Good afternoon and welcome to this webinar on update on bovine endometritis. So both of them, just to introduce quickly myself. My name is Giovanni and I'm a vet.
I grew up on a dairy farm. I graduated in Italy in 2012, worked as a practitioner, done my residency at the University of Glasgow, for the European College of Bovine and Management, and I'm a diplomat since 2023. And from the end of 2023, I'm a clinicical assistant professor in environmental, health and welfare at the University of Nottingham.
In terms of the learning learning objective today, I think we'll try to wrap up all these learning objectives, so describe the current definition, diagnostic approach for me endometritis, and also, Explain some of the latest insight on the pathophysiology and to evaluate the evidence-based treatment, also identify, yeah, the key risk factors to prevent, preventative strategy, as well as the, the, yeah, as I said, the treatment, and also, we see some of the emerging tools, some of the sensor based give us information. So in terms of the outline again. With the definition at the beginning, some, part of introduction, pathogenesis, diagnosis, treatment, prevention, and take on messages.
So in terms of definition, I think we need to start from here because actually it's quite interesting if we have a look and on the literature, so if we go with the definition of Sheldon 2006, merati is characterised by enlarged uterus, watery red brown fluid, and, viscous purulent material uter discharge, usually have this fat auto, the metritis is most commonly as, seen within 10 days of parturition as here you can see this summary about the, right-hand side of the screen. So we have the, the different papers and you can see that this definition has been mentioned in quite a few papers, probably in 37% of them, but still there's not clear associated definition in 40% of them. This is also create a problem either, either for researcher, I mean both for research, set up and also from, As a clinical point of view sometimes.
In terms of definition of grading, most of you probably are aware of this grading, so grade one, is usually animals with abnormally enlarged uterus, the prevalent uterine discharge but without any systemic signs of illness, grade 2, it normally enlarged uterus and a purulent uterine discharge with additional signs of systemic illness such milky or dull, dropping milk kilt or dullness or fever, great, basically we have a sign of toxaemia and. And in terms of, yeah, this chart, if you see here the two pictures, the right hand side, yeah, we have different colour as well and yeah, different different appearance and consistency sometimes. If we, instead, we have a look of definitions for, endometritis, we have two main ones, clinical endometritis, which is characterised by the presence of pollent material or mucopurulent, .
Exited in the vagina 21 days or more postpartum. And usually not combined by systemic signs, you have the have the grade between 012, and 30 is completely healthy, and between 1 and 3 is different degree er material, subclinical endometritis instead is defined as more than 18% of neurotrophils in uterine cytology samples, usually collected between 20 and 30 each days postpartum, or 10% of more than 10% of neurotrophil. Between 34 and 47ish days, in the absence of critical endometritis, and you can see here some of the polymorphonic plates, on the bottom rhyme different picture highlighted by the black arrows.
And I guess the other. Question is what is new, about definition, about, in this field, and, what is newish in the sense that's been proposed in the last few decades is the couple of definitions. One is the, the one that a lot of practitioner they're using which is the pleural and vaginal discharge, which is including not only endometriitis but also.
Vaginitis or cerviciitis, so pollen material that is coming also from other part of the reproductive tract and also cytological endometriitis, Which is defined as increased proportional percentile polymorph nuclear nucleates in the endometrial cytology sample and what is again interesting if you look this Venn diagram. That sometimes these two definitions, they somehow overlap, so there's some cows that have both the purer and but in the cheeological, but only 42% of them have both of them. And this is important, of course, for clinical differentiation.
And if we have a look, more in details what the literature, literature is telling us, And we have looked this graph from a paper from Vallejote Marran and collaborators of 2021. We see different patterns if we, for different cows in this particular study, they evaluate almost 250 cows and you can see here at the top right and in the pattern number one is, was cows that were completely normal, 2 cows that developed metritis, but 3, interestingly, is cows that do not, did not have, metritis, but they developed, they did develop clinical endometritis and cytological endometritis, however, only 8% of them developed both, and pattern 4 is cows that have metrite and eventually develop either clinical endometritis or cytological endometritis. But if you have a look here in the middle between, all the tree c because only 5% develop, all the tree.
Then if we have a look instead what are this disorder, what is the incidence, what are the targets, what do we have again in literature, so if we have a look at this summary table, so we have again the disorder on the left, . Enzyme column, so metritis, clinical endometritis, subclinical endometrites incidence does range from meteoritis between, yeah, 16-ish to 30 up to 40%, so ideally we would like less than 15%. Clinical endometriitis range between 10 to 20.
