Clinical evaluation of the use of aglepristone, with or without ...

1552F. Fieni / Theriogenology 66 (2006) 1550–15562.3. Statistical evaluationQualitative results, such as the success of thetreatment, were reported with a confidence interval of95%. Quantitative results were reported as means S.D. Data were analyzed by Statview (SAS InstituteInc., Cary, NC, USA). Treatment efficacy and theclinical response of metritis/pyometra were comparedusing a Chi-square test. A Student-Fisher test was usedto compare the mean decrease in the diameter of theuterine lumen, the mean leucocyte count and the meanperipheral plasma progesterone concentration betweentreatments at various times during the experiment.Values were considered statistically significant whenP < 0.05.3. ResultsWhen measuring efficacy at day 90, 54/67 bitcheswere cured (i.e. 80.6%, with a confidence interval rangeof 71.1–90.1%). The overall recovery rate was lower(P < 0.001) at day 14 (24/68, 35.3%) than at day 28 (46/67, 68.6%) and day 90 (54/67, 80.6%). The effectivenessof the treatment was not dependent on the clinicalform of uterine disease (Table 1).In bitches with metritis, treatment with aglepristonealone gave a high cure rate, with clinical resolution inover half of the bitches (9/15) within 2 weeks and within4 weeks for the remainder with, one exception. Thebitch cured at day 90 had only a slight serous dischargeon day 28. This was visible by the clinician during thegenital exam but not by the owner.Clinically, the administration of aglepristone incases of pyometra led to changes in the nature of thevaginal discharge, which changed from purulent, tomucous-like, before finally becoming serous, with aconcurrent decrease in volume. The last clinical signrecorded was self-cleaning of the vulval area by thebitch. For all bitches with closed pyometra, cervicalopening was induced following the first two aglepristonetreatments (18/18). The mean time to cervicalopening was 25.8 12.2 h. The shortest time was 4 hafter the first administration of aglepristone; however,Table 1Number of bitches cured, at various stages in the trial, based on theform of uterine diseaseDay 14 Day 28 Day 90Metritis (%) 9/15 (60.0) 14/15 (93.3) 15/15 (100)Open pyometra (%) 13/35 (37.1) 20/35 (57.1) 26/35 (74.3)Closed pyometra (%) 2/18 (11.1) 12/17 (70.6) 13/17 (76.5)cervical opening was complete within 48 h in all of thebitches. Cervical opening induced enabled the evacuationof large volumes of purulent discharge, which wasassociated with an immediate improvement in generalcondition and, in most cases, with increased appetite.For bitches with open or closed pyometra, additionaltreatment with cloprostenol from days 3 to 7 improvedthe overall success rate at day 90 (P < 0.05); 27/32(84.4%) with cloprostenol versus 12/20 (60.0%) withoutcloprostenol (Table 2). Recovery was accompanied by agradual decrease in the diameter of the uterine lumen,which became non-detectable ultrasonographically. Themean decrease in the diameter of the uterine lumen overtime depended on the treatment used (Fig. 1) and wassignificantly greater between days 8 and 14 in bitchesreceiving the combined aglepristone–cloprostenol treatmentthan in those treated with aglepristone alone(84.8 20.7% versus 64.6 41.0%).The general condition of bitches suffering frommetritis was not altered; it remained good throughout thetrial. Bitches suffering from open or closed pyometrapresented were depressed and anorexic in 41/53 (77.3%)and 34/53 (64.1%) cases, respectively. In all animalstreated, there was a marked improvement in this criterionby the second day of treatment. On day 8, moderatelethargy was observed in 9 bitches (17.3%) and 14bitches (26.9%) showed loss of appetite. On day 15, allbitches still receiving treatment were in good generalcondition, with only one showing any loss of appetite. Noside effects were observed after treatment with cloprostenolin 15/33 bitches (45.5%). In the remainder, nauseawas the most commonly observed side effect (12/33), andvomiting occurred in six bitches.None of the bitches had a noticeable change in redblood cell count. The mean white blood cell counts inbitches suffering from metritis were normal and,remained lower (P < 0.05) than the counts in bitcheswith open or closed pyometra (Fig. 2) throughout thetrial. In bitches recovering from pyometra, a markeddecrease in leucocytosis was observed over the courseof treatment. This mean decrease was significant on dayTable 2Number of bitches with open or closed pyometra (Group 1 + Group 2)cured by the administration of aglepristone alone compared to thecombined administration of aglepristone + cloprostenolTreatment Day 14 Day 28 Day 90Aglepristone (%) 3/20 (15.0) 9/20 (45.3) 12/20 (60.0)Aglepristone +cloprostenol (%)12/33 (36.4) 23/32 (71.9) 27/32 (84.4)Difference in cure rate between the two treatments on day 90(P < 0.05).

F. Fieni / Theriogenology 66 (2006) 1550–1556 1553Fig. 1. Mean (S.E.M.) rates of decreases in the diameter of the uterine lumen at various stages in the trial, in bitches with open or closed pyometra(Group 1 + Group 2) cured by the administration of aglepristone alone (n = 12), in comparison with those receiving a combination ofaglepristone + cloprostenol (n = 27). (*) Differences (P < 0.05).Fig. 2. Mean (S.E.M.) concentration of leucocytes at various stages in the trial, in bitches with metritis (n = 15), open pyometra (n = 26) or closedpyometra (n = 13) cured by treatment with aglepristone or aglepristone + cloprostenol. For each day, the mean white blood cell count wassignificantly lower in cases of metritis than in cases of open or closed pyometra. In bitches with closed pyometra, the white blood cell count waslower at day 14 (P < 0.01) and at day 28 (P < 0.001) than at day 0.

1554F. Fieni / Theriogenology 66 (2006) 1550–1556Table 3Means (S.D.) plasma progesterone concentrations (nmol/L) in bitches with open or closed pyometra (Group 1 + Group 2) treated with aglepristonealone, compared to those treated with a combination of aglepristone + cloprostenolTreatment Day 1 Day 8 Day 14 Day 28Aglepristone (n = 20) 12.8 14.4 a 5.6 6.6 bx 4.8 5.1 b 3.3 4.2 bAglepristone + cloprostenol (n = 32) 19.3 11.6 a 15.08 10.5 ay 4.7 1.1 b 3.96 2.8 bWithin a row, values with different superscript letters (a and b) differ (P < 0.05); within a column, values with different superscript letters (x and y)differ (P < 0.05).15 for bitches with closed pyometra (Fig. 2). Among the67 treated bitches, on day 1, 15 had plasma progesteroneconcentrations below 3.18 nmol/L. Treatment wassuccessful in all of them, except for two bitches withopen pyometra. For bitches with open or closedpyometra treated with cloprostenol (n = 32), therewas a significant decrease in mean peripheral plasmaprogesterone concentration at day 8 (12.8 14.4 nmol/L versus 5.6 6.6 nmol/L on days 1 versus 8,respectively). However, in bitches treated withoutcloprostenol (n = 20), no significant decrease in meanplasma progesterone concentration was observed untilday 14 (19.3 11.6 nmol/L versus 4.7 1.1 nmol/Lon days 1 versus 14; Table 3).Among the 13 failures using this treatment, onebitch did not present for follow-up and recovery couldnot be confirmed. One bitch with open pyometratreated with aglepristone died on day 5 in the owner’shouse, and another treated with aglepristone andcloprostenol was euthanized in a private clinic on day15 due to declining health. Ten bitches underwent anovariohysterectomy. In this last group, six had ovariancysts. After recovery, 23 bitches underwent follow-upvisits over the 24 months following the beginning oftreatment. Three of them developed pyometra between7 and 12 months later (3/23, 13.0%) and anotherdeveloped it at 19 months (4/21, 19.0%). Two of themreceived an additional, successful course of treatment(aglepristone + cloprostenol) and no pyometra wasobserved at the next cycle. We have kept in contactwith the owners of three of the bitches used in the trialfor some considerable time. They were treated morethan 6 years ago and have come into estrus normally,with no recurrence of uterine disease. Five bitcheswere mated at the first estrus after recovery; fourbecame pregnant.4. DiscussionThe use of aglepristone alone cured 27/35 (77.1%)bitches in 90 days. These results are equivalent tothosereportedbyHoffmannetal.[11] (25/31, 80.6%at day 30) and by Trasch et al. [12] (44/52, 84.6% atday 90). The number of animals treated is insufficientto show any difference in efficacy depending onclinical type (metritis, open pyometra and closedpyometra). This study, however, demonstrated thesatisfactory results obtained fromtheuseofaglepristonein bitches suffering from metritis (recovery rate,15/15). The use of aglepristone is also of particularinterest in the treatment of closed pyometra, since itinduces cervical opening, and the subsequent evacuationof purulent discharge with a marked improvementin the animal’s general condition. These resultsdemonstrated that surgery is no longer the onlytreatment for closed pyometra. Moreover, even ifsurgery has been planned, it is possible to recommendmedication as a first-line treatment (aglepristone andrehydration) to improve the general health of the bitchand minimize surgical risk. In this study, the cervix ofall the bitches with closed pyometra opened within48 h. In a study of nine bitches with closed pyometra,Wehrend et al. [14] observed cervical opening within72 h and the same marked improvement in theanimal’s general condition.In bitches with open or closed pyometra, the repeatedadministration of low dose cloprostenol significantlyincreased the success rate at day 90 (27/32, 84.4%). Theuterotonic action of cloprostenol lead to a significantlyfaster decrease in the diameter of the uterine lumen andits luteolytic action caused a faster drop in mean plasmaprogesterone concentration. This decline in progesteronewas commonly observed in bitches treated forpyometra with cloprostenol alone [15], or withcloprostenol associated with aglepristone [13]. In thepresent study, a decrease in progesterone concentrationswas also observed in bitches treated with aglepristoneonly, but at a later stage. Because of the antiprogesteroneproperties of aglepristone, this luteolysisdoes not seem to modify short-term effectiveness.Between 30 and 90 days, we did not note any correlationbetween blood progesterone concentration and successrate. The low dose of cloprostenol given (1 mg/kg) doesnot usually cause any adverse reactions [16–18].Contrary to the results of a similar study [13], 56%of bitches treated had side effects, usually vomiting.

