Maternal Anatomy PDF

MATERNAL ANATOMY ABEGAIL A. LAMAYRA, MD, FPOGS Maternal anatomy • Anterior abdominal wall • External Generative Organs – Vulva – Vagina, Hymen – Perineum • Internal Generative Organs – – – – Uterus Ligaments Ovaries Fallopian Tubes • Pelvic Anatomy LAYERS OF THE ANTERIOR ABDOMINAL WALL • Ski...

MATERNAL ANATOMY ABEGAIL A. LAMAYRA, MD, FPOGS Maternal anatomy • Anterior abdominal wall • External Generative Organs – Vulva – Vagina, Hymen – Perineum • Internal Generative Organs – – – – Uterus Ligaments Ovaries Fallopian Tubes • Pelvic Anatomy LAYERS OF THE ANTERIOR ABDOMINAL WALL • Skin – Langer lines • Subcutaneous Layer – Camper’s fascia – Scarpa’s fascia • Primary fascia (aponeurosis) • Abdominal wall muscles – – – – Obliques (Ext. & Int.) Tranversalis abdominis Rectus abdominis Pyramidalis LAYERS OF THE ANTERIOR ABDOMINAL WALL • Skin – Langer lines • Dermal fibers within the skin • Arranged transversely ANTERIOR ABDOMINAL WALL • Skin, Subcutaneous Layer, and Fascia • Functions: •confines abdominal viscera •stretches to accommodate the expanding uterus •provides surgical access to the internal reproductive organs. •Langer lines - describe the orientation of dermal fibers within the skin LAYERS OF THE ANTERIOR ABDOMINAL WALL • Skin – Langer lines • Subcutaneous Layer – Camper’s fascia – Scarpa’s fascia • subcutaneous layer : •Camper fascia - superficial and predominantly fatty layer •provide fatty substance to the mons pubis and labia majora and then to blend with the fat of the ischioanal fossa • Scarpa fascia - deeper membranous layer •continues inferiorly onto the perineum as Colles fascia, described in Perineum. LAYERS OF THE ANTERIOR ABDOMINAL WALL • Skin – Langer lines • Subcutaneous Layer – Camper’s fascia – Scarpa’s fascia • Primary fascia (aponeurosis) • Abdominal wall muscles • Peritoneum – +/- Transversalis fascia LAYERS OF THE ANTERIOR ABDOMINAL WALL • Primary fascia (aponeurosis), Rectus sheath LAYERS OF THE ANTERIOR ABDOMINAL WALL • Skin – Langer lines • Subcutaneous Layer – Camper’s fascia – Scarpa’s fascia • Primary fascia (aponeurosis) • Abdominal wall muscles • Peritoneum – +/- Transversalis fascia • Muscles: • consist of the midline rectus abdominis and pyramidalis muscles • External oblique • internal oblique • transversus abdominis muscles • Linea alba – found in the midline as fused fibrous aponeuroses of the three muscle • measures 10 to 15 mm wide below the umbilicus • Diastasis recti or hernia - an abnormally wide separation LAYERS OF THE ANTERIOR ABDOMINAL WALL • Skin – Langer lines • Subcutaneous Layer – Camper’s fascia – Scarpa’s fascia • Primary fascia (aponeurosis) • Abdominal wall muscles • Peritoneum – +/- Transversalis fascia Blood Supply of the ANTERIOR ABDOMINAL WALL Blood Supply • femoral artery (femoral triangle) – branches to: • superficial epigastric • superficial circumflex iliac • superficial external pudendal arteriesx • supply the skin and subcutaneous layers of the anterior abdominal wall and mons pubis • superficial epigastric vessels • surgically important to the obstetrician • course diagonally from their origin toward the umbilicus Blood Supply of the ANTERIOR ABDOMINAL WALL Anterior abdominal wall • the inferior “deep” epigastric vessels • branches of the external iliac vessels • supply anterior abdominal wall muscles and fascia. • course lateral to, then posterior to the rectus abdominis muscles, which they supply • near the umbilicus - the inferior epigastric vessels anastomose with the superior epigastric artery and vein Blood Supply of the ANTERIOR ABDOMINAL WALL Anterior abdominal wall Hesselbach’s Triangle • Borders: ➢ Medial- lateral border of the rectus abdominis muscle ➢ Lateral – inferior epigastric vessels ➢ Inferior – inguinal ligament • Contents: ➢ ➢ Layers of abdominal wall Does not contain any structures of clinical significance Hesselbach’s Triangle • Clinical significance: • Demarcates area of potential abdominal weakness • Direct hernia: • bowel herniates through the weakness in the inguinal triangle and enters inguinal canal • more common in females • usually occurs medially to the inferior epigastric vessels • Indirect Hernia: • bowel enters the inguinal canal via the deep inguinal ring (males) Nerve Supply of the ANTERIOR ABDOMINAL WALL Anterior abdominal wall • Innervation - - entire anterior abdominal wall • intercostal nerves (T7–11) • subcostal nerve (T12) • iliohypogastric and the ilioinguinal nerves (L1) • transversus abdominis plane – space used for postcesarean analgesia blockade • intercostal and subcostal nerves are anterior rami of the thoracic