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Resumen ANTECEDENTES: Los leiomiomas son neoplasias benignas comunes durante la edad reproductiva. Su aparición en adolescentes es excepcional y un reto diagnóstico en menores de 18 años de edad. El caso aquí reportado se integra a los 26 casos asentados en la bibliografía y se trata del tumor más grande en la paciente más joven hasta ahora comunicado. CASO CLÍNICO: Paciente de 14 años, con inicio de sangrado uterino anormal, aumento del perímetro abdominal y tres semanas con hipermenorrea. El reporte inicial de la química sanguínea informó: anemia severa y el ultrasonido pélvico: un gran tumor anexial sólido. Luego de mejorar las condiciones hemodinámicas de la paciente por medio de transfusiones de concentrados eritrocitarios se practicó una laparotomía exploradora y se extirpó un leiomioma gigante, dependiente del útero. El informe histopatológico fue de: leiomioma de 16 cm de diámetro, con degeneración roja. La paciente cursó sin complicaciones posquirúrgicas y hasta la actualidad no ha experimentado datos de recurrencia ni sangrado uterino anormal. CONCLUSIÓN: La fisiopatología de la miomatosis uterina sigue aún sin comprenderse del todo. El tratamiento quirúrgico a una edad temprana debe tomar en consideración el deseo de embarazo y llevar a cabo un seguimiento estrecho para valorar: la fertilidad, recurrencia, atipia celular y trastornos menstruales.

Abstract BACKGROUND: Leiomyomas are common benign neoplasms during reproductive age. Its appearance in adolescents is exceptional and a diagnostic challenge in children under 18 years of age. The case reported here is one of the 26 cases reported in the bibliography and it is the largest tumor reported in the youngest patient to date. CLINICAL CASE: A 14-year-old patient with onset of abnormal uterine bleeding, increased abdominal circumference and three weeks with hypermenorrhea. Initial blood chemistry report: severe anemia and pelvic ultrasound: a large solid adnexal tumor. After improving the patient's hemodynamic conditions through transfusions of erythrocyte concentrates, an exploratory laparotomy was performed and a giant leiomyoma, dependent on the uterus, was removed. The histopathological report was: leiomyoma of 16 cm in diameter, with red degeneration. The patient had no postoperative complications and to date she has not experienced recurrence or abnormal uterine bleeding. CONCLUSION: The pathophysiology of uterine fibroids remains poorly understood. Surgical treatment at an early age should take into account the desire for pregnancy and carry out a close follow-up to assess: fertility, recurrence, cellular atypia and menstrual disorders.

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ABSTRACT Introduction: breast cancer is the cancer with the highest incidence in women in Brazil, representing 29.7% of all cancers. More than two thirds of women with breast cancer show expression for hormone receptors, and in these cases, hormone therapy with tamoxifen is indicated, which may represent a risk factor for the development of endometrial cancer (four-fold greater relative risk). Objective: this study aimed to evaluate the association of tamoxifen and the development of endometrial disturbances and to assess possible other associated risk factors. Patients and method: a total of 364 breast cancer patients were evaluated, 286 who used tamoxifen and 78 who did not use this hormone therapy. Results: patients who used tamoxifen had a mean follow-up time of 51.42 months similar to those without hormone therapy (p=0.081). A total of 21 (7.3%) women who used tamofixen and no cases among women without hormone therapy presented endometrial changes during follow-up (p=0.01). Despite information regarding obesity was available for only 270 women, obesity was also significantly associated with the development of endometrial changes (p=0.008). Conclusion: furthermore, the association between tamofixen and endometrial changes remained significant (p=0.039) after adjusting for obesity.

RESUMO Introdução: o câncer da mama é o câncer de maior incidência no sexo feminino no Brasil, representando 29,7% de todos os cânceres. Mais de dois terços das mulheres com câncer da mama apresentam expressão para receptores hormonais, estando, nestes casos, indicada a terapia hormonal com tamoxifeno, que pode representar fator de risco para o desenvolvimento do câncer do endométrio (risco relativo quatro vezes maior). Objetivo: este trabalho teve como objetivo avaliar a associação entre o uso de tamoxifeno e o desenvolvimento de distúrbios endometriais bem como eventuais outros fatores associados. Pacientes e método: Estudo de coorte retrospectivo de 364 pacientes com câncer da mama, das quais 286 utilizaram tamoxifeno e 78 não utilizaram esta hormonioterapia. Resultados: pacientes que usaram tamoxifeno tiveram um seguimento médio de 51,42 meses, semelhante àquelas sem terapia hormonal (p=0,081). Um total de 21 (7,3%) mulheres que usaram tamofixeno e nenhuma mulher sem terapia hormonal apresentaram alterações endometriais durante o seguimento (p=0,01). Nas 270 mulheres que tinham informação sobre obesidade, esta se associou significantemente com o desenvolvimento de alterações endometriais (p=0,008). A associação entre tamofixeno e alterações endometriais permaneceu significante (p=0,039) após ajustar para interação com obesidade. Conclusão: o uso de tamoxifeno no tratamento do câncer da mama esteve associado ao maior risco para desenvolvimento de alterações endometriais especialmente quando associado à obesidade.

