Enrofloxacin‐based therapeutic strategy for the prevention of endometritis in susceptible mares

González, C., Moreno, L., Fumuso, E., García, J., Rivulgo, M., Confalonieri, A., Sparo, M., Sanchez Bruni, S. Enrofloxacin‐based therapeutic strategy for the prevention of endometritis in susceptible mares. J. vet. Pharmacol. Therap. 33 , 287–294. Enrofloxacin (EFX) is often used empirically to prevent uterine infections in mares in order to improve efficiency on Commercial Embryo Transfer Farms. This study investigated the uterine distribution of EFX and its metabolite ciprofloxacin (CFX) in mares and assessed the minimal inhibitory concentrations (MIC) of EFX against various common pathogens as a basis for establishing a rational dosing schedule. Plasma and uterine pharmacokinetic (PK) studies were performed in two groups (n = 5) of healthy mares following intravenous (i.v.) administration of EFX at either 2.5 and at 5 mg/kg bodyweight. Plasma and endometrial tissue samples, taken before for up to 48 h after treatment were analysed by Reverse Phase HPLC. MIC values for wild strains of Gram‐negative (Escherichia coli, Pseudomonas aeruginosa) and Gram‐positive bacteria (β‐haemolytic streptococci) ranged from 0.25–2 and 1.5–3.0 μg/mL respectively. In terms of tissue distribution, the sum of the endometrial concentrations of the parent drug (EFX) and its active metabolite (CFX) (in terms of AUC), exceeded those in plasma by 249% and 941% following administration of EFX at 2.5 and 5 mg/kg respectively. After i.v. treatment with EFX at 5 mg/kg, endometrial concentrations of EFX and CFX above the MIC value were detected for 36–48 and 22–43 h posttreatment for Gram‐negative and ‐positive isolates respectively. Concentrations above MIC were maintained for much shorter periods at the lower (2.5 mg/kg) treatment dose. Based on these results, a conventional dose (5 mg/kg) of EFX given prebreeding followed by two further doses at 36–48 h postbreeding are proposed as a rational strategy for using of EFX as a preventative therapy against a variety of common bacterial strains associated with equine endometritis.     

Administration of ticarcillin in combination with clavulanic acid intravenously and intrauterinely to clinically normal oestrous mares

Ticarcillin and clavulanic acid (potassium clavulanate) were administered to normal oestrous mares intravenously (i.v.) at a dose of 50 and 1.67 mg/kg for ticarcillin and clavulanate, respectively. In a crossover design, the same drugs were administered intrauterine (i.u.) at a dose of 12.4 and 0.4 mg/kg for ticarcillin and clavulanate, respectively. The i.u. dose was administered in 100 mL of saline solution. Endometrial tissue biopsies and plasma samples were collected after drug administration for the determination of ticarcillin and clavulanate concentrations by high-pressure liquid chromatography and pharmacokinetic calculations. After i.u. administration both drugs were poorly absorbed into the plasma. The ticarcillin half-life from tissue and plasma was short after i.v. administration. Although concentrations in tissue were higher after i.u. administration than i.v., concentrations of ticarcillin declined rapidly, which would necessitate frequent treatment in order to maintain drug concentrations above the minimum inhibitory concentrations (MIC) throughout the treatment period. Clavulanate concentrations in tissue were either low or persisted for only a short time after administration via either route. It appears that addition of clavulanate to the formulation for treatment of i.u. infections in mares is of questionable value based on these concentrations.     

Measurement of total volume and protein concentration of intrauterine secretion after intrauterine inoculation of bacteria in mares that were either resistant or susceptible to chronic uterine infection.

Undiluted uterine secretion was used to determine the concentration of total protein and the accumulated volume of uterine secretion after a bacterial inoculation in mares susceptible and resistant to chronic uterine infection (CUI). The uterus of 6 susceptible and 5 resistant mares was inoculated with 5 x 10(6) Streptococcus zooepidemicus on the third day of estrus. Using a tampon inserted in the uterus, secretions were sampled at 5, 12, 24, and 36 hours after inoculation, followed by intrauterine lavage with phosphate buffered saline solution. The concentration of protein was determined in the undiluted secretion as well as in the uterine washing and the total amount of accumulated uterine secretion was calculated. Protein concentrations in plasma were compared before and after absorption by the tampon. Protein concentration of plasma before and after absorption by the tampon did not differ. Mares susceptible to CUI accumulated significantly (P less than 0.001) more fluid in the uterus than mares resistant to CUI, and uterine washings from the resistant mares were significantly (P less than 0.05) more dilute than those from the susceptible mares. Significant differences in protein concentrations between susceptible and resistant mares were not found. It was concluded from this study that the described method to sample undiluted uterine secretion was practical and reliable for the analysis of protein concentration. Various concentrations of uterine secretions in washings from susceptible and resistant mares emphasizes the importance in using undiluted uterine secretions or dilution markers in washings when intrauterine products are analyzed.     