spinal nerves and run along the lateral and then anterior abdominal wall between the transversus abdominis and internal oblique muscles • rectus sheath or ilioinguinal-iliohypogastric nerve blocks to decrease postoperative pain Nerve Supply of the ANTERIOR ABDOMINAL WALL Subcostal nerves • ilioinguinal nerve • course medially travels through the inguinal canal and exits through the superficial inguinal ring, • supplies the skin of the mons pubis, upper labia majora, and medial upper thigh. • low transverse incision • ilioinguinal and iliohypogastric nerves can be severed during a or entrapped during closure, especially if incisions extend beyond the lateral borders of the rectus abdominis muscle • These nerves carry sensory information only, and injury leads to loss of sensation within the areas supplied. • Rarely, chronic pain may develop Nerve Supply of the ANTERIOR ABDOMINAL WALL Anterior abdominal wall • Maylard incision • used for cesarean delivery = the inferior epigastric vessels may be lacerated lateral to the rectus belly during muscle transection • Pfannenstiel incision - the nerve branches may be severed creation during the step in which the overlying anterior rectus sheath is separated from the rectus abdominis • near the rectus abdominis lateral borders, anterior branches of the intercostal and subcostal nerves pierce the posterior sheath, rectus muscle, and then anterior sheath to reach the skin muscle Anesthesia during CS • T10 dermatome – • approximates the level of the umbilicus • analgesia to this level is suitable for labor and vaginal birth. • regional analgesia for cesarean delivery or for puerperal sterilization ideally extends to T4. EXTERNAL GENERATIVE ORGANS Vulva (Pudenda) ▪ Structures visible externally from Symphysis pubis to the perineal body ▪ Includes: ▪ mons pubis ▪ labia majora ▪ labia minora ▪ Hymen ▪ Vestibule ▪ Urethral opening ▪ greater vestibular gland ▪ minor vestibular glands ▪ Clitoris ▪ paraurethral glands EXTERNAL GENERATIVE ORGANS Vulva (pudenda) • The vulva (pudendum) refers to the external female genitalia. • receives innervations and vascular support from the pudendal nerve • Its functions are threefold: • Acts as sensory tissue during sexual intercourse • Assists in micturition by directing the flow of urine • Protects the internal female reproductive tract from infection EXTERNAL GENERATIVE ORGANS Cunningham, et. al. Williams Obstetrics, 24th Edition. McGraw-Hill Education, New York, 2014 EXTERNAL GENERATIVE ORGANS VESTIBULE • Boundaries – P: fourchette – A: clitoral frenulum anteriorly – L: Hart line laterally – M: external surface of hymen medially • fossa navicularis – posterior portion of the vestibule between the fourchette and the vaginal opening ✓ nulliparas EXTERNAL GENERATIVE ORGANS • Vulvar structures and subcutaneous layer of the anterior perineal triangle. • Note the continuity of Colles and Scarpa fasciae • Vulva (pudenda): includes all structures visible externally from the symphysis pubis to the perineal body. Cunningham, et. al. Williams Obstetrics, 24th Edition. McGraw-Hill Education, New York, 2014 EXTERNAL GENERATIVE ORGANS VESTIBULE • perforated by 6 openings – – – – Urethra Vagina Bartholin gland ducts Skene glands VESTIBULE • Bartholin glands – Greater vestibular glands – Bartholin cyst (obstructed) – Bartholin abscess (if infected) • Paraurethral glands • Skene glands – largest • Inflammation, duct obstruction → urethral diverticulum formation mons pubis • fat-filled cushion overlying the symphysis pubis • skin is covered by curly hair that forms the triangular escutcheon • whose base aligns with the upper margin of the symphysis pubis • in men and some hirsute women, the escutcheon extends farther onto the anterior abdominal wall toward the umbilicus. Labia majora • 7 to 8 cm long, 2 to 3 cm wide, and 1 to 1.5 cm thick • continuous directly with the mons pubis superiorly, and the round ligaments terminate at their upper borders covered with hair • with abundant apocrine, eccrine, and sebaceous glands • beneath the skin- a dense connective tissue layer nearly void of muscular elements but rich in elastic fibers and fat • fat mass provides bulk to the labia majora and is supplied with a rich venous plexus. Labia majora • During pregnancy: may develop varicosities, especially in multiparas, from increased venous pressure created by the enlarging uterus • appear as engorged tortuous veins or as small grapelike clusters, but are typically asymptomatic and require no treatment labium minus or minora • thin tissue fold that lies medial to each labium majus or majora • extend superiorly