F. Fieni / Theriogenology 66 (2006) 1550–1556 1555This particular sensitivity to low doses of cloprostenolcan be explained by the poor general condition of thebitches. Nevertheless, the owners did not make anycomments.Among the treated bitches, 17 had basal progesteroneconcentrations. Cases of pyometra were observed atall stages of the reproductive cycle in a previous study[1]. The effects of aglepristone in pyometra have beenstudied in diestrus bitches selected with a progesteroneconcentration of more than 3.2 mm/L [1,10,11]. In thepresent study 15/17 bitches with a low progesteroneconcentration were cured after the administration ofaglepristone. Similar results were observed in anotherreport [13]. This seems to confirm that, in thepathogenesis of pyometra in bitches, the action ofprogesterone on the uterus is dependent on the numberof progesterone receptors or their specific sensitivity,and not on the plasma progesterone concentration ofthis hormone.The recurrence rate of pyometra after treatmentdiffered from results reported in other studies. We didnot observe any recurrence between days 30 and 90,and the cure rate was higher, whereas Trasch et al.[12] reported a recurrence rate of 9.8% (4/41) for thesame interval; this may be due to the length oftreatment and the repeated administration of aglepristoneuntil day 28 if needed (whereas Trasch onlyadministered aglepristone on days 1, 2 and 7). Therecurrence rate from 12 to 14 months after treatmentwas 18.9% (4/37) for Trasch et al. [12], 9% (1/11) forHoffmann et al. [11] and 21.4% (3/14) for Gobelloet al. [13]. The mean age of the bitches (8 years) mayexplain the recurrence of pyometra in the 24 monthsfollowing the end of treatment, since age is a majorepidemiological factor in the onset of pyometra inbitches. However, treatment failure or recurrence ofthe disease is closely linked to the presence of ovariancysts, which maintain a permanent endocrine imbalance.Ovariancystswereobservedin6of10bitcheswho underwent ovariohysterectomy due to the failureof medical treatment.Conservative treatment with prostaglandins, which isrecommended for bitches with metritis or pyometrawith mild dilatation of the uterine lumen, produces acure rate of 83–100%, with recurrence rates varyingfrom 10 to 40%. The treatment, which requires severaladministrations, produces discomfort and is oftenassociated with side effects such as hypersalivation,vomiting and diarrhea [3,4].In conclusion, treatment with aglepristone alone wasa safe and effective treatment for metritis, and aneffective means of inducing cervical opening in cases ofclosed pyometra. The combination of aglepristone andcloprostenol was more effective in the medicaltreatment of open and closed pyometra than aglepristonealone. Nevertheless, in all cases, we onlyrecommend such treatment in bitches with no liver orkidney dysfunction, and advise close clinical monitoringthroughout the entire course of treatment.References[1] Blendiger K, Bostedt H, Hoffmann B. Hormonal effects of theuse of an antiprogestin in the bitches with pyometra. J ReprodFertil 1997;(Suppl. 51):317–25.[2] Noakes DE, Dhaliwal GK, England GC. Cystic endometrialhyperplasic/pyometra in dogs: a review of the causes andpathogenesis. J Reprod Fertil 2001;(Suppl. 57):395–406.[3] Gilbert RO, Nöthling JO, Oettlé EE. A retrospective study of 40cases of canine pyometra–metritis treated with prostaglandinF2a and broad-spectrum antibacterial drugs. J Reprod Fertil1989;(Suppl. 39):225–9.[4] Meyers Wallen VN, Goldschmidt MH, Flickinger GL. ProstaglandinF2a treatment of canine pyometra. J Am Vet Med Assoc1986;189:1557–61.[5] Johnston SD, Root-Kustritz MV, Olson PNS. Disorders of thecanine uterus and uterine tubes. In: Canine and feline theriogenology.Philadelphia: WB Saunders Ed.; 2001. p. 206–24.[6] Fiéni F, Tainturier D, Bruyas JF, Badinand F, Berthelot X, RonsinP, et al. Étude clinique d’une antihormone pour provoquerl’avortement chez la chienne: l’aglépristone. Rec Med Vet1996;172:359–67.[7] Galac S, Kooistra HS, Butinar J, Bevers MM, Dieleman SJ,Voorhout G, et al. Termination of mid-gestation pregnancy inbitches with aglepristone, a progesterone receptor antagonist.Theriogenology 2000;53:941–50.[8] Fieni F, Martal J, Marnet PG, Siliart B, Bernard F, Riou M, et al.Hormonal variation after early or mid-pregnancy termination inbitches with aglepristone (RU534). J Reprod Fertil 2001;(Suppl.57):243–8.[9] Fieni F, Marnet PG, Martal J, Siliart B, Touzeau N, Bruyas JF,et al. Comparison of two protocols to induce parturition inbitches with a progesterone antagonist: aglepristone (RU534).J Reprod Fertil 2001;(Suppl. 57):237–42.[10] Breitkopf M, Hoffmann B, Bostedt H. Treatment of pyometra(cystic endometrial hyperplasia) in bitches with an antiprogestin.J Reprod Fertil 1997;(Suppl. 51):327–31.[11] Hoffmann B, Lemmer W, Fieni F, Linde-Forsberg C, VerstegenJ. Effects of treatments with Aglepristone on the pyometra in thebitch: observations of a multicenter preclinical study. In: Proceedingof the Fifth Annual Conference of the European Societyof Domestic Animal Reproduction; 2001.[12] Trasch K, Wehrend A, Bostedt H. Follow-up examination ofbitches after conservative treatment of pyometra with the antigestagenaglepristone. J Vet Med Assoc 2003;50:375–9.[13] Gobello C, Castex G, Klima L, Rodriguez R, Corrada Y. A studyof two protocols combining aglepristone and cloprostenol totreat open cervix pyometra in the bitch. Theriogenology 2003;60:901–8.[14] Wehrend A, Trasch K, Bostedt H. Treatment of the closed type ofpyometra by the antigestagen, aglepristone, in bitch. Kleintierpraxis2003;48:679–83.

1556F. Fieni / Theriogenology 66 (2006) 1550–1556[15] Tainturier D, Treboz C. Traitement de la métrite chronique de lachienne par le cloprosténol, un analogue de la PgF2a. PMCAC1985;20:239–44.[16] Fieni F, Fuhrer M, Tainturier D, Bruyas JF, Dridi S, Siliart B,et al. Utilisation d’un analogue de synthèse des prostaglandines:le cloprosténol dans l’avortement provoqué de la chienne.PMCAC 1989;24:557–72.[17] Fieni F, Fuhrer M, Tainturier D, Bruyas JF, Dridi S. Use of PGF2a analog, cloprostenol, for pregnancy termination in dogs. JReprod Fertil 1989;(Suppl. 39):332–3.[18] Onclin K, Verstegen JP. Comparisons of different combinationsof analogues of PGF2 alpha and dopamine agonistsfor the termination of pregnancy in dogs. Vet Rec 1999;144:416–9.

J. Vet. Med. A 50, 375–379 (2003)Ó 2003 Blackwell Verlag, BerlinISSN 0931–184XClinic for Obstetrics, Gynaecology and Andrology of Large and Small Animals, Justus-Liebig University, Gießen, GermanyFollow-up Examinations of Bitches after Conservative Treatment of Pyometrawith the Antigestagen AglepristoneK. Trasch 1 , A. Wehrend and H. BostedtAddress of authors:Clinic for Obstetrics, Gynaecology and Andrology of Large and Small Animals, Justus-Liebig University,Germany, Frankfurter Str. 106, 35392 Gießen, Germany; 1 Corresponding author:E-mail:katjatrasch@yahoo.deWith 2 figures and 2 tables Received for publication:February 13, 2003SummaryThe aim of this study was to determine the therapeutic successof the medical treatment of canine pyometra with the antigestagenaglepristone and to document the recurrence rate inrelation to the time interval after treatment with antigestagens.In 48 (92.8%) of the 52 treated bitches, healing could beachieved within the first 3 weeks after the treatment had beenstarted. One bitch died as a result of renal insufficiency; inthree bitches there was no emptying of the uterus, so ovariohysterectomybecame necessary. In these three patients, ovarianand endometrial cysts were present. Forty-one bitchescould be followed up for 3 months. Four animals developed arecurrence (9.8%). In three bitches ovarian cysts and cysticendometrial hyperlasia could be found intra operationem. Thedevelopment of 37 bitches could be followed for at least 1 year.Seven animals developed a pyometra again (18.9%). Tworeceived a repeated treatment with aglepristone and have beenfree from recurrence for over 12 months. In 37 animals data onthe subsequent sex cycles are available. In 22 bitches next heatstarted at the expected time, in seven animals heat started tooearly. In eight bitches the period of anoestrus was prolonged.Five of the six bred bitches delivered at least one litter.Thepresented data show that treatment of pyometra by aglepristoneresults in a high healing rate. The recurrence rate can beminimized by the selection of bitches without ovarian cysts andcystic endometrial hyperplasia.IntroductionPyometra has so far mostly been treated by ovariohysterectomy.The advantage of this treatment is the exclusion of the riskof recurrence. However, surgical treatment has its limits wherethe risk of surgery is increased or in case where the ownerrefuses ovariohysterectomy. For this reason, different strategiesof conservative treatment have been developed. Theadvantages of a non-surgical intervention are that the ability tobreed can be maintained and that the risks of anaesthesia andsurgery are excluded.Different procedures of conservative pyometra treatmenthave been described. One of those is the single systemic andlocal use of antibiotics (Querol, 1981; Threlfall, 1995).A significant number of cases treated as above and transferredafterwards, show, however, that this treatment frequently didnot result in a healing but a protraction of the disease.Another medical treatment is the parenteral application ofprostaglandin F 2a . Even single cases of shock and death havebeen reported (Berchtold, 1997). In order to minimize theserisks, low concentrations are administered with a high applicationfrequency (Hubler et al., 1991; Nolte et al., 1993). Thisregime clearly restricts the practicability of the proposedtreatment protocols in practice, particularly in outpatients.Fieni et al. (2001a) treated bitches with the closed and openform of pyometra with a combination of aglepristone andcloprostenol successfully, but 68% of the bitches showed sideeffectslike vomiting.The effects of oestrogen administration such as cervixrelaxation and opening, as well as the increase of uteruscontractility justify theoretically the use of this hormone in thetreatment of pyometra. However, its mediocre therapeuticsuccess and a high potential of undesired side-effects make itsuse rather questionable (Watson, 1942; Legendre, 1976; Kraftand Kuffer, 1995).The use of oxytocin and secale alkaloids was also discussed(Hardy and Osborne, 1974; Funkquist et al., 1983). Thetherapeutic effect has not been proven to date. All forms ofmedical treatment presented so far show clear limitations intheir usage and go along with undesired effects. Regarding therecurrence rates of the different therapeutic regimens, there areeither no data available, or, with regard to prostaglandintreatment, the published data in literature vary strongly(Johnston et al., 2001).With the introduction of antigestagen-based drugs inveterinary medicine new therapeutic agents for the treatmentof progesterone-dependent disorders have become available.After the demonstration of the antigestagenic effect of thisgroup of substances in the bitch (Hoffmann and Gerres, 1989),the field of indication of this pharmaceutical agent in gynaecologyand obstetrics of small animals has been constantlyenlarged. The successful use of this medication could be shownnot only in the treatment of canine and feline pyometra(Blendinger et al., 1997; Breitkopf et al., 1997; Hecker et al.,2000; Hoffmann et al., 2000; Fieni et al., 2001a), but also inthe prevention of nidation (Hubler and Arnold, 2000), in theinduction of abortion (Blendinger et al., 1994), in the treatmentof fibroadenomatosis (Wehrend et al., 2001) and in theinduction of labour (Riesenbeck et al., 1999; Fieni et al.,2001b).In order to assess the use of antigestagens in the treatment ofpyometra compared with other therapeutic procedures, it isnecessary to know the healing and recurrence rate after the useof antigestagens. So far, the only information available isbased only on a few number of animals and does not allow adifferentiated examination of the recurrence rate in differenttime intervals following successful treatment for more thanU.S. Copyright Clearance Center Code Statement: 0931–184X/2003/5007–0375 $15.00/0www.blackwell.de/synergy

