Female Anatomy PDF

[OB 1] P.01 THE FEMALE ANATOMY | DR. ARCELLANA | August 14, 2024 EXTERNAL GENERATIVE ORGANS Lacks hair follicles, eccrine glands, and apocrine glands, but with All female reproductive organs seen...

[OB 1] P.01 THE FEMALE ANATOMY | DR. ARCELLANA | August 14, 2024 EXTERNAL GENERATIVE ORGANS Lacks hair follicles, eccrine glands, and apocrine glands, but with All female reproductive organs seen on the outside, from the symphysis pubis to the abundance of sebaceous glands. perineal body, is considered as the Vulva. Each is a thin tissue fold that lies medial to each labia majora VULVA From each side: MONS Fat-filled cushion overlying the symphysis pubis o Upper Lamellae fuses to form the prepuce of clitoris PUBIS/ After puberty, the Vulva is covered by curly hair that forms the triangular o Lower Lamellae fuses to form the frenulum of clitoris MONS escutcheon. Inferiorly: extends to approach the midline as low ridges of tissue that VENERIS Escutcheon - often inverted triangle in distribution except in cases of joins to form the fourchette. hyperandrogenic wherein the distribution is the same with males (PCOS Composed of connective tissue with numerous vessels, elastin fiber and or Virilizing Tumor of the Ovary) very smooth muscle fibers. Borders The lining epithelium differs with location: o Base: Symphysis Pubis o Outer surface: covered with thinly keratinized stratified o Tip/ Apex: Clitoral End squamous epithelium up to the demarcation line a.k.a. Hart Males: hair distribution can stretch up to the anterior abdominal wall or line. umbilicus. o Medial to the Hart line: non-keratinizing stratified squamous Shaving this area prior to delivery is discouraged as it increases risk of epithelium. infection on the surgical site. o CLINICAL CORRELATION: Straddle Injury CLINICAL CORRELATION: HIRSUTISM – d/t predominance of § May cause lacerations to the labia minora, leading to testosterone among females, hair distribution may mimic that of a males moderate bleeding from numerous blood vessels LABIA Dimensions: CLITORIS Principal erogenous organ MAJORA o 7-8 cm length (Homologue: Rarely exceeds 2 cm in length (Homologue: o 2-3 cm depth Penis) Composed of: Glans, Corpus/Body, Male o 1-1.5 cm thickness and 2 Crura Scrotum) Abundant in apocrine, eccrine, and Located beneath the prepuce, above sebaceous glands. the frenulum and urethra During pregnancy (2nd /3rd trimester) Projects downward and inward toward blood vessels in this area dilate d/t inc the vaginal opening venous pressure created by the Extending from the clitoral body, each corpus cavernosum diverges enlarging uterus and can be grossly laterally to form a long, narrow crus visualized called vulvoginal varicosities o During pregnancy: Clitoris may become swollen as the blood o Patient may complain of inguinal pain or tenderness around flows down the labia majora or feeling that it is swollen. Rise in hormone levels and increase in blood flow may also cause o If these varicosities are traversed during episiotomy bleeding clitoris to change color and become darker may occur, thus they are avoided during episiotomy. Glans o May also occur in females taking over the counter o 0.5 cm in diameter, covered by stratified squamous epithelium contraceptives (OCP) containing estrogen and progesterone. o Richly innervated o Prolonged exposure to estrogen predisposes patients to Clitoral Body – Contains 2 corpora cavernosa thromboembolic disease. prior to the thromboembolic event, Crus – Each lies along the inferior surface of its respective ischiopubic there may be engorgement of the blood vessels first. rami & deep to the ischiocavernous muscle § An episiotomy is a cut (incision) made in the tissue Blood supply between the vaginal opening and the anus during o Branch of internal pudendal artery, composed of: childbirth. § Deep artery of the clitoris (corpus) LABIA Dimensions § Dorsal artery of the clitoris (glans and prepuce) MINORA o 2-10 cm in length VESTIBULE Functionally mature female structure from embryonic urogenital (Homologue: o 1-5 cm in width membrane Ventral shaft Extremely sensitive due to many nerve endings. Adult women: Appears almond shape of penis) Laterally: enclosed by Hart line [OB 1] P.01 THE FEMALE ANATOMY | DR. ARCELLANA | August 14, 2024 Medially: external surface of the § 2 largest are Skene’s glands & their ducts lie distally hymen near the urethral meatus Anteriorly: the clitoral frenulum CLINICAL CORRELATION: URETHRAL Posteriorly: fourchette DIVERTICULUM Perforated by 6 openings: o Inflammation & duct obstruction o (1) Urethral opening of any of paraurethral gland o (1) Vaginal opening o Does not warrant treatment since o (2) Openings from majority is asymptomatic Bartholin’s gland/Greater vestibular URETHRA Lower 2/3 lie immediately above the anterior vaginal wall gland The meatus is in the middle of the vestibule, 1-1.5 cm below the pubic o (2) Openings from the Skene’s arch, & a short distance above the vaginal opening gland/Paraurethral glands – largest Urinary Tract Infections (UTI) are more common among females paraurethral gland compared to males. Fossa Navicularis HYMEN A membrane of varying thickness that o Posterior portion of the vestibule surrounds the vaginal opening more o B/n the fourchette and the vaginal or less completely. opening Subdivided into: 2 Bartholin glands/Greater vestibular glands