Who could resist this good news story? - Veterinary Practice
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Who could resist this good news story?

Gareth Cross leaves controversial matters behind for a month and turns instead to a veterinary surgeon at Bristol Zoo who was involved with the birth there of a gorilla by caesarean.

AFTER A COUPLE OF MONTHS OF COVERING CONTENTIOUS SUBJECTS at the Cross-words desk, namely of locking horns with the insurance company RSA and then the editor and I receiving (on a totally different subject from a different company) a lengthy arse-spanking from a group of corporate lawyers, I was looking for something less controversial to cover this month. There could be nothing more different from the financial and legal scrummage of veterinary business than the fantastic good-news story that broke in February concerning the birth of a baby Western Lowland Gorilla at Bristol Zoo Gardens.

The baby was born after an emergency caesarean procedure after the mother, Kera, showed symptoms of potentially life threatening pre-eclampsia. The baby is yet to be named and was born weighing just over a kilo (2lb 10oz).

It is the first time a gorilla has been born by caesarean at Bristol Zoo and one of only a handful of instances of it occurring worldwide.

So for this month’s column we have a world exclusive vet-to-vet interview with one of the zoo vets involved: Rowena Killick. This will help answer many of the questions I have heard vets asking, and read vets discussing on the online forums, about the case.

I managed to persuade Rowena to answer some questions for me and what follows is a real privilege for us to be able to get a first hand vet’s-eye view of what has been international headline news. My first question was about the background to this remarkable event.

Rowena explained that the Western Lowland Gorillas at the zoo are part of an EEP (European Endangered Species) breeding programme. “The hope was that Kera would become pregnant once she settled into our gorilla group after arriving in 2008. The keepers regularly perform pregnancy tests (using human test kits) on urine collected from the floor of the enclosure from our adult female gorillas. Kera’s urine first tested positive on 22nd July last year.

“We have not delivered a baby gorilla by caesarean at this zoo before and from a quick check online we could only find records of nine other gorillas worldwide ever born this way.”

GC. I was intrigued by the doctors’ involvement and they said that they had been involved in Kera’s care during the pregnancy. From this it would seem that human and veterinary medicine become almost one and the same thing with higher primates. Can you expand on this a bit?

RK. As zoo vets we literally treat all creatures great and small so we often call on other veterinary, medical and dentistry colleagues to help us, just as general practice vets use referral vet services. For example, we often call on our farm and equine vet colleagues at Langford for help with our hoof stock (such as okapis and tapirs).

It is common for zoo vets working with great apes such as gorillas to call on medical colleagues in the same way. Professor Cahill, who performed the caesarean, has given us advice over the years on fertility testing and treatment of our gorillas and has always said he would be willing to help with a caesarean section should the need arise.

In many ways great apes are closer in anatomy and biology to humans than to any other zoo animals. Kera’s case was a classic example: how many vets have come across pre-eclampsia in their patients? Whereas it is a fairly common condition in women and, it would seem, in gorillas.

GC. We don’t see pre-eclampsia in our more usual veterinary patients, so can you just summarise what it is for those of us more used to dealing with cows, sheep, dogs, cats, etc.?

RK. I believe it is still quite a poorly understood condition even in humans. The main gist seems to be protein loss from the kidneys of the mother (hence diagnosis via dipstick of urine samples) which can lead to oedema – we have seen it show before in one of our other gorillas whose face looked “puffy”, and there also seems to be involvement of high blood pressure. Ultimately, the only effective treatment is the birth of the baby, after which the proteinuria gradually resolves.

GC. Amongst other clinicians involved was Nic Hayward (RCVS specialist in diagnostic imaging) who scanned Kera; what sort of pregnancy monitoring was being done generally and how co-operative was Kera or was she sedated?

RK. Kera was trained by the keepers to accept ultrasound scanning conscious during her pregnancy but unfortunately we never managed to get diagnostic images from this due to difficulties with positioning of the probe while she was conscious, and also unfortunately once she started to feel unwell she wouldn’t respond to the keepers asking her to take part (they offered her favourite food items as encouragement). So Kera was under full GA when Nic scanned her.

Although the keepers train the gorillas and can make some physical contact with them, it is all done through a strong wire mesh (“protected contact”). Gorillas are considered “Category A” dangerous animals and we would never have full contact with them without heavy sedation/anaesthesia (except for gorilla babies being hand-reared!).

GC. Could you give us a timeline about what happened on the day of the caesarean and how the decision was made to go for it and who made it?

