Veterinary Practitioner Vol. 14 No.

2 December 2013

DIAGNOSIS OF ENDOMETRITIS IN COWS USING METRICHECK, UTERINE

CYTOLOGY AND ULTRASONOGRAPHY AND EFFICACY OF DIFFERENT
TREATMENTS
Pramod Kumar, G. N. Purohit and J. S. Mehta
Department of Veterinary Gynaecology and Obstetrics, College of Veterinary and Animal Science
Rajasthan University of Veterinary and Animal Sciences, Bikaner, Raiasthan, India

ARSTRACT

The objective of this study was to evaluate the methods of diagnosis and therapy of endometritis in dairy cows. postpartum dairy
cows (n=65) were examined at day 25 and 40 post partum (CD group), whereas clinical cases (n=78) with a history of repeat
breeding presented to the clinical outdoor (CC group), and at two infertility camps (lC group) (n=62) were evaluated. All cows were
evaluated for the presence of endometritis by four or three tests in succession, namely vaginoscopy, metricheck, ultrasonography
and uterine cytology. The sensiiivity of uterine lavage for detection of endometritis in group CD cows was significanly highLr (p5
0.01) compared to all other tests and the differences between the specificity of different diagnostic tests for detection of endometritis
in group CD cows were non-significant (P>0.05). A proportion of cows with endometritis were treated with either a single infusion
(n=10) of cephapirin (Metricef, Intervet) (MCF group), daily infusion of ciprofloxacin and tinidazole (Cflox Tz, Intas) (CFT group) for 3
days (n=10), or two injections of a prostaglandin (Clostenol, ZydusAHL) (PG group) at 10 days interval. Cows were inseminated at
the oestrus following last treatment. Pregnancy rates were evaluated in the CD group of cows and in cows treated in the CC and lC
groups. This study showed that uterine lavage appears to be the most efficient method for the diagnosis of endometritis followed by
metricheck, ultrasonography and vaginoscopy and endometritis can be treated with either antibiotics or prostaglandin injections.

Key words. Endometritis, vaginoscopy, metricheck, ultrasonography, uterine cytology

lntroduction diagnostic criteria for postpartum endometritis ano

I Endometritis is defined as the condition of bovine females endometritis in repeat breeding cows and compare the efficacy
I characterized by muco-purulent discharge and sometimes with of different drugs for the treatment of endometritis in dairy cows.
remnants of foetal membranes. Endometritis is one of the
conditions of highest impact on industrial dairy farms (Cantemir, Materials and Methods
2006), with the reported incidences ranging from 10.17o to Experimental animals
32% (Bbrsberry and Dobson' 1989)' lt is considered that 'ine stuoywas conducted in
three groups of animars. In
retained placenta is the main risk factor (R = 0 90), (YeonKyung the first group 65 postpartum dairy cows of the college dairy
and lllHwa, 2005). Subclinical endometritis is d.c^^; ^^ ^^
innammation or the endometrium in ttre ansenJe
signs of endometritis (sheldon et al', 2006)' Dlagnosis. of :i:lGi !%"nT":3',["T,"::T'::t"?tff *"1lf3fr"ii;1il:?J l:
suclession (vaginoscopy, metricheck, urtrasonography ano
subclinical endometritis can be performed by eitherthe uterine
uterine lavage). In the second part of study clinical cases of
cytology or ultrasonography' samples for uterine.cytology are
cows (group cc) with a history of repeat breeding (n=7g)
obtainedbylavagetechnique(Barlundetal',zooe]--cj3lo9,ic1l presented to the referat
centre during the study period were
smears are evaluated for the proportion of polymorphonuclear
screened using the same four tests for endometritis. Repeat
cells (PMN) present in a sample' An increased proportion of oi""Jing cows presented at two infertility camps (group lc)
PMN is prognostic for impaired subsequent t:ll:^d::tll:(n=62) were evatuated for endometritis by vaginoscopy,
performance (Barlund et a! ,2008)' The threshold yalul
proportion of PMN to define subclinical endometritis {91tle
is
metricirecr< and urtrasonography in succession.