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Innate immunity is the principal sensor responsible of the local immune response to control mucosal bacterial contamination of the reproductive tract after parturition, triggering a pro-inflammatory process in the mucosa of the uterus, the vaginal and the cervix. However, knowledge about the inflammation process and outcome of the cervix in dairy cows is scarce even though it plays an important anatomic and functional role between the vagina and the uterus. The objective of the present study was to describe the cellular and humoral local innate immune response during clinical cervicitis (CC) in the uterus and vaginal fornix in pre- and post-partum periods of dairy cows. A retrospective descriptive study was performed involving 26 animals, characterized as clinical cervicitis cows (n = 19) and healthy cows (n = 7). Blood and mucus of the different compartments of the genital tract were sampled and records of the cows' genital exam were performed four times: -1 w (day -7 ± 2, prepartum), +1 w (day +7 ± 4), +3 w (day +21 ± 4) and +5 w (day +35 ± 4) postpartum. Clinical cervicitis was defined as cows exhibiting a cervix grade-2 and healthy cows were defined as a cow clinically normal with a grade-0 cervix at time +5 w. Blood white cell count, vaginal fornix and endometrial neutrophils percentage, and the concentrations of interleukin 1α (IL1), interleukin 8 (IL8), and α1-acid glycoprotein (AGP) in mucus were determined. The results showed that 23% of the cows were categorized as CC at time +5 w. Cases of CC with purulent vaginal discharge or subclinical endometritis shown the highest cytokine production. At +3 w, IL1, IL8, and AGP concentrations in the uterus and the fornix were significantly higher in CC than healthy cows (CH). In conclusion, the 3-week postpartum is a critical point to evaluate cytokines and acute phase proteins; where IL1 and IL8 variation kept a direct relation with neutrophils numbers and function. The presence of AGP in the endometrium infer a homeostatic proinflammatory protective balance effect, modulating the local uterine innate immune response during peripartum.

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Resumen OBJETIVO: Comunicar la nueva terminología del sangrado uterino anormal y de la clasificación PALM COEIN. MÉTODO: Búsqueda bibliográfica de artículos publicados en inglés o español con la palabra clave PALM COEIN. Desde el primer artículo publicado en 2010 hasta 2018 en las bases de datos MedLine, PubMed, Embase y Ovid. RESULTADOS: Se reunieron 64 artículos, pero solo 18 mencionaban el término, 24 eran repetidos. Se seleccionaron 22 que trataban el tema en estudio y eran referidos con la clasificación actual, de esos trabajos 6 eran de cohorte, 2 de revisión sistemática, 2 boletines y 12 revisiones de tema. CONCLUSIÓN: Esta nueva terminología facilitará el entendimiento y la comunicación, independiente del idioma y la cultura, además del acercamiento más entendible con nuestras pacientes. La clasificación PALM COEIN facilita la investigación epidemiológica, etiológica y el tratamiento de las pacientes con sangrado uterino anormal.

Abstract OBJECTIVE: To update the new terminology of abnormal uterine bleeding and the PALM COEIN classification METHOD: Bibliographic search of articles published in English or Spanish with the keyword PALM COEIN. From the first article published in 2010 to 2018 in the MedLine, PubMed, Embase and Ovid databases. RESULTS: 64 articles were collected, but only 18 mentioned the term, 24 were repeated. 22 were selected that dealt with the subject under study and were referred to with the current classification, of these works 6 were cohort, 2 systematic review, 2 newsletters and 12 theme reviews. CONCLUSION: This new terminology will facilitate understanding and communication, independent of language and culture, in addition to the most understandable approach with our patients. This classification of PALM COEIN facilitates the epidemiological, etiological investigation and treatment of patients with abnormal uterine bleeding.

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SUMMARY Uterine inversion is an uncommon complication of the puerperium and it is an even rarer complication of the non-puerperal period. In this way, uterine inversions are classified into two groups, being of puerperal origin due to obstetric problems and non-puerperal origin due to gynecological problems. In general, a non-puerperal uterine inversion occurs as a possible complication of a sub mucosal leiomyoma, after an expansive process, a dilation of the cervix occurs and thus its protuberance over the vaginal canal.

RESUMO A inversão uterina é uma complicação incomum do puerpério e é uma complicação ainda mais rara do período não puerperal. Dessa forma, as inversões uterinas são classificadas em dois grupos, sendo as de origem puerperal decorrentes de problemas obstétricos e as inversões de origem não puerperal decorrentes de problemas ginecológicos. Em geral, a inversão uterina não puerperal decorre como uma possível complicação de um leiomioma submucoso — após o processo expansivo, ocorre a dilatação do colo uterino e, dessa forma, a sua protusão sobre o canal vaginal.

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ABSTRACT Objective: To evaluate the best surgical approach for the female urinary incontinence. Methods: Systematic review conducted in MEDLINE® Cochrane, EMBASE and LILACS database up to September 1st, 2017. Articles were selected according to study type, type of intervention and outcomes. Articles were selected by more than one researcher based on title, abstract and full text. The SIGN checklist was used for bias assessment. Results: A total of 165 articles were retrieved from MEDLINE® . Twenty-five studies were elected for full text reading, and 11 of them were selected for the final text analysis. The heterogeneity between questionnaires used in different studies precluded a meta-analysis of results. Conclusion: This study yielded evidences supporting the hypothesis that total and subtotal hysterectomy have different impacts on urinary function of patients with benign uterine diseases. Articles revealed higher frequency of urinary incontinence following subtotal compared to total hysterectomy.