RK. This is a summary from my report from the day: Gorilla 10415 Kera 12/2/16. Morning check: no improvement overnight – no evidence of having eaten or drunk anything and still appeared lethargic. Decision made (vet RK plus senior curators and mammal keepers) to proceed to GA this afternoon for diagnostic tests and possible surgery.

Procedure planned to start at 2pm. Prof. David Cahill and Nic Hayward informed. At 2pm keeper tried to get Kera to position for hand injection but unsuccessful. Therefore she was injected via dart gun with medetomidine and ketamine. Once Kera was fully anaesthetised she was moved to the vet clinic taking all necessary precautions.

Once on the clinic operating table Kera was given oxygen by mask and then 8% sevoflurane. She required another top-up of ketamine i/m due to showing signs of starting to regain consciousness during intubation, which was challenging. She was eventually successfully intubated with a 7.5mm cuffed tube. She was maintained on 6-8% sevoflurane in oxygen initially and then switched to iso urane and maintained on 5% then 3-4%. A bain circuit was used.

Under GA Kera’s heart rate was 80bpm and her respiratory rate was 16-40 per minute. Once Kera had been intubated an i/v catheter was placed. Kera was given Hartmann’s solution i/v throughout the procedure. Blood samples were collected. Veterinary imaging specialist Nicolette Hayward performed ultrasonography of the foetus, uterus, liver and heart.

The foetus was found to have a heartbeat but not very much fluid surrounding it and it was not responsive. Kera’s liver and heart appeared grossly normal on the scan. Her kidneys were inaccessible. Prof. Cahill and his colleague Aamna Ali catheterised Kera’s urethra and a very small volume of urine was collected (Kera had urinated during darting). This tested positive for protein ++ using a dipstick. These findings led to a continued presumptive diagnosis of pre-eclampsia. DC performed a vaginal exam and found the cervix to be soft but not yet open. He explained that labour might commence within the next 24-48 hours if Kera was left. In a human, induction would be started at this point using prostaglandin gel, but this was not feasible to obtain quickly at this time of day. The options were to wake Kera up and see if labour commenced naturally within 24 hours or so and perform a caesarean section if not, or to perform an emergency C-section straight away. There was a risk that the baby would die if this approach was taken.

The options were discussed with appropriate zoo staff and going ahead with an emergency C-section was agreed on. DC and AA then performed a C section. Kera was given buprenorphine i/m prior to the start of surgery at 4.10pm. The surgeons made a transverse incision in the pelvic region, incised through the muscle layer, using radiocautery for haemostasis, and incised the uterus.

The female baby was delivered at 5.10pm and the cord clamped after allowing some cord blood to drain into the baby. The uterus was sutured using Vicryl 1 and oxytocin was then given i/v. The abdominal musclelayer was then closed using Vicryl 2/0. Lignocaine was injected into the subcutaneous fat layer and the wound was then closed with intradermal sutures (Vicryl 2/0).

An Opsite clear sterile dressing was placed over the wound. “Distraction sutures” were placed on Kera’s limbs to distract her from picking at the surgical wound. Kera was given amoxyclav i/m and marbo oxacin s/c. The iso urane was switched off at 6pm and Kera was transferred to a vet bed in a transport crate in the room next to the vet clinic and covered with vet beds. She was given atipamezole i/m at 6:15pm and her recovery was closely monitored.

GC. Can we have some more detail on the neonatal care?

RK. The initial neonatal care was done by me, our veterinary intern Charlotte Day and one of our vet nurses Teresa Horspool, with some help from the mammal keepers as well. It took two to three hours to get the baby breathing properly by herself and during that time we gave her sublingual doxapram drops, also i/m atipamezole and naloxone to reverse any effects passed from the drugs given to Kera, subcutaneous glucose saline and amoxyclav, and also drained and syringed fluid from her larynx (helped by holding her upside down a few times to drain fluid from her lungs). We also started nebulising her with acetylcysteine. She was also given oxygen throughout via face mask/ET tube.

GC. And an update of how things are going now?

RK. The baby is doing well. Kera has taken longer to recover and we are still treating her quite intensively and monitoring her closely.

Thanks to Rowena for sharing that with us. We have all read the general press releases but it is fascinating to have so much detail from a vet’s viewpoint.

As if that isn’t keeping her busy enough, Rowena also went on to tell me about the veterinary hospital they are planning to build at the zoo, but that is, as they say, another story…

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