controversial and ranges from 4o/o to 18o/o (Barlund et a1.,2008; Diagnostic procedures
Gilbert ef a|.,2005: Kasimanickam et al., 2004, Raab, 2003). First the perineum and vulva were cleansed with paper
Dairy cows frequently evidence clinical and subclinical towel, and a lubricated vaginal speculum was inserted into the
endometritis as the most frequent cause of repeating to vagina far enough to enable visualization of the cervix. With the
f services (Purohit, 2008) but diagnostic criterion include aid of a light source, evidence of purulent or mucopurulent
I
I
are cervical discharge was recorded. Next, the metricheck
vaginoscopy and rectal palpation, the results of which
t suboptimal. Cows with subclinical endometritis have a (Simcrotech, Hamilton, New Zealand) device was advanced
decreased reproductive performance and an increased through the cleaned vulval lips to the anterior end of the vagina
incidence of repeat breeder syndrome (Salasel et al., 2010). and then the handle end was slightly elevated and the device
The objectives of this study were to determine and compare was retracted caudally. The material within the concave surface
#1Part of M.VSc. Thesis. Present address Veterinary
Officer, Incharge Veterinary Hospital Losin, Department of Animal Husbandry, District Udaipur,
+9 1 941 4541 407, ema il dhatenval. pramod@gma il.com

?41
;..