RESUMO Objetivo: Avaliar qual a melhor conduta cirúrgica na incontinência urinária feminina. Métodos: Revisão sistemática conduzida no MEDLINE®, Cochrane, EMBASE e LILACS até 1º de setembro de 2017. Os artigos foram escolhidos de acordo com o tipo de estudo e de intervenção, e seus resultados. Os artigos foram selecionados por mais de um pesquisador, com base no título, no resumo e no texto completo. O checklist SIGN foi usado para avaliar vieses. Resultados: No MEDLINE®, foram recuperados 165 artigos. Foram escolhidos 25 estudos para leitura do texto completo, e somente 11 foram escolhidos para análise do texto final. Não foi realizada metanálise dos resultados devido à heterogeneidade dos questionários usados em cada estudo. Conclusão: Encontrou-se evidência que suporta a hipótese de que as histerectomias total e subtotal causam impactos diferentes na função urinária de pacientes com doença uterina benigna. Os artigos mostraram maior frequência de incontinência urinária após histerectomia subtotal quando comparada à total.

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Resumen OBJETIVO: Revisar la bibliografía de la prevalencia, factores de riesgo, síntomas, diagnósticos y tratamiento de las pacientes con istmocele. MÉTODO: Búsqueda electrónica en las bases de datos: PubMed, EMBASE y Google Scholar. Se utilizaron los siguientes términos, palabras y sus combinaciones: "Cesarean section defect, uterine niche, isthmocele, uterine sacculation, uterine diverticulum, uterine pouch, isthmocele diagnosis, segmentocele y isthmocele treatment". La variable primaria estudiada fueron los síntomas asociados con el istmocele. Las variables secundarias: prevalencia, factores de riesgo, diagnóstico y tratamiento. RESULTADOS: Se reunieron 549 artículos de los que se eliminaron 288 por duplicidad y 228 no cumplieron los criterios de inclusión; al final solo se analizaron 33 artículos. El istmocele tiene una prevalencia de 15 a 84% en mujeres con antecedente de cesárea. Su incidencia se correlaciona directamente con la cantidad de cesáreas previas. Su aparición puede ser sintomática o asintomática. La manifestación clínica más común es el sangrado uterino anormal, que sucede en 28.9 a 82% de los casos. Incluso 88% se diagnostican en el ultrasonido transvaginal. La histeroscopia quirúrgica se asoció con disminución de los síntomas en 56.9 a 100%. CONCLUSIONES: El istmocele suele identificarse de manera fortuita en el ultrasonido transvaginal y casi siempre es asintomático. Puede ocasionar sangrado uterino anormal e infertilidad secundaria. Su prevalencia depende del método diagnóstico utilizado. La histeroscopia es el método de tratamiento más efectivo.

Abstract OBJECTIVE: Review the literature on the prevalence, risk factors, symptoms, diagnoses and treatment of patients with isthmocele. METHOD: An electronic search was performed using the following databases: PubMed, EMBASE and Google Scholar. The following terms, words and their combinations were used: "Cesarean section defect, uterine niche, isthmocele, uterine sacculation, uterine diverticulum, uterine pouch, isthmocele diagnosis, segmentocele y isthmocele treatment". The primary outcome was the symptoms associated with a cesarean scar defect. The secondary outcomes were prevalence, risk factors, diagnosis and treatment of istomocele. RESULTS: 549 articles were collected, of which 288 were eliminated due to duplication and 228 did not meet the inclusion criteria; In the end, only 33 articles were analyzed. A prevalence of 15 to 84% was found in women with a previous caesarean section. The prevalence of this alteration is correlated with the number of cesarean sections; the greater the number of caesarean sections, the greater the risk of developing an isthmocele. Its presence can be symptomatic or asymptomatic. The most common symptom is abnormal uterine bleeding, occurring in a 28.9% to 82% of the patients. Up to 88% of cases are diagnosed by a transvaginal ultrasound. A surgical hysteroscopy was associated with a 56.9% to a 100% improvement of symptoms. CONCLUSIONS: Isthmocele is commonly identified incidentally through a transvaginal ultrasound and is usually asymptomatic. It can cause abnormal uterine bleeding and secondary infertility. Its prevalence depends on the diagnostic method used. A surgical hysteroscopy is the most effective treatment method.

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El objetivo de este artículo es revisar los criterios ecográficos de hiperplasia endometrial y evaluar los puntos de corte para indicar la realización de biopsia endometrial. Se reporta el caso de una mujer de 47 años, con cuadro clínico de 4 años de evolución de sangrado vaginal anormal tipo menorragia, metrorragia e hipermenorrea, en manejo con anticonceptivos orales, sin mejoría, y con ecografía transvaginal con diagnóstico de hiperplasia endometrial. Para el diagnóstico de patología endometrial en las mujeres posmenopáusicas con sangrado vaginal, los autores recomiendan un valor de corte del grosor endometrial por ecografía transvaginal entre 4-5 mm con sensibilidad del 98% y valor predictivo negativo del 99% debido a que valores superiores están altamente relacionados con carcinoma endometrial.