376 K. Trasch et al.1 year (Hoffmann et al., 2000; Fieni et al., 2001a). Thepurpose of this study is to show the success of the treatmentof pyometra with antigestagens as well as the recurrence rate inrelation to the time interval after treatment.Materials and MethodsThe data of 52 bitches of different breeds who suffered frompyometra and were treated with aglepristone were evaluated.All bitches underwent a general and gynaecological examinationincluding ultrasonography (5 MHz convex probe, KretzSA 9900 Ò ; Kretz, Zipf, Austria) and differential bloodcount (CELL - DYN 3500 Ò ; Abbott Diagnostika GmbH,Wiesbaden-Delkenheim, Germany). To determine ureaand creatinine concentrations a photometric procedure(Reflotron Ò ; Boehringer, Mannheim, Germany) was used.The inclusion criteria for this study were:1 Filled uterus detectable by ultrasonography (Fig. 1)2 Putrid vaginal discharge at the day of presentation (openpyometra) or onset of putrid vaginal discharge within thefirst 24 h after first application (closed pyometra)Poor general condition, as well as increased renal parameters(normal values:urea >8.3 mmol/l, creatinine >106 lmol/l;Kraft and Du¨ rr, 1999) did not count as exclusion criterion.Only bitches with an uterus rupture were excluded fromconservative treatment.The antigestagenic agent aglepristone was licensed in Francein 1996 in form of the veterinary drug Alicine Ò (Virbac,Carros, France) for the prevention of nidation and abortioninduction in the dog. The treatment protocol for subcutaneousapplication of 10 mg/kg body weight on day 1, two and sevenwas applied (Hoffmann et al., 2000). All animals receivedantibiotic treatment for at least 7 days. Amoxicillin combinedwith clavulanic acid (Synulox Ò ; Pfizer, Karlsruhe, Germany)or enrofloxacin (Baytril Ò ; Bayer, Lever-kusen, Germany) indosages according to the manufacturer’s instructions wereused.The bitches underwent outpatient treatments, except forthree bitches. The reasons for inpatient treatment were thattwo of these had increased renal parameters and requiredinfusion therapy, and the other one was in an extremely badcondition.The examination plan was furthermore applied on day 2and 7 following the first presentation. Another consultationtook place between day 14 and 21 after the first treatment. Theshort-term success of the treatment was defined up to day 21after the start of the treatment, the medium-term success up to3 months after the first application. The long-term successreflects the situation up to date, but at least up to the period of1 year. The necessary information regarding general andreproduction health were collected after the fourth consultationby questioning the owner by phone.ResultsData of anamnesisThe average age was 6.9 ± 4.5 years (1–17 years). Table 1shows the reasons for consultation. The duration of thesymptoms was between 2 days and 4 weeks.The main portion of patients was found to be in dioestrus(n ¼ 34, 65.4%), followed by those in anoestrus (n ¼ 8;15.3%). In seven bitches the heat was regularly suppressedby progestins (n ¼ 7, 13.5%). In three animals, nidation hadbeen prevented by oestrogens prior to the date of theconsultation (two times 2 weeks earlier, once 8 weeks earlier)because of unwanted breeding (n ¼ 3, 5.8%).Findings upon admittanceTwenty-two bitches were in good general condition, 25 animalsshowed slight impairments. Five of the bitches were in a poorgeneral condition, three of them were not able to get up. Therectally measured inner body temperature of 21 animals wasabove 39.0°C, that of the others was within the referencerange. In 44 animals an open form of pyometra was detected.In eight patients, a closed pyometra was diagnosed.The maximum total diameter of the filled uterus wasbetween 0.6 and 6.3 cm.The blood count of 27 bitches showed leucocytosis (leucocytes>12 g/l), in three animals leucopaenia could be noticed(leucocytes

Treatment of Canine Pyometra with Aglepristone 377treatment, despite immediate admission to a clinic and thestart of infusion therapy. In the second bitch, a lastingimprovement of the renal parameters under infusion therapywith isotonic 0.9% sodium chloride solution (sodium chloridesolution ad usum veterinarium, Selectavet, Weyau-Holzolling,Germany) could be recorded within 3 days. Up to day 7 theinner body temperature returned to normal in all patients. Adecline of the initial leucocytosis could be observed in allaffected animals until the fourth consultation.A distinctive increase of vaginal discharge could be detectedin all bitches within the first 24 h after application ofaglepristone. The uterus lumen of 48 animals showed adistinctive reduction up to day 7. The ultrasonographic findingof the uterus was inconspicuous in these animals upon thefourth consultation. Ultrasonographic examination of threepatients showed neither an increase in a reduction of the uteruslumen nor an increase in vaginal discharge within the first fewdays. In these animals ovariohysterectomy was performed.Cystic changes of the ovaries and cystic endometrial hyperplasiacould be detected intra operationem (Fig. 2). One of thebitches was oestrogen-pretreated, two animals were in thephase of dioestrus.In 48 of the 52 bitches, a clinical healing of the pyometracould be achieved. This corresponds to a short-term successrate of 92.3% (Table 2).Medium-term success up to month 3 after treatmentThe general and reproduction health of 41 bitches could befollowed (Table 2). Four of these animals developed a recurrencewithin 3 months (recurrence rate of 9.8%). In theseanimals an ovariohysterectomy was performed. In three cases,a cystic change of the ovaries and the endometrium could bedetected. None of the bitches was pretreated with hormones.The remaining 37 bitches did not show any abnormalities orsigns of a new metropathy during this period of time.Long-term success during, at least, 1 year after treatmentThe further course could be observed in 37 bitches. Seven ofthese animals developed a pyometra within 1 year (recurrenceTable 2. Recurrence and healing rates of bitches with pyometra up to21 days, 3 month and at least 1 year after medical treatment withaglepristonen (%)Short-term up to day 21Total no. of bitches 52 (100.0)Dead (on second day of treatment) 1 (1.9)No emptying of the uterus 3 (5.8)Initial emptying of the uterus 49 (94.2)Healing rate 48 (92.3)Medium-term up to month 3Total no. of bitches 41 (100.0)Recurrence rate 4 (9.8)Long-term, at least 1 yearTotal no. of bitches 37 (100.0)Recurrence rate 7 (18.9)rate 18.9%). In five of these animals, ovariohysterectomy wasperformed by general veterinary practitioners. For this reason,the findings of the ovaries and the uterus are unknown. In twoanimals, the treatment with aglepristone was successfullyrepeated; they did not show new signs of an uteropathy overa period of, at least, 12 months (Table 2).Data on the further reproductive behaviour of totally37 bitches are available. In 22 bitches, the next heat startedat the expected time. The course of the heat in these animalswas normal. Five of these animals developed a pyometra in thestage of dioestrus following oestrus. Seven animals showedpremature signs of subsequent heat. One of this bitchesdeveloped a pyometra 8 weeks after oestrous behaviour. Ineight bitches the period of anoestrus was prolonged. In onebitch the following heat was delayed by 6 months so that thelength of the interoestrus interval was 12 months. However, aregulation to the normal cycle could be detected in sevenanimals until the second heat after treatment. One bitch withdelayed interoestrus interval developed a pyometra.Six of the bitches were bred during the time until the end ofthe observation period, five delivered at least one litter ofwhelps.Fig. 2. Cystic endometrial hyperplasia in a bitch, which develops apyometra after initial successful medical treatment of pyometra withaglepristone.DiscussionThe aim of this clinical study was to evaluate the success of thetreatment of canine pyometra by the antigestagen aglepristoneand to document the lasting therapeutic success in differenttime stages.The information obtained by anamnesis and the clinicalfindings reflect the already known data from literature(Blendinger and Bostedt, 1991; Berchtold, 1997). Therefore,it can be assumed that the population examined in this study isrepresentative of bitches diseased with pyometra.The fact that a conservative treatment of the closed form ofpyometra can be successfully carried out, in contradiction tothe recommendations made by Johnston et al. (2001), seems tobe noteworthy. In seven of the eight animals diseased with thisform of pyometra, the opening of the cervix and thus anemptying of the uterus could be induced. Only one bitch had toundergo surgery because no vaginal discharge occurred. Noneof the seven successfully treated bitches developed a reccurrence.These data confirm with Hoffmann et al. (2000) and

378 K. Trasch et al.Fieni et al. (2001a), who have been shown that bitches with aclosed form of pyometra can be treated successfully.In 98.1% of the treated bitches, an improvement of thegeneral condition developed within the first two days after thefirst application. In 94.2% of the cases an initial induction ofthe emptying of the uterus could be realized within 12–24 h,along with an increase in the vaginal discharge.A normalization of leucocytosis could be realized in eachcase during the following 21 days after beginning of treatment.In none of the animals an increase in renal parameters orundesired effects were observed.With a short-term healing success rate of 92.3% the use ofaglepristone is certainly justifiable, at least in order to gain thepossibility of postponing surgery in the case of a poor generalhealth condition and associated increased surgical and anaestheticrisk. For medium and long-term success, however, it isimportant that the participation of relatively or absolutelyincreased oestrogen values can be excluded. In case of anabsolutely or relatively increased oestrogen concentration,such as in relation to the ovarian cysts, a successful treatmentcannot be expected. Lemmer (1999) also indicated already thata conservative treatment of pyometra is not successful in thepresence of ovarian cysts.In most cases of recurrence, the presence of cystic changes ofthe ovaries and the endometrium could be detected. Unfortunately,it was not possible to examine the individual plasmahormone concentrations. It is concluded that the recurrencerate can be minimized by the selection of bitches withoutovarian cysts and cystic endometrial hyperplasia. One possibilityof detecting oestrogen influence without determining theexact oestrogen value is the performance of an exfoliativevaginal cytology (Tammer et al., 1994). Ultrasonographicdiagnosis of ovarian cysts is also possible in some cases. Butit is not possible to differenciate between oestrogen-producingovarian cysts, clinically irrelevant paraovarian cysts andcorpora lutea with a fluid filled cavity by ultrasonography(Wehrend and Bostedt, 2002).To compare the healing and recurrence rate in the presentstudy with the results of other authors it might be helpful tocalculate the final recurrence rate from our data. In ouropinion this give false information because not all of theanimals could be followed up for the same period of time.There is a significantly higher number of recurrences afteraglepristone treatment in the present study in comparison withthe study by Hoffmann et al. (2000). In this study, 21 of 22successfully treated bitches could be further examined during aperiod of 14 months on average. Potential recurrence in threeof these animals could not be commented on, as they werekilled due to another clinical picture. In seven animals, norepeated heat could be detected within the observation period.In only one case of the residual 11 animals, purulent vaginaldischarge occurred again. Two of the bitches were bred; one ofthem had a miscarriage for unknown reasons during the lastquarter of pregnancy. Unfortunately, the data do not showduring which period of time recurrence took place. Only a totalaverage observation period of 14 months and no individualcourses of time are given. Fieni et al. (2001a) treated bitcheswith the closed and open form of pyometra with a combinationof aglepristone and cloprostenol in comparison with thetreatment with only aglepristone. The global success rate onday 90 after first treatment was 87% with cloprostenol andaglepristone versus 63% with aglepristone alone. Nevertheless,they used very small doses of cloprostenol, 68% of the bitchesshowed side-effects like vomiting. The authors gave no clearinformation about the recurrence rate after day 90 followingthe first treatment.Johnston et al. (2001) gave an overview of healing successand recurrence rates after conservative treatment of pyometrawith prostaglandins. However, the underlying clinical studiesincluded only low number of bitches. The therapeutic successvaries between 100% (n ¼ 10) and 46% (n ¼ 15); all knownside-effects such as restlessness, hypersalivation, vomiting anddiarrhoea were described in these studies. The recurrence ratesare 10% on average. There are regularly no data described onthe times of the recurrence of the disease. Only Meyers-Wallenet al. (1989) offer more details on the number of recurrences.They describe a therapeutic success in all of the 10 treatedanimals. In 40% of the bitches under follow-up examinations arecurrence could be observed within 1 year, in 77% of thebitches pyometra symptoms recurred within 27 months.Before starting antigestagen treatment, the advantages anddisadvantages of the treatment have to be discussed with theowner. Due to the distinctive improvement of the generalcondition a trial of the treatment can be justified, because asurgery at a later time, after health condition has improved, isstill possible. The good conception rate of the subsequentbreedings allow the use of antigestagens especially in breedingbitches; however, the results regarding further fertility have tobe secured by further examinations in a higher number ofbitches.ReferencesBerchtold, M., 1997:Pyometra der Hu¨ ndin. In:Freudiger, U., E. G.Gru¨ nbaum, E. Schimke (Hrsg.), Klinik der Hundekrankheiten. 2.,u¨ berarb. Enke, Aufl. – Stuttgart.Blendinger, K., and H. Bostedt, 1991:Zum Alter und Zyklusstadiumbei Hu¨ ndinnen mit Pyometra. Tierärztl. Prax. 19, 307–310.Blendinger, K., H. Bostedt, and B. Hoffmann, 1994:Aborteinleitungund konservative Behandlung der Fibroadenomatose bei einerKatze unter Verwendung des Antigestagens RU 46534. Kleintierpraxis39, 495–499.Blendinger, K., H. Bostedt, and B. Hoffmann, 1997:Hormonal stateand effects of the use of an antiprogestin in bitches with pyometra.J. Reprod. Fertil. Suppl. 51, 317–325.Breitkopf, M., B. Hoffmann, and H. Bostedt, 1997:Treatment ofpyometra (cystic endometrial hyperplasia) in bitches with anantiprogestin. J. Reprod. Fertil. Suppl. 51, 327–331.Fieni, F., J. F. Bruyas, D. Tainturnier, and I. Battut, 2001a:Clinicaluse of antigestagins in the treatment of metritis/pyometra in thebitch. EVSSAR Newslett. 1, 13–14.Fieni, F., P. G. Marnet, B. Siliart, N. Touzeau, J. F. Bruyas, and D.Tainturier, 2001b:Comparison of two protocols with a progesteroneantagonist aglepristone (RU 534) to induce parturition inbitches. J. Reprod. Fertil. Suppl. 57, 237–242.Funkquist, B., A.-S. Lagerstedt, C. Linde, and N. Obel, 1983:Intrauterinedrainage for treatment of pyometra in the bitch. Zbl. Vet.Med. A 30, 72–80.Hardy, R. M., and C. A. Osborne, 1974:Canine pyometra:pathophysiology,diagnosis and treatment of uterine and extrauterinelesions. J. Am. Anim. Hosp. Assoc. 10, 245–268.Hecker, B. R., A. Wehrend, and H. Bostedt, 2000:KonservativeTherapie der Pyometra bei der Katze mit dem AntigestagenAglépristone. Kleintierpraxis 45, 845–848.Hoffmann, B., and S. Gerres, 1989:Modellversuch zur Darstellung derantigestagenen Wirkung von RU 38486 bei der Hu¨ ndin. Wien.Tierärztl. Mschr. 76, 10–14.