and divides into two lamellae • lower lamellae fuse to form the frenulum of the clitoris • upper lamellae merge to form the prepuce • Inferiorly, the labia minora extend to approach the midline as low ridges of tissue that join to form the fourchette. • dimensions vary greatly among individuals • Length =2 to 10 cm and width =1 to 5 cm labium minus or minora • composed of connective tissue with numerous vessels, elastin fibers, and very few smooth muscle fibers • epithelia differ with location • outer surface of each labium = thinly keratinized stratified squamous epithelium • inner surface • lateral portion = covered by the same epithelium up to a demarcating line, Hart line. • Medial = each labium is covered by nonkeratinized squamous epithelium • lack hair follicles, eccrine glands, and apocrine glands • sebaceous glands are numerous EXTERNAL GENERATIVE ORGANS CLITORIS • Principal female erogenous organ • Parts: – Glans – richly innervated – Corpus – (2) crura • Blood supply: – Branches of the internal pudendal artery Clitoris • principal female erogenous organ. • located beneath the prepuce, above the frenulum and urethra, and projects downward and inward toward the vaginal opening • rarely exceeds 2 cm in length • composed of a glans, a corpus or body, and two crura • glans is usually less than 0.5 cm in diameter, is covered by stratified squamous epithelium, and is richly innervated • clitoral body contains two corpora cavernosa. • Extending from the clitoral body, each corpus cavernosum diverges laterally to form a long, narrow crus. • Each crus lies along the inferior surface of its respective ischiopubic ramus and deep to the ischiocavernosus muscle. • blood supply stems from branches of the internal pudendal artery • the deep artery of the clitoris supplies the clitoral body, whereas the dorsal artery of the clitoris supplies the glans and prepuce. Innervation of the External Generative Organs • The vulva receives sensory and parasympathetic nervous supply • To describe the sensory distribution, the vulva can be divided into anterior and posterior sections: • Anterior: ilioinguinal nerve, genital branch of the genitofemoral nerve • Posterior: pudendal nerve of the thigh • The clitoris and the vestibule also receive parasympathetic innervation from the cavernous nerves – derived from the uterovaginal plexus Bartholin glands • bilateral, also termed greater vestibular glands • measure 0.5 to 1 cm in diameter. • each lies inferior to the vestibular bulb and deep to the inferior end of the bulbospongiosus muscle (former bulbocavernosus muscle) • duct extends medially from each gland, measures 1.5 to 2 cm • long, and opens distal to the hymeneal ring—one at 5 and the other at 7 o’clock on the vestibule. • Following trauma or infection, either duct may swell and obstruct to form a cyst or, if infected, an abscess • minor vestibular glands are shallow glands lined by simple mucin-secreting epithelium and open along Hart line. Paraurethral glands • collective arborization of glands whose numerous small ducts open predominantly along the entire inferior aspect of the urethra • Skene glands - two largest glands • • ducts typically lie distally and near the urethral meatus. inflammation and duct obstruction of any of the can lead to urethral diverticulum formation Urethral opening or meatus • in the midline of the vestibule, 1 to 1.5 cm below the pubic arch, and a short distance above the vaginal opening. Vagina and Hymen • Hymen • is a membrane of varying thickness that surrounds the vaginal opening more or less completely • composed mainly of elastic and collagenous connective tissue, and both outer and inner surfaces are covered by nonkeratinized stratified squamous epithelium. • The aperture of the intact hymen ranges in diameter from pinpoint to one that admits one or even two fingertips. • As a rule, the hymen is torn at several sites during first coitus. • Identical tears may form by other penetration, for example, by tampons used during menstruation. • The edges of the torn tissue soon reepithelialize HYMEN • In pregnant women • hymeneal epithelium is thick and rich in glycogen. • Changes produced in the hymen by childbirth are usually readily recognizable. • over time, the hymen transforms into several nodules of various sizes, termed hymeneal or myrtiform caruncle Vagina • It has several roles within the female reproductive system: • Sexual intercourse – receives the penis and ejaculate, assisting in its transport to the uterus. • Childbirth – expands to provide a channel for delivery of a newborn from the uterus. • Menstruation – serves