We target between 5 and 15 depending on milk yield, as highlighted by the Hare. And subclinical endometritis is much higher, 6 to 45, and . And the less probably around 20 again if you have a look at this graph here on the right hand side of the, the screen you have in the vertical axis, the percentage of the animal, and in the horizontal axis, the there is postpartum.
And you can see how important are this disease in terms of metritis and endometritis, but also, yeah, there's a huge variability of cow affecting affected by subclinical endometriitiss. The other question I guess is what is the economic impact of this disease and again another summary table, we have here different items, the milk, in kikilograms, the percentage of cow that, the treatment cost in dollars and the percentage of cow cult. And you see the difference, yeah, between again the column here and the 2nd and 3rd column, so 2nd column is cow with metritis, and 3rd column is cow with no metritis, and yeah, the difference here in the very, very last column, yeah.
Cowweat nomatritis, they produce more milk, the death rate, it's the percentage of that, it's, it's less average cost, probably, yeah, it does vary again and probably is a bit slightly old, . Estimation of appro $120 and also the percentage or cult cow, it's higher in cows with metritis. Of course, there is also an effect on fertility, this is pretty well known, again, cows with meteoritis have, longer term to first ovulation and higher risk of double ovulation.
Causes for cows with cytological endometriitis, the median days open. Was 206 compared to cows with no cytological endometritis, which is around 120 days. So yeah, generally speaking, there is a long-term effect in uterine environment and ovarian function and fertility.
If you have a look at this graph, the red eye right side of the screen, this is taken from Julio Dore collaborator of 2013, you have in the vertical axis, the proportion of, of pregnant cows. And that there is a, a risk in terms of, fertility, and you see, you know, the two different lines, there's, full line for no endometritis, so there's a risk is less in clinical endometriitis, yeah. For the person that proportion of a non-pregnant cow it's it's higher.
Then the other thing that we need to address is the pathogenesis, so we know that after calving there are some modification inside the cow, so there is a degeneration of the placental tissue, but also because the cervix is open, there's some bacteria invasion and that it's . Often does happen which can cause, can stimulate an inflammatory response, so the, the development of uterine disease is a mix of the pathogen load, the environment, but also the host accessibility. What can we found inside, the uterus in cowed metritis with endo endometritis, again, if you have a look, for example, the paper, Around culture and there is a very nice paper of 2019 of Galvao and collaborators where they try to give an answer to that, the one that we know it's, there are five main bacteria that we always find, in cows with metris endometritis which E.
Coli, it is. Associated with that, but, sometimes we have also normal cows. This stays on the surface of the uterus superellapiogenes, but also 3 ana anaerobes bacteria which Flusobacterium necrophorum probotella melanogenica and Perummonas leve levi.
They work in synergy to populate the uterus, evade the uterine defence, and also. They can cause again the uterine inflammation, whereas in health uterus, the population is different, so we have alpha molitic streptococci and negative coagulla streptococci most of the time. And there's also And, done, work done with the next sequencing genomic, testing, and if you see this image again from Galvaco Laborators, we can see that cows with LT uterus between 0 and 2 days, they have this kind of pattern, so bacteriophobacteria, protoacteria, and so on, whereas in cows after between, between 4 and 14 days, postpartum.
Yeah, there is a shift in the microbiota, so. Cows with metritis, we have, yeah, morehos of bacteria and bacterios, and also there is a less richness in terms of the variety, whereas healthy cows. Yeah, it's slightly different and there is more in term, in terms of bacteria, so we have more protobacteria, for example, but also there is a higher richness of mm different bacteria in healthy uterus.
And what is really interesting is also that some of the photosobacterium Porphyromonas bacterios bacterios, they've been found also in healthy cows within the metal surface and also from the blood. So which does suggest that in some cases, there is also an inflammatory response that is not necessarily only about the bacterial load, but there are also other factors affecting yeah, the pathogenesis of the disease. And, and if I look, the, the put on vaginal discharge, we, I was talking about, again, we have similar bacteria, so bacterios strepoellafosobacterium, and cytological endometritis is slightly different, .
So, Lactobasilus, Ainobacter as well. So in terms of pulling vaginal surgery microbiota is different from the healthy microbiota, but in terms of physiological endometritis, this is not, the macrobiota is not really different. So, and again, this is another thing suggesting there's other factor probably that causing, the onset of the diseases.