Treatment of Canine Pyometra with Aglepristone 379Hoffmann, B., W. Lemmer, H. Bostedt, and K. Failing, 2000:DieAnwendung des Antigestagens Aglépristone zur konservativenBehandlung der Pyometra bei der Hu¨ ndin. Tierärztl. Prax. 28,323–329.Hubler, M., and S. Arnold, 2000:Prevention of pregnancy in bitcheswith the progesterone antagonist aglépristone (Alicine). Schweiz.Arch. Tierheilk. 142, 381–386.Hubler, M., S. Arnold, M. Casal, M. Flu¨ ckinger, B. Hauser, L.Corboz, and P. Ru¨ sch, 1991:Anwendung von niedrig dosiertemProstaglandin F2 a bei Hu¨ ndinnen. Schweiz. Arch. Tierheilk. 133,323–329.Johnston, S. D., M. V. RootKustritz, and P. N. S. Olson, 2001. Disordersof the canine uterus. In:Johnston, S. D., M. V. RootKustritz, P. N. S. Olson (eds), Canine and Feline Theriogenology.W. B. Saunders Company, Philadelphia, pp. 206–224.Kraft, W., and U. M. Du¨ rr, 1999:Klinische Labordiagnostik in derTiermedizin – 5., u¨ berarb. und erw. Schattauer, New York, Aufl. –Stuttgart.Kraft, W., and M. Kuffer, 1995:Behandlung schwerer Neutropenienbei Hund und Katze mit Filgrastim. Tierärztl. Prax. 23, 609–613.Legendre, A. M. 1976:Estrogen-induced bone marrow hypoplasia in adog. J. Am. Ani. Hosp. Assoc. 12, 525–527.Lemmer, W. 1999:Untersuchungen zur konservativen Pyometrabehandlungder Hu¨ ndin mittels eines Antigestagens im Rahmen eineroffenen klinischen Studie. Diss. Med. Vet. Gießen.Meyers-Wallen, V. N., M. H. Goldschmidt, and G. L. Flickinger,1989:Prostaglandin F2a treatment of canine pyometra. J. Am. Vet.Med. Assoc. 189, 1557–1561.Nolte, I., S. Mo¨ ller, A. Brass, N. Schossier, H.-A. Schoon, andW. Gru¨ nberg, 1993:Zur Therapie des Endometritis-Pyometra-Komplexes der Hu¨ ndin mit niedrig dosiertem ProstaglandinF2 a . Kleintierpraxis 38, 363–372.Querol, M. 1981:Die Behandlung der Pyometra der Hu¨ ndin mitdem Mastitis- und Metritispräparat Ubrocelan Ò , Entamast Ò undEntamast Ò Uterino. Tierärztl. Umsch. 36, 359–360.Riesenbeck, A., R. Klein, B. Hoffmann, and R. Hospes, 1999:Geburtsinduktion infolge verla¨ ngerter Gravidität bei einer Hu¨ ndinunter Verwendung eines Antigestagens. Tierärztl. Prax. 27, 186–188.Tammer, I., K. Blendinger, A. Sobiraj, and H. Bostedt, 1994:U¨ ber denEinsatz der exfoliativen Vaginalzytologie im Rahmen der gynäkologischenBefunderhebung bei der Hu¨ ndin. Tierärztl. Prax. 22,199–207.Threlfall, W. R. 1995:Diagnosis and medical management of pyometra.Semin. Vet. Med. Surg. Small Anim. 10, 21–29.Watson, M. 1942:Stilboestrol in pyometra of the bitch. Vet. Rec. 54,489.Wehrend, A., and H. Bostedt, 2002:Zur Bedeutung und Behandlungdes Ovarialzystensyndroms bei der Hu¨ ndin. Proceedings, 48.Jahrestagung der FK-DVG vom 30.08. bis 01.09.2002 Magdeburg,261–264.Wehrend, A., R. Hospes, and A. Gruber, 2001:Alternative treatmentof feline fibroadenomatous hyperplasia with a progesteron antagonist.Vet. Rec. 148, 346–347.

Theriogenology 60 (2003) 901–908A study of two protocols combining aglepristoneand cloprostenol to treat open cervix pyometrain the bitchCristina Gobello a,* , Gervasio Castex a,1 , Liliana Klima b ,Raúl Rodríguez b , Yanina Corrada ba Small Animal Clinic, Faculty of Veterinary Medicine, National University of La Plata, CC 296,La Plata B1900 AVVW, Argentinab Image Diagnostic Service, Faculty of Veterinary Medicine, National University of La Plata, CC 296,La Plata B1900 AVVW, ArgentinaReceived 21 June 2002; accepted 9 December 2002AbstractTo compare the efficacy and safety of two protocols using a combination of aglepristone andcloprostenol for the treatment of open cervix pyometra in the bitch and to describe theprogesterone (P 4 ) serum profiles before and during treatments, 15 bitches were randomly allocatedinto two treatment groups: I (n ¼ 8): aglepristone was administered at 10 mg/kg, s.c., on Days 1,3, 8, and 15 (if not cured), combined with cloprostenol at the dose of 1 mg/kg, s.c., on Days 3 and8, and II (n ¼ 7): received the same treatment with aglepristone as Treatment I but cloprostenol onDays 3, 5, 8 10, 12, and 15 (if not cured). Before the beginning of the treatments and then on Days8, 15, and 29 all bitches were evaluated for clinical signs, side effects, hemogram, serum P 4concentrations, and uterus diameters. Bitches in both treatment groups, with (n ¼ 6) or without(n ¼ 9; 1.2 ng/ml) initial basal P 4 serum concentrations, achieved treatment success without sideeffects and no significant differences, either on Day 15 (6/8 for Treatment I and 4/7 for TreatmentII) or on Day 29 (2/8 for Treatment I and 3/7 for Treatment II). In both treatments groups, clinicalsigns, blood parameters, and uterine diameters improved to normal values throughout theexperiments. A significant interaction between day and treatment was found for percentagechange in P 4 when all bitches were considered together. Redevelopment of pyometra in the nextestrous cycle occurred in 20% of the bitches. One nonrecurrent bitch was mated and whelped anormal litter. It is concluded that these two combined protocols proved to be efficient and safe inreversing clinical signs of open cervix pyometra independently of initial P 4 concentrations and* Corresponding author. Fax: þ54-221-4259780.E-mail address: cgobello@fcv.unlp.edu.ar (C. Gobello).1 Gervasio Castex is a Research Fellow of the Comisión de Investigaciones Científicas (CIC) de la provinciade Bs As, Argentina.0093-691X/$ – see front matter # 2003 Elsevier Science Inc. All rights reserved.doi:10.1016/S0093-691X(03)00094-3

902 C. Gobello et al. / Theriogenology 60 (2003) 901–908that the number of cloprostenol administrations seemed to have an effect on P 4 serum changesthroughout treatments.# 2003 Elsevier Science Inc. All rights reserved.Keywords: Pyometra; Bitch; Aglepristone; Cloprostenol1. IntroductionThe cystic endometrial hyperplasia—pyometra complex (CEH-P) is a common progesterone(P 4 )-dependent disease of the genital tract that appears clinically either in thediestrous or anestrous period of the canine estrous cycle [1–4]. Medical treatment of CEH-P is usually required for bitches intended for breeding. Either prostaglandins (PG) orantiprogestins have been proved to be effective for this purpose [3,5–8]. Prostaglandinsincrease myometrial contractions, may enhance cervical relaxation and have a luteolyticeffect after Day 5 of diestrus, decreasing serum P 4 concentrations [2]. Cloprostenol sodiumis a synthetic PG F2a analogue that has a luteolytic effect and potent uterotonic activity[2,8].Antiprogestins are synthetic steroids which bind with great affinity to P 4 receptorswithout any effects of P 4 [9]. Aglepristone (RU 534) is an antiprogestin, recently marketedfor veterinary use, which competes for uterine receptors with a fixating rate three-fold thatof P 4 in the bitch [10]. In human beings, a combination of antiprogestin (mifepristone, RU486) and PGs have been successfully used to induce abortion [11]. A combination of PGand aglepristone has shown the best results for the treatment of canine CEH-P as recentlyreported in two studies [12,13]. In the first study, an improvement in success rate of 22 and32% was found on Days 14 and 28, respectively, when compared with antiprogestin-treatedbitches [12]. Progesterone serum concentrations during these combined protocols,although potentially useful to describe their mechanism of action, have not been reported.Moreover, further work is necessary to determine the optimum administration of thesecombined treatments.Therefore, the objective of this study was two-fold: to compare the clinical efficacy andsafety of two different administration intervals for cloprostenol combined with aglepristonefor the treatment of open cervix CEH-P, and to describe the P 4 serum profiles beforeand during treatment in this species.2. Materials and methods2.1. AnimalsFifteen mixed and purebred bitches, ranging from 16 months to 15 years of age,weighing 4–50 kg, with open cervix CEH-P (defined as an enlarged fluid-filled uterus andvaginal discharge) were recruited and included in this study. Diagnosis of CEH-P wasconfirmed by routine uterine ultrasound findings [14]. All the bitches had serum urea andcreatinine