o Anterior o 0.5 – 1 cm in dm, each lies inferior to the vascular vestibular o Posterior bulb & deep to the inferior end of the BBS (bulbocavernosus) o Two lateral fornixes by the muscle cervix o Duct from each measure 1.5- 2 cm long and opens distal to Composed mainly of elastic and the hymenal ring – at 5 o’clock & 7 o’clock collagenous connective tissue, CLINICAL CORRELATION: BARTHOLIN CYST/ABSCESS covered (both outer and inner) by o Occurs when ducts are obstructed by mucin or infection nonkeratinized stratified squamous epithelium. o Following trauma or infection, either duct may swell and Changes produced in the hymen by childbirth are usually readily obstruct to form a cyst recognizable o Causes: Secondary to STI such as gonorrhea; Multiorgan Overtime, hymen may transform into several nodules of various size = infection such as Gardnerella vaginalis Myrtiform caruncles/hymeneal o Bartholin’s Cyst – When there is obstruction of its secretion In pregnant women: The hymen epith is thick & rich in glycogen o Bartholin’s Abscess – infection, composed of mucopurulent In pre-menopausal women: Rugae which line the anterior and posterior material. vaginal walls along their length o This may warrant medical or surgical intervention because In nulliparous women: Annular Hymen patients are symptomatic with a chief complaint of pain CLINICAL CORRELATION: IMPERFORATE HYMEN o Treatment: o A rare malformation, in which the vaginal orifice is occluded § Marsupialization (Drainage) completely (no opening in the hymen), causing retention of § Excision of the Bartholin’s Glands (only done in menstrual blood perimenopausal or menopausal patients with o Warrants surgical intervention recurrent infection) o When they reach puberty and are about to have menarche, the § Surgical Management if with abscess menstrual blood is trapped inside the vaginal and uterine o Minor vestibular glands cavity called Hematocolpos/Hematometra o Shallow glands lined by simple mucin-secreting epithelium o Symptoms: The patient experiences cyclic pains but with no and open along Hart line menstrual blood. o Paraurethral Glands § HEMATOCOLPOS - blood accumulated in the § Collective arborization of glands whose small ducts vaginal cervical cavity open predominantly along the entire inferior aspect of the urethra [OB 1] P.01 THE FEMALE ANATOMY | DR. ARCELLANA | August 14, 2024 § HEMATOMETRA - blood accumulated in the uterine Lubrication comes from the vaginal subepithelial capillary plexus and activity crosses permeable epithelium Treatment: cruciate incision and leave it open In pregnancy: increased vaginal secretions due to increased vascularity VAGINA Proximal to the hymen which may be confused with amniotic fluid (AF) leakage Musculomembranous tube that extends to the uterus & is interposed After birth-related trauma & healing: fragments of stratified epithelium lengthwise between the bladder and rectum occasionally are embedded beneath the vaginal surface. Anteriorly: vagina is separated from the bladder and urethra by This buried epithelium continues to shed degenerated cells and keratin vesicovaginal septum (a connective tissue) forming Epidermal Inclusion Cyst (EIC) Posteriorly: lower portion of vagina separated from the rectum by Common vaginal cyst- May not warrant surgical interventions unless rectovaginal septum there are symptoms of vaginal discomfort o Upper 4th of the vagina is separated from the rectum by the CLINICAL CORRELATION: CULDOTOMY ‘rectovaginal pouch’/‘Posterior cul-de-sac’/ ‘Pouch of Douglas’ o Used to find out if the blood is from an ectopic pregnancy, o Anterior cul-de-sac is the space between the lower uterine insert a needle at the posterior fornix and access the posterior segment and the bladder cul-de-sac. o Normally, the anterior and posterior walls of the vaginal lumen, o Previously used in the absence of ultrasound lie in contact with only slight space, intervening at the lateral o Pregnant women may complain of watery discharge and margins confuse it with Amniotic fluid. o Vaginal length varies: Anterior wall: 6-8 cm ; Posterior wall: 7- o To differentiate vaginal fluid vs amniotic fluid: 10 cm § Do speculum exam to determine whether the fluid is o Upper end of the vaginal vault is subdivided into: coming from the cervix or if the fluid is just § Anterior concentrated in the vaginal walls. If it’s really coming § Posterior from the cervix, it probably is amniotic fluid. § 2 lateral fornices by the cervix § Use litmus paper to determine pH § Of considerable clinical importance because the § Vaginal fluid: ACIDIC ; Amniotic fluid: BASIC internal pelvic organs usually can be palpated Vascular supply through the thin walls of these fornices. o The different portions of the vagina are supplied by the § Posterior fornix: provides surgical access to the different arteries peritoneal cavity o Proximal portion: Cervical branch of the uterine artery and by Mid Portions of the vagina: lateral walls are attached to the pelvis by vaginal artery visceral CT, that blend into the investing fascia of the levator ani à Vaginal artery: may variably arise from create an anterior and posterior lateral vaginal sulci à Runs the length uterine or inferior vesicle artery or directly of the vaginal side walls and give an H-shaped when reviewed in cross- from internal iliac artery section. § Posterior vaginal wall: middle