What are these other factors, we talk about, resilience but also immunity. So resilience is the ability basically of the body system to limit the effect of the pathogens, so which are the physical barriers like the vagina, the vulva, the cervix, the adrial integrity, the mucous layer, and the, and the microbial peptides, and, . If you can see here this picture on the left-hand side, so we have LT status in the vertical axis and the patrogen load on horizontal axis, so, and this is a graph taken from.
Work of Sheldon in 2018 and so you can see with the red line are. Cows with that are rested resilience and blue line with normal resilience, you, you can see, yeah, with the same pathogen load cow that mm. are .
Mm, the same pathogen load, cows with a resi and they have, decreased health status. In terms of what is affecting this, we did see in some of these works that reduce, is this resilience is reducing in eye ying cows. But what happens when, yeah, there's resilience, .
Disappeared, it was impaired, impaired, that is the immunity, that is important, and which is the ability to limit the pathogens load. Again, this is a similar graph on the left-hand side of the screen, we have the health status on the vertical axis and pathogen load on the horizontal axis. And you can see the blue that's impaired one and the the red, yeah, normal immunity and you can see a higher health status for the one with a normal immunity.
We have two main types of immunity, innate immunity and adaptive immunity, and all, all of them somehow, I mean I summarise here, not all of them somehow, play a role in this, . And what is also really interesting, it's some of the work from Pascoin Le Blanco of 2020. Here you have three graphs, and the first one on the top left, you have the aptoglobin, in the vertical axis, and the day is relatively calvin which range between 17 and 35.
In the horizontal axis and you see cows that have higher haptoglobin, so the ones with top clinical, Endometritis, they actually Yeah, they have higher optooptoglobin because problems relate to inflammation and, compared to the other two groups and, and similarly, if you have a look at this graph at the bottom, which is the NIFA and the, the one on the top, right, which is the BHB again, the yellow line, cows affected, they have higher, higher values and that is probably linked also to the metabolic status, of the cows themselves. What are these metabolic stress? Well, hypocalcemia, negative energy balance again, that are, that is definitely post .
Of factors, and there is a certain, irritability which is, yeah, does vary between 0.04 to 0.26, but also, of course, that, alteration of physical barrier such retained placenta, dystopia male cows, which usually are bigger twins and stillbirth, and prim primivorous cows, they have usually higher risk, although there is also a bit of you shading because cows that are a bit older, they're usually are more prone, to it because Simmons so, so yeah, but most of the time Premier persons is the one at higher risk.
In terms of diagnostic tritis, this is a summary table, again from the review that I mentioned before, or guard's own and collaborators in 2022, and you have here on the left, all the variables and the description. And again, if we think about the description that I was saying before and the definition actually. There is, in terms of diagnostic tool, there is a lack of gold standard, but the one that I described more often is the rectal palpation, definitely, and the one that are most frequently reported in the papers is the colour of the vaginal discharge, which is red brown, the viscosity watery.
The odour is fated, of course there is, an abnormally a large, uterus, but also fever, you have two different measurements between 39.5 and 39.2, and most of the literature is reported 39.5.
Also systemic signs such drop in milk, depression, and also I think this important, other important aspect are the sampling frequency and when is diagnosed the the disease, which usually is in the first two or three weeks. And last but not least, we need to acknowledge the fact that There are also different people making the diagnosis which are not necessary. They are veterinary surgeons, but sometimes can be the employee and farm manager or owner or researcher and so on.
And again, from the same review, it's from the same paper, it's really actually interesting to see the categories that I'm just talking about in the years of publication and especially in terms of viscosity, the smell of the vaginal discharge, this milk and the fever. And this graph that you see here is a score is basically a graph, indicating a correspondence, analysis, and basically what is highlighting is if some of this. Categories as close to each other, it means that they're more closely related.
So if you, example, think from the, The top, to the bottom here in the middle after 2006, actually, the foetid, odour, the water discharge, the fever, and the fact that diagnosis, are, is made between 0 and 40 days are closely related to each other, whereas before 2006, that is a much a bit more blurry, if we want to, think about this, so, And again, this is another way to show you how the definition can impact actually the clinical work. And in terms of frequency also and diagnosis days postpartum, again here you have a chart where you have in the vertical axis, the frequency and horizontal axis the day postpartum, and you can see from the work of Galvao collaborator 2006211, that, yeah, a lot of diagnosis made probably in the first week, but not only, and if we summarise this in a by this in milk. And the percentage, which you can be seen in this table, you know, most of the time again, probably around 50% is around 0 and 1414 days.