i,
v
&
 Veteinary Practitioner Vol. 14 No. 2
of the device was scored on a G.3 scale (0 no discharge,
= 1=
dear mucus, 2 = flecks of purulent material within otherwisl
cbar
mucus, 3 = mucopurulent but <50% purulent material) as
described previously (pletictra et at., 2009).
Next, the entire reproductive tract was examined usino
transrectal ultrasonography emproying a portabre urtrasound
(AGROSCAN tineal ECM 1.6 Bd de ta Republique, F16000
devid
Anguleme, France) with a dual frequenry ($7.5 MHz) linear anay
probe as per procedures described previously (Kumar
and purohit,
2009). lf intraluminal fluid was dectected during the initiai
ultrasound examination of the uterus then an attempt was made
to measure the luminal diameter in the area of greatest fluid
accumulation. lntrauterine fluid accumulation were categorized
as uterine size at the base of uterine hom diameter (<3, 35lnd >5
cm, respectively) (Kasimanickam ef al., 2OO4). Uterine horn
diameter >3 crn were regarded as endometritis. (Fig. l)
Lastly, cellular material was harvested for cytological
evaluation by uterine lavage as per previously describ"O
procedures by Kasimanickam et al. (2005a). The uterine
bodv of
cow to be examined was lavaged by infusing 60_mL of 0.'9%
sodium.chloride solution into the uterine bodywith a 6&mL syringe
attached to a disposable plastic sheath. The uterus was manually
massaged for 5'10 s and aspiration of fluid was done. As much
fluid as possible was recovered by negative pressure aspiration
into the syringe and transfened to a 2GmL polystyrene centrifuge
tube without preservatives. Uterine lavage samples were brought
to the laboratory immediately and centrifuged at 600X g. A drofof
sediment was streaked on to a clean microscopic slide and air
dried. All slides were fixed and stained with Gimesa stain.
Cytological assessment was performed by counting a minimum
of 100 cells at 400 and 1000X magnification of a microscope to
determine the percentage of neutrophils (% pMN). Cows with
>5% PMN in the samples were regarded as affected
by
endometritis as described previously (Drillich et at.,2OOS) (Fig. Zj.
Uterine lavage was considered the standard for comparing the
presence of endometritis by other methods.
Therapy \ and ultrasonography respectively fable 1).
Cows confirmed to evidence endometritis in thebC and lC
groups were randomally treated by a single inlra uterine infusion
of 19 gm cephapirin (group MCF; n=1 0) (Metricet Intervet Schering_
PloughAnimal Health mntaining 500 mg of cephapirin benzathine),
or3 days intra uterine therapywith ciprofloxacin 125 mg + tinidazole
150 mg (C-flox TZ, Intas pharmaceuticals Ltd.) (group CFZ; n=10)
during estrus or two injections of a prostaglandin (group pG;
n=10), ( Inj- Clostenol, Zydus AHL, 2 ml lM) administered at 10
days interval starting from day 10 of estrus.
Covvs in all the three groups were checked for the presence
of endometritis in the oestrus following last treatment and
inseminated with frozen semen. pregnancy diagnosis was
performed by transrectal palpation and transreclal ultrasonograpny
at 40 and 60 days of gestation, to evaluate the effect of endometritis
on pregnancy rates.
Statistical analysis
Data obtained were analyzed by Chi square test (x2 test) as
described previously (Snedecor and Cochran, .l ggZ). The sensitivitv
(Se) and specificity (Sp) of the diagnostic tests were calculated by
considering uterine lavage as the standard and using the below
mentioned formula:
December 2013
a
Sensitivity(Se)= -, xl00
a+d
L
Specificity(Sp)=-x100
c+l)
Diagnosis of Positive Negative
endometritis
Positive a (Correct +ve) b (lncorrect +ve
Neoatlve D (lncorrect -ve) c (Correct -ve)
Resultsand Discussion
ln College dairy cows (CD group) a total of 7.690/o, l'l.4ff/o,
1230% and 29.23o/o of the cows were detected suffering fom
endometritis by vaginoscopy, metricheck, ultrasonography and
uterine lavage atday 25 post partum while at day 40
fiost pirt rn
it was 6. 1 5%, 1 538%, 1 0.7 6% and 23.07 %, respeCivety
ftabte 1 ).
Significantly higher (P:0.05) proportions of cows were detecled to
have endometritis by uterine lavage compared to all other methods.
The proportion of cows found to have endometritis at dav 40
decreased compared to those at day 25 probably because of
spontaneous recovery.
The diagnostic performance of the tests for detection of
endometritis in post partum cows was evaluated by computing
their sensitivity and specificity. The sensitivity of uterine lavage for
detection of endometritis in group CD cows was signifiCanfly higher
(Pa0.01) compared to all other tests (Table 2j. However, the
differences between the specificity of different diagnostic tests for
detection of endometritis in group CD cows were non_significant
(P>0.05) Oable 2).
In CC group of mws uterine lavage could detect significanily
higher (P<0.05) proportion of cows with endometritis comoared
to all other diagnostic tests applied in parallel. The effcienry of
ultrasonography and vaginoscopy in detecting cows with
endometritis was lower compared to metricheck (lable 1). In group
lC metricheck could detect significanily higher (p<0.05)proportion
of cows suffering from endometritis compared to vaginoscopy
A few of the diagnostic approaches described recently
compared the usefulness of vaginoscopy, metricheck,
ultrasonography and uterine lavage for diagnosis of endometritis
in dairy cows (Mc Dougall et a1.,2007; Barlund et at.,2008; Orat et
a 1., 2009 ; Drillich ef a/., 2004). Vagi noscopy had the lowest
efi cienry
of detection. The results are similar to previous studies (Drillich ef
al., 2004; Mc Dougall et al., 2007: Barlund ef a/., 2008). Cases
missed to be diagnosed with vaginoscopy may be those cows
which had a lower degree of vaginal accumulation of uterine
secretions or cows with low grade infection without any fluicl/muos
accumulation in the vagina.
Metricheck device was detecting more proportion of cows to
be suffering from endometritis in group CD cows compared to
vaginoscopy and ultrasonography. In clinical cases also metricheck
evidenced similar diagnostic efficiency. In group lC cows since
uterine lavage was not performed metricheck evidenced the
highest efficiency. Thus, the device can !e largley suggested for
clinical use for diagnosis of endometritis rtn cotir with a history of
repeat breeding and in post partum cows. previous studies
2OO7 : pleticha et al., 2009:
(Barlund et al., 2008; Mc Dougall et al.,
Pleticha and Heuwieser, 2009; Runciman et a/., 2009) have
similarly recorded that by using metricheck significanily more