The aim of this article is to review the sonographic criteria of endometrial hyperplasia and define the cutoff value to indicate the completion of the endometrial biopsy due to its relationship with the risk of endometrial carcinoma. We report the case of a woman aged 47 with four years of vaginal bleeding characterized by menorrhagia, metrorrhagia, and hypermenorrhea being treated with oral contraceptives without improvement, and transvaginal ultrasound diagnosis of endometrial hyperplasia. For the diagnosis of endometrial pathology in postmenopausal women with vaginal bleeding, the authors recommend a cutoff value of endometrial thickness by transvaginal ultrasound of 4-5 mm with sensitivity of 98% and negative predictive value of 99% since higher values are closely related to endometrial carcinoma.

O objetivo deste artigo é revisar os critérios ecográficos de hiperplasia endometrial e avaliar os pontos de corte para indicar a realização de biopsia endometrial. Se reporta o caso de uma mulher de 47 anos, com quadro clínico de 4 anos de evolução de sangrado vaginal anormal tipo menorragia, metrorragia e hipermenorreia, em manejo com anticonceptivos orais, sem melhora, com ecografia transvaginal com diagnóstico de hiperplasia endometrial. Para o diagnóstico de patologia endometrial nas mulheres pós-menopáusicas com sangrado vaginal, os autores recomendam um valor de corte do espessura endometrial por ecografia transvaginal entre 4-5 mmcom sensibilidade de 98% e valor preditivo negativo de 99% devido a que valores superiores estão altamente relacionados com carcinoma endometrial.

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Postpartum uterine diseases are important for animal welfare and economic reasons, causing cow discomfort, elimination from the herd and impaired reproductive performance. Metritis is characterized as an abnormally enlarged uterus and a fetid, watery, red-brown uterine discharge within 21 days after parturition. Endometritis is defined as inflammation of the endometrium after 21 days postpartum without systemic signs of illness, and can be considered the chronic stage of uterine inflammation. It has been reported that the metritis affects 10 to 20% of cows, and endometritis affects 5.3 to 52.6% of cows. Metritis affects the cow systemically, and has a negative impact on milk production and reproductive performance. Cows affected with endometritis are not systemically ill, and do not have their milk production altered; however, they have impaired reproductive performance. Metritis and endometritis are complex multifactorial diseases, and a wide range of factors contributes to their occurrence. They are often associated with mixed bacterial infection of the uterus, and the major pathogens associated with uterine diseases are Escherichia coli, Trueperella pyogenes and Fusobacterium necrophorum. Events during the transition period related to negative energy balance and metabolic imbalance, mineral deficiencies, leading to immunosuppression are of great important during establishment of intrauterine bacterial infections. This, combined with endometrium trauma events during parturition (such as calving related problems), and environmental factors (poor hygiene at calving, housing type and calving season), increases the risk of metritis and endometritis.

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Postpartum uterine diseases are important for animal welfare and economic reasons, causing cow discomfort, elimination from the herd and impaired reproductive performance. Metritis is characterized as an abnormally enlarged uterus and a fetid, watery, red-brown uterine discharge within 21 days after parturition. Endometritis is defined as inflammation of the endometrium after 21 days postpartum without systemic signs of illness, and can be considered the chronic stage of uterine inflammation. It has been reported that the metritis affects 10 to 20% of cows, and endometritis affects 5.3 to 52.6% of cows. Metritis affects the cow systemically, and has a negative impact on milk production and reproductive performance. Cows affected with endometritis are not systemically ill, and do not have their milk production altered; however, they have impaired reproductive performance. Metritis and endometritis are complex multifactorial diseases, and a wide range of factors contributes to their occurrence. They are often associated with mixed bacterial infection of the uterus, and the major pathogens associated with uterine diseases are Escherichia coli, Trueperella pyogenes and Fusobacterium necrophorum. Events during the transition period related to negative energy balance and metabolic imbalance, mineral deficiencies, leading to immunosuppression are of great important during establishment of intrauterine bacterial infections. This, combined with endometrium trauma events during parturition (such as calving related problems), and environmental factors (poor hygiene at calving, housing type and calving season), increases the risk of metritis and endometritis.(AU)

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As células endometriais apresentam modificações nos mecanismos de defesa, que consistem em imunotolerância aos espermatozoides e ao feto, considerados alogênicos, ou intolerância aos microrganismos invasores que contaminam o ambiente uterino durante a cópula ou após o parto. A regulação da resposta imunológica determina a importância do endométrio para a manutenção da fertilidade, verificando-se que processos inflamatórios exacerbados e/ou persistentes são prejudiciais. O impacto econômico decorrente da subfertilidade associada às elevadas incidências de doenças uterinas estimula a realização de estudos que visam compreender os mecanismos envolvidos na imunidade do trato reprodutivo das mulheres e fêmeas das espécies domésticas. As principais informações obtidas nos últimos anos serão abordadas nesta revisão de literatura, com foco especial em vacas leiteiras.