C. Gobello et al. / Theriogenology 60 (2003) 901–908 9032.2. ProcedureThe bitches were randomly allocated to one of the following groups: Treatment I(n ¼ 8): aglepristone (Alizine 1 , Virbac, Carros, France) was administered at 10 mg/kg,s.c., on Days 1, 3, 8, and 15 (if not cured) and cloprostenol (Estrumate 1 , Schering Plough,Bs. As, Argentina) far from feeding time was administered at the dose of 1 mg/kg, s.c., onDays 3 and 8; or Treatment II (n ¼ 7): the bitches received the same treatment withaglepristone as for Treatment I, but the cloprostenol (same dose) was administered in thesame way on Days 3, 5, 8, 10, 12, and 15 (if not cured). Day 1 was considered as the day ofpresentation of the bitch.A combination of amoxycillin–clavulanate at 12.5 mg/kg (bid p.o., Clavamox 1 ,Pfizer,Bs. As, Argentina) and supportive hydration were administered during both therapeuticprotocols. Before the beginning of the treatments on Day 1 and then on Days 3, 8, 15, and29 (if not cured), all bitches were evaluated for body weight and temperature, hydration,anorexia, polyuria/polydipsia, uterus total, and lumen diameters assessed by ultrasonography(Pie Medical S100, 5 MHz transducer, Maastricht, The Netherlands), and vulvardischarge. On Days 1, 8, 15, and 29 (if not cured), blood samples were taken for hemogramand serum P 4 concentrations (Coat-A-Count, DPC 1 , Los Angeles, CA) determinations.Animals were observed for possible side effects during the treatments. All the bitches werefollowed up to their next estrous cycle.2.3. Statistical analysesCategorical data for the frequency of bitches achieving clinical success (defined asrecovery to general health and ultrasonographic observation of normal uterus) and sideeffects either for Treatments I and II, or for bitches with initial basal or nonbasal P 4 serumconcentrations were analyzed by PROC FREQ [15] on Days 15 or 29 (bitches not cured onDay 15). For this purpose, P 4 serum concentrations on Day 1 were categorized as basal ornonbasal (< or 1.2 ng/ml, respectively).Percent change of serum P 4 concentrations ((final value [Days 8, 15, or 29] initial value[Day 1]/initial value) 100) was analyzed by least-squares analysis of variance using theGeneral Linear Model procedure PROC GLM [15]. The mathematical model included themain effects of treatment (I or II) and day (8, 15, or 29) and the treatment by dayinteraction. Descriptive statistics of all parameters assessed were analyzed by PROCMEANS [15] and expressed as LSM S:E:M: The level of significance was set atP < 0:05.3. ResultsAll bitches in Treatments I (8/8) and II (7/7) achieved treatment success either on Day 15(6/8 for Treatment I and 4/7 for Treatment II) or 29 (2/8 for Group I and 3/7 for Treatment II)of the protocols. No significant differences in achieving success was found betweentreatments or initial P 4 concentrations either on Day 15 or 29. None of the bitches showedeither systemic or local side effects in relation to the treatment (0/15).

904 C. Gobello et al. / Theriogenology 60 (2003) 901–908Vulvar discharge was increased in all the bitches within the 24–48 h after the firstadministration of aglepristone with an improvement in general health condition. Bodytemperature, hydration, appetite, and polyuria/polydipsia began to improve markedly tonormalcy from Day 3 in both groups. Hemogram parameters had a clear tendency towardnormal values at the end of the treatments, being the white blood cells within physiologicalrange at that time (Fig. 1). Uterine diameters diminished to normal size and the lumen wasundetectable or without contents on Days 15 or 29 in both groups (Fig. 2).Progesterone serum concentrations before and during Treatments I and II in bitcheseither with basal or nonbasal initial P 4 are represented in Fig. 3. Progesterone showed adecreasing tendency in three of the four subgroups.A significant interaction between day and treatment was found for P 4 percentage changewhen all the bitches were considered together and when only the bitches with nonbasalinitial P 4 concentrations (n ¼ 9) were analyzed (P > 0:05). The number of bitches (n ¼ 6)with basal initial P 4 concentrations was statistically insufficient to be analyzed.Redevelopment of CEH-P in the next estrous cycle occurred in 3/15 old bitches (7–15years old); two of these had had more than two previous episodes of CEH-P. One bitch wasovariohysterectomized before her next cycle. Nonrecurrence in the next cycle occurred in11/15 bitches; four of these were treated with amoxicillin during the next open cervixperiod (proestrus and estrus). One (2 years old) of these four bitches was mated andwhelped a normal litter.Fig. 1. Least square means of the white blood cells (WBC) of 15 bitches suffering cystic endometrialhyperplasia—pyometra complex treated with two combined protocols of PG and aglepristone before and duringtreatments. No significant differences in WBC were found between treatment, so they were represented together.Bars on symbols represent the corresponding S.E.M.

C. Gobello et al. / Theriogenology 60 (2003) 901–908 905Fig. 2. Least square means of uterine total and lumen diameters assessed by ultrasonography of the sameanimals (n ¼ 15) before and during the treatments. Bars on symbols represent the corresponding S.E.M.Fig. 3. Least square means of serum P 4 concentrations of the same animals (n ¼ 15) divided into four subgroupsaccording to treatment (I or II) and initial (Day 1) P 4 concentrations (basal or nonbasal, < or 1.2 ng/ml,respectively) before and during treatment. Bars on symbols represent the corresponding S.E.M.

906 C. Gobello et al. / Theriogenology 60 (2003) 901–9084. DiscussionThe proportion of bitches with initial basal P 4 concentrations in the present trial washigher than that reported in two previous studies [3,12]. Although this finding was probablyincidental, it does confirm that this complex can become clinically evident either duringdiestrus or anestrus [1,6].In line with a recent study but in contradiction with a previous one, in which onlyaglepristone was used, no relationship between initial basal P 4 concentrations andtreatment success was found in this study [12,16].Some bitches were cured without achieving basal P 4 serum concentrations at the end ofthe treatments. Moreover, pregnancy termination with aglepristone in the bitch occurs inthe presence of high P 4 serum concentrations [17]. These findings seem to confirm thatantiprogestins decrease intrauterine P 4 through the number or sensitivity of P 4 receptorsand not through the serum concentrations of this hormone [12]. The initial serum rise(on Day 8) of a nonbasal group could be explained by the blocking of uterine receptors andthe consequent elevation of P 4 in blood. Ecbolic PG effect could have also contributed tosuccess in these cases.More difficult to explain is the clinical improvement in bitches with basal P 4 concentrationsthroughout treatments. Although the uterotonic effect of PG could have causedthe success in these cases, clinical improvement and the increase in the vaginal dischargewas seen before the first treatment with PG on Day 3.Although in the present study, cloprostenol was administered at 48 h or longer intervals,the results on Day 15 (6/8 and 4/7 for Treatments I and II, respectively) were better thanthose reported in another study (50%), using the same drug and doses on a daily basis [12].In the current study, based on two treatment protocols for cloprostenol, the number oftreatments did not seem to be crucial in the resolution of the clinical cases, although a largernumber of treated bitches would be necessary to either confirm or reject this initial finding.Conversely, the number of PG treatments seemed to influence P 4 serum changes during thedifferent days of the study.In disagreement with two recent studies [2,12], but in line with a previous report inwhich only aglepristone was used [5], nosideeffectswerereportedinthisstudy.Theadministration of a low dose of a potent PG at a time far from feeding could haveaccounted for these differences. Moreover, all the bitches were in a better conditionon the day of the first cloprostenol injection (Day 3) than at the beginning of thetreatments.In this study, recurrence rate was higher than in a similar previous study in which noredevelopment appeared in 12 bitches that were followed up to the next estrous cycle [12],and also higher than in one study in which only aglepristone was used [16]. The higherrecurrence rate may be due to the advanced age of most of the bitches used in the presentstudy. Conversely, the present results were in the lower limit range of recurrence for bitchestreated only with PG (10–77%) [6,7]. These findings suggest that the uterotonic effect ofPG does not reverse CEH and many dogs may have a decrease in clinical signs towardssubclinical levels which then becomes undetectable. We hypothesized that antiprogestintreatment might better manage endometrial abnormalities depending on the depth ofinflammatory infiltration measured using Dow’s classification [18]. Conversely, a study in

C. Gobello et al. / Theriogenology 60 (2003) 901–908 907which histological examination of uteri was carried out revealed no differences between 6days-antiprogestin-treated and control bitches [3].Consistent with a previous report [5], fertility after treatment did not seem to be affectedby endometrial pathology in the young bitch that was mated. This young bitch was one ofthe most representative of the population for which these combined protocols aremainly intended in clinical practice. Further studies including larger number of bitchesof different ages, with or with out past episodes of CEH-P are required to evaluate fertilityafter treatment.We concluded that these two combined protocols proved to be efficient and safe inreversing clinical signs and abnormal uterine ultrasonographic findings in bitches sufferingCEH-P, independently of initial P 4 serum concentrations. Also, the number of PG administrationsseemed to have an effect on P 4 serum concentrations throughout treatments.Further work with a larger number of bitches is necessary to confirm these initial findings.AcknowledgementsThe authors thank Virbac, France for its support and Alizine 1 supply, Schering Plough,Argentina for Estrumate 1 supply and all the owners who participated in this study.References[1] Dow C. The cystic hyperplasia—pyometra complex in bitch. Vet Rec 1957;69:1409–15.[2] van der Horst CJ, Vogel F. Some effects of PG F2a on corpora lutea and on the uterus in the cycling dog.Tijdsschr Dierge-neeskd 1977;102:117–23.[3] Blendinger K, Bostedt H, Hoffmann B. Hormonal effects of the use of an antiprogestin in bitches withpyometra. J Reprod Fertil Suppl 1997;51:317–25.[4] Noakes DE, Dhaliwal GK, England GC. Cystic endometrial hyperplasic/pyometra in dogs: a review of thecauses and pathogenesis. J Reprod Fertil Suppl 2001;57:395–406.[5] Breitkopt M, Hoffmann B, Bostedt H. Treatment of pyometra in bitches with an antiprogestin. J ReprodFertil Suppl 1997;51:327–31.[6] Renton JP, Boyd JS, Harvey MJ. Observation of the treatment and diagnosis of open pyometra in the bitch.J Reprod Fertil Suppl 1993;47:465–9.[7] Nelson RW, Feldman EC, Stabenfeldt GH. Treatment of canine pyometra with PG F2a. J Am Vet MedAssoc 1982;181:899–903.[8] Tainturier D, Treboz D. Traitement del la metrite chronique de la chienne para un analogue de la F2a. PratMed Chir Anim Comp 1985;20:239–44.[9] Hoffmann B, Schuler G. Receptor blockers—general aspects with respect to their use in domestic animalreproduction. Anim Reprod Sci 2000;60/61:295–312.[10] Philibert D. RU 46534. Affinité relative de liaison pour les récepteurs stéroïdiens—activité antiprogestéronein vivo. Rapport d’étude interne Roussel Uclaf 1994; pp. 4.[11] Cadepond F, Ulmann A, Beaulieu EE. RU 486 (mifepristone): mechanism of action and clinical uses. AnnRev Med 1997;48:129–56.[12] Fieni F, Bruyas D, Tainturier D, Battut I. Clinical use of antiprogestins in the treatment of metrits/pyometra in the bitch. In: Proceedings of the Fifth Annual Conference of the European Society ofDomestic Animal Reproduction. Vienna, Austria; 2001.[13] Gobello C, Corrada Y, Castex G, Klima L, Rodríguez R, Giannoni M. A study of two combined protocolsof aglepristone and cloprostenol to treat open cervix pyometra in the bitch. In: Proceedings of the AnnualSymposium of European Society of Small Animal Reproduction. Liege, Belgium; 2002. p. 130–1.

908 C. Gobello et al. / Theriogenology 60 (2003) 901–908[14] Yeager AE, Concannon P. Ultrasonography of the reproductive tract of the female dog and cat. In:Bonagura JD, Kirk KW, editors. Current veterinary therapy, vol. XII. Philadelphia: Saunders; 1995.p. 1040–52.[15] SAS Institute Inc., SAS/STAT 1 . User’s guide, version 6, vol. 189. 4th ed. Cary, NC: SAS Institute Inc.;1989.[16] Hoffmann B, Lemmer W, Bostedt H, Failing K. Application of the antiprogestin aglepristone for theconservative treatment of pyometra in the dog. Tierarztl Prax 2000;28:323–9.[17] Fieni F, Martal J, Marnet PG, Siliart B, Bernard F, Riou M, et al. Hormonal variations in bitches after earlyor mid pregnancy termination with aglepristone (Ru 534). J Reprod Fertil Suppl 2001;57:243–8.[18] Dow C. The cystic hyperplasia—pyometra complex in the bitch. J Comp Pathol 1959;69:237–50.