as a canal for menstrual fluid and tissue to leave the body Vagina • is a musculomembranous tube that extends to the uterus and is interposed lengthwise between the bladder and the rectum • Anteriorly - separated from the bladder and urethra by connective tissue—the vesicovaginal septum • Posteriorly - between the lower portion of the vagina and the rectum, similar tissues together form the rectovaginal septum • The upper fourth of the vagina is separated from the rectum by the rectouterine pouch called the cul-de-sac or pouch of Douglas. VAGINA Anatomical Position • The vagina is closely related to many of the organs in the pelvic region: • Anterior – bladder and urethra. • Posterior – rectouterine pouch, rectum and anal canal. • Lateral – ureters and levator ani muscle • the anterior and posterior walls of the vaginal lumen lie in contact, with only a slight space intervening at the lateral margins • anterior wall =6 to 8 cm • posterior vaginal wall =7 to 10 cm • the upper end of the vaginal vault is subdivided by the cervix into anterior, posterior, and two lateral fornices. • vaginal lining is composed of nonkeratinized stratified squamous epithelium and underlying lamina propria • premenopausal women, this lining is thrown into numerous thin transverse ridges, known as rugae, which line the anterior and posterior vaginal walls along their length. VAGINA ▪anterior wall: 6 to 8 cm ▪posterior vaginal wall: 7 to 10 cm Lining: NKSS  There are no vaginal glands. Bloodsupply: Middle rectal artery Internal pudedal artery VAGINA ▪anterior wall: 6 to 8 cm ▪posterior vaginal wall: 7 to 10 cm ▪ Lining: NKSS – non keratinized Stratified Squamous epithelium Histology of the Vagina • The vagina is composed of four histological layers (internal to external): • Stratified squamous epithelium – this layer provides protection and is lubricated by cervical mucus (the vagina itself does not contain any glands). • Elastic lamina propria – a dense connective tissue layer which projects papillae into the overlying epithelium. The larger veins are located here. • Fibromuscular layer – comprising two layers of smooth muscle; an inner circular and an outer longitudinal layer. • Adventitia – a fibrous layer, which provides additional strength to the vagina whilst also binding it to surrounding structures. • Deep to this, a muscular layer contains smooth muscle, collagen, and elastin. • Beneath this muscularis lies an adventitial layer consisting of collagen and elastin and lacks glands • lubricated by a transudate that originates from the vaginal subepithelial capillary plexus and crosses the permeable epithelium • Due to increased vascularity during pregnancy, vaginal secretions are notably increased. • may be confused with amnionic fluid leakage • After birth-related epithelial trauma and healing: • fragments of stratified epithelium occasionally are embedded beneath the vaginal surface • buried epithelium continues to shed degenerated cells and keratin • as result, epidermal inclusion cysts - filled with keratin debris, may form. (common vaginal cyst) VAGINA ▪ anteriorwall: 6to8cm ▪ posteriorvaginalwall:7to10cm • Lining: • NKSS  There are no vaginal glands. Bloodsupply: cervical branch of the uterine artery and by the vaginal artery Vascular supply • • proximal portion - cervical branch of the uterine artery and by the vaginal artery (arise from the uterine or inferior vesical artery or directly from the internal iliac artery) • middle rectal artery contributes supply to the posterior vaginal wall • distal walls receive contributions from the internal pudendal artery. At each level, vessels supplying each side of the vagina course medially across the anterior or posterior vaginal wall and form midline anastomoses. Lymphatics • An extensive venous plexus also surrounds the vagina and follows the course of the arteries. • Lymphatics from the lower third, along with those of the vulva, drain primarily into the inguinal lymph nodes. • Those from the middle third drain into the internal iliac nodes, and those from the upper third drain into the external, internal, and common iliac nodes. Vascular Supply and Lymphatics • The arterial supply to the vagina is via the uterine and vaginal arteries – both branches of the internal iliac artery. • Venous return is by the vaginal venous plexus, which drains into the internal iliac veins via the uterine vein. • Lymphatic drainage is divided into three sections: • Superior (upper third)– drains to external iliac nodes • Middle (middle third)– drains to internal iliac nodes • Inferior (lower third) – drains to superficial inguinal lymph