I was talking in the learning objective also about the of emerging tools. As most of the practition, aware, there are a lot of tools, in the field such neck collars in the, in the welding boluss or hair tag equipped with the accelerometer. And they measure different things and in particular, if we have a look, some of the work from Stanga Ferre collaborators, there's a really interesting work and they This is one graph taken from that, that paper where you have here on the left-hand side of the screen, you have the, the vertical axis axis of the rumination by in minutes per day, and also the peripar, peripartton period which range between in the horizontal axis, range between -5 and +5.
And you can see here, three different categories, so you have a black, basically non-sease animal, the one that is HI negative, it means it is a health index, created by the algorithm. Of the, of the, of the tool itself and the one with the HI in LT index positive and you can see that the one that basically, Are high lighting as sick animals for some reason they have a much less degree of rumination and this in getting this calculation is including metriitiss. And similarly, if you have a look at the graph on the right-hand side, you have the vertical axis, the line time in our day.
And then the horizontal axis, the periparton period, ranging between -10 and 10. Blue line is the healthy cows and the red line is the cows with metritis. It's really interesting because, Cows with metritis again lying down, .
Less, before carving, but . But also they are lying down more after parturition bra because they are sick and they need to rest more. So it is again, something that you can apply with your clients or with your farms and this is really interesting, I think.
Similarly, we have, some work done by ATSI and collaborators, and this is really interesting again because we have the one on the left-hand side, we have in the vertical axis. The dry, metal intakes and kilogramme per day, again, the horizontal axis, the peripart period. What is interesting about this paper is also the fact that they, Evaluated healthy animals, but also they differentiate between mildly and severely metritic, and you can see how actually dry metric is dramatically lower in severely metritic cows and the, the, for the graph on the right hand side of the screen.
This is similar, but, what we have in the vertical axis, the hourly water intakes and the, in the horizontal axis, the hour of the day, and again you see how this rarely the cows, they basically drink less. Terms of diagnosis, . What we're gonna review now is the purulent vaginal, discharge, which by Metrochecks, there is some work by, Irish group.
There's a, work, highlighted also some ultrasonography methods, and for subclinical endometritis, we have cytoflushing, cytos cytotape, leukocyte esterases. And also one slide about, yeah, biopsy as well. So in terms of Bruenberg general discharge, Diagnosed by Amitricek, this is quite interesting, so you can see here the score on the right-hand side of the screen.
So score 0 is no clear mkos, score 1, Flacko pass, score 2, which is here. The 3rd 1. Less than 50% of micro discharge score is more than 50%.
And what you can see here in this graph is a survival analysis, so we have in the vertical axis, the proportion of cows that are pregnant, and the days is open in the breeding season, . In the horizontal axis, you see the cows, . That are scored 0, so you have sort of all the vertical dashed line are basically the median, and you can see that basically for scored 0, the proportion of cows is higher and yeah, and early days open, so this is all the, and the all the other ones score 1, 23 is our worst results, .
I did report also for interest also the sensitivity and the specificity of the method, which I guess, yeah, can be interesting as well, . And if we have a look also the, some of the ultrasonographic method, again, this is a similar, graph, again here you have the ultra sonography of the score zero here on the, top right of the screen, and then score 1, trace of interluminal fluid, less than 0.2 centimetres, score two, between 0.2 and 0.5 centimetres, score 3 as a moderate volume, between 0.5 and 1, and score 4 is, more than 1 centimetre, which is here at the bottom, and again, Again, the vertical, again, another survival analysis with the proportion of pregnant cows in the vertical axis and in the horizontal axis, days open in the breeding season, again scored zero, you have basically, higher proportion of cows.
And in the breeding season. In terms of subclinical endometritis, said that, which is we call, which, yeah, is what we can see here at the bottom left side of the screen which we have the neotrophils, the endometrial cells, reple cell. This is based, basically is so far it's considered a gold standard.
There is not a really A gold standard, but actually this was considered a gold standard, and this again is based on the percentage of polymorphic nucleates. And there is a very busy summary, table with all the reference for all the papers, and yeah, the polymorphism of the threshold that doesn't make the prevalence, but I think what I want to highlight here is again, the variability between threshold, which is the range, is quite wide and . Yeah, again, this threshold is still under discussion, but if we have a look at closer, research in terms of timeline, there is Drucker and collaborators of 2022, .