Close this window to return to IVISwww.ivis.orgABSTRACTS6 th International Symposium onCanine and Feline Reproduction&6 th Biennial EVSSAR CongressEuropean Veterinary Society for Small Animal Reproduction"Reproductive biology and medicine ofdomestic and exotic carnivores"University of Veterinary Sciences9 th – 11 th July 2008Vienna, AustriaEditors: G. England, P. Concannon, S. Schäfer-SomiReprinted in IVIS with the permission of the Symposium Organizers

Reprinted in IVIS with the permission of the Symposium OrganizersClose this window to return to IVISDIAGNOSIS OF ENDOMETRITIS IN THE INFERTILE BITCH: A NEWAPPROACHFontaine E.(1), Levy X.(1), Grellet A.(1), Luc A.(1), Bernex F.(1), Fontbonne A.(1)(1) Ecole Nationale Vétérinaire, 7 avenue du Général de Gaulle, 94700 Maisons-Alfort,France E-mail : efontaine@vet-alfort.frIntroduction - Very few reports have been made about endometritis in the bitch; itsrelationship with failure to conceive remains unclear. It may be due to the difficulty to collectuterine samples for further investigations. Today, transcervical catheterization by vaginalendoscopy allows us to evaluate the endometrium in infertile bitches. Diagnosis criteria weredetermined according to previous studies on uterine cytology and bacteriology[1-3]. The aimof our study was to test the efficiency of this technique to diagnose endometritis in the bitchand furthermore, to evaluate the incidence of endometritis within infertile bitches.Material and methods - 26 bitches presented for infertility in Alfort Veterinary College wereincluded in this study. Classical infertility investigations were not indicative: time of matinghad been correctly determined by progesterone assays, male used had sired successfully,clinical examination and genital ultrasonography revealed no abnormalities. A vaginalendoscopy was performed and presence of vaginitis and cervical discharge was evaluated. Inall bitches, a transcervical catheterization was performed using a human ureteral catheter(Ureteral CRU® ch.6 223602). Flushing of the uterine lumen was realized with sterile salinefluid (NaCl 0.9%, 2mL/10 kg instilled then reabsorbed) and collected samples were used foruterine cytology and aerobic bacteriology (Amies agar gel with charcoal).The normal leucocyte score, which reflected absolute and relative numbers of leucocytesversus endometrial cells, was defined by Watts [3]. All cytologies exceeding normal scoreswere considered as endometritis.If cytology pointed out an inflammatory state correlated to bacterial heavy growth, the bitchwas considered to suffer from infectious endometritis. A cytologic inflammatory state of theuterus in the absence of bacterial growth was considered to be a non infectious endometritis.Results - Fourteen different breeds were concerned, from Shi-Tsu (5kg) to Mastiff (96kg).Bitches were mainly large and giant breeds and were aged 1 to 7 years (mean 4years/SD=1.5). Uterine investigations were realized in dioestrus (21 bitches), anoestrus (4)and pro-oestrus (1). 10/26 bitches suffered from endometritis. Among them, seven sufferedfrom infectious endometritis. Three bitches had a bacterial heavy growth without cytologicabnormalities and we considered that it was a sign of contamination by the normal vaginalflora. In 4/10 bitches suffering from endometritis, a cervical discharge was observed byvaginal endoscopy. Surprisingly, another bitch negative towards cytological andbacteriological criteria was found to show also a purulent cervical discharge. A clear cervicalinflammation was also observed in 3/7 bitches suffering from infectious endometritis. Signsof vaginitis were visualised in two bitches, both of them suffering from infectious (1/10) andnon infectious (1/10) endometritis. One bitch suffering from infectious endometritis presentedsigns of vaginitis, cervicitis and cervical discharge. Infectious endometritis was diagnosedduring dioestrus (6/7) and prooestrus (1/7). Non infectious endometritis was diagnosed indioestrus (2/3) and anoestrus (1/3). Four bitches for which endoscopy was performed indioestrus encountered pyometra after flushing, two of which were not initially suffering fromendometritis. Five bitches suffering from endometritis were further bred after treatmentcombining antibiotics +/- aglepristone (Alizine ®) and they all went pregnant. 4/5 bitcheswhelped normally and 1/5 had a premature parturition at 59 days of pregnancy.Proceedings of the 6th International Symposium on Canine and Feline Reproduction &6th Biannual European Veterinary Society for Small Animal Reproduction Congress2008 - Vienna, Austria

Reprinted in IVIS with the permission of the Symposium OrganizersClose this window to return to IVISDiscussion - In our study, endometritis seemed to have in most cases an infectious origin(70% of affected bitches), but these results may be underestimated, as some other pathogens(anaerobic bacteria, mycoplasms, fungi), were not searched for. Dioestrus seems to be the bestperiod to diagnose endometritis. However, the endometrium impregnated with progesterone ismore sensitive and despite all precautions, this could explain that we got induced pyometraafter endoscopy. Early anoestrus may be a more adequate period to perform thoseinvestigations, as progesterone impregnation is over. One bitch showed a purulent cervicaldischarge without a positive endometrial cytology. Our diagnosis technique lacks comparisonwith histology, which should be done to ensure a more accurate diagnosis. Indeed, impact ofendometritis is underestimated. Endometritis, in our opinion, should be investigated in eachunexplained case of infertility in bitches. The technic used here seems reliable: all bitchestreated were bred successfully whereas previous infertility treatments had not succeeded.Defining more accurate criteria will improve the efficiency of this non invasive technique thatcould help to treat unexplained infertility cases.References(1). Watts JR, W.P., Investigating uterine disease in the bitch: uterine cannulation forcytology, microbiology and hysteroscopy. J. Small Anim. Pract., 1995. 35: p. 201-206.(2). Watts JR, W.P., Whithear KC, Uterine, cervical and vaginal microflora of the normalbitch throughout the reproductive cycle. J. Small Anim. Pract., 1996. 37: p. 54-60.(3). Watts JR; Wright, P., Endometrial cytology of the normal bitch throughout thereproductive cycle. J. Small Anim. Pract., 1998. 39: p. 2-9.Proceedings of the 6th International Symposium on Canine and Feline Reproduction &6th Biannual European Veterinary Society for Small Animal Reproduction Congress2008 - Vienna, Austria

CLINICAL UPDATEMedical Treatment of PyoD1etraandthe Use of AglepristoneSteven Metcalfe and Claudia VischeraApplecross Veterinary Hospital9 Sleat Rd, Canning Bridge, WA 6153aTechnicalServices Manager - Companion AnimalsVirbac Australia, 15 Pritchard Place, Peakhurst, NSW 2010Pyometra is a common disease in bitches over eightyears of age. The disease generally occurs during the dioestrousphase of the reproductive cycle (Blendiger et al1997). Currently, it is generally accepted that cysticendometrial hyperplasia(CEH)-pyometra complex isvery closely associated with increased circulating bloodprogesterone concentrations (Noakes et al 2001).Progesterone promotes multiplication of the glandularcells in the uterus, which may result in cysticendometrial hyperplasia. Progesterone also depresseslocal mechanisms that clear bacteria from the genitaltract. Infections with E. coli, ascending the urogenitaltract, from the bowel, have been identified as the mostcommon bacterial component of the canine pyometracomplex (Hagman & Kunh, 2002, Wadas et al 1996).Pyometra is associated with inflammation of theendometrium with the accumulation of purulent and/orhaemorrhagic secretions in the uterus. Depending on thedegree of cervical opening, a vaginal discharge may bepresent. Without treatment the infection has highmorbidity and mortality due to endotoxaemia andsepticaemia (Hagman et al2006).Surgical treatment of pyometra by ovariohysterectomy iscurative. Anaesthetic and surgical risk may be increaseddue to the systemic effects of pyometra and these mustbe addressed before, during and after surgery.Due to the luteolytic and uterotonic properties of prostaglandin-F2alpha (PGF2a), the repeated administrationof PGF2a has been used to treat pyometra (Gilbert et al1989, Meyers et al 1986). To avoid the risk of seriousside effects, prostaglandins are only recommended foruse in young bitches with no liver, kidney orcardiovascular disease. The duration of treatment andthe onset of side "effects related to the action of theprostaglandins on smooth muscle, causing diarrhoea,salivation and vomiting, do not make it an ideal singlemodality treatment option for pyometra.Ph: 08 93647666. Fax: 08 93611662Email: applecrossvet@aapt.net.auGiven the major role of progesterone in inducing CEHpyometracomplex, anti-progestins such as aglepristonel,could be expected to be useful in a medical treatmentprotocol. Aglepristone is a potent progesterone antagonist,with an affinityfor progesteronereceptors in vitrothree times greater than that of progesterone.Aglepristone binds to uterine progesterone receptorswithout producing the biological effects of progesterone.Aglepristone has been shown to effectively suppress thebiological action of progesterone during gestation,interruptinggestation(Fieni et al1996, Galac et al 2000,"Fieni et al 200la), and causing cervical opening andinducing parturition (Fieni et al 200lb). The moleculehas been effectively used in the treatment of uterineinfections associated with the presence of a high level ofplasma progesterone (Blendiger et al 1997, Breitkopf etal1997, Hoffman et al200l). Recent work has describedthe use of aglepristone to treat pyometra, for a short ormedium term after the initial acute recovery (Trasch et al2003), including its combined use with cloprostenol(Gobello et al 2003).In a recent large clinical study (Fieni, 2006) the use ofaglepristone, alone and in combination with low doses ofcloprostenol, was evaluated in the treatment of metritispyometra.Sixty-seven bitches, aged 8.2 :t 3.5 years,with a uterine infection were accordingly allocated intothree groups: group 1 - metritis (n=15); group 2 - openpyometra (n=35); and group 3 - closed pyometra (n=17).All bitches were injected subcutaneously three timeswith lOmg/kg of aglepristone on Days 1,2 and 8. It wasthe only treatment administered to bitches with metritis.In addition to this treatment, half the bitches with openand closed pyometra were injected daily from Day 3 toDay 7 with If.lglkg cloprostenoJ2 subcutaneously. Allpyometra bitches were concurrently treated withamoxicillinlclavulinic acid antibioties3. All bitches were1Alizin, Virbac2Estrumate, Schering-Plough Animal Health3Synulox, PfizerAust Vet Practit 36(4) December 2006 - 171

PYOMETRARESPONSE TO TREATMENT WITH AGLEPRISTONE WITH AND WITHOUT PROSTAGLANDINSSpecies Single Standard Standard + PG Extended Extended + PGBitches 3/5 (60.0) 27/31 (87.1) 2/3 (66.7) 4/5 (80.0) 1/1 (100.0)Queens 2/2 (100.0) 8/8 (100) (0) 1/1 (100.0) (0)TABLE 1: Number (%) of bitches and queens that achieved successful outcomes based on aglepristone treatment protocolsat Applecross VeterinaryHospital (2001-2006).closely monitored with regular clinical andgynaecological examinations and full blood counts. Theefficacy criteria were assessed as recovery of generalhealth, lack of vulvar discharge and lack of uterinelumen enlargement. If necessary an additional treatmentwith aglepristone was administered on Days 14 and 28.The final examination was on Day 90.At Day 90, 80.6% (54/67) of the bitches were curedincluding all of the bitches with metritis (15/15),receiving only aglepristone; the closed pyometra cases(17/17) had cervical opening within 48 hours ofreceiving aglepristone. In the bitches with open orclosed pyometra, additional treatment with cloprostenolfrom Days 3 to 7 significantly improved the globalsuccess rate at Day 90 to 84.4% (27/32) compared to60% (12/20) in bitches without cloprostenol (p