Veterinary Practitioner Vol. 14 No. 2
number of cows could be diagnosed as affected with endomeftritis
compared to those with a speculum. The secretions from the
uterus frequently accumulate in tre fornix of cranial vagina and are
easily retrieved in the cup of metricheck, but in cows with sub-
clinical endometritis with litUe fluid accumulation in the vagina
endometritis is less peciseV detected with metricheck compared
to uterine cytology.
Presumably, clear cut fluid accumulation were not existent in
cows with sub-clinical endometritis and such cases thus missed
diagnosis by ultrasonography solely on the basis of fluid
accumulation. Similar to the present study Barlund et al' (2008)
recorded the sensitivity and specificity of ultrasonographic
assessment of uterine fluid volume to be 30'8% and 92.8'/"
respectively. Drillich et al. (2004) recorded the sensitivity of
ultrasonograhy lo tr57 .7% in cows. Lenz et al. (2007) have stated
that cows wih uterine fluid accumulation of more than 0.2 cm had
a negative conelation with pregnancy.
Gytological samples were obtained by flushing the uterine
lumen (Barlund et at.,2008; Pleticha et a1.,2009) and such
estimates provide a more precise evaluation of uterine condition
and are useful adjunct to identify cows with subclinical endometritis
without any uterine discharge in the vagina. The incidence of sub-
dinical endometritis in cows range from 12 from to 94ol. (Gilbed et
at., 2OO5: Hammon et at., 2006; Kasimanickam et al., 20Q4:
Kasimanickam et al., 20Q5a). Although different threshold values
of PMN's have been used in different studies howeverthe threshold
used in the present study was set as 5% PMN's similar to that
used in some of the previous studies (Barlund'et a/', 2008; Gilbed
et at.,2OA5). The sensitivity and specificity of lavage cytology was
high which was similar to previous studies (Drillich et al.' 2004;
Dubuc etai., 2010; Kasimanickam et a1.,2005a; Oral et al''2009).
Thus, overall metricheck can be suggested for cows with
clinical endometritis while uterine cytology is recommended for
sub-clinical endometnis and especially repeat breeder cows with
no clinical signs.
The pregnancy rates in endometritis affected group CD dairy
cows were much lower compared to cows without endometdis in
the present study. Similar to the present study, large number of
orevious studies have recorded lowered pregnancy rates in cows
affected with endometritis (Gautam et al., 2010; Ghanem et ai.,
2002; Robert et al.,2OO5: Salasel et al.,2Q1O; Santos etal., 2009).
The altered uterine environment hampers the normal
establishment of pregnancy in cows.
Repeat breeding cows confirmed to have endometritis in the
group CC and group lC were randomly treated and there was
disappearance of signs of endometritis in 6, 8 and 9 cows in MCF
CFT and PG groups, respectively. In CD group of cows significantly
Table 1: Overall incidence of endometritis in dairy cows during post partum period and in clinical cases of
and infertility camPs
Animal Days post-
No. of
animals Vaginoscope
D NUM
5 12
z5 65 (7.69"/"\
College
dairy
40 65 (6.1 570)
Beyond day o IJ
Clinics 7A (7 690/.\
40
Infertility Beyond day a 9
ca mos 40 12.90"/.\
.Significant (P
s 0.05)
December 2013
higher (P<0.05) proportion of endometritis negative cows were
found pregnant at 100 days pospanum compared to cows affected