Effect of seminal plasma on uterine inflammation, contractility and pregnancy rates in mares

REASONS FOR PERFORMING STUDY: There is conflicting evidence over the role seminal plasma plays in sperm transport and inflammation within the uterus of mares. In in vitro studies, seminal plasma has been shown to reduce polymorphonuclear neutrophil (PMN) function, but the opposite effect on uterine inflammation has been reported in vivo. OBJECTIVES: To study the effect of seminal plasma on uterine contractility, inflammation and pregnancy rates by inseminating mares with low doses of sperm free from seminal plasma (Group 1) and containing seminal plasma (Group 2). METHODS: Synchronised mares were inseminated with 50 x 10(6) sperm in either skim milk extender or seminal plasma. Uterine lavage was performed 6 h after insemination to assess the inflammatory response. The contraction frequency of the uterus was measured over a 4 min period 10 mins and 6 h after insemination, using B-mode ultrasonography. Pregnancy rates were assessed 16 days after insemination. RESULTS: Uterine contractions were less frequent in Group 1 mares inseminated with seminal plasma and significantly more PMNs were found in the lavage fluid of those mares. Pregnancy rates were identical in both groups (62%). CONCLUSIONS: This study provides evidence that seminal plasma decreases uterine contractility and increases the inflammatory response of the uterus to semen. No effect of seminal plasma on pregnancy rates was demonstrated. POTENTIAL RELEVANCE: Mares that develop persistent mating-induced endometritis may have inherently poor uterine contractility and impaired uterine clearance. The presence of seminal plasma during breeding may not be desirable in these mares. The role of seminal plasma in problem mares warrants additional study.     

Investigations on the Endometrial Response to Intrauterine Administration of N‐Acetylcysteine in Oestrous Mares

In mares, mating‐induced persistent endometritis contributes to low fertility. The condition is in part related to delayed clearance of mucus accumulated within the uterine lumen. The objective of this study was to investigate the endometrial response of healthy mares to intrauterine (i.u.) treatment with N‐acetylcysteine (NAC). Oestrous mares (n = 12) were randomly assigned to a treatment (TM) or control (C) group and received an i.u. infusion of 5% NAC and saline (total volume 140 ml), respectively. Endometrial biopsies were collected in five of the mares 24 h after treatment, in the remaining seven mares 72 h after treatment. Endometrial biopsies were evaluated for integrity of the luminal epithelium, number of polymorphonuclear neutrophils (PMN), staining for cyclooxygenase 2 (COX2), staining with Kiel 67 antigen (Ki‐67), lectins and periodic acid‐Schiff (PAS). The integrity of endometrial epithelial cells was not affected by treatment (no statistical differences between groups or times). At 24 h after treatment, the mean number of PMN in endometrial biopsies from NAC‐ and C‐mares did not differ, but at 72 h after treatment, number of PMN was significantly higher (p < 0.05) in C (3.9 ± 0.6 PMN/field) compared with NAC‐treated mares (2.3 ± 0.2 PMN/field). At 72 h after treatment, the intensity of staining for COX2 was significantly higher after saline than after NAC treatment (p < 0.05). In the epithelium, no differences in staining for the proliferation marker Ki‐67 were seen with respect to time and treatment. Score for the lectin wheat germ agglutinin (WGA) was slightly higher in NAC‐treated mares than in C‐mares 72 h after treatment (p < 0.05). Score for PAS staining of mucus in deep uterine glands differed significantly between groups at 24 h after treatment (p < 0.05). The present study demonstrates that NAC does not adversely affect the endometrial function. Moreover, an anti‐inflammatory effect on the equine endometrium was observed.     

