The Case: Eclampsia with Financial Constraints

Presentation

A 5-year-old intact female miniature pinscher was presented at 3:00 pm for tremors lasting several hours. Eleven days ago the dog had whelped 4 puppies, 1 of which died shortly after birth. The other puppies were all doing well. The patient’s vaccination status was unknown. She had not been receiving any medications or supplements and had no known toxin exposure. She was being fed adult canned dog food along with chicken and rice and had a good appetite. No other significant medical history was reported.

Physical Examination

• Temperature: 105.7°F

• Heart rate: 180 bpm

• Respiratory rate: pant

• Body weight: 6.48 lb/2.9 kg

• Trembling diffusely, stiffness of forelimbs, salivating, not willing to ambulate, normal mentation

• No vulvar discharge noted 

Remainder of the exam was unremarkable.

Diagnostics

• No blood work was performed and the patient could not be hospitalized due to severe financial constraints.

Management

3:30 pm

• Electrocardiography was initiated. No bradycardia or arrhythmias were noted during treatment. 

• 10% Calcium gluconate: 0.5 mL/kg IV over 20 minutes 

 Tremors continued.

3:50 pm

• 10% Calcium gluconate: 0.5 mL/kg IV over 20 minutes 

• Temperature: 102.7°F

• Heart rate: 120 bpm

Tremors continued.

4:10 pm

• 10% Calcium gluconate: 0.5 mL/kg IV over 20 minutes 

• Heart rate: 118 bpm

Tremors almost resolved; minimal muscle fasciculations of the left pelvic limb were noted.

Patient was discharged with the following recommendations:

• Calcium carbonate (Tums Extra Strength [750 mg]): 1 tablet PO twice daily × 2 weeks

• Wean puppies immediately; instructed owners about how to bottle-feed. 

• Feed patient high quality, balanced, commercial puppy food for at least 1 month. 

• Spay the dog to prevent the development of eclampsia with future pregnancies. 

• Return to clinic immediately if tremors return or patient develops ataxia, nervousness, heavy panting, or collapse.

Outcome

Patient was not presented for further care. A follow-up call 4 days after discharge discovered the dog was doing well, as were the puppies.

The Generalist’s Opinion

Barak Benaryeh, DVM, DABVP 

Despite the client’s financial constraints, the veterinarian managed this case well and the dog had a successful outcome. This presentation provides a good opportunity to look at the issues surrounding puerperal tetany (eclampsia) and serves as a reminder that sometimes we need to operate within the confines of the limited diagnostic and treatment choices available to us.

Treating Puerperal Tetany

To confirm the diagnosis, one needs to demonstrate a low calcium or low ionized calcium. In addition to the calcium level, a complete blood panel should be run to rule out any underlying causes that may have triggered the disease. A blood glucose is also important as extended muscle spasms can deplete glycogen levels and cause severe hypoglycemia. Either total calcium or ionized calcium should be monitored to determine whether treatment is effective. Electrocardiography should be checked throughout calcium administration as ventricular fibrillation can occur if calcium is administered too rapidly. Body temperature also should be evaluated throughout treatment as muscle spasms can cause hyperthermia, which was evidenced by this dog’s elevated initial temperature.

In this particular case, the diagnosis was made solely based on history and clinical signs. Treatment was initiated without determining calcium or blood glucose levels, or any blood work. The practitioner did monitor the patient with electrocardiography to be sure there were no side effects from the calcium administration. These choices were made based on the client’s limited financial resources. Body temperature was monitored and calcium was given intravenously in small doses and slowly until the patient’s clinical signs resolved. This is not ideal treatment but was clearly effective in this case. An additional safety measure that could have been taken for very little cost would have been to measure blood glucose. In rare cases, dogs can continue to exhibit tremors or even seizures from hypoglycemia and, rather than needing more calcium, they need glucose.

