Postpartum Hemorrhage: Physical Examination

By | 2012-10-25

Unremitting signs of colic in the postfoaling mare warrant a thorough examination by a veterinarian. The restlessness may be caused by uterine contractions, especially if oxytocin has been administered to promote passage of the fetal membranes. If the discomfort continues, however, the possibility of a dissecting hematoma in the broad ligament must be considered. If at any time the pressure causes the ligament to tear, blood can flow freely into the abdominal cavity.

Clinical signs associated with hemorrhage can vary greatly from mare to mare (Table Clinical Signs of Postpartum Hemorrhage). Most will exhibit colicky behavior to varying degrees, but some will be stoic. The unpredictable and dangerous behavior of many of these mares, along with the fact that most have a viable and newly ambulating foal, make it imperative that at least one, if not more, competent handlers be present. If manpower permits, a very small enclosure can be constructed of straw bales outside the stall door allowing safety of the foal and comfort to an anxious mare.

Table Clinical Signs of Postpartum Hemorrhage

Clinical Signs Comments
Mental status Agitated
Pain and associated signs Rolling or curling of upper lip
Frequent standing up and lying down
“Stomping” at abdomen with hindlegs
In author’s experience, less pawing and rolling than is seen with bowel problems such as large colon torsion
Mucous membranes Gums often severely blanched
Capillary refill undetectable
Skin Coldness
Clammy feel
Jugular distensibility Increased jugular fill time (may be difficult to place an IV catheter)
Pulse character May not even be detectable at facial artery
Heart rate Usually tachycardic in the range of 80-100+ bpm
Possibly normal
Rectal temperature Frequently <95° F
Respiration Usually increased and labored; a reflection of metabolic acidosis

IV, Intravenous; bpm, beats per minute.

It bears restating that treatment of a mare in hemorrhagic shock involves expedience and a concert of activities going on at once. Thus, diagnosis and treatment usually occur simultaneously. After the initial physical examination, if hemorrhage is presumed, vascular access needs to be established and preliminary fluids started. Handlers can usually take care of the latter while the veterinarian continues with further diagnostics, such as ultrasound. In this day of evaluation of ovarian follicular growth and 14-day pregnancies, many practitioners are privileged to have at their disposal ultrasound machines with a 5.0-MHz linear rectal probe. Although a 3.0-MHz probe is preferable, the 5.0 rectal probe can be used to evaluate a mare’s abdomen for signs of hemoperitoneum. Blood will appear hypoechoic and swirling of the cellular elements may be seen. Palpation per rectum and an internal ultrasound exam are discouraged because manipulation in this area can cause further problems. Application of a twitch to these mares can cause even more agitation, not to mention that placing an arm in a distressed mare is even more dangerous than bending down to scan an abdomen. If no fluid is seen with the transabdominal examination, it can be assumed that the hemorrhage is contained within the broad ligament or uterine wall. Symptotic treatment for these mares should continue. If fluid is seen, abdominocentesis is highly recommended to differentiate between other possible diagnoses including colon rupture, uterine tear or rupture, or mesenteric tear with hemorrhage and possible spillage of gut contents.