rectal artery Vaginal lining: nonkeratinized § Distal walls: internal pudendal artery stratified squamous epithelium § At each level blood supply from each side forms Underneath: is a muscle layer anastomosis on the anterior and posterior vaginal consisting of smooth muscle, walls with contralateral corresponding vessels collagen, and elastin § These arteries cross the midline and form the Beneath the muscle layer midline anastomoses adventitia layer consisting of o Venous Plexus: Immediately surrounds the vagina and follows collagen and elastin. the course of the arteries For premenopausal women: o Lymphatics: Lining is thrown into numerous § Lower 3rd (along with those of vulva): inguinal thin transverse ridges knowns as lymph node rugae, which line the anterior and posterior wall of the vagina § Middle 3rd: internal iliac lymph node No vaginal glands § Upper 3rd: External, internal and common iliac nodes [OB 1] P.01 THE FEMALE ANATOMY | DR. ARCELLANA | August 14, 2024 CLINICAL CORRELATION: A 32-year-old parent primigravida came to the § Must know : length of your fingers. ER due to labor pains IE done revealing 9 cm cervical dilatations, § If the sacral promontory ca not be palpated by cephalic at station 0 wherein intact bag of waters. What is the anatomic fingers, it means that the pelvis is adequate and is landmark for saying that the cephalic is already at station 0? What will not contracted. you palpate? § Example: If the length of your finger is 10 cm and o Palpate for the ischial spine you can palpate the sacral promontory within 10 o Ischial spine is part of the pelvic midplane cm it is a contracted pelvis, of cephalic pelvic disproportion or a small pelvis. But if the length of COMPONENTS OF THE PELVIS the finger is 13 cm but the promontory is not felt, TRUE PELVIS Of obstetrical significance the pelvis is adequate, the inlet is big. Lies below false pelvis FALSE PELVIS Lies above the Linea terminalis The side walls of the true pelvis of an adult converge somewhat above Bounded: the Linea terminalis o Posteriorly: lumbar vertebra Important in childbearing o Laterally: iliac fossa Described as an obliquely truncated, bent cylinder with its greatest o Anteriorly: lower portion of the anterior abdominal wall. height posteriorly Pelvic Joints Boundaries: o Anteriorly joined together by the symphysis pubis o Superior – Linea o Symphysis pubis - Consist of fibrocartilage and superior and terminalis inferior pubic ligaments which is designated as the arcuate o Inferior – Pelvic ligament of the pubis outlet o Posteriorly, the pelvic bones are joined by the articulations o Posterior – between the sacrum and the iliac portions of the innominate Anterior surface bones to form the sacroiliac joints of sacrum o These joint in general have a limited degree of mobility o Anterior – Pubic bones, Ascending superior rami of the Sacroiliac joints ischial bones, and Obturator foramina o During pregnancy, o Lateral – Inner surface of ischial bones and sacrosciatic there is remarkable notches and ligaments relaxation of joints Ischial Spines at term, caused by o Extending from the upward gliding of middle of the posterior the sacroiliac joint. margin of each Ischium The displacement, o Of great obstetrical which is greatest in the dorsal lithotomy position, may importance because: increase the diameter of the outlet by 1.5 to 2.0 cm § Distance b/n o Sacroiliac joint mobility is also the likely reason that the them McRoberts maneuver often is successful in releasing an represents the shortest diameter of the true pelvis obstructed shoulder in a case of shoulder dystocia. § Serve as valuable landmarks in assessing the level 3 Important things to consider during normal vaginal delivery: to which the presenting part of the fetus has o Power – uterine contractions are adequate descended into the true pelvis o Passenger – the average Filipino baby size: 2.5-3 kg § Also serves as landmark for the location of o Passageway – Pelvic bones should be adequate pudendal nerve block placement Precipitous delivery – there is a vaginal delivery within 3 hrs from the o The sacrum forms the posterior wall of the true pelvis. Its active contractions, 3 mins and 10 mins. upper anterior margin corresponds to the promontory that Contractions – can be monitored through cardiotocogram, measures may be felt during bimanual pelvic examination in women the strength of uterine contractions. Ex: 180mmhg is an adequate with a small pelvis. It can provide landmark for clinical contraction, from 3cm fully leading to precipitate labor and delivery. pelvimetry. o Inlet contractions – MC contraction [OB 1] P.01 THE FEMALE ANATOMY | DR. ARCELLANA | August 14, 2024 o Midplane contraction – least pelvic diameter bi-ischial o AP Diameter spine o Uppermost margin of the symphysis pubis to the sacral o Outlet contraction – cord loop MC problem promontory Obstetrical Conjugate PLANES AND DIAMETER OF THE PELVIS o Clinically important The pelvis is described as having four o Shortest distance b/n the sacral promontory and the imaginary planes: symphysis pubis o Plane of the pelvic inlet – the o 10cm or more superior strait o Estimated indirectly by subtracting 1.5cm to 2cm from the o The plane of the pelvic outlet – the diagonal conjugate inferior strait Diagonal Conjugate o The plane of the midpelvis – the o Distance from the lowest margin of the