Theriogenology 66 (2006) 1550–1556www.journals.elsevierhealth.com/periodicals/theClinical evaluation of the use of aglepristone, with orwithout cloprostenol, to treat cystic endometrialhyperplasia-pyometra complex in bitchesF. Fieni *Laboratory of Biotechnology and Pathology of Reproduction, National Veterinary School,BP 40706, 44307 Nantes Cedex 03, FranceAbstractThe aim of the study was to evaluate the efficacy of aglepristone (10 mg/kg on days 1, 2 and 8) for the treatment of metritis orpyometra in bitches (n = 67) either alone for cases of metritis (n = 15), or in cases of pyometra (n = 52) with (n = 32) or without(n = 20) the addition of low doses (1 mg/kg) of cloprostenol for 5 days (days 3–7). Examinations performed on day 90, in addition todays 8, 14 and 28, determined that treatments had been curative in the long term in 54/67 bitches (80.6%). Bitches in whompyometra did not resolve, were given additional aglepristone on day 14 (n = 38) and day 28 (n = 20). Aglepristone alone wascurative in 15/15 bitches with metritis. In 17/17 bitches with closed pyometra, cervical opening occurred within 48 h of aglepristoneadministration. Amongst the 52 bitches with open (n = 35) or closed (n = 17) pyometra, the additional treatment with cloprostenolfrom days 3 to 7, significantly improved the overall success rate at day 90, which was 27/32 (84.4%), compared to 12/20 (60.0%) inbitches without cloprostenol (P < 0.05). The leucocyte count and plasma progesterone concentrations significantly decreased overthe course of treatment. Thirteen of 15 bitches in whom plasma progesterone concentrations were initially low (

F. Fieni / Theriogenology 66 (2006) 1550–1556 1551kidney dysfunction or cardiac disease. Some authorsalso suggested that the cervix must be open and theuterus non-hypertrophied [5]. The duration of treatmentand the onset of side effects related to the action of theprostaglandins on smooth muscle (diarrhea, salivationand vomiting) make this a demanding course oftreatment, which usually requires hospitalization ofthe bitch.Given the major role of progesterone in inducingcystic endometrial hyperplasia-pyometra complex,antiprogestins such as aglepristone could be expectedto be useful in a medical treatment protocol. Aglepristonehas been shown to effectively suppress thebiological action of progesterone during gestation,interrupting gestation [6–8], causing cervical opening,and inducing parturition [9]. The molecule has beeneffectively used in the treatment of uterine infectionsassociated with elevated plasma progesterone concentrations(n = 6, 7 and 31) [1,10,11]. Recent work hasdescribed the use of aglepristone to treat pyometra inbitches, in terms of the short or medium term result afterthe initial acute recovery (n = 52) [12], and including itscombined use with cloprostenol (n =15)[13]. However,to be suitable for medical use by practitioners, atreatment needs to be efficient, fast, and prescribed onthe basis of immediate clinical findings, without theneed for lengthy laboratory testing.The aim of this clinical study was to evaluate theefficacy and safety of the treatment of metritis/pyometrain bitches by the administration of aglepristone inbitches with various forms of infectious uterinediseases, that were presented to the clinics at theVeterinary School in Nantes, and to evaluate it incomparison with the administration of combinedaglepristone and low dose cloprostenol. The lattertreatment strategy was designed to improve outcomesand hasten recovery without the side effects usuallyinduced by prostaglandins in bitches with open orclosed pyometra.2. Materials and methods2.1. AnimalsThis study involved 67 bitches of different breeds,aged 8.5 3.2 years, with ‘‘open’’ or ‘‘closed’’ forms ofmetritis or cystic endometrial hyperplasia-pyometracomplex. The diagnosis was confirmed by the observationof purulent or hemorrhagic vaginal dischargeassociated in some, but not all, cases with enlargementof the uterine lumen detected using uterine ultrasonography.Irrespective of their general health, all bitchestreated had a serum concentration of urea and creatinineof less than 0.6 g/L and 10 mg/L, respectively.2.2. ProcedureThe bitches were allocated into three groups basedon clinical observation: Group 1, metritis (putridvaginal discharge with no enlargement of the uterinelumen detected on uterine ultrasonography, n = 15);Group 2, open pyometra (putrid vaginal discharge withenlargement of the uterine lumen, n = 35) and Group 3,closed pyometra (enlargement of the uterine lumenwithout vaginal discharge, n = 17).Treatment varied, depending on the clinical situation,but all the bitches received one subcutaneousinjection of 10 mg/kg body weight of aglepristone(Alizine 1 ; Virbac, Carros, France) once daily on days1, 2 and 8. This was the only treatment administered inbitches with metritis (Group 1). In addition to thistreatment, two-thirds of each group of the bitches withopen (Group 2, n = 10/17) or closed (Group 3, n = 21/35) pyometra were given daily subcutaneous injectionsfrom days 3 to 7, with 1 mg/kg of cloprostenol(Estrumate 1 ; Schering-Plough, Levallois-Perret,France). Bitches with hyperthermia or dehydrationand all bitches with closed pyometra received additionaltreatment, i.e. intravenous infusion of ringer lactate atday 1 and 24 mg/kg/day of amoxicillin-clavulanic acidfrom days 1 to 5 (Synulox 1 ; Pfizer, Paris, France).The bitches from all three groups were checked ondays 14, 28 and 90. Bitches in whom pyometra did notresolve, were given additional aglepristone on day 14(n = 38) and day 28 (n = 20). The efficacy criteria wererecovery of good general health, absence of uterinelumen enlargement and absence of vaginal discharge.At the beginning of the trial and at various stages duringthe study, the bitches underwent a general clinicalexamination, gynecological examination and an ultrasoundexamination of the uterus (Aloka Echo CameraSSD-500 with 5 MHz transducer; Aloka, Cergy St.Christophe, France). A blood sample was also takenfrom the jugular vein. Mean white and red blood cellcounts were measured using an impedance counter(MS9; Melet Schloesing Laboratoire, Cergy-Pointoise,France). An automated biochemistry analyzer (BP144;Ph Diagnostics, Montpellier, France) was used todetermine the plasma concentrations of urea andcreatinine via photospectrometry. Peripheral progesteroneconcentrations were measured using a commercialRIA kit (Diria-progk kit from Diasorin, Antony,France). The assay sensitivity was 0.3 nmol/L andassay specificity was 97.5%.

1552F. Fieni / Theriogenology 66 (2006) 1550–15562.3. Statistical evaluationQualitative results, such as the success of thetreatment, were reported with a confidence interval of95%. Quantitative results were reported as means S.D. Data were analyzed by Statview (SAS InstituteInc., Cary, NC, USA). Treatment efficacy and theclinical response of metritis/pyometra were comparedusing a Chi-square test. A Student-Fisher test was usedto compare the mean decrease in the diameter of theuterine lumen, the mean leucocyte count and the meanperipheral plasma progesterone concentration betweentreatments at various times during the experiment.Values were considered statistically significant whenP < 0.05.3. ResultsWhen measuring efficacy at day 90, 54/67 bitcheswere cured (i.e. 80.6%, with a confidence interval rangeof 71.1–90.1%). The overall recovery rate was lower(P < 0.001) at day 14 (24/68, 35.3%) than at day 28 (46/67, 68.6%) and day 90 (54/67, 80.6%). The effectivenessof the treatment was not dependent on the clinicalform of uterine disease (Table 1).In bitches with metritis, treatment with aglepristonealone gave a high cure rate, with clinical resolution inover half of the bitches (9/15) within 2 weeks and within4 weeks for the remainder with, one exception. Thebitch cured at day 90 had only a slight serous dischargeon day 28. This was visible by the clinician during thegenital exam but not by the owner.Clinically, the administration of aglepristone incases of pyometra led to changes in the nature of thevaginal discharge, which changed from purulent, tomucous-like, before finally becoming serous, with aconcurrent decrease in volume. The last clinical signrecorded was self-cleaning of the vulval area by thebitch. For all bitches with closed pyometra, cervicalopening was induced following the first two aglepristonetreatments (18/18). The mean time to cervicalopening was 25.8 12.2 h. The shortest time was 4 hafter the first administration of aglepristone; however,Table 1Number of bitches cured, at various stages in the trial, based on theform of uterine diseaseDay 14 Day 28 Day 90Metritis (%) 9/15 (60.0) 14/15 (93.3) 15/15 (100)Open pyometra (%) 13/35 (37.1) 20/35 (57.1) 26/35 (74.3)Closed pyometra (%) 2/18 (11.1) 12/17 (70.6) 13/17 (76.5)cervical opening was complete within 48 h in all of thebitches. Cervical opening induced enabled the evacuationof large volumes of purulent discharge, which wasassociated with an immediate improvement in generalcondition and, in most cases, with increased appetite.For bitches with open or closed pyometra, additionaltreatment with cloprostenol from days 3 to 7 improvedthe overall success rate at day 90 (P < 0.05); 27/32(84.4%) with cloprostenol versus 12/20 (60.0%) withoutcloprostenol (Table 2). Recovery was accompanied by agradual decrease in the diameter of the uterine lumen,which became non-detectable ultrasonographically. Themean decrease in the diameter of the uterine lumen overtime depended on the treatment used (Fig. 1) and wassignificantly greater between days 8 and 14 in bitchesreceiving the combined aglepristone–cloprostenol treatmentthan in those treated with aglepristone alone(84.8 20.7% versus 64.6 41.0%).The general condition of bitches suffering frommetritis was not altered; it remained good throughout thetrial. Bitches suffering from open or closed pyometrapresented were depressed and anorexic in 41/53 (77.3%)and 34/53 (64.1%) cases, respectively. In all animalstreated, there was a marked improvement in this criterionby the second day of treatment. On day 8, moderatelethargy was observed in 9 bitches (17.3%) and 14bitches (26.9%) showed loss of appetite. On day 15, allbitches still receiving treatment were in good generalcondition, with only one showing any loss of appetite. Noside effects were observed after treatment with cloprostenolin 15/33 bitches (45.5%). In the remainder, nauseawas the most commonly observed side effect (12/33), andvomiting occurred in six bitches.None of the bitches had a noticeable change in redblood cell count. The mean white blood cell counts inbitches suffering from metritis were normal and,remained lower (P < 0.05) than the counts in bitcheswith open or closed pyometra (Fig. 2) throughout thetrial. In bitches recovering from pyometra, a markeddecrease in leucocytosis was observed over the courseof treatment. This mean decrease was significant on dayTable 2Number of bitches with open or closed pyometra (Group 1 + Group 2)cured by the administration of aglepristone alone compared to thecombined administration of aglepristone + cloprostenolTreatment Day 14 Day 28 Day 90Aglepristone (%) 3/20 (15.0) 9/20 (45.3) 12/20 (60.0)Aglepristone +cloprostenol (%)12/33 (36.4) 23/32 (71.9) 27/32 (84.4)Difference in cure rate between the two treatments on day 90(P < 0.05).

F. Fieni / Theriogenology 66 (2006) 1550–1556 1553Fig. 1. Mean (S.E.M.) rates of decreases in the diameter of the uterine lumen at various stages in the trial, in bitches with open or closed pyometra(Group 1 + Group 2) cured by the administration of aglepristone alone (n = 12), in comparison with those receiving a combination ofaglepristone + cloprostenol (n = 27). (*) Differences (P < 0.05).Fig. 2. Mean (S.E.M.) concentration of leucocytes at various stages in the trial, in bitches with metritis (n = 15), open pyometra (n = 26) or closedpyometra (n = 13) cured by treatment with aglepristone or aglepristone + cloprostenol. For each day, the mean white blood cell count wassignificantly lower in cases of metritis than in cases of open or closed pyometra. In bitches with closed pyometra, the white blood cell count waslower at day 14 (P < 0.01) and at day 28 (P < 0.001) than at day 0.