Influence of bacterial challenge and long-term progesterone on endometritis of mares

Progress in treatment of endometritis in mares has been impeded by lack of an experimental model. This study tests the hypothesis that exposure of a mare's uterus to bacteria, while being treated with progesterone, will result in a compromised uterine defense after progesterone has been withdrawn. Ten mares were administered progesterone for 8 months and inoculated at the onset of treatment with a 5 x los colony forming units of(CFU) of Streptococcuszooepidemicus into the uterus. Mares were re-inoculated to maintain uterine infection, if necessary. Ten uninoculated mares with normal uteri served as controls. After the end of progesterone treat- ment all mares (treated and controls) experienced a normal estrous cycle and were inoculated with 5 x l0s CFU of Streptococcus zooepidemicus. Results of reproductive evalu- ations performed on days 2, 7 and 12 after bacterial inoculation were similar (P>0.05) for treated and controls. Pregnancy rates for treated and controls were also similar (P>0.05). Thus, the treatment evaluated in this study did not cause an alteration in the mare's ability to resolve endometritis.     

Morphologic evaluation of acute endometritis in mares with differing resistance to uterine infections

The study was designed to determine differences between normal mares and mares with endometrial pathology in the inflammatory response after bacterial challenge. Six normal mares (biopsy category I) and 4 mares with pathological endometrial changes (biopsy category II) were given an intrauterine infusion of β-hemolytic streptococci on the second day of estrus. All mares had a similar kind of inflammatory response after the bacterial inoculation as assessed by rectal and vaginal examinations. There were no significant differences in the amount of discharge, uterine tone, uterine size and cervical relaxation between the groups. Leukocytic response, as determined by endometrial smears and biopsies, was of the same magnitude in both groups. Two mares from the pathological group were not able to eliminate the infection, but had vaginal discharge and bacteriologically positive uterine swabs until the end of the experiment. It is concluded that the inability of some mares to clear uterine infections cannot be explained by a deficient inflammatory response.     

Effect of exogenous ovarian steroids on the uterine luminal prostaglandins in ovariectomised mares with experimental endometritis

Prostaglandins (PGs) F and E2 were measured in lavage fluid from the uterus of ovariectomised mares after experimental induction of uterine inflammation. Treatment with progesterone alone, or progesterone followed by oestradiol, significantly increased the concentrations of these PGs in the lavage compared with mares treated with oestradiol or control mares. Ovarian steroids, therefore, influenced uterine PG synthesis in response to an inflammatory stimulus. To determine whether the uterine lavage procedure might contribute to the concentrations of prostaglandins in the lavage, the procedure was also performed on six intact mares. With the exception of washings obtained at luteolysis, uterine concentrations of PGF (measured as the plasma metabolite 15-keto-13,14-dihydro PGF2 alpha) had returned to prewashing levels within 30 minutes of the start of uterine lavage. Lavage was therefore unlikely to have influenced the concentrations of prostaglandins in the lavage fluid.     

Effect of administration of phenylbutazone or progesterone on recovery of embryos from the uterus of mares 5 days after ovulation.

Twelve horse mares were used to investigate the effect of phenylbutazone or progesterone administration on uterine tubal motility, as reflected by embryo recovery from the uterus on day 5 after ovulation. Four treatment groups were used: group A (controls), in which uterine flush was performed 7 to 11 days after ovulation; group B (5-day controls), in which uterine flush was performed 5 days after ovulation; group C, in which uterine flush was performed 5 days after ovulation following administration of phenylbutazone (2 g, IV) on day 3; and group D, in which uterine flush was performed 5 days after ovulation following administration of progesterone in oil (250 mg, IM) on days 0, 1, and 2. Each mare was randomly assigned to each group once. Embryo recovery for each group was: group A, 13 embryos from 12 mares; group B, 3 embryos from 12 mares; group C, 4 embryos from 11 mares; and group D, 1 embryo from 11 mares. Recovery of embryos on day 5 in 3 of 12 nontreated mares indicated that equine embryos may enter the uterus before day 6. Neither treatment increased embryo recovery from the uterus on day 5 over that from the uterus of the 5-day controls.     