symphysis to the least pelvic dimensions sacral promontory. o The plane of the greatest pelvic dimension o This is used to measure pelvic inlet § Of no obstetrical significance o When you get the measurement subtract 1.5 to 2 cm and the PELVIC INLET value should be more than 10 cm Bounded posteriorly by the promontory and alae of the sacrum, laterally by the linea § If the value is >10 cm for obstetrical conjugate, terminalis, and anteriorly by the horizontal pubic rami and the symphysis pubis. which means the pelvic inlet is adequate Important because engagement occurs when the biparietal diameter enters the pelvic Measuring from the pubis to the inlet sacrococcygeal joint During labor, fetal head engagement is defined by the fetal head’s diameter or fetal NOTE: biparietal diameter passing through this plane. To aid this passage, the inlet of the female o Obstetrical – clinically pelvis compared with the male pelvis typically is more nearing down or ovoid or the significant gynecologic type gynecoid type of pelvic shape. o Diagonal – measurable The most two important are the: o Symphysis pubis TRANSVERSE Constructed at right angles to the obstetrical conjugate and represents o Sacral promontory DIAMETER the greatest distance between the Linea Terminalis on each side Four (4) diameters: Intersects the obstetrical conjugate at a point approximately 5cm in o Anteroposterior (AP) - most cephalad front of the promontory. o Transverse Measures approximately 13cm. o Two (2) Oblique diameters Assessed clinically by measuring the distance between the ischial Ischial Spine tuberosities along a plane passing across the anus o Landmark of the Pelvic Inlet OBLIQUE Each extends from one sacroiliac synchondrosis to the contralateral o LEAST pelvic diameter (Inter-ischial spine/Bi-ischial diameter) DIAMETER Iliopubic eminence. § Inter-ischial spine should be AT LEAST 10 CM so that the bi-parietal Average less than 13cm. diameter of the fetus’ head may pass through. PELVIC 0UTLET o Cephalic station 0: Fetal’s head is at the level of the ischial spine. Seldom are pelvic outlet problems encountered § Cephalic station -3: 3 cm above station 0 To measure pelvic outlet: § Cephalic station -2: 2 cm above o Measure the bi-ischial tuberosity § Cephalic station -1: 1 cm above o Usually just estimated using the fist § Cephalic station +1: 1 cm below o More than 8cm = Adequate § Cephalic station +2: 2 cm below Borders of the pelvic outlet: § Cephalic station +3: 3 cm below o Anteriorly: Pubic arch ANTERO- There are three conjugates; the clinically significant is the obstetrical o Laterally: Ischial Tuberosity POSTERIOR conjugates o Posteriorly: Tip of the coccyx DIAMETER Anteriorly – Diagonal – Obstetrical – True conjugate OTHER MUSCULOSKELETAL STRUCTURES – Symphysis pubis & Sacroiliac joint True Conjugate [OB 1] P.01 THE FEMALE ANATOMY | DR. ARCELLANA | August 14, 2024 o Failure to do so would lead to vulvar hematoma. PELVIC SHAPES § Vulvar hematoma can be conservatively CALDWELL-MOLOY CONFIGURATION managed by cold compress, anti-inflammatory Gynecoid or antibiotics. o Most favorable for vaginal delivery § But if the hematoma is already expanding and o Anterior-posterior (AP) diameter is equal to occupying the fat-filled cushion of the mons the transverse diameter. pubis or the gluteal area. Platypeloid § There will be a need to open up the o Transverse diameter is wider than the AP hematoma, ligate the bleeder and ligate the diameter drainage. o Fetal head’s common position when in the DEEP PERINEAL Pubococcygeus and Internal anal sphincter. womb is Left occiput posterior (LOP) POUCH/SPACE Continuous superiorly with the pelvic cavity. o If the pelvis is platypeloid, it will have a Contains portion of the urethra. transverse position. PELVIC Muscles: Persistent Occiput Transverse will lead to failure of descent, secondary to CPD. DIAPHRAGM o Levator ani muscle Anthropoid and Android § Composed of: o Least favorable for vaginal delivery. § Pubococcygeus o AP diameter is longer compared to the transverse diameter. Composed of: Pubovaginalis SOFT STRUCTURES THAT COULD OBSTRUCT FETAL DESCENT Puboperinealis Subcutaneous fat – enlarged subcutaneous fat due to obesity can block fetal descent. Puboanalis Bladder and/or Rectal wall – May block fetal descent when full. § Puborectalis o Encourage patients in labor to urinate as often as they could. § Illococcygeus o They should also be allowed to defecate, if need be, for a better fetal descent. o Coccygeus muscle PERINEUM POSTERIOR TRIANGLE (ANAL TRIANGLE) Diamond-shaped composed of an anterior triangle and posterior triangle Contains: Ischioanal fossa , Anal canal , Anal sphincter SUPERFICIAL The anterior triangle is important in obstetrical practice. complex PERINEAL o Muscles traversed during Right mediolateral episiotomy: Branches of the pudendal nerve and internal pudendal MUSCLES § Bulbocavernosus muscle vessels are also found within. § Transverse perineal muscle Pregnant women complaining of hemorrhoids: o Muscled traversed during Midline episiotomy: o Due to the increased size of the abdomen putting § Perineal body pressure into the pelvis. § If cut too deep however, the deep transverse o Pushing due to labor may also cause inflammation perineal muscle which includes the internal and enlargement. and external sphincter muscle may be cut. o Hemorrhoids complicates midline