Pathogenesis and treatment of endometritis in the mare: a review

Inflammatory conditions of the uterus, collectively known as endometritis, can be classified as acute, chronic, active, or subclinical. This condition causes substantial reductions in mare fertility. To diagnose and treat mares with endometrial inflammation, it is imperative to identify predisposing factors and challenges to the reproductive tract of the mare in a chronological order; these factors change from those of the young maiden filly to the older, multiparous broodmare. This paper addresses predisposing factors, diagnostic procedures and therapy strategies for different mare groups.     

Post-breeding inflammation and endometrial cytology in mares

Endometritis has been reported to be the third most common medical condition of horses. Timely diagnosis and treatment of endometritis in mares increases the chance of pregnancy. Exfoliative endometrial cytology is often used as a clinical tool to evaluate endometrial inflammation through detection of neutrophils. There is a lack of information on the time frame for changes in endometrial cytologic parameters following breeding. The main objectives of this article are to use current information to describe systematic analysis of endometrial cytology using standardized methods for sample collection and interpretation, and discuss how these parameters change in relationship to post-breeding interval and mare susceptibility.     

High concentrations of myeloperoxidase in the equine uterus as an indicator of endometritis

Intraluminal fluid and excessive abnormal hyperedema are regularly used for the diagnosis of endometritis in the mare, which is routinely confirmed by the presence of neutrophils on endometrial smears. Studies show a relation between neutrophils and myeloperoxidase (MPO), an enzyme contained in and released by neutrophils during degranulation or after cell lysis. This enzyme has been found in many fluids and tissues, and associated with different inflammatory pathologies in the horse. The aims of this study were to assess the presence and concentration of MPO in the equine uterus, and to investigate its relation with neutrophils, and other clinical signs of endometritis. Mares (n = 51) were evaluated for the presence of intraluminal fluid and excessive endometrial edema before breeding, and a small volume lavage and cytology samples were obtained. From 69 cycles, supernatant of the uterine flushes was analyzed with a specific equine MPO ELISA assay to measure MPO concentration. Cytology samples were used for the diagnosis of endometritis. Myeloperoxidase was present in the uterus of all estrus mares in highly variable concentrations. Myeloperoxidase concentrations were significantly (P < 0.05) higher in samples with positive cytologies and in the presence of intraluminal fluid. Occasionally, some samples with negative cytologies showed high MPO concentration, but the opposite was never observed. Cycles presenting hyperedema weren't associated with high concentration of MPO, intraluminal fluid, or positive cytology, making it a poor diagnostic tool of endometritis.     

The effects of EDTA-Tris infusion on the equine endometrium

Four groups of five pony mares each were used to determine if the intrauterine infusion of EDTA-Tris solution caused adverse effects on the endometrium. The uteri of mares were infused with either saline or EDTA-Tris solution or biopsied or sham-biopsied without infusion. Acute endometritis developed in one (20%) to three (60%) mares in each group during the seven days following treatment, but there were no differences (P > 0.05) in the incidence of endometritis among the groups. Endometrial fibrosis was not evident in biopsies taken on days 14, 30 and 60 following infusion of saline or EDTA-Tris. It was concluded that the endometrial response to saline and EDTA-Tris was not different and that EDTA-Tris may be a useful adjunct to treatment of uterine infections in the mare.     

Effect of a povidone-iodine intrauterine infusion on progesterone levels and endometrial steroid receptor expression in mares

Background  

Intrauterine infusions have been widely used for the treatment of endometritis in the mare. Nevertheless, their consequences on endocrine and endometrial molecular aspects are unknown. We studied the effect of a 1% povidone-iodine solution intrauterine infusion on progesterone levels, endometrial histology and estrogen (ERα) and progesterone (PR) receptor distribution by immunohistochemistry.     

Disease transmission in horses

Bacterial, viral and protozoal infections may cause severe reproductive losses. The present paper reviews the risk factors, clinical signs and preventive measures for the most important venereal or potential sexually transmitted diseases in horses. The stallion and use of semen for artificial insemination represent major risk factors for the transmission of bacterial contaminants of the penis, including Streptococcus equi subspecies zooepidemicus, Pseudomonas aeruginosa and Klebsiella pneumoniae, known to cause endometritis and infertility in the mare. The role of the stallion in disease transmission is also due to the non-clinical manifestation of diseases such as contagious equine metritis and equine viral arteritis. Dourine has been eradicated from many countries, but continues to be a problem in other areas of the globe. Strategies for the prevention of introduction and transmission of diseases in breeding operation are discussed.     