Presence of Bacteria on the External Genitalia of Healthy Stallions and its Transmission to the Mare at the Time of Breeding by Live Cover

The current field study used thoroughbred stallions and mares from central Kentucky to investigate the occurrence of potentially pathogenic bacteria on the stallion's external genitalia, based on cultures, and investigated the occurrence of bacteria and type of isolate in the mare's uterus after breeding by live cover to stallions with or without positive bacterial cultures. Fifteen thoroughbred stallions and 206 mares from two central Kentucky thoroughbred farms were used during the 2010 and 2011 breeding seasons. Samples for bacteriological evaluation were taken from the prepuce and postejaculate urethra (n = 201) of stallions. Uterine swabs (n = 264) were collected 12-18 hours postbreeding. For statistical analyses, a chi-squared test was used to test the relationship between stallion culture results and postbreeding uterine culture results, as well as the effect of bacterial types found on the stallion cultures with bacterial types found on the postbreeding uterine cultures. Of stallion cultures, 22.4% were positive for potentially pathogenic bacteria, with Streptococcus equi subspecies zooepidemicus (51.1%) being the most common isolate. Uterine cultures resulted in a 29.2% positive rate for potentially pathogenic bacteria, with S. equi subsp. zooepidemicus (90.9%) being the most common. There was no difference (P > .05) in the occurrence of bacteria or type of isolate found on uterine cultures after breeding stallions with or without positive cultures. In conclusion, potentially pathogenic bacteria found on the stallion's external genitalia did not affect the occurrence and type of bacterial isolate found in the mare's uterus after breeding by live cover.     

Problems After Breeding

Breeding induces an inflammatory response in the uterus. The inflammation is a physiological reaction with the purpose of clearing the uterus from excess spermatozoa, seminal plasma, and bacterial contamination. Breeding-induced endometritis is transient and most mares resolve the inflammation within 24 to 36 hours. If a mare fails to resolve the breeding-induced inflammation before an embryo enters the uterus, the pregnancy is likely to be lost. Susceptibility to persistent breeding-induced endometritis occurs in approximately 15% of a normal brood mare population.     

Distribution of mast cells in vaginal, cervical and uterine tissue of non-pregnant mares: investigations on correlations with ovarian steroids

Mast cells constitute part of the cellular immune system of the genital tract. They play a potential role in cervical remodelling during parturition and are subject to the influence of ovarian steroids. In this study, the influence of oestradiol‐17β and progesterone on the distribution of mast cells in equine vaginal, cervical and uterine tissue was evaluated. Genital tracts were retrieved from healthy mares at a local slaughterhouse. The cervix was divided along the longitudinal axis into five equivalent regions from cranial to caudal (R1 to R5). Toluidine blue staining was used for the detection of mast cells. Hormone values were determined via radioimmunoassay. In cervical tissue, mast cells were present at higher frequency and higher density than in vaginal and uterine tissue. Statistically significant differences were obtained between cervical R1 (cranial) and uterus as well as cervical R2 and uterus (p < 0.05). In cervical tissue, an association between the presence of mast cells and peripheral oestrogen concentrations was observed, whereas such correlation could not be established for vaginal and uterine tissue. With increasing oestradiol‐17β concentrations, the density of mast cells in cervical tissue increased to a statistically significant degree in the cranial (r = 0.46; p = 0.05) and caudal (r = 0.5; p = 0.03) regions. We propose that mast cells play a role in the cyclic remodelling of the equine cervix during the course of the oestrous cycle. Elucidation of mechanisms controlling cervical remodelling could contribute to development of therapies for mares showing a lack in cervical opening during oestrus.     

Elevating the uterus (uteropexy) of five mares by laparoscopically imbricating the mesometrium

Reasons for performing study: There is a need for study of a method for restoring a ventrally positioned uterus to a horizontal position involving fertility of mares with delayed uterine clearance. Hypothesis: A ventrally‐angled uterus can be elevated to a horizontal position using a laparoscopic technique. Objective: To develop a laparoscopic technique of imbricating the mesometria to elevate the uterus to a horizontal position. Methods: The right and left mesometria of 5 pluriparous mares, all barren for 1–8 years (mean 3.8 years), with a pendulous, ventrally‐angled uterus were shortened laparoscopically, by imbrication, with the mares standing, to raise the uterine body and horns to a horizontal position. Sutures were placed through the dorsal aspect of the uterine body and uterine horn and the adjacent region of the mesometrium using a simple continuous suture pattern. Results: The uterus of all 5 mares was elevated successfully to a horizontal position. Three of the mares became pregnant the same year, without other treatment, after the procedure. Conclusions: A pendulous, ventrally‐angled uterus can be returned to a normal, horizontal position by imbricating the mesometria, using a laparoscopic technique. Potential relevance: Elevating a ventrally‐angled uterus to a horizontal position may improve egress of uterine debris, thereby improving fertility.     