episiotomy due This would lead to 4th degree lacerations. to risk of cutting the vessels. DEEP PERINEAL Pubococcygeus - Internal anal sphincter Contains: MUSCLES o Ischioanal fossa o Anal canal ANTERIOR UROGENITAL TRIANGLE o Anal sphincter complex SUPERFICIAL Important in this compartment: Branches of the pudendal nerve and internal pudendal vessels are also found within. PERINEAL o Episiotomy and repair in this closed compartment is at Pregnant women complaining of hemorrhoids: POUCH/SPACE risk for vulvar hematoma. o Due to the increased size of the abdomen putting pressure into the pelvis. o When suturing the skin in this area, make sure that o Pushing due to labor may also cause inflammation and enlargement. there is no more bleeding in the muscle layer. o Hemorrhoids complicate midline episiotomy due to risk of cutting the vessels. [OB 1] P.01 THE FEMALE ANATOMY | DR. ARCELLANA | August 14, 2024 UTERUS Commonly during pregnancy, the cervical endocervical epithelium Major bulk of the internal pelvic organs moves out and onto the ectocervix in a physiological process called Normal: 6-7cm à Pregnancy: expands to accommodate a fetus Eversion. Divided into two unequal parts: Everted columnar epithelium is replaced by squamous epithelium and o Corpus (Body) this is known as the squamous metaplasia. o Cervix Vaginal discharge can be that of the amniotic fluid or that of Isthmus becomes the lower uterine segment during pregnancy. transudate. o Where the Low-Segment Cesarean Section is performed. Cervical discharge is commonly mucopurulent. o Landmark: Vesico-vaginal fold Mucopurulent cervical discharge: § 1-2cm above will be the lower uterine segment. o Secondary to Neisseria gonorrhoeae Classical Cesarean Section: Incision on the fundus or corpus o Chlamydia trachomatis causing PID o Cannot be done as the myometrium thickens during pregnancy. Vaginal discharge: § Massive blood loss may occur as a result. o Candida albicans (fungal infection) The pregnancy stimulated remarkable uterine growth due to muscle fiber hypertrophy. § Whitish It is more on hypertrophy than it is hyperplasia § Itchy The uterine fundus is a previously flattened convexity between tubal insertions, now o Bacterial vaginosis become dome shaped to accommodate the fetus in utero. § Grayish Insertion of Fallopian tube at the uterine at the back is the ovary and in front of the § Fish-like odor adnexal area. Trichomonas infection has a strawberry cervix characteristic with foul Adnexae: consists of fallopian tube, ovary and round ligament. smelling vaginal discharge Round ligament is always anterior to the fallopian tubes and the ovary. CERVIX Fusiform and opened at each end by small apertures: Internal os External os The upper boundary of the cervix is called the internal os 2 parts of the Internal os: o Portio Supravaginalis § Cardinal ligament originates here laterally Figure 9. Cervical os § The upper segment which is the portion Seen among nulliparous patients. Before child birth the external cervical os is supravaginalis lies above the vaginal attachment of small regular and oval opening (Fig. 2A). Seen in multiparous patients, After the cervix labor especially vaginal birth the orifice is converted into a transverse slit that is § It is covered by peritoneum on the posterior divided such that it is called anterior and posterior cervical lips (Fig. 2B). If torn surface, cardinal ligament attached laterally and is deeply during labor delivery the cervix may heal in such a manner that it appears separated from the overlying bladder by loose regular, nodular, or stellate connective tissue. Significant in the cervix is the squamo-columnar junction or the o Portio Vaginalis transformation zone. § Touches the lower vaginal portion, uterosacral The transformation zone: usually where cancer would occur. ligament originates here posteriorly Cervical cancer is the most common female genitalia cancer in the § The lower cervical portion protrudes into the Philippines. Cervical cancer is only the third most common in other vagina as portio vaginalis. countries having uterine cancer as the most common followed by Length: 2-3 cms ovarian cancer because the are given complete dose of the nanovalent Mucosa: ciliated columnar epithelium vaccine. Cervical glands: thick, tenacious cervical secretions Latest vaccine for HPV infection would be the nine-in-one anti-cervical cancer vaccine. Ectocervix: lined by nonkeratinized stratified squamous epithelium Endocervical canal: lined by single layer of mucin secreting If you do a Pap smear make sure to collect at the transformation zone. columnar epithelium [OB 1] P.01 THE FEMALE ANATOMY | DR. ARCELLANA | August 14, 2024 Cervical stroma is composed of collagen elastin and proteoglycan and The endometrium varies greatly throughout the little smooth muscle. Changes in these composition and orientation of menstrual cycle and during pregnancy. these components leads to cervical ripening prior to delivery onset. Pregnant patient observe these changes: o In early pregnancy increased vascularity within the cervical stroma beneath the epithelium creates an ecto-cervical bluish coloration or tint called the Chadwick’s sign o Goodell Sign: softening of the cervix (Cervical edema) o Hegar Sign: softening of the isthmus or the lower uterine segment. Later in the pregnancy these could occur simultaneously but in