Comparison of three diagnostic methods to identify subclinical endometritis in mares

The objective of this study was to compare the accuracy of a uterine swab (US), a cytological brush (CB) and an endometrial biopsy (EB) to detect subclinical endometritis in mares. Cytological and bacteriological results of all three techniques were related to histological occurrence of polymorphonuclear neutrophils (PMNs) in the stratum compactum, commonly known as ‘best standard'; to diagnose endometritis.Samples were taken from 55 mares of different breeds without clinical signs of endometritis. Samples for US, CB and EB were collected, smeared on a microscopic slide and cultured for bacterial growth. Endometrial biopsy samples were additionally stored in 4% formaldehyde for histological analysis. Bacteriological cultures and cytological samples of all techniques were classified as negative (no uterine pathogens in monoculture; < 2% PMNs) or positive (uterine pathogens in > 90% of the grown colonies; > 2% PMNs) for endometritis. Uterine pathogens were diagnosed in 20.0% of the mares. Isolation of pathogens was not associated with positive cytological findings (r = −0.23; P = 0.87). None of the six mares with an Escherichia coli infection (10.9%) showed a positive cytological result. In contrast, two of five mares infected with Streptococcus zooepidemicus had a positive cytological result.Histologically, the presence of PMNs in the stratum compactum was regarded as positive for endometritis when the mare was in diestrus at time of sampling. Compared to the ‘best standard', sensitivity for cytology of CB, US and EB was 0.17, 0.00 and 0.25, respectively. Specificity for cytology of CB, US and EB was 0.83, 0.93 and 0.85, respectively. Sensitivity of uterine culture was 0.25, 0.33 and 0.25 for CB, US and EB, respectively. Specificity for culture of CB, US and EB was 0.80, 0.83 and 0.95, respectively. In conclusion, cytological or bacteriological examinations alone provide a high incidence of false negative results. Sensitivity of cytology combined with bacteriology of CB was 0.42. A combination of a bacteriological and a cytological examination of a CB sample improved the diagnostic performance in subfertile mares. Based on these results, we can recommend the CB to improve the diagnosis of subclinical endometritis in the mare compared to the US alone as currently used routine method.     

Development and comparison of in vivo and in vitro models for endometritis in cows and mares

In order to investigate pathogenic mechanisms of acute endometritis in cows and mares, we established an in vivo model in both species. Based on the results of an in vitro transmigration system, human recombinant interleukin-8 (rhIL-8; 1.25 microg per mare and 5 microg per cow in 50 ml phosphate-buffered saline) was used to attract polymorphonuclear neutrophil granulocytes (PMNs) into the uteri. Peak numbers of uterine neutrophils were attracted after 6h, in both cows and mares. On average, mares responded more sensitively than cows, with 15 times higher numbers of rhIL-8-attracted uterine neutrophils (72+/-8 x 10(7)cells). In contrast to in vitro studies, in vivo migrated neutrophils (uterine neutrophils) of both species displayed a significantly reduced MHC class I expression. Expression of the CD11a molecule was significantly enhanced on equine uterine neutrophils but downregulated on bovine cells. Compared with untreated autologous peripheral neutrophils, both uterine and in vitro migrated neutrophils showed no alteration of phagocytic capacity. The ability to generate reactive oxygen species (ROS) was significantly upregulated in bovine and equine uterine neutrophils. This was also observed after in vitro migration of equine neutrophils, whereas ROS generation by bovine neutrophils was significantly depressed. In summary, the concept of inducing endometritis directly by local application of human interleukin-8 has been reliably successful in cows and mares. The model permits the analysis of PMN migration into the uterus under defined and controlled conditions. The observed differences between cows and mares with respect to phenotypical and functional characteristics of in vivo attracted uterine cells point to species-related features of neutrophil migration. In vitro transmigrated bovine and equine cells partially differ in phenotype and function from uterine neutrophils. Therefore, the in vitro transmigration assay cannot completely represent the in vivo endometritis model described here.     