Plasma concentrations of 13,14-dihydro-15-ketoprostaglandin F2 alpha in mares during uterine involution.

Twelve mares were allowed to foal naturally, after which they were monitored to study uterine involution. Starting on day 3 after parturition, the internal genital tract was examined per rectum manually and ultrasonographically every other day for changes in uterine characteristics and ovarian activity. By day 5, gravid and nongravid uterine horns were similar in size, and by day 7, uterine fluid was absent. On day 7 after parturition, endometrial biopsy samples were obtained for histologic evaluation, and uterine swab specimens were obtained for microbiologic culture. Uterine swab specimens from 10 of 12 mares had slight bacterial growth. The uteri of 8 of the 12 mares were histologically involuted by day 7. All mares ovulated 7 to 12 days after parturition. Concentrations of 13,14-dihydro-15-keto-PGF2 alpha (PGFM) were measured in jugular plasma samples obtained daily for 21 days after parturition. Concentrations of PGFM were low by the day after parturition, and there was no significant correlation between uterine involution and PGFM concentrations in these mares. All 12 mares were bred at the first estrus after parturition, and 9 became pregnant.     

Use of a cervical stent for long‐term treatment of pyometra in the mare: A report of three cases

An effective long‐term treatment is necessary for mares with pyometra, because the condition tends to recur. In many affected animals, several conformational or anatomical anomalies contribute to impaired uterine clearance. Ovariohysterectomy is the surgical procedure of choice. Conservative therapy consists of draining and flushing the uterus, and systemic anti‐inflammatory and antimicrobial treatment. Uterine secretions tend to accumulate again after local treatment, especially in mares with poor vaginal conformation or cervical adhesions. Herein, we describe three cases in which a cervical stent was used in mares after mechanical or manual dilation of the cervix to achieve permanent draining of the uterus. The mares remained symptom‐free for up to 6 years and exhibited good clinical progress and good performance in competitions. Potential complications of the procedure include loss of the stent and obstruction caused by viscous secretion. A cervical stent is a relatively easy and low‐cost option for the long‐term treatment of pyometra in mares, particularly in cases where excessive costs of surgery and risks of a general anaesthesia are to be avoided.     

Effect on fertility of uterine lavage performed immediately prior to insemination in mares

OBJECTIVE: To determine the effect on fertility of large-volume uterine lavage with lactated Ringer's solution (LRS) performed immediately prior to insemination in mares. DESIGN: Prospective randomized controlled study. ANIMALS: 20 mares. PROCEDURE: Control mares (n = 10) were inseminated with 1 billion (estimated before cooling) progressively motile spermatozoa that had been cooled in a passive cooling unit for 24 hours. Mares (n = 10) in the treatment group were inseminated with 1 billion progressively motile spermatozoa (cooled as described for control mares) immediately after uterine lavage with 4 L of sterile LRS. RESULTS: There were no significant differences in pregnancy rates or size of the embryonic vesicle on days 12, 13, and 14 after ovulation between control and treated mares. CONCLUSIONS AND CLINICAL RELEVANCE: Results indicate that uterine lavage with LRS can be performed immediately prior to insemination without adversely affecting fertility in mares. This is clinically important, because insemination may be necessary when a mare has inflammation-associated fluid (detectable ultrasonographically) in the uterus; removal of the fluid is desirable, because it adversely affects spermatozoal motility and fertility. This situation typically arises when mares require rebreeding after they have developed persistent mating-induced endometritis or are inseminated multiple times in a 24-hour period (during the period of physiologic mating-induced inflammation), which is a common practice when using cooled or frozen-thawed semen.     