with endometritis (41.3% Vs 21.05%).ln cows treated for
endometritis higher proportion of cows were found pregnant in
CFT and PG groups compared to MCF group however the
difierences were non signi{icant (P>0.05) (Table 3). The foetal
fluids and the foetus proper were visible ultrasonographically at
40 and 60 days of pregnancy in the pregnant mws (Fig. 3).
The treatment of clinical endometritis has been the objective
of numerous studies in recent years (Le Blanc ef al., 2002a' b:
Sheldon and Noakes, 1998; Kasimanickam et aL, 2005b). The
effect of single dose of cephapirin in resolving endometritis in
dairy cows has been demonstrated previously (Ahmadi and
Dehghan 2007; Runciman et a1.,2009). Similar beneficial effects
of ciprofloxacin alone or in combination with tinidazole intra uterine
infusions have been shown in previous studies on dairy cows
(Purohit et at., 2003; Purohit and Sharma, 2007). Discrepancies
recorded between the various reports (Etherington et al., 1994;
Heuwieser et at.,2000; Dubuc et a/., 2011 ) on the efficacy of either
antibiotics or prostaglandins in resolving endometrtis in dairy cows
appear to be because of differences in the type of organisms
present, time since parturition and many other factors (Jackson'
1 92; Munay et al., 1990; Lincke et a/., 2007).
The administration of PGFr6 and its analogues have been
described as an adequate intervention (LeBlanc et al.,2O02a; Le
Blanc ef at., 2002b; Dhaliwal et al', 2001; Falkenberg and
Heuwieser,2005; Galvao et al.,2OQ9; Knutti etal.,2000; Tenhagen
and Heuwieser, 1999). Even though PGFrd is widely used as an
interyention strategy for endometritis, science-based evidence of
its effect on cows with endometritis but without corpus luteum is
yet to be demonstrated.
Similar to the present study many previous studies (LeBlanc
etal.,2002b; Lincke etal., 2007;Jackson 1977;Munay eial., 1990;
Pepper and Dobson,1987; Sheldon and Noakes, 1998) found no
dif{erence in the effect of either intrauterine antibiotics or
prostaglandins in resolving endometritis in dairy cows.
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repeat breeding presented to the outdoor
Methods of diagnosis
UltrasonograPhY
Uterine I
vatue
Metricheck lavaoe
a 19 d.Jc
1A.46"/"\ 12 300/-\ Q9.23'/"\
10 5.04
15_3aol.) 10.76"/"\ 122 670/^\
1a 9.36'
6.6670) (6.410/.' (23 070/-\
1
7.34-
(35.44./o'l 14.51'/.\
 December 2013
Veterinary Practitioner Vol' 14 No. 2

p"rform"d
Table 2: Diagno6tic Peformance of muttiple techniques 'n_rF!l"l O
^^^i{i^it\t
Sensitivitv
Method of diagnosis Dav 25 Dav 40 Dav 25
21 .42"/" 1OO"/"
\/aoinoscooe 26.31'/" 1 007"
trita*rinhank 61 I 1Y" 66.66%
42.85"/" 95.b5'/o 9833'
UltrasonographY 35.29"/"
A9.477o 93.33"/" 95.45"k
t*. 40*' o.oa/ N5 o.015 NS
--ft-rgn signiticant (P d" 0.0 i, NS= non signiticant (P>0

laDle u: Effect of treatment on endometritis affected cows

3: trfi
PregnancY 7o
No of animals Treatment tYPe and frequencY X2 value
Group treated After therapy
l.U. once 5Q "/"
MCF 10 0.436
l.U. for 3 daYs during estrus 70"/.
crz 10
80%
NS
PG 10 2Iniection at 10 daYS interval
NS P>0.05

dairy cow showing intraluminal uterine fluid

Fig. 3: Ulttatonogram of a pregnant dairy cow at
ilXtt"""*St"t "f " p"-ttut. The foetal fluid and the foetus are visible
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