The endometrial cells present changes in defense mechanisms, which consist of immune tolerance to allogeneic sperm and fetus, or intolerance to invading microorganisms that contaminate the uterine environment during the copulation or after the parturition. The regulation of the immune response determines the importance of the endometrium to maintain fertility of cows, verifying that exacerbated and/or persistent inflammatory conditions are harmful. The damages arising from subfertility associated with high incidence of uterine diseases stimulate the accomplishment of studies with the aim of understanding the mechanisms involved in immunity of the reproductive tract of women and females of domestic species. The main information will be reported in this review, with focus in dairy cows.

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As células endometriais apresentam modificações nos mecanismos de defesa, que consistem em imunotolerância aos espermatozoides e ao feto, considerados alogênicos, ou intolerância aos microrganismos invasores que contaminam o ambiente uterino durante a cópula ou após o parto. A regulação da resposta imunológica determina a importância do endométrio para a manutenção da fertilidade, verificando-se que processos inflamatórios exacerbados e/ou persistentes são prejudiciais. O impacto econômico decorrente da subfertilidade associada às elevadas incidências de doenças uterinas estimula a realização de estudos que visam compreender os mecanismos envolvidos na imunidade do trato reprodutivo das mulheres e fêmeas das espécies domésticas. As principais informações obtidas nos últimos anos serão abordadas nesta revisão de literatura, com foco especial em vacas leiteiras.(AU)

The endometrial cells present changes in defense mechanisms, which consist of immune tolerance to allogeneic sperm and fetus, or intolerance to invading microorganisms that contaminate the uterine environment during the copulation or after the parturition. The regulation of the immune response determines the importance of the endometrium to maintain fertility of cows, verifying that exacerbated and/or persistent inflammatory conditions are harmful. The damages arising from subfertility associated with high incidence of uterine diseases stimulate the accomplishment of studies with the aim of understanding the mechanisms involved in immunity of the reproductive tract of women and females of domestic species. The main information will be reported in this review, with focus in dairy cows.(AU)

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La piometra es una acumulación de pus en la cavidad endometrial. Aparece cuando existe una estenosis del orificio cervical debida a procesos malignos de cuerpo uterino o de cérvix, tras tratamientos con cirugía o radioterapia y por atrofia senil. Se presenta el caso de una paciente de 84 años remitida al Servicio de Urgencias Hospitalarias del Hospital Universitario Basurto, en Bilbao, España por el médico de la residencia donde se encuentra institucionalizada debido a que presentaba fiebre mantenida desde hacía dos semanas, sin focalidad aparente, diagnosticada como infección urinaria y tratada con amoxicilina-clavulánico. Por los exámenes imagenológicos se diagnosticó piometra en útero bicorne. Fue sometida al drenaje del piometra por vía vaginal, bajo anestesia general, tras dilatación mecánica del canal cervical. Se puso tratamiento con ertapenen. La evolución fue satisfactoria. Por lo poco común del caso se decidió su presentación.

Pyometra is an accumulation of pus in the endometrial cavity. It occurs when there is a stenosed cervical os as a result of malignant growths in the uterus or cervix, surgery or radiation therapy and senile atrophy. We present the case of an 84-year-old female patient referred to the Emergency Service of the Basurto University Hospital in Bilbao, Spain by the doctor of the nursing home where she is institutionalized because of a two-week history of continued fever without apparent cause. She was diagnosed with urinary tract infection and treated with amoxicillin/clavulanate. Based on the imaging tests, a pyometra in bicornuate uterus was diagnosed. She underwent drainage of the pyometra via the vaginal route, under general anesthesia, after mechanical dilation of the cervical canal. Treatment with ertapenen was prescribed. Progression was satisfactory. Given the rarity of this case, we decided to present it.

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O puerpério é conhecido como o período que se inicia após o parto e persiste até o restabelecimento da condição de um animal não gestante. Compreendem na liberação dos restos placentários, involução uterina e mecanismos tais como contração uterina e digestão enzimática contribuem para a correta execução desses processos. Sua duração é variável e dependente de vários fatores tais como escore de condição corporal (ECC), produção leiteira, nutrição, condição uterina, entre outros. Tem-se também que para o estabelecimento de nova prenhez, é necessário que ocorra o retorno à ciclicidade por meio do crescimento, maturação e ovulação de um folículo e oócito sadios. Tal fato pode ser afetado pela presença do bezerro, amamentação e ECC em bovinos de corte e balanço energético, escore corporal, parição, estação do ano e doenças em bovinos de leite. Adicionalmente, é de extrema importância a característica do útero para o restabelecimento do estado reprodutivo fisiológico. Doenças uterinas podem afetar na liberação de substâncias que podem ser responsáveis pelo encurtamento ou prolongamento dos ciclos ovarianos, o que pode ocasionar perdas econômicas pelo fato de não atingir-se o desejável de produção de um bezerro/vaca/ano.