Progesterone and estrogen receptor distribution in the endometrium of the mare

An immunoperoxidase staining technique was used to localize receptors for progesterone and estrogen in the uterus of the mare. Specific staining for receptors was limited to cell nuclei. During estrus, stromal cells tended to stain more intensely for both receptor types than myometrial cells or luminal and glandular epithelial cells. During diestrus, staining intensities in stromal and myometrial cells tended to decrease. Staining intensities of epithelial cells were not affected by the cycle stage. Early pregnancy did not markedly affect the staining intensities of pregnant mares compared with the nonpregnant mares on Day 14 of diestrus. In mares susceptible to endometritis from which samples were taken during diestrus, stromal and myometrial staining for estrogen receptors was more intense than in endometrium from genitally-normal mares.     

Contagious equine metritis: a review

Contagious Equine Metritis (CEM) is a highly contagious venereal disease of horses caused by a fastidious, Gram-negative coccobacillus which grows best on chocolate agar under microaerophilic conditions (5-10% CO2). Clinically, the disease is characterized by a copious watery-to-mucopurulent, vaginal discharge two to ten days after breeding by an infected stallion (11, 13). Shortened estrous cycle lengths are common and may be the only indication of endometritis in some instances (7). Inapparent carriers of the disease in both the mare and stallion make control of the disease more difficult. Outbreaks of CEM have been reported in England, Ireland, France, Australia and the United States. The current information concerning CEM is reviewed.     

Spontaneous recovery or persistence of postpartum endometritis and risk factors for its persistence in Holstein cows

It has been stated that postpartum endometritis in dairy cows has a tendency to cure without intervention. The objectives of this field study, therefore, were to determine the proportions of cows with spontaneous clinical recovery or persistence of postpartum endometritis and to determine some risk factors for its persistency in dairy cows (Bos taurus). Holstein-Friesian cows (n = 441 lactations) from seven dairy herds were examined monthly by vaginoscopy and transrectal palpation. A cow was considered to have “postpartum endometritis” if it had pus in the cervico-vaginal discharge at the first postpartum examination during Days 15 to 60 (Day 0 = day of calving); this was classified as mild, mucopurulent, or purulent endometritis, or endometritis with fluid in uterus. Furthermore, a cow with evidence of endometritis at least once during Days 61 to 150 was considered to have “persistence (or recurrence) of endometritis.” A total of 104 (23.6%) lactations had postpartum endometritis, of which 25.3% had persistence or recurrence of clinical endometritis. Cows with persistence or recurrence of endometritis became pregnant at a slower rate (hazard ratio [HR] = 0.28; P < 0.001) than those with no endometritis until Day 150. Calving in summer (odds ratio [OR] = 7.00; P = 0.04), early postpartum complications (OR = 6.58; P = 0.05), moderate (OR = 4.03; P = 0.08) and severe (OR = 30.99; P = 004) degrees of urovagina, and mucopurulent (OR = 9.54; P = 0.02) and purulent (OR = 5.70; P = 0.04) endometritis were risk factors for the persistence or recurrence of endometritis. Furthermore, 10.6% of cows that had not shown signs of postpartum endometritis had a new diagnosis of endometritis during Days 61 to 150. Some risk factors for the new diagnosis of endometritis beyond Day 60 were early postpartum complications (OR = 2.82; P = 0.03) and moderate (OR = 5.00; P = 0.001) or severe (OR = 12.63; P < 0.001) degrees of urovagina. In conclusion, approximately one quarter of cows with postpartum endometritis had persistence of endometritis until or beyond the breeding period. Risk factors for the persistence of clinical endometritis were summer calving, early postpartum complications, clinically relevant urovagina, and clinically relevant endometritis within 2 mo postpartum.     