1554F. Fieni / Theriogenology 66 (2006) 1550–1556Table 3Means (S.D.) plasma progesterone concentrations (nmol/L) in bitches with open or closed pyometra (Group 1 + Group 2) treated with aglepristonealone, compared to those treated with a combination of aglepristone + cloprostenolTreatment Day 1 Day 8 Day 14 Day 28Aglepristone (n = 20) 12.8 14.4 a 5.6 6.6 bx 4.8 5.1 b 3.3 4.2 bAglepristone + cloprostenol (n = 32) 19.3 11.6 a 15.08 10.5 ay 4.7 1.1 b 3.96 2.8 bWithin a row, values with different superscript letters (a and b) differ (P < 0.05); within a column, values with different superscript letters (x and y)differ (P < 0.05).15 for bitches with closed pyometra (Fig. 2). Among the67 treated bitches, on day 1, 15 had plasma progesteroneconcentrations below 3.18 nmol/L. Treatment wassuccessful in all of them, except for two bitches withopen pyometra. For bitches with open or closedpyometra treated with cloprostenol (n = 32), therewas a significant decrease in mean peripheral plasmaprogesterone concentration at day 8 (12.8 14.4 nmol/L versus 5.6 6.6 nmol/L on days 1 versus 8,respectively). However, in bitches treated withoutcloprostenol (n = 20), no significant decrease in meanplasma progesterone concentration was observed untilday 14 (19.3 11.6 nmol/L versus 4.7 1.1 nmol/Lon days 1 versus 14; Table 3).Among the 13 failures using this treatment, onebitch did not present for follow-up and recovery couldnot be confirmed. One bitch with open pyometratreated with aglepristone died on day 5 in the owner’shouse, and another treated with aglepristone andcloprostenol was euthanized in a private clinic on day15 due to declining health. Ten bitches underwent anovariohysterectomy. In this last group, six had ovariancysts. After recovery, 23 bitches underwent follow-upvisits over the 24 months following the beginning oftreatment. Three of them developed pyometra between7 and 12 months later (3/23, 13.0%) and anotherdeveloped it at 19 months (4/21, 19.0%). Two of themreceived an additional, successful course of treatment(aglepristone + cloprostenol) and no pyometra wasobserved at the next cycle. We have kept in contactwith the owners of three of the bitches used in the trialfor some considerable time. They were treated morethan 6 years ago and have come into estrus normally,with no recurrence of uterine disease. Five bitcheswere mated at the first estrus after recovery; fourbecame pregnant.4. DiscussionThe use of aglepristone alone cured 27/35 (77.1%)bitches in 90 days. These results are equivalent tothosereportedbyHoffmannetal.[11] (25/31, 80.6%at day 30) and by Trasch et al. [12] (44/52, 84.6% atday 90). The number of animals treated is insufficientto show any difference in efficacy depending onclinical type (metritis, open pyometra and closedpyometra). This study, however, demonstrated thesatisfactory results obtained fromtheuseofaglepristonein bitches suffering from metritis (recovery rate,15/15). The use of aglepristone is also of particularinterest in the treatment of closed pyometra, since itinduces cervical opening, and the subsequent evacuationof purulent discharge with a marked improvementin the animal’s general condition. These resultsdemonstrated that surgery is no longer the onlytreatment for closed pyometra. Moreover, even ifsurgery has been planned, it is possible to recommendmedication as a first-line treatment (aglepristone andrehydration) to improve the general health of the bitchand minimize surgical risk. In this study, the cervix ofall the bitches with closed pyometra opened within48 h. In a study of nine bitches with closed pyometra,Wehrend et al. [14] observed cervical opening within72 h and the same marked improvement in theanimal’s general condition.In bitches with open or closed pyometra, the repeatedadministration of low dose cloprostenol significantlyincreased the success rate at day 90 (27/32, 84.4%). Theuterotonic action of cloprostenol lead to a significantlyfaster decrease in the diameter of the uterine lumen andits luteolytic action caused a faster drop in mean plasmaprogesterone concentration. This decline in progesteronewas commonly observed in bitches treated forpyometra with cloprostenol alone [15], or withcloprostenol associated with aglepristone [13]. In thepresent study, a decrease in progesterone concentrationswas also observed in bitches treated with aglepristoneonly, but at a later stage. Because of the antiprogesteroneproperties of aglepristone, this luteolysisdoes not seem to modify short-term effectiveness.Between 30 and 90 days, we did not note any correlationbetween blood progesterone concentration and successrate. The low dose of cloprostenol given (1 mg/kg) doesnot usually cause any adverse reactions [16–18].Contrary to the results of a similar study [13], 56%of bitches treated had side effects, usually vomiting.

F. Fieni / Theriogenology 66 (2006) 1550–1556 1555This particular sensitivity to low doses of cloprostenolcan be explained by the poor general condition of thebitches. Nevertheless, the owners did not make anycomments.Among the treated bitches, 17 had basal progesteroneconcentrations. Cases of pyometra were observed atall stages of the reproductive cycle in a previous study[1]. The effects of aglepristone in pyometra have beenstudied in diestrus bitches selected with a progesteroneconcentration of more than 3.2 mm/L [1,10,11]. In thepresent study 15/17 bitches with a low progesteroneconcentration were cured after the administration ofaglepristone. Similar results were observed in anotherreport [13]. This seems to confirm that, in thepathogenesis of pyometra in bitches, the action ofprogesterone on the uterus is dependent on the numberof progesterone receptors or their specific sensitivity,and not on the plasma progesterone concentration ofthis hormone.The recurrence rate of pyometra after treatmentdiffered from results reported in other studies. We didnot observe any recurrence between days 30 and 90,and the cure rate was higher, whereas Trasch et al.[12] reported a recurrence rate of 9.8% (4/41) for thesame interval; this may be due to the length oftreatment and the repeated administration of aglepristoneuntil day 28 if needed (whereas Trasch onlyadministered aglepristone on days 1, 2 and 7). Therecurrence rate from 12 to 14 months after treatmentwas 18.9% (4/37) for Trasch et al. [12], 9% (1/11) forHoffmann et al. [11] and 21.4% (3/14) for Gobelloet al. [13]. The mean age of the bitches (8 years) mayexplain the recurrence of pyometra in the 24 monthsfollowing the end of treatment, since age is a majorepidemiological factor in the onset of pyometra inbitches. However, treatment failure or recurrence ofthe disease is closely linked to the presence of ovariancysts, which maintain a permanent endocrine imbalance.Ovariancystswereobservedin6of10bitcheswho underwent ovariohysterectomy due to the failureof medical treatment.Conservative treatment with prostaglandins, which isrecommended for bitches with metritis or pyometrawith mild dilatation of the uterine lumen, produces acure rate of 83–100%, with recurrence rates varyingfrom 10 to 40%. The treatment, which requires severaladministrations, produces discomfort and is oftenassociated with side effects such as hypersalivation,vomiting and diarrhea [3,4].In conclusion, treatment with aglepristone alone wasa safe and effective treatment for metritis, and aneffective means of inducing cervical opening in cases ofclosed pyometra. The combination of aglepristone andcloprostenol was more effective in the medicaltreatment of open and closed pyometra than aglepristonealone. Nevertheless, in all cases, we onlyrecommend such treatment in bitches with no liver orkidney dysfunction, and advise close clinical monitoringthroughout the entire course of treatment.References[1] Blendiger K, Bostedt H, Hoffmann B. Hormonal effects of theuse of an antiprogestin in the bitches with pyometra. J ReprodFertil 1997;(Suppl. 51):317–25.[2] Noakes DE, Dhaliwal GK, England GC. Cystic endometrialhyperplasic/pyometra in dogs: a review of the causes andpathogenesis. J Reprod Fertil 2001;(Suppl. 57):395–406.[3] Gilbert RO, Nöthling JO, Oettlé EE. A retrospective study of 40cases of canine pyometra–metritis treated with prostaglandinF2a and broad-spectrum antibacterial drugs. J Reprod Fertil1989;(Suppl. 39):225–9.[4] Meyers Wallen VN, Goldschmidt MH, Flickinger GL. ProstaglandinF2a treatment of canine pyometra. J Am Vet Med Assoc1986;189:1557–61.[5] Johnston SD, Root-Kustritz MV, Olson PNS. Disorders of thecanine uterus and uterine tubes. In: Canine and feline theriogenology.Philadelphia: WB Saunders Ed.; 2001. p. 206–24.[6] Fiéni F, Tainturier D, Bruyas JF, Badinand F, Berthelot X, RonsinP, et al. Étude clinique d’une antihormone pour provoquerl’avortement chez la chienne: l’aglépristone. Rec Med Vet1996;172:359–67.[7] Galac S, Kooistra HS, Butinar J, Bevers MM, Dieleman SJ,Voorhout G, et al. Termination of mid-gestation pregnancy inbitches with aglepristone, a progesterone receptor antagonist.Theriogenology 2000;53:941–50.[8] Fieni F, Martal J, Marnet PG, Siliart B, Bernard F, Riou M, et al.Hormonal variation after early or mid-pregnancy termination inbitches with aglepristone (RU534). J Reprod Fertil 2001;(Suppl.57):243–8.[9] Fieni F, Marnet PG, Martal J, Siliart B, Touzeau N, Bruyas JF,et al. Comparison of two protocols to induce parturition inbitches with a progesterone antagonist: aglepristone (RU534).J Reprod Fertil 2001;(Suppl. 57):237–42.[10] Breitkopf M, Hoffmann B, Bostedt H. Treatment of pyometra(cystic endometrial hyperplasia) in bitches with an antiprogestin.J Reprod Fertil 1997;(Suppl. 51):327–31.[11] Hoffmann B, Lemmer W, Fieni F, Linde-Forsberg C, VerstegenJ. Effects of treatments with Aglepristone on the pyometra in thebitch: observations of a multicenter preclinical study. In: Proceedingof the Fifth Annual Conference of the European Societyof Domestic Animal Reproduction; 2001.[12] Trasch K, Wehrend A, Bostedt H. Follow-up examination ofbitches after conservative treatment of pyometra with the antigestagenaglepristone. J Vet Med Assoc 2003;50:375–9.[13] Gobello C, Castex G, Klima L, Rodriguez R, Corrada Y. A studyof two protocols combining aglepristone and cloprostenol totreat open cervix pyometra in the bitch. Theriogenology 2003;60:901–8.[14] Wehrend A, Trasch K, Bostedt H. Treatment of the closed type ofpyometra by the antigestagen, aglepristone, in bitch. Kleintierpraxis2003;48:679–83.

1556F. Fieni / Theriogenology 66 (2006) 1550–1556[15] Tainturier D, Treboz C. Traitement de la métrite chronique de lachienne par le cloprosténol, un analogue de la PgF2a. PMCAC1985;20:239–44.[16] Fieni F, Fuhrer M, Tainturier D, Bruyas JF, Dridi S, Siliart B,et al. Utilisation d’un analogue de synthèse des prostaglandines:le cloprosténol dans l’avortement provoqué de la chienne.PMCAC 1989;24:557–72.[17] Fieni F, Fuhrer M, Tainturier D, Bruyas JF, Dridi S. Use of PGF2a analog, cloprostenol, for pregnancy termination in dogs. JReprod Fertil 1989;(Suppl. 39):332–3.[18] Onclin K, Verstegen JP. Comparisons of different combinationsof analogues of PGF2 alpha and dopamine agonistsfor the termination of pregnancy in dogs. Vet Rec 1999;144:416–9.