chronological order the first to appear is the Chadwick’s Sign LIGAMENTS LINING OF Lined by the peritoneum called as the uterine serosa layer, a very thin ROUND Contains the sampsons artery, a branch of the uterine artery, THE UTERUS layer covering the uterus LIGAMENT extending laterally and downward into the inguinal canal and The bulk of the uterus is composed of the muscle layer known as the myometrial muscle terminates in the upper portion of the labium maju. It is the female homologue of the male gabernaculum testes MYOMETRIUM Smooth muscle bundles united by connective It originates below and anterior to the fallopian tube tissue containing many elastic fibers. In pregnant patient, when there is stretching of the round ligament The greatest myometrial fibers is in the uterine because the uterus enlarges, would usually complain of labial pain or body and only 10% in the cervix. That’s why we do inguinal pain. no do classical cesarean section but there are During pregnancy this ligament also undergoes hypertrophy and indications when we have to do it like when there increases in both length and diameter is placenta previa totalis, the placenta is occupying the lower uterine segment and it totally encroaches It measures about 3-5mm in diameter, smooth bundles separated by the cervix so we cannot do the CS in the lower fibrous septa segment as it might lead to hemorrhage. Location of the round ligament helps to differentiate the anterior and posterior view of the uterus. If the round ligament is seen anterior to Importance: most contractions come from the the fallopian tube, it is the posterior section of the uterus. myometrium during labor and delivery, especially at the fundal area BROAD Contain the uterine vessels, the ureter are found on its base LIGAMENT It divides the pelvic cavity into the anterior and posterior The interlacing myometrial fibers surround compartments myometrial vessels and contract to compress Seen in the broad ligament is the Adnexae containing the ovaries, (refer to figure 2) This fallopian tube, mesothelium, mesosalpinx and mesoovarium anatomy is integral to The infundibulopelvic ligament/ suspensory ligament of the ovary hemostasis of the suspends the ovary to the pelvic side wall. Contains the ovarian placental site during the vessels, artery and veins 3rd stage of labor There are also varicosities in the broad ligament, during pregnancy During pregnancy, the because of the increase demand of the fetus, there is increased upper myometrium cardiac output, increased blood supply to the uterus which causes undergoes marked the blood vessels to dilate. So, in some cases of cesarean section ENDOMETRIUM Innermost lining of the uterine cavity, overlying there is bleeding due to trauma epithelium, invaginating glands and vascular Ovaries are supposed to be smooth pearly white. In figure 5 the ovary stroma is pinkish with numerous blebs which is referred to the It is composed of: decidualization of pregnancy brought about by progesterone. Functionalis layer (shed off during menstruation) Progesterone hormones causes decidualization characterized by bleb Basalis layer (area of regeneration) formation to the surface of the ovary, surface of the uterus and sometimes at the posterior uterine surface. [OB 1] P.01 THE FEMALE ANATOMY | DR. ARCELLANA | August 14, 2024 During pregnancy these vessels, especially the venous plexus is In the myometrium, before it reaches the endometrium, the arcuate artery dramatically enlarged (Fig.5) specifically the diameter of the ovarian is more tubular and straight then it becomes the radial artery branching vascular pedicle increases from 0.9 cm to 2.6 cm into the basal artery until it becomes spiral known as the coiled artery. Vascularity of this blood vessels is seen during pregnancy The uterine artery supplies the uterus from the outermost layer of the CARDINAL An important ligament because it provides pelvic support uterus going into the endometrium. LIGAMENT Also known as the Transverse Cervical Ligament or Mackenrodt The spiral arteries supply the functionalis layer. These vessels respond by ligament vasoconstriction and dilatation to a number of hormones, thus serve and It is found inferior to the broad ligament and the ureter is very near important role in menstruation. the cardinal ligament, making the ureter prone to injury during Also called the “Straight Artery”, these basal arteries extend into the hysterectomy or major gynecological procedure. Locate the ureter in basalis layer and are not responsive to hormonal influences. the three levels in order to avoid its injury. Once the uterine artery reaches the supravaginal portion of the Three levels: cervix it divides. 