The postpartum period is known as the period that begins after birth and persists until the recovery of the condition of an animal that is not pregnant. They include the release of placental membranes, the uterine involution and mechanisms such as uterine contraction and enzymatic digestion contribute to the proper execution of these processes. Its duration is variable and dependent on several factors such as body condition score (BCS), milk production, nutrition, uterine condition, among others. It has also for the establishment of new pregnancy, it is necessary the return to cyclicity through growth, maturation and ovulation of a healthy follicle and oocyte. This can be affected by the presence of the calf, breast-feeding and BCS in beef cattle and energy balance, body condition score, parity, season and disease in dairy cattle. Additionally, it is extremely important the characteristic of the uterus for restoration, reproductive physiology. Uterine diseases can affect the release of substances that may be responsible for shortening or lengthening of ovarian cycles, which can cause economic losses because of not achieving is desirable to produce a calf / cow / year.

El puerperio es conocido como el periodo que se inicia después del parto y persiste hasta el restablecimiento de la condición de un animal no gestante. Comprende desde la liberación de los restos placentarios, involución uterina y mecanismos tales como contracción uterina y digestión enzimática, que contribuyen para la correcta ejecución de estos procesos. Su duración es variable y depende de varios factores, como condición corporal (CC), producción lechera, nutrición, estado del útero, entre otros. Para el restablecimiento de una nueva preñez, es necesario que ocurra el retorno del ciclo estral por medio del crecimiento, maduración y ovulación de un folículo y oocito sanos. Esto puede ser afectado por la presencia del ternero, amamantamiento y condición corporal en bovinos de corte y balance energético, condición corporal, parto, estación del año y enfermedades en bovinos de leche. Adicionalmente, es de extrema importancia la característica del útero para el restablecimiento del estado reproductivo fisiológico. Enfermedades uterinas pueden afectar la liberación de sustancias que pueden ser responsables del acortamiento o prolongación de los ciclos ovarianos, lo que puede ocasionar perdidas económicas por el hecho de no alcanzar lo deseado de producción de 1 ternero/vaca/año.

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Uterine diseases such as metritis and endometritis are highly prevalent in high producing dairy cows. These diseases lead to impaired welfare and fertility , and result in economic loss. The objective of this review article is to provide the current understanding of the underlying causes of uterine diseases and to provide some strategies to prevent them. The causes of uterine diseases are complex and multifactorial; therefore a holistic approach must be taken when trying identitythe causes or prevent them. The dairy cow undergoes a state of negative energy, mineral and vitamin balance during the transition into lactation, which leads to immunosuppression and increased susceptibility to disease. The main risk factors for uterine diseases are primiparity (for metritis only), dystocia , male offspring, twins, stillbirth, abortion, prolapsed uterus, retained placenta (RP), ketosis, and hypocalcemia. Prevention strategies should be focused on maximizing cow comfort and dry matter intake (DMI), preventing hypocalcemia and hyperketonemia, preventing dystocia, prolapsed uterus, abortion, stillbirth and RP. Maximization of cow comfort and DMI can be achieved with appropriate housing and cooling. Management strategies to prevent metabolic and calving related problems include the use of anionic diets, the use of feed additives such as monensin and rumen protected choline, implementation of sound vaccination programs, and the use of sexed semen. Trace mineral and vitamin supplementation beyond what is fed in the diet is still controversial; however some trial s have shown a decrease in RP and stillbirths.mProphylactic treatment ofmcows at high risk for metritis with PGF2α and/ormoxytocin is not warrantedmbecause there is no beneficialmeffect. Prophylactic treatment of cows at high risk for metritis with NSAIDs is contraindicated because it has been found to decrease DMI and increase the degree of negative energy balance; therefore, leading to an increase in the risk of RP and metritis. Prophylactic treatment of cows at high risk for metritis with estradiol is contraindicated because there is no beneficial e ffect on the prevention of metritis and there is a negative effect on long term fertility. Prophylactic treatment of cows at high risk for metritis with antibiotics can reduce the incidence of uterine disease but has no positive longterm effects on fertil ity; therefore, decision to implement prophylactic antibiotic treatment should be based on welfare, economic and legal considerations. Given that most treatments are not very efficacious, efforts should be focused on management strategies to decrease metab olic problems such as hypocalcemia and ketosis, and to prevent risk factors such as dystocia, male calves, abortions, stillbirths, and retained placenta.