If we talk about primeparous, we are thinking of a threshold of polymorph rate of more than 7%, around 30, 40 days in milk, and multiple cows would be more than 4% between 60 and 70 days in milk. Pascotini and collaborators also evaluate endometrial cytotape. They basically, basically they did both if you have a look at this picture here on the left.
So they insert this catheter, so they take acito brush, scissor, yeah, and aceto tape and then acito brush, and this graph is showing that is Concord conficient graph, and you can see there's quite good, except, yeah, here at the bottom left, there's a, there's a red, red surf circle, this is probably the auto say there was some contamination between the two. Yeah, but there is a good agreement that's something that it can be used potentially, for diagnosis. We can also use low volume nerogen flushing, basically, as you can see here, injecting 20 mL of solution, .
Again, there is another. Graph here where it's showing in the, vertical axis, the polymorphic nuclede with the low volume and with the, and the, and the horizontal axis, the pitto brush polymorphic euclide, the dashed line is perfect, perfect agreement and blue line is the agreement between two, the two with the dashed grey area indicating 95%. .
Confidence interval and again this is around 0.6, so yeah, it's a good agreement between the two. Another interesting one, it was because it's a quick one and some of the practitioners, especially in North America, they use it, probably some of the practition in the UK too, but it's, becoming a bit more popular, it's the Lecoset ERs, test, which is a cow test, which has a high correlation between, this, The, the percentage of neurotrophils through your er lava and this enzymes, so it's works basically, almost as a ketton strip, so you have a calorimetric scale, as you can see here, the picture.
And yeah, you have a test really between 0 to 4 and I guess this is yeah, quite useful because it can give you direct information about, yeah, the, the cow in that moment, sensitivity is a bit low, as you can see, but again, because you have the chance of treating the cow immediately, that probably is a good advantage for this one. Can we do biopsy Technically, yes, this is much more common in, In horses, as most of you are aware, and, yeah, it's a bit out of fashion also because there is a bit of poor agreement between the biopsy and the pseudo brush, also because during the, during the phase. there is a poor agreement because there's increased polymorphone creating the deeper layer of the endometrium and not in the superficial one.
So this is one of the reasons of the poor agreement, it's relatively invasive technique, but according to, mm, the some one review, Ramirez and Garson, yeah, it's low reproductive risk, so technically it's doable, and you can see here some on the right-hand side of the screen. Some of the features and some of the histologies and just for reference. I guess the other interesting part now will be the treatment, in terms of antimicrobial, I put here a summary table.
There is also a very nice recent review of 2026 of Fratina and collaborators, which highlight all this knowledge. We know that prosystemic antibiotic is the one we use the most, the one is both miss has shown a good result is the Setiur reduction in prevalence, but also reducing economic losses. Ampicillin is a similar.
But it's better in terms of efficient for reproductive performance, and then also penicillin or oxy tetracycline, which, yeah, are, as well, been tested and, are somehow used, I guess what we really need to be careful here, of course, we have Cftour, it's high critical antibiotic and it's, in the scale of, The European categorization of medicine is higher up, so which it's less use, especially in Europe, but a lot of the research is coming from this, is coming from North America. So I guess the caveat to all this is again using a low risk antibiotic for the treatment. And And also, there is what have been seen also is, .
There is basically an association with the daisy milk and the haptoglobin. So, there is a detrimental effect of non-treatment only if it's less than 8 days in milk and, there is higher inflammation up to, yeah, more than 0.5 milligrammes deciliter, according to much other collaborators, so there is the space for target therapy and I think this is important as a practical point of view.
You can, certainly there's some work about intraterri antimicrobial, oxytacycline cote cycling, but also Sale, saline levich and so oxytocycline in combination with . With ampicillin in improving reproductive performance, it's, chloro tetracycline as well, and saline la which is, can be an option, although you have the risk of wall damage and toxic absorption, but, and also what is important to highlight that within intraterri oxytocine, there is higher odds of resistant E. Coli, .
And so for this reason, what also we can. The research has been looking also for the effect of the anti-inflammatory and especially for meloxicam and flunexim melamine, the effect is not as important and there is not much additional benefit unless that you add antibiotic. ketoprofen has been showing, good result, so there is reduced antibiobiotic usage actually by 15 92% with comparable outcomes.
Again, highlighted this, this very good review of the Flatina collaborators, although the cavity with that is sometimes is a second treatment. Some of the cows that received ketoprofen, they had to be treated with, with the antibiotic as well, so that again is a bit of a caveat there. I summarise also alternative treatment, some of them are more promising than other ones.