1. Found posterior to the internal iliac crossing at the posterior The smaller cervical vaginal artery supplies blood to the lower cervix and infundibulopelvic ligament. upper vagina and the main branch turns abruptly upwards and extend as 2. Uterine artery – because the ureter crosses the uterine artery. highly convoluted vessels that traverse along the lateral margin of the 3. Cardinal ligament – because of their 2-3 cm distance uterus. UTEROSACRAL Originates from the posterolateral attachment to the supravaginal The ureter crosses over the uterine artery making it the most common LIGAMENT portion of the cervix and inserts into the fascia over the sacrum. injury when we do hysterectomy. Provides support to the posterior uterus. Identification is important to prevent ligation of the ureter Uterosacral ligament composed of connective tissue small bundle of Sign that there was ligation of ureter: no urine output in the IFC after the vessels and nerves and some smooth muscle covered by surgery. peritoneum. BRANCHES In addition to the uterine artery the uterus receives supply from the This ligament forms the lateral boundary of the Pouch of Douglas. OF THE ovarian artery. Parametrium: the connective tissue adjacent and lateral to the UTERINE This artery could be a direct branch of the aorta and enters the broad uterus within the broad ligament ARTERY TO ligament through the infundibulopelvic ligament/suspensory ligament of Paracervical: tissues adjacent to the cervix THE the ovary. Paracorpium: tissues lateral to the vaginal walls. OVARIES At the ovarian hilum, it divides into smaller branches that enter the ovary. As the ovarian artery runs along the hilum, it also sends several branches BLOOD SUPPLY to the mesosalpinx to supply the fallopian tubes. Its main stem traverses The bifurcation of the common iliac artery occurs at the L4 vertebra. the entire length of the broad ligament and makes its way to the uterine Internal iliac artery branches into anterior and posterior division. cornu.. Here it forms an anastomosis with the ovarian branch of the Internal iliac artery is also called the hypogastric artery. uterine artery. This dual uterine blood supply creates a vascular reserve to The anterior division provides most of the blood supply of the internal pelvic organs. prevent uterine ischemia if ligation of the uterine or internal iliac artery is UTERINE performed to control postpartum hemorrhage. Supplies the cervix, uterus, fallopian tube ARTERY CLINICAL CORRELATION: If we perform inferior hypogastric artery and the ovary by its branches ligation because there would still be blood supply to the uterus there is Branches out into the: still an ovarian artery that would supply it, and because of the o Tubal artery: makes its way anastomoses, there would still be supply of the contralateral side through the mesosalpinx to o Intrapartum Hemorrhage supply the fallopian tube.. § Ligate these arteries to preserve the uterus o Ovarian artery: supplies the § Surgical interventions: ovary and forms anastomosis Hypogastric artery ligation/Bilateral with the terminal branch of the hypogastric artery ligation (Internal Iliac ovarian artery ligation) o Fundal branch: penetrates the uppermost portion of the uterus. Specific uterine artery ligation Penetrates the serosa going to the endometrium. § Ovarian artery: hard to identify so is usually not ligated. [OB 1] P.01 THE FEMALE ANATOMY | DR. ARCELLANA | August 14, 2024 Extension of inferior hypogastric plexus also reach the perineum URETERS along the vagina and urethra to innervate the clitoris and vestibular Commonly injured during OBGYNE procedures. bulbs. Medial to and parallel with internal iliac artery. The uterovaginal plexus is composed of variable sized ganglia but Uterine artery crosses over the ureter (water under the bridge). particularly of large ganglionic plate suited on each side of the cervix Remaining 2-3 cm of the ureter passes through the cardinal ligament into the bladder. proximate to the uterosacral and cardinal ligaments. Perform adhesiolysis for patients with adhesions to deliver the uterus injury free. Most afferent sensory fibers from the uterus ascend through the CLINICAL CORRELATION inferior hypogastric plexus and enter into spinal cord via T10 through o During radical hysterectomy, the ureters are isolated, because in radical T11 and L1 spinal nerves transmitting painful stimuli of contractions hysterectomy the upper third of the vagina is included. to CNS. § The ureters might be injured during the procedure, as well as in Sensory nerves from the cervix and upper part of the birth canal pass uterine artery ligation. thru the pelvic splanchnic nerves to S2, S3, S4.. Lower portion of the birth canal pass primarily through pudendal LYMPHATIC DRAINAGE nerve. Endometrium: confined to the basalis layer Myometrium: abundant plexus OVARIES Cervix: terminate mainly in the internal iliac nodes NORMAL SIZE: 2.5-5 cm x1.5-3cm x0.16-1.5cm Uterine corpus: internal iliac and paraaortic LN Function: for ovulation and production of hormones. In cases where there are malignancies like uterine, endometrial, ovarian, fallopian tube Attached to the uterus by the utero-ovarian ligament. cancer, lymph node dissection should always be part of the complete surgical Ovary is composed of the cortex and medulla.. intervention. Uteroovarian ligament: 3-4 mm in diameter; connection between The uterus and the ovaries; it is made up of muscle and connective tissue and is covered INNERVATION by the peritoneum known as mesovarium; originates from the lateral and upper portion Pelvic Visceral innervation is predominantly autonomic by the parasympathetic and of the uterus just beneath the tubal insertion level and extends to the uterine pole of the sympathetic innervations. ovary. sympathetic innervation to the pelvic viscera begin with the Lies in the upper part of the pelvic cavity and rests on a slight depression on the lateral superior hypogastric plexus also termed as the presacral nerve. wall of the pelvis. This ovarian fossa of