Ovariohysterectomy in Six Mares

Six mares had ovariohysterectomy performed for chronic pyometra associated with cervical abnormalities, uterine neoplasia, or removal of a macerated fetus. Ovariohysterectomy was performed through a ventral midline incision with access to the ovarian and uterine vessels aided by traction on the uterus and retraction of abdominal viscera. Abdominal pain, the most common complication after surgery, occurred in four mares but resolved within 36 hours. Peritonitis occurred in two mares; one mare was subsequently euthanatized. Other complications that resolved with treatment included infection of the uterine stump (two mares), abdominal hemorrhage (one mare), diarrhea (one mare), and incisional infection (one mare). Complications after surgery can be reduced by removing as much of the uterus as possible, minimizing peritoneal contamination with uterine contents, and providing a secure closure of the caudal reproductive tract.     

Laparoscopic Application of PGE2 to the Uterine Tube Surface Enhances Fertility in Selected Subfertile Mares

Topical application of prostaglandin E₂ (PGE₂) gel to the surface of the uterine tubes via a laparoscopic procedure improved embryo recovery rates or pregnancy rates in 28 subfertile mares suspected of uterine tubal pathology. Gelatinous masses may occlude the lumen of the uterine tube and prevent sperm from reaching the site of fertilization or prevent embryos from reaching the uterus. PGE₂ is secreted by the early equine embryo, promoting passage of the embryo into the uterus; topical administration of PGE₂ onto the surface of the uterine tube has been shown to stimulate early transport of the embryo into the uterus. Embryos were produced or a pregnancy was obtained from 24 of the 28 barren mares treated with direct laparoscopic application of 0.2 mg of PGE₂ to their uterine tubes. Mares had been barren for an average duration of 1.9 ± 0.6 years and an average of 6.9 ± 3.8 estrous cycles prior to treatment, without donating an embryo or becoming pregnant. Seventeen of 20 mares bred as embryo donors produced one or more embryos with an average of 2.1 ± 1.9 embryos collected per mare (0.45 embryos per cycle) after PGE₂ treatment. Seven of 8 mares bred to carry their own pregnancy became pregnant within the first two cycles following PGE₂ treatment. These 8 mares were bred an average of 5.6 ± 1.8 cycles without a pregnancy prior to treatment. The laparoscopic PGE₂ procedure was performed during various stages of the estrous cycle; the stage varied among treated mares.     

Post-partum uterine rupture: Standing repair in three mares using a laparoscopic technique

Three mares underwent diagnostic laparoscopy because of suspicion of post-partum uterine ruptures. All three horses showed clinical signs of a uterine rupture between 1 and 3 days after parturition and underwent diagnostic laparoscopy. In all cases a full thickness uterine rupture could be detected and was sutured laparoscopically. Availability of suture material and surgeon experience were responsible for the surgical methods chosen for repair. In the first case, a hand-assisted laparoscopic approach was chosen for suturing the ruptured uterus, whereas in the other cases the approach was entirely laparoscopic. In the second case, extracorporeal knots were used for the repair and in the last case described a barbed loop suture was available for closure of the uterus. Two of three mares were alive for at least 12 months after surgery without any abdominal problems. One of these mares delivered a healthy foal 2 years after surgery. The remaining mare died 3 months after surgery but no necropsy was done. Laparoscopy should be considered for post-partum mares with signs of peritonitis to access the uterus and repair a rupture if it is accessible. A laparoscopic approach using intracorporeal knots or barbed sutures for the repair of the uterine rupture as well as a hand-assisted laparoscopic approach are feasible. The use of the barbed suture for intracorporeal closure makes the minimal invasive laparoscopic technique easier to perform.     

Making sense of equine uterine infections: the many faces of physical clearance

Equine uterine infections inflict major losses on the equine industry. Persistent inflammation of the oviduct and uterus leads to loss of the conceptus and mares susceptible to infection have weakened uterine defences partly due to retention of inflammatory exudate. Bacteria may trigger inflammation, resist phagocytosis, or adhere to the endometrium and types of infection range from genital commensals in susceptible mares to reproductive pathogens in normal mares. Uterine infections are diagnosed by history, detection of uterine inflammation, and isolation of typical organisms and susceptible mares may be identified by detection of intrauterine fluid during oestrus, or at 6-48 h post-breeding. Therapy includes oxytocin, uterine lavage, antibiotics, and prostaglandin analogues and clinical studies indicate additive benefits of oxytocin and antibiotics. Improved conception rates have been associated with autologous, intrauterine plasma, despite controversy about its bactericidal efficacy. Because of the potential for endometrial damage, intrauterine antiseptics require caution.