Separating Litter from Dam (or Queen) 

The choice was made to wean the 11-day-old puppies from the dam and bottle-feed them. In any eclampsia case, this is an important decision. One needs to consider the severity of the case, the size of the litter, the age of the puppies, and the ability of the client to bottle-feed properly. Weaning benefits the nursing mother, as it relieves the need to continually mobilize calcium, but there is a down side to this choice: The puppies are exposed to additional risk, as bottle-feeding increases the risk for aspiration pneumonia. In addition, milk replacer has been shown to be inferior to bitch’s milk in terms of kilocalories, protein, calcium, and phosphorus levels.¹ It is also widely believed that bottle-fed puppies and kittens tend to have more behavioral issues than their nursed counterparts. To my knowledge there has not been a study that confirms this observation, but it is a commonly held opinion among veterinarians and trainers. In any case, one needs to weigh the pros and cons when making the decision about whether to separate the litter from the dam. An alternative is to continue to allow the puppies to nurse, but to supplement their feeding with formula.

Shortcuts 

Every practitioner in the private sector has faced cases in which our hands were tied due to financial constraints or choices made by our clients. We can elect to be bothered by this fact or take it as a challenge to do our best given the circumstances. Experience often comes into play when one needs to choose which compromises to make and which are not appropriate. These may vary among veterinarians. It is vital of course to document extensively that additional treatments or diagnostics were recommended. Not everyone can afford the highest level of veterinary care, and our clients differ widely in the relationship they want or can afford to sustain with their pets, financially and emotionally. Unless abuse is involved, our role as veterinarians is to facilitate the bond our clients want, not to judge it.

The Specialist’s Opinion

Erin Runcan, DVM, DACT

Eclampsia, or puerperal tetany, occurs due to a depletion of ionized calcium resulting from an inability of calcium homeostatic mechanisms to compensate for the loss of calcium in milk.¹ This condition commonly affects small breed dogs, typically being fed an inappropriate diet for gestation and lactation, and often with large litters. The authors of this case did a wonderful job of immediately recognizing the clinical signs noted in this patient and quickly instituting appropriate care. Improvements in intervention in a few areas could have made the diagnosis and management of this case more complete, even with severe financial limitations.

Physical Examination & Diagnostics

At presentation, this bitch had an elevated body temperature (105.7⁰F); external cooling mechanisms should have been instituted to help quickly normalize the core body temperature. Bitches with eclampsia often have extremely elevated body temperatures due to the increased muscle activity and tetany which, if untreated can lead to cerebral edema.^1,2 While financial constraints limited the diagnostics that could be performed, the authors could have obtained a quick blood glucose measurement using a standard glucometer. Hypoglycemia often occurs concurrently with hypocalcemia due to muscle tetany and can contribute to seizure activity.^1,2

Case Management

I am very pleased to see that, despite financial issues, the authors were able to institute cardiac monitoring along with calcium supplementation. Bradycardia and arrhythmias are common sequelae to intravenous calcium being administered too quickly.¹ Treatment was appropriate and the bitch quickly improved with appropriate care.

Aftercare & Recommendations

This is the largest area where I can see possible improvement in management. It is not stated whether this bitch was considered a valuable breeding animal. A decision to perform ovariohysterectomy in order to avoid further episodes of eclampsia is a drastic one if this bitch was valuable to the owner’s breeding program. While future episodes of eclampsia could in theory occur with subsequent pregnancies, appropriate dietary management during and after gestation could very well prevent the problem. In one study evaluating 31 patients with eclampsia presented to a university hospital, 39% of bitches had prior litters, none of which involved eclampsia.³

Similarly, whether or not to wean the neonates should not be decided lightly. The best environment for nursing pups is with the dam. As this litter was only 11 days old, there would have been much benefit from obtaining the bitch’s milk until the puppies could be safely weaned at approximately 3 weeks of age.¹ Bitches with eclampsia can be allowed to continue to nurse their pups with appropriate management and close monitoring. Once the bitch is stable, the pups should be gradually reintroduced to the dam with limited nursing time and concurrent supplementation with milk replacer. Calcium supplementation should be continued, and the dam should be fed an appropriate diet formulated for lactation (containing at least 1.4% calcium and a 1:1 calcium:phosphorus ratio).¹ While commercial puppy foods should, in theory, meet this demand, with the recent market entry by numerous diet manufacturers, the mineral composition of the chosen diet should be verified. Pups should receive supplemental feedings with a commercial milk replacer formulated to meet the composition of canine milk. If clinical signs return despite appropriate management, the pups should be weaned completely.

In summary, the authors of this case worked quickly to provide a favorable outcome for both mother and pups. Client education is always essential to managing breeding dogs and, despite financial limitations, these owners will hopefully be better prepared if they decide to produce litters in the future.