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Uterine diseases such as metritis and endometritis are highly prevalent in high producing dairy cows. These diseases lead to impaired welfare and fertility , and result in economic loss. The objective of this review article is to provide the current understanding of the underlying causes of uterine diseases and to provide some strategies to prevent them. The causes of uterine diseases are complex and multifactorial; therefore a holistic approach must be taken when trying identitythe causes or prevent them. The dairy cow undergoes a state of negative energy, mineral and vitamin balance during the transition into lactation, which leads to immunosuppression and increased susceptibility to disease. The main risk factors for uterine diseases are primiparity (for metritis only), dystocia , male offspring, twins, stillbirth, abortion, prolapsed uterus, retained placenta (RP), ketosis, and hypocalcemia. Prevention strategies should be focused on maximizing cow comfort and dry matter intake (DMI), preventing hypocalcemia and hyperketonemia, preventing dystocia, prolapsed uterus, abortion, stillbirth and RP. Maximization of cow comfort and DMI can be achieved with appropriate housing and cooling. Management strategies to prevent metabolic and calving related problems include the use of anionic diets, the use of feed additives such as monensin and rumen protected choline, implementation of sound vaccination programs, and the use of sexed semen. Trace mineral and vitamin supplementation beyond what is fed in the diet is still controversial; however some trial s have shown a decrease in RP and stillbirths.mProphylactic treatment ofmcows at high risk for metritis with PGF2α and/ormoxytocin is not warrantedmbecause there is no beneficialmeffect. Prophylactic treatment of cows at high risk for metritis with NSAIDs is contraindicated because it has been found to decrease DMI and increase the degree of negative energy balance; therefore, leading to an increase in the risk of RP and metritis. Prophylactic treatment of cows at high risk for metritis with estradiol is contraindicated because there is no beneficial e ffect on the prevention of metritis and there is a negative effect on long term fertility. Prophylactic treatment of cows at high risk for metritis with antibiotics can reduce the incidence of uterine disease but has no positive longterm effects on fertil ity; therefore, decision to implement prophylactic antibiotic treatment should be based on welfare, economic and legal considerations. Given that most treatments are not very efficacious, efforts should be focused on management strategies to decrease metab olic problems such as hypocalcemia and ketosis, and to prevent risk factors such as dystocia, male calves, abortions, stillbirths, and retained placenta.(AU)

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Objetivou-se comparar duas técnicas frequentemente usadas na colheita de células endometriais e inflamatórias e caracterizar a citologia endometrial (CE) de vacas leiteiras mestiças no pós-parto fisiológico, criadas em sistemas de fazendas leiteiras do sudoeste do Brasil. Foram utilizadas 34 vacas clinicamente sadias com parto e puerpério fisiológico, completa involução uterina e sem qualquer tratamento até os 42 dias pós-parto (dpp). Realizou-se o exame clínico e ginecológico no parto e aos 7, 14, 21, 28 e 42 dpp. O exame ginecológico foi executado pela palpação retal, ultrassonografia, vaginoscopia, avaliação de muco vaginal e CE realizada com escova citológica (CB) ou por lavado uterino de baixo volume (LVF). A concordância (Kappa statistic) entre os técnicos na contagem da porcentagem de neutrófilos foi boa para CB (86%) e para LVF (80,3%). A média de neutrófilos foi maior em todos os momentos na técnica de LVF, porém a redução de neutrófilos foi observada durante o pós-parto nas duas técnicas de citologia. A contagem de macrófagos, linfócitos e eosinófilos não variou durante o pós-parto e não houve diferença entre as técnicas CB e LVF. Houve diferença apenas aos 28 dpp, na porcentagem de vacas com endometrite subclínica, entre as técnicas CB (22.2%) e LVF (59.3%).

This study compared two frequently employed techniques for the collection of endometrial and inflammatory cells and characterized postpartum endometrial cytology (EC) of clinically normal postpartum crossbred dairy cows in dairy farming system in Southwestern Brazil. Thirty-four crossbred, clinically healthy dairy cows with normal delivery and puerperium, complete uterine involution and without any treatment were monitored until 42 days in milk (DIM). All cows were evaluated by complete clinical and gynecological examinations at days 0, 7, 14, 21, 28, and 42 DIM. The gynecological examinations were done by transrectal palpation, ultrasonography, vaginoscopy, evaluation of the vaginal mucus and EC by using the cytobrush (CB) and low-volume uterine flush (LVF) techniques. The agreement (Kappa statistic) between the two technicians was good for CB (86%) and LVF (80.3%) for the counting of the percentage of neutrophils. The average number of neutrophils was significantly higher throughout the experiment for LVF, but a reduced percentage of neutrophils were observed during the postpartum period for both techniques. The amount of macrophages, lymphocytes, and eosinophils were not affected during postpartum and there was no significant difference relative to these cells when the two techniques were compared. There were significant differences in the percentage of cows with subclinical

RESUMO

Objetivou-se comparar duas técnicas frequentemente usadas na colheita de células endometriais e inflamatórias e caracterizar a citologia endometrial (CE) de vacas leiteiras mestiças no pós-parto fisiológico, criadas em sistemas de fazendas leiteiras do sudoeste do Brasil. Foram utilizadas 34 vacas clinicamente sadias com parto e puerpério fisiológico, completa involução uterina e sem qualquer tratamento até os 42 dias pós-parto (dpp). Realizou-se o exame clínico e ginecológico no parto e aos 7, 14, 21, 28 e 42 dpp. O exame ginecológico foi executado pela palpação retal, ultrassonografia, vaginoscopia, avaliação de muco vaginal e CE realizada com escova citológica (CB) ou por lavado uterino de baixo volume (LVF). A concordância (Kappa statistic) entre os técnicos na contagem da porcentagem de neutrófilos foi boa para CB (86%) e para LVF (80,3%). A média de neutrófilos foi maior em todos os momentos na técnica de LVF, porém a redução de neutrófilos foi observada durante o pós-parto nas duas técnicas de citologia. A contagem de macrófagos, linfócitos e eosinófilos não variou durante o pós-parto e não houve diferença entre as técnicas CB e LVF. Houve diferença apenas aos 28 dpp, na porcentagem de vacas com endometrite subclínica, entre as técnicas CB (22.2%) e LVF (59.3%). 