Effects of oral treatment with N-acetylcysteine on the viscosity of intrauterine mucus and endometrial function in estrous mares

Persistent breeding-induced endometritis is ranked as the third most common medical problem in the adult mare and leads to enormous economic loss in horse breeding. In mares suffering from persistent breeding-induced endometritis, increased amounts of intrauterine (i.u.) fluid or viscous mucus in estrus or after breeding may act as a barrier for sperm and can contribute to low fertility. Current therapies of these mares aim to eliminate i.u. fluid and mucus by uterine lavage and/or administration of ecbolic drugs. Recently, i.u. administration of N-acetylcysteine (NAC) has been shown to support therapy in mares with endometritis. It was the objective of the present study to investigate effects of an oral administration of NAC on the viscosity of i.u. fluid in estrous mares. It was hypothesized that oral treatment with NAC reduces the viscosity of i.u. fluid and has a positive effect on the inflammatory response of the endometrium. Mares (n = 12) were included in the study as soon as estrus was detected (ovarian follicle >3.0 cm and endometrial edema), which was defined as Day 1. They were randomly assigned to a treatment (10 mg/kg NAC on Days 1-4) or a control group (no treatment). On days 1 and 5 i.u. mucus was collected and its rheologic properties were accessed. On Day 5, endometrial biopsies were obtained and evaluated for integrity of the luminal epithelium, number of polymorphonuclear neutrophils (PMN), staining for cyclooxygenase 2 (COX2), staining with Kiel 67 antigen (Ki-67), lectins and periodic acid Schiff (PAS). In the treatment group, viscosity of i.u. mucus increased significantly between Days 1 and 5 (P < 0.05), while no differences were found in control mares (n.s.). At no time were significant differences between treated and control mares seen. Integrity of epithelium was not affected. After NAC treatment the mean number of PMN in endometrial biopsies was significantly lower compared to mares of the control group (1.9 ± 0.3 vs. 4.8 ± 0.4; P < 0.05). Nuclear immunostaining for COX2 was significantly lower after NAC treatment compared to control mares (P < 0.05). Score for PAS and Alcain staining of mucus in deep uterine glands differed significantly between groups (both P < 0.05). We conclude that oral NAC treatment does not reduce viscosity of uterine mucus but has an antiinflammatory effect on the equine endometrium.     

Detection of parturition in cow and mare by a useful warning system

An automatic device that uses the prolonged elevated position of the tail as an index of parturition in the cow and the mare has been tested, and the tail movements which accompany eliminative behavior and other events have been recorded in pre-partum vs mid-gestation animals.During the last week of pregnancy in the cow and the last 48 h in the mare, the mean elevated positions of the tail, corresponding to urination and defecation, increased from 19.5 to 27.6 from 16.4 to 17.4 per day in the mare.The presence of tail movements lasting more than 2 min in duration occurred at the time of parturition in the cow and the mare, but were also detected occasionally from 2 to 5 days before parturition.The use of a warning system which screens out all tail movements lasting less than 150 sec was found suitable for monitoring the time of parturition, especially in the mare. In this species, the number of false alarms occurred only one or two times during the 48 h preceeding parturition, while in the cow such movements lasting less than 240 sec will eliminate the alarms related to fetal kinesis or uterine contractions rather than parturition.     

The role of nonsporulating anaerobic bacteria in the etiology of postabortion and postpartal endometritis

As the result of the study carried out by the authors, a conclusion has been made on the leading role of polymicrobial aerobic-anaerobic complexes, capable of producing a synergic effect, in the etiology of endometritis, anaerobic microorganisms prevailing in their importance. In the etiology of endometritis the most important organisms are bacteroids and peptostreptococci among anaerobes, enterobacteria and group D streptococci among aerobes. Anaerobic bacteria causing endometritis are most sensitive to dalacin and lincomycin, least sensitive to benzylpenicillin, resistant to aminoglycosides. The amounts of aerobic and anaerobic microflora contaminating the uterine cavity correlate with the severity of endometritis.     

Lysozyme, alkaline phosphatase and neutrophils in uterine secretions of mares with differing resistance to endometritis

A study was conducted to 1) determine differences in the inflammatory response following bacterial challenge between normal mares and mares with chronic endometritis and 2) to determine if enzyme activity in uterine fluid can be used to evaluate degree of inflammation in the equine uterus. Six normal mares (Group 1) and four mares with chronic endometritis (Group 2) received an intrauterine infusion of beta-hemolytic streptococci on the second day of estrus. Neutrophil concentration as well as lysozyme and alkaline phosphatase activity were determined in uterine secretions obtained by placing tampons in the uterus of mares. All mares had a similar inflammatory response following bacterial challenge of the uterus, as indicated by a neutrophil response of the same magnitude. Neutrophil numbers, lysozyme and alkaline phosphatase concentrations were all increased 12 h postinoculation and declined rapidly to normal preinoculation values by 48 h after inoculation. In spite of the similarity of the clinical signs, neutrophil concentrations and enzyme activity, mares in group 1 demonstrated a markedly higher ability to eliminate the infection than mares in group 2. It is concluded that factors other than neutrophil numbers, lysozyme and alkaline phosphatase activity account for the inability of the mare to eliminate uterine infections.     