the wall layer is between the divergent external Beginning below the aortic bifurcation and extending downward retroperitoneally this and internal iliac vessel. plexus is formed by Sympathetic fibers arising from spinal levels T10 -L2. Infundibulopelvic ligament/Suspensory ligament: connection to the lateral pelvis. At the level of the sacral promontory, this superior hypogastric plexus (presacral nerve) CORTEX Outermost portion: tunica albuginea divides into a right and a left hypogastric nerve which run downward along the pelvic Contains the germinal epithelium of Waldeyer that is covered by a single sidewalls. cuboidal layer and contains the oocytes and developing follicles. Parasympathetic innervation to the pelvic viscera derived from the neurons at the spinal In ultrasound of the ovaries, follicles lie peripherally, and inner surface is levels S2-S4. Their axons exit as part of the anterior rami of the spinal nerves for those devoid of follicles. levels. MEDULLA Composed of loose connective tissue, with large number of arteries and This combined on each side to form the pelvic splanchnic nerves also termed as nervi veins erigentes. Supplied by both sympathetic (ovarian plexus. Plexus from ovarian branch Blending of the two hypogastric nerves (sympathetic) and the two pelvic splanchnic of uterine artery) and parasympathetic nerves (from Vagus nerve nerves (parasympathetic) gives rise to the inferior hypogastric plexus (pelvic plexus) that Sensory afferent follows the ovarian artery and enter T10 lies at S2 and S5 level INFERIOR 3 PLEXUSES: FALLOPIAN TUBE (OVIDUCTS) HYPOGASTRIC 1. VESICAL- bladder Infundibulum: funnel-shaped and fimbriated PLEXUS 2. MID RECTAL- rectum Ampullary: 5-8 cm; last to rupture when ectopic pregnancy occurs; most common 3. UTEROVAGINAL/ Frankenhauser- pro fallopian tube, occurrence of ectopic pregnancy Isthmus: narrowest, 2-3 mm, first to rupture when ectopic pregnancy occurs Interstitium: embodies in the uterine muscular wall, closest to the uterine cornu [OB 1] P.01 THE FEMALE ANATOMY | DR. ARCELLANA | August 14, 2024 Supplied richly with elastic tissue, blood vessels and Lymphatics Fallopian tube with enlarged ampulla. The diameter is more than 1 centimeter. Patient has Sympathetic innervation > Parasympathetic innervation a paratubal cyst. Nerve supply derives partly from the ovarian plexus & partly from the uterovaginal Leakage of blood at the center. Upon opening the tube there is an ectopic pregnancy. plexus Salpingectomy: Removal of the entire fallopian tube Sensory afferent fibers ascend to T10 spinal cord levels Salpingostomy or salpingotomy: removal only of the ectopic pregnancy The isthmus, ampulla, and infundibulum extrauterine portions are covered by the In this case, it is already rupture with hemoperitoneum (exuding blood and blood clots), mesosalpinx at the superior margin of the broad ligament. The mesosalpinx is single cell therefore, salpingectomy was done. mesothelial layer functioning as the visceral peritoneum. CASE 2 In the myosalpinx, smooth muscle is arranged in an inner circular and an outer 47-year-old, complaining of abnormal uterine longitudinal layer bleeding with heavy menses. In the distal tube, the 2 layers are less distinct and are replaced near the fimbriated extremity by a sparse interlacing muscle fiber. Figure 20. Intramural myoma Tubal musculature undergoes rhythmic contractions in which varies with cyclical ovarian Fallopian tube is small in diameter hormonal changes Hysterectomy was done. Removal of uterus Tubal mucosa or Endosalpinx is lined by single columnar epithelium composed of from the fundus to the cervix including the ciliated (in discrete patches) and secretory cells resting on a sparse lamina propria. It is fallopian tube in close contact underlying myosalpinx Posteriorly there is a huge intramural The ciliated cells are most abundant at the fimbriated extremity but else where they are myoma and upon cutting the uterus, the found in discreet patches endometrium is also filled with myoma The mucosa is arranged in longitudinal folds to become progressively more complex Submucous myoma: Intracavitary towards the fimbriae Intramural myoma: found only in the endometrium Ampulla Subserous myoma: there is growth outside the uterus o Lumen almost completely occupied by the arborescent mucosa o Current produced by tubal cilia such that the direction of flow-toward the uterine cavity o Tubal peristalsis: created by cilia and muscular layer contraction; important factor in ovum transport CASE 1 14 year old patient came in with acute abdomen with tenderness. Ultrasound was done, patient had a huge adnexal mass. Right ovary was transformed into a huge unilocular mass compared to the left normal ovary. Component is solid. Differential diagnosis: Ovarian Cancer Diagnosis: Fibroma Management: Removal of the right ovary. Leaving the left ovary intact so that we would not make the patient surgically menopaused A normal looking ovary is usually pearly white in appearance. The patient is asymptomatic but upon ultrasound they found out that the patient has a dermoid cyst (Dermal plug, Rokitansky nodule is seen in the ultrasound) Dermoid cyst is the most common mass of the ovary composed of the three-germ cell layer: o Ectoderm o Mesoderm o Endoderm Presence of hair, sebum and microscopically we can observe presence of thyroid tissues.