This study compared two frequently employed techniques for the collection of endometrial and inflammatory cells and characterized postpartum endometrial cytology (EC) of clinically normal postpartum crossbred dairy cows in dairy farming system in Southwestern Brazil. Thirty-four crossbred, clinically healthy dairy cows with normal delivery and puerperium, complete uterine involution and without any treatment were monitored until 42 days in milk (DIM). All cows were evaluated by complete clinical and gynecological examinations at days 0, 7, 14, 21, 28, and 42 DIM. The gynecological examinations were done by transrectal palpation, ultrasonography, vaginoscopy, evaluation of the vaginal mucus and EC by using the cytobrush (CB) and low-volume uterine flush (LVF) techniques. The agreement (Kappa statistic) between the two technicians was good for CB (86%) and LVF (80.3%) for the counting of the percentage of neutrophils. The average number of neutrophils was significantly higher throughout the experiment for LVF, but a reduced percentage of neutrophils were observed during the postpartum period for both techniques. The amount of macrophages, lymphocytes, and eosinophils were not affected during postpartum and there was no significant difference relative to these cells when the two techniques were compared. There were significant differences in the percentage of cows with subclinical

RESUMO

The transition to lactation (3 weeks before to 3 weeks after calving) is char acterized by a decrease in dry-matter intake (DMI), lead ing to a sharp decrease in glucose and calcium, and an increase in body fat mobilization in the form of non-esterified fatty acids (NEFA). This results in products such as beta- hydroxybutyrate (BHB A) accumulating from incomplete oxidation of NEFA (Vazquez-Añon et al ., 1994). Neutrophils (PMN) are the main leukocyte type involved in clearing bacteria after uterine infection; however, during the period of negative energy balance, dairy cows experience a reduction in PMN function, including reduced phagocytosis and killing capacity. This reduction is more pronounced in cows that develop uterine disease. Glycogen is the main source of energy for PMN phagocytosis and killing; calcium is an important second messenger for PMN activation; NEFA is associated with impaired PMN oxidative burst activity; and BHBA redu ces PMN phagocytosis, extracellular trap formation, and killing of bacteria. If the immune system is not ab le to eliminate bacterial infection, disease is established. Pathogenic bacteria associated with metritis and endometritis are E. coli , A. pyogenes , F. necrophorum , and P. maleninogenicus . E. coli increases the susceptibility of the endometrium to subsequent infection with A. pyogen es, and A . pyogenes acts synergistically with F. necrophorum and P. melaninogenicus to enhance the severity of uterine disease. Among their effects, E. coli releases bacterial-wall LPS; A. pyogenes produces the cholesterol-dependent cytotoxin pyolysin and a growth factor for F. necrophorum ; F. necrophorum produces a leukotoxin; and P. melaninogenicu s produces a substance that inhibits phagocytosis. A specific E. coli , called EnPEC/IUEC, causes uterine disease, and the virulence factor fimH was mostly associated with disease. For A. pyogenes , fimA was the only virulence factor associated with uter ine disease. The combined effect of bacterial infection and activation of inflammation is damage to the endometrium and embryo, delayed ovulation, shortened or extended luteal phase after ovulation, increased time to first insemination, decreased conception rates, increased time to conception, and increased pregnancy loss.(AU)

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Uterine diseases in dairy cows can be classified as puerperal metritis, clinical metritis, clinical endometritis, and subclinical endometritis. These diseases are highly prevalen t (affect between 20 and 30% of dairy cows) in high producing dairy cows and have been associated with decreased pregnancy per artificial insemination (AI), extended interval to pregnancy, increased culling, and economic losses. Puerperal metritis is characterized by the presence of an abnormally enlarged uterus, a fetid watery red-brownish uterine discharge associated with signs of systemic illness, and fever (>39.5 o C) within 21 days in milk (DIM). Animals without systemic signs but with an enlarged uterus and a fetid uterine discharge within 21 DIM may be classified as having clinical metritis. Clinical endometritis is characterized by the presence of purulent (>50%) uterine discharge after 21 DIM or mucopurulent (50% pus, 50% mucus) after 26 DIM. In the absence of clinical endometritis, subclinical endometritis is defined by the presence of >18% neutrophils (PMN) in uterine cytology samples collected between 21 and 33 DIM or >10% PMN between 34 and 47 DIM. The main risk factors are dystocia, twins, retained placenta, stillbirth, abortion, prolapsed uterus, and ketosis. Metritis can be successfully treated either by systemic or intrauterine antibiotic treatment. Ceftiofur hydrochloride (Excenel ® ) intramuscularly or ceftiofur crystalline-free acid (Excede ® ) subcutaneously are effective in treating metritis, and oxytetracycline intrauterine is effective in abrogating the negative effects of metritis on milk yield and fertility. Intrauterine administration of cephapirin benzathine (Metricure ® ) is an effective treatment for clinical and subclinical endometritis, although not approved in the United States. Administration of PGF2 α does not seem effective for th e treatment of clinical or subclinical endometritis.(AU)

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