameter at the time of onset of spontaneous parturition varies too much to accurately predict readiness for CS. During the last few days of gestation, P4 with cut-off concentrations at 15.8, 8.7 and 3.18 nM, but not plasma cortisol concentrations, hold promise as predictors of onset of parturition and when to perform pre-parturient CSs. A protocol associating medetomidine hydrochloride as premedicant with propofol as induction agent and sevoflurane as maintenance is safe for scheduled CS and yields good maternal and puppy survival rates at delivery, 2 hr and 7 days after CSs. Clinicians have to pay attention to the haematocrit of bitches at the time of cervical dilatation which is at the lower end of the normal reference ranges for non-pregnant dogs and to the decline in haematocrit during CS (as a proxy for blood loss) which is approximately 7% for both parturient (open cervix) and pre-parturient (closed cervix) CSs. Pre-parturient CSs can be scheduled and performed 57 days after onset of cytological dioestrus with puppy survival rates of 99%. Collectively, these studies provide a protocol to safely perform elective CSs in a large proportion of the obstetric population at a convenient time of the day but more research is required with larger numbers to establish whether this practice is routinely safe and safe in all breeds.

Maternal and neonatal wellbeing during elective C-section induced with a combination of propofol and dexmedetomidine: How effective is the placental barrier in dogs?

Anaesthetics administered during C-section (CS) can cross the placenta and the foetal blood-brain barrier contributing to distress up to neonatal mortality. Therefore, to prevent neonatal risks, sedatives and analgesics are not commonly administered to the bitch until all pups are delivered. This study aims to evaluate the effect of a new anaesthetic and analgesic protocol for elective CS in dogs, focused on both maternal and neonatal wellbeing. General anaesthesia was induced by a combination of propofol (PPF) and dexmedetomidine (DEX) and maintained with isoflurane. DEX was added to PPF in order to provide analgesia and to reduce PPF dose. Propofol and DEX concentrations in maternal blood, amniotic fluid, and placenta were correlated to maternal and neonatal parameters. Maternal pain score was assessed with Glasgow Composite Measure Pain Scale short-form. Nine healthy purebred dogs scheduled for elective CS delivered 54 pups. The 77.8% of pups were vigorous at birth and assigned to the highest Apgar score (AS). The lowest AS was recorded in pups from mothers receiving additional doses of PPF (p < 0.001). Apgar scores improved with the increase in time between induction and pups' extraction, starting from 30 min after induction (p < 0.01). This study could contribute to clarify the controversy about the optimal extraction's time of pups after induction i.e. the best time between PPF administration and birth. No bitch showed post-operative pain or required additional analgesic doses based on their pain score. Maternal blood PPF and DEX, as well as placental PPF concentrations, decreased over time (p < 0.01). Conversely, placental DEX was fair uniformly detected in littermate pups. Both PPF and DEX were not detectable in amniotic fluid. Placenta resulted an effective barrier against foetal DEX exposure, making this protocol safe, analgesic and advisable for elective CS in dogs.

Neonatal puppy survival after planned caesarean section in the bitch using aglepristone as a primer: A retrospective study on 74 cases

Since most of dystocia end up in caesarean sections (C-sections), the history of any problem during whelping is a good reason to plan in advance a further C-section. Our aim was to confirm that on a large sample and over an extended period of time, mortality in puppies <2 weeks of age was low, born after a planned C-section using aglepristone as a primer. Seventy-four C-sections on 59 different bitches were included. Bitches were monitored during oestrus to estimate the day of ovulation by progesterone assays; 60, 61 or 62 days after ovulation, foetal viability was checked by ultrasonography and progesterone plasma level was measured. None of the bitches was at term (progesterone plasma level >2 ng/ml). An injection of aglepristone was performed in late afternoon to block the effect of progesterone, mimicking its drop at the end of pregnancy. The C-section was conducted the following morning. Twenty-one breeds were represented most of which were bulldogs (26%, 21/74) and Great Danes (16%, 13/74). Four hundred and thirty-five puppies were born. A total of 43/435 puppies died within the first 2 weeks (9.89%). None of the puppies showed any external signs of prematurity. The average number of deaths per litter relative to the date after ovulation was similar (0.5 pups per litter at day 60, 0.7 at day 61, 0.4 at day 62). This study shows that planned C-section after an accurate determination of ovulation and using aglepristone as a primer is a safe procedure for bitches and their offspring. It may be offered to owners if a pregnant bitch is "at risk" of dystocia.