The mare model for follicular maturation and reproductive aging in the woman

Reproductive aging and assisted reproduction are becoming progressively more relevant in human medicine. Research with human subjects is limited in many aspects, and consequently animal models may have considerable utility. Such models have provided insight into follicular function, oocyte maturation, and reproductive aging. However, models are often selected based on factors other than physiological or functional similarities. Although the mare has received limited attention as a model for reproduction in women, comparisons between these species indicate that the mare has many attributes of a good model. As the mare ages, cyclic and hormonal changes parallel those of older women. The initial sign of reproductive aging in both species is a shortening of the reproductive cycle with elevated concentrations of FSH. Subsequently, cycles become longer with intermittent ovulations and elevated concentrations of FSH and LH. Reproduction ceases with failure of follicular growth and elevated gonadotropins, apparently because of ovarian failure. In the older woman and mare, oocytes have been maintained in meiotic arrest for decades -- approximately four to five for the woman and two to three for the mare; in both species, reduced oocyte quality is the end factor identified in age-associated infertility. After induction of oocyte maturation in vivo, the timeline to ovulation is the same for the mare and woman, suggesting a comparable sequence of events. The mare's anatomy, long follicular phase and single dominant follicle provide a foundation for studies in oocyte and follicular development. The aim of this review is to evaluate the mare as an animal model to study age-associated changes in reproduction and to improve our understanding of oocyte and follicular maturation in vivo.     

Comparison of the cytobrush, cottonswab, and low-volume uterine flush techniques to evaluate endometrial cytology for diagnosing endometritis in chronically infertile mares

Endometritis is the most important cause of infertility in barren mares. The quick method of endometrial cytology (EC) has a relatively high reliability in diagnosing endometrial inflammation in the mare. For reliable cytological results, a collection technique that yields many well-preserved cells representative of a large uterine surface area without causing harm to the reproductive tract is required. The aim of the study was to compare three usually employed techniques for collection of endometrial and inflammatory cells (guarded cotton swab, uterine lavage, and cytobrush) in chronically infertile mares. Twenty Standardbred mares were used. In each mare, samples for EC were collected, first by a cotton swab (DGS), then by a cytobrush (CB), and finally by low volume flush (LVF). The slides were stained using the Diff Quick stain. The following parameters were assessed for each tested technique: background content of the slides; quality of the cells harvested; total cellularity; neutrophils; ratio PMN/uterine epithelial cells; inflammatory cells; vaginal epithelium cells. Categorical variables were compared using contingency tables and Pearson Chi-square tests, whereas continuous variables were compared using one-way analysis of variance (ANOVA); P < 0.05 was considered significant. Samplings by DGS and CB resulted easy and quick to perform via a single operator in all cases. LVF was performed easily, but required the presence of 2-3 players and took more time. The background content of the slides prepared by DGS appeared proteinaceous, slides prepared by LVF appeared contaminated by red blood cells or debris, whereas slides prepared by CB appeared clear. All smears showed a good total cellularity. The CB yielded significantly more cells (P < 0.0001) than DGS and LVF. The DGS produced significant more cells than LVF (P < 0.0001). The DGS produced significantly more (P = 0.003) intact cells than CB and LVF. Distorted cells were significantly (P = 0.001) more frequent in smears by LVF. The CB harvested significantly (P = 0.009) more fragmented cells. CB and LVF produced significantly (P < 0.0001; P = 0.02) more PMNs/HPF than DGS. In smears collected by LVF the proportion of PMNs/uterine epithelial cells was significantly (P = 0.0062; P = 0.0023) higher than in smears by CB and DGS. CB collected a significantly higher (P = 0.0011) proportion of PMNs than DGS. Acute endometritis was diagnosed in 50% (10/20) of the mares by DGS cytological samples, 25% (5/20) by CB, and 75% (15/20) by LVF. Inflammatory cells other than PMN (lymphocytes, macrophages, eosinophils) were collected exclusively by CB method. Epithelial cells from the vagina were only detected in LVF slides. The agreement of the diagnosis of endometritis between the three techniques of collection and between the different criteria adopted to evaluate smears obtained with the same technique was poor (k ≤ 0.3). In conclusion, results show that cytobrush and flush specimens were superior in all parameters to cotton swab smears. Even though the cytobrush technique requires specialized equipment, sample collection by this method was easier, more consistent, and quicker than the lavage method, indicating that the brush would be the preferred collection method for use on field in the mare. More studies are needed to establish criteria for interpretation of inflammation in the mare on cytobrush samples.     