I mean, in, get some microparticles, for example, and, and also some micronized. Purified fla flavonoid fraction, I guess it's one of these other ones that been investigated but there's been no effect at all like man Magnos and bactero fish, this is more for interest really and for reference. Again, now, in terms of treatment for endometritis, this is really interesting.
There's a lot of debate, how to treat endometritis in the field, and a lot of opinions. What is evidence-based, yeah, is the use of cefainne that it's there is an improvement in, in the conception rate, the first insemination, and also if you use, yeah, it depends how you use once or twice. Prostaglandin instead, there is not a significant improvement of pregnancy rate or rooted in health, but also, that is the fact that we should inject prostaglandin when Of course, there is a CL present.
Having said that, what is really important to, to highlight about this, there is the self-Q is relatively high between, yeah, 33 to 46%, so 46%. So there is also when we think about the treatment for endometritis, I think we always need to think about this aspect of self-cure. So, For example, you might want to apply synchronisation protocol and wait for the cows to resolve, the, the infection by yourself, but yeah, it's case dependent, of course.
Again, as I did for the metritis, there are, other, treatment being tested like detrol, dextrose, for example, which is improved by general discharge, a concept rate are similar to LT cows. But another one who found another work of Machado collaborators didn't find a good improvement of electro performance, leva with, 2% COVIDO iodine. Has, has, has done good result, the same, similar with ozone with carp profile systemically, there is not actually a lot of effect about this one and this is the work done in 2013.
And we have also some probiotics, some vaccine that has been, they have basically. They have some particles of E. Coli and also some the Mpecopebovirati if I pronounce it well, which improve the circulating neutrophils, but there is no reduction in metros incidents.
Again, if you want to read about this, yeah, some, some very interesting papers. And now we are approaching the conclusion in terms of the risk factor. I think what is important to say if we have to look at the two types of uterine disease, metritis and endometritis, yeah, you have some odd ratio here.
That is a table taken from a a book, slightly modified, and if we have a look, metritis cow, they retained foetal membrane, stillbirth or twins, or hypocalcemia, also clinic subclinical ketosis a higher risk, . With higher odds and and similarly for cows with endometritis, which have, for example, yeah, retained foetal members is the one, the most, most, most important one, some, but also some of the metabolic disease such ketosis and hypocalcemia. Mm, there are also some practical recommendation.
For the farmer, I'm not gonna. Tell you all the details about energy diet, feedback access, and feed feed space access, lang time and so on. But I think it's always really important to keep in mind the environment and of course, some of these aspects are really important for prevention and so, That can really help in some cases, to improve the situation.
And to conclude, and I did highlight, some of those the research gaps, so probably we need a bit more high-quality research standardised about case definition and also standardisation about metritis and also to expand the understanding of the pathogenesis metritis using more sequencing technologies. Probably we can still Improve our knowledge about Kawacyte test for endometritis and also about research of treatment itself, so, It's a take home message, I think, yeah, me try this, treatment, . Is definitely with systemic antibiotic, but not necessarily in all the cases.
Sys, systematic diagnosis of endometritis is really important, especially to identify early case, and also we talk about also this negative energy imbalance and also the inflammation, so there's also this aspect to address, . Which, yeah, can identify also some early transition problem, which can be done also with cytological endometritis tests, for example, the use of leucocyte esteriasis. Again, sensitivity is a bit low, as I say, but it's quite useful.
Again, treatment efficiency has been not completely approved for endometritis, so, What I really conclude is two slides, which are relatively ambitious. So one is kind of about decision tree about uterine discharge. So if you have dense, red but not smelling, discharge, probably you can monitor the cows.
If you have a liquid bound, Liquid, putrid brown discharge, you probably can assess the temperature, but also the room and feel, and also the milk production, and based on that, you can give antibiotic and monitor or only anti-inflammatory. And for endometriitis, again, similar, I think here again we need to think more about the, The cow and the fact that can, that can self cure, so if it's a CL present, probably you can do a synchronisation protocol, if it's absent, you need to think, and evaluate if it's, yeah, it's worth to wait, if there's a flushing or not, or you use an anti intrauterine antibiotic. So, I would like to thank you to, to other diplomats of the European College of Bovi and Management, in the first place to help me to put together this presentation and if you have any question, please, you can, email me.
Thank you very much.