Effect of delivery management on first-week neonatal outcome: How to improve it in Great Danes

A different incidence of neonatal complications has been reported in several species according to the duration of the various labour stages and the type of delivery. Trauma associated with dystocia may result in the release of neonatal catecholamines and cortisol that negatively affect neonatal metabolism, thus survival. Aim of the present study was to assess how the first-week neonatal outcome is affected by a different management of parturition. Clinical records of 46 Great Dane litters from 8 different kennels were evaluated retrospectively. Data were grouped in 3 categories: vaginal delivery (VD), emergency C-section (ES), planned C-section (PS). The risk of stillbirth, early neonatal mortality and perinatal mortality was calculated at puppy and at litter level in each group. Data were statistically compared by the ANOVA and Chi-Square test (p < 0.05). Seventy-eight puppies were naturally delivered (VD), 120 experienced dystocia at birth that required emergency C-section (ES) and 105 came from planned C-section (PS). No statistical difference in neonatal bodyweight and litter size was observed among groups. In PS, both stillbirth and neonatal mortality resulted significantly lower than in VD and ES, resulting in the lowest observed perinatal mortality. The number of litters with stillbirth was significantly higher in ES than VD and PS. The number of litters with neonatal mortality resulted significantly lower in PS than VD and ES. The overall perinatal mortality in VD resulted statistically influenced from both stillbirth and neonatal mortality, while it resulted strongly affected by the high stillbirth in ES. No difference was observed for PS perinatal mortality. Present results, reporting a high incidence of dystocia as well as high perinatal and neonatal mortality, lead us to evaluate the opportunity to plan an elective C-section in Great Dane bitches, in order to minimize perinatal mortality.

Curtailing parturition observation and performing preparturient cesarean section in bitches

Properly planned elective cesarean section (CS) in bitches is considered safe and justified for some breeds. Therefore, planning a scheduled (fixed date and time) preparturient CS in bitches belonging to a subpopulation where a CS is unavoidable, seems justified. The first day of cytological diestrus (D0) was used to predict the date of parturition. The aims of this study were to (1) compare the mortality of puppies delivered by preparturient CS to those delivered by parturient CS, (2) determine the extent to which a preparturient CS (performed at 08:00 on D57, while the cervix is closed) would shorten gestation, (3) compare the level of progesterone at the time of preparturient CS to that at the time of parturient CS, (4) compare the change in hematocrit before and after CS for parturient- and preparturient CSs. Out of 99 gestations for which D0 was known and a preparturient CS planned, the CS was performed at the scheduled time in 61%, before the scheduled time because cervical dilatation had started in 32% and before the scheduled time in 7% because the bitches had started showing signs of impending parturition, although their cervices were still closed. This study showed high neonatal survival ratios and good Apgar scores after preparturient CS with 99% of puppies delivered by preparturient CS born alive and 98.8% surviving to 2 h. Performing preparturient CSs shortened gestation by four to 52 h. Progesterone level was significantly higher at the time of preparturient CSs than at the time of parturient CSs. Further studies are required to determine whether preparturient CSs on D57 are routinely safe in all breeds, does not affect long term survival of the puppies and to timeously identify bitches in which parturition starts prior to the date and time for the scheduled elective preparturient CS.

Is the biparietal diameter of fetuses in late gestation too variable to predict readiness for cesarean section in dogs?

Correct assessment of readiness for cesarean section is essential for timing elective cesarean section during late pregnancy in the bitch. In humans, biparietal diameter is sufficiently precise and accurate and used in a clinical setting daily. The objectives of this study were to determine whether fetal biparietal diameter in late gestation in the dog could be used to predict readiness for cesarean section by having reached a minimum cut-off value and to correlate the biparietal diameter to birth weight. The biparietal diameter of 208 puppies in 34 litters from 31 English bulldog bitches and 660 puppies in 78 litters from 70 Boerboel bitches were measured immediately after delivery by cesarean section, performed at full term, using digital calipers. At the same time the birth weight of the same 208 English bulldog puppies and 494 of the same Boerboel puppies in 59 litters from 54 bitches was measured by means of an electronic scale. With a cesarean section, all the puppies in a litter are delivered simultaneously and readiness for cesarean section must be determined for a litter. The minimum, median and maximum biparietal diameter varied from 21.1 to 47.8, 32.9 to 50.0 and 34.2-58.2 mm, respectively, among English bulldog litters and from 18.4 to 48.7, 35.5 to 49.7 and 39.8-54.3 mm among Boerboel litters. This large variation suggests that biparietal diameter is too variable within and among litters to be useful as a means of determining readiness for cesarean section.

The precision of predicting the time of onset of parturition in the bitch using the level of progesterone in plasma during the preparturient period

Precise prediction of the time of onset of parturition in the bitch is of clinical importance. Many parturition management cases in clinical practice are presented in the last two weeks of pregnancy without a reliable estimate of the parturition date. The aim of this study was to assess the value of a single progesterone level in the blood plasma from a preparturient bitch to predict the time of onset of parturition. The temporal relationship between the decrease in the plasma progesterone levels and the time of cervical dilatation (TCD)-which correlates to the onset of stage 1 of parturition-was evaluated in 25 bitches in the preparturient period. Among bitches destined to reach TCD within 12 h there is a 2% probability of having a plasma progesterone level of 15.8 nmoL/L or above and a 6% probability of having a level of 8.7 nmoL/L or above. Conversely, if the level is below 8.7 nmoL/L there is a 99% probability of reaching TCD within 48 h and if the level is below 3.18 nmoL/L there is a 100% probability of reaching TCD within 24 h. These results allow the veterinary obstetrician to make prompt decisions in the management of parturition.