Uterine clearance and resistance to persistent endometritis in the mare

The objective of this article is to review the role of uterine defense mechanisms in natural resistance to chronic or persistent endometritis. A breakdown of uterine physical clearance mechanisms is currently believed to play a major role in susceptibility to persistent endometritis. Mares with increased susceptibility to persistent endometritis have impaired myometrial contractility in response to an acute inflammation, resulting in an accumulation of fluid and inflammatory products within the uterine lumen. The origin of this defect remains unknown. Recent studies have demonstrated that spermatozoa trigger PMN chemotaxis into the uterine lumen. This observation suggests that a transient endometritis is a normal physiological response to breeding. However, in mares with impaired uterine defense mechanisms, the condition may develop into a persistent endometritis and subsequent subfertility. In contrast to spermatozoa, seminal plasma has a suppressive effect on complement activation and PMN chemotaxis (65). The exact role of seminal components in breeding-induced inflammation needs further investigation.     

Endometrial biopsy findings in mares with contagious equine metritis.

Endometrial biopsy samples before and after treatment were obtained from 10 mares naturally infected and one Pony mare experimentally infected with Contagious Equine Metritis in 1977. The histopathological features were a short-lived polymorphonuclear cell infiltration of the luminal epithelium and stroma followed by a very early and marked mononuclear cell infiltration of the stroma, including many plasma cells. The luminal epithelium responded with cellular proliferation which may have reflected a regenerative response. Following the initial acute response, intercellular basal vacuoles containing amorphous and granular material and degenerate leucocytes, were seen in association with the basement membrane for several weeks following infection and apparent recovery. Specimens taken from 9 mares after treatment suggested a varied response. Endometrial biopsy was useful in demonstrating an endometrial response to infection in individual mares prior to the isolation of the causal organism. Its usefullness as a screening test was limited by the ability of mares to harbour the organism in the lower genital tract whilst showing little or no evidence of acute endometritis.     

Ceftiofur derivates in serum and endometrial tissue after intramuscular administration in healthy mares

Endometritis is one of the major problems in the horse breeding industry. The use of antibiotics for treatment of endometritis in the mare is recommended as best practice. The intrauterine application of antibiotics, however, has been under discussion over the last years because of concerns about its efficacy. The systemic use of antibiotics has been considered more effective because of its better distribution within the uterus. The objective of the present study was to determine the concentration of ceftiofur derivates in serum and endometrial tissue after intramuscular administration. Specifically, the authors tested the hypothesis that ceftiofur concentrations in serum and endometrial tissue remain above the minimum inhibitory concentration (MIC) for common uterine pathogens for 24 h. Nine mares in estrus received a single dose of 2.2 mg/kg ceftiofur hydrochloride intramuscular per kg of body weight. Blood samples and endometrial tissue were obtained immediately before treatment (−1 h) and 2 h and 24 h after treatment. Endometrial tissue was collected with a Kevorkian biopsy punch. Additional blood samples were collected 4 h and 10 h after treatment from the jugular veins. For determination of ceftiofur derivates in serum and endometrial tissue a high performance liquid chromatography (HPLC) assay was used. Results in serum and uterine tissue revealed greatest concentration of ceftiofur at 2 h and lowest concentrations at 24 h after treatment. Concentrations of ceftiofur at 2 and 24 h after treatment were significantly greater in serum than in endometrial tissue, but remained above the reported MIC for Streptococcus equi zooepidemicus and Escherichia coli in both serum and endometrial tissue until 24 h after treatment.