nodes. Perineum • diamond-shaped area between the thighs has boundaries that mirror those of the bony pelvic outlet: • the pubic symphysis anteriorly, ischiopubic rami and ischial tuberosities anterolaterally, sacrotuberous ligaments posterolaterally, and coccyx posteriorly. • Urogenital triangle - an arbitrary line joining the ischial tuberosities and divides the perineum into an anterior triangle and a posterior triangle, termed the anal triangle. ANATOMY OF THE PERINEUM Cunningham, et. al. Williams Obstetrics, 24th Edition. McGraw-Hill Education, New York, 2014 ANATOMY OF THE ANTERIOR TRIANGLE ANATOMY OF THE ANTERIOR TRIANGLE • Urethra – Measures 3-4cm – Lining: transitional to NKSS epithelium – Blood supply: • Inferior vessical • Vaginal • Internal pudendal – Smooth muscle: ILOC – Striated urogenital sphincter (Skeletal muscle) • Sphincter urethrae • Urethrovaginal sphincter • Compressor urethrae Innervated by pudendal nerve PELVIC DIAPHRAGM • broad muscular sling that provides substantial support to the pelvic viscera • composed of: – Levator Ani* ✓ Pubococcygeus ✓ puborectalis ✓ iliococcygeus – Coccygeus Muscle ANATOMY OF THE POSTERIOR TRIANGLE ISCHIOANAL FOSSAE • two fat-filled wedge-shaped spaces found on either side of the anal canal (comprise the bulk of the posterior triangle) ANAL CANAL distal continuation of the rectum: ✓ begins at the level of levator ani attachment to the rectum and ends at the anal skin (4 to 5-cm long) • Anal cushion – aids in the complete closure of canal and fecal continence when Hemorrhoids apposed • External • Lining (mucosa): ✓ CC: pain (inferior rectal nerve) – columnar epithelium (upper) – stratified squamous epithelium • Internal ✓ CC: bleeding (dentate line) The perineal body • fibromuscular pyramidal mass found in the midline at the junction between these anterior and posterior triangles called the central tendon of the perineum • the perineal body measures 8 mm tall and 14 mm wide and thick • serves as the junction for several structures and provides significant perineal support • Superficially, the bulbospongiosus, superficial transverse perineal, and external anal sphincter muscles converge on the perineal body. • Deeper, the perineal membrane is formed from portions of the pubococcygeus muscle, and internal anal sphincter • The perineal body is incised by an episiotomy incision and is torn with second-, third-, and fourth-degree lacerations. PUDENDAL NERVE • Anterior rami of S2-4 • Lies within the Alcock canal • 3 terminal branches: – Dorsal nerve of the clitoris – Perineal nerve • Posterior labial branches • Muscular branches – Inferior rectal The ANAL SPHINCTER Complex Function Symptoms EAS Striated muscle attaching to PB anteriorly Provides squeeze pressure responsible or maintaining fecal continence when continence is threatened 25% resting pressure Provides emergency control for liquid stool and flatus Fecal urgency Urge incontinence: IAS Keeps anal canal closed at rest, Fecal soiling Incontinence of liquid stool and Description Continuation of the rectal circular smooth muscle. (70-85% resting pressure) maintenance of fecal continence at rest Receives parasympathetic nerve fibers continence of liquid stool & flatus liquid & flatus flatus INTERNAL GENERATIVE ORGANS • • • • Cervix Uterus Ovaries Fallopian tubes • • • • Ligaments Blood supply Lymphatics innervation Cervix • Small opening (nulli) • Slit-like (parous) • Ectocervix: NKSS epithelium • Endocervix: Simple Columnar ep. • SCJ (squamo-columnar junction) is the most common site of malignant transformation • Eversion – during pregnancy • Composition: collagen, elastin, proteoglycans, very little SM • Chadwick sign – bluish discoloration due to increased vascularity. • Goodell sign – softening due to cervical edema • Hegar sign – isthmic softening Uterus nulligravid multiparous Weight 60kg Weighs more Length 6-8cm 9-10cm Fundus Equal in and length cervix Cervix is only a third of entire length FALLOPIAN TUBE FALLOPIAN TUBE FALLOPIAN TUBE ROUND LIGAMENT OVARIAN LIGAMENT OVARIAN LIGAMENT ROUND LIGAMENT ANTERIOR POSTERIOR LATERAL ANTERIOR POSTERIOR LATERAL ANTERIOR POSTERIOR LATERAL Where does the ROUND ligament terminate? LABIA MAJORA Where ARTERY courses through the ROUND ligament? SAMPSON artery Ligaments Cunningham, et. al. Williams Obstetrics, 24th Edition. McGraw-Hill Education, New York, 2014 Ligaments The broad ligaments • two winglike structures that extend from the lateral uterine margins to the pelvic sidewalls. • Peritoneum that folds over the fallopian tube mesosalpinx, round ligament is the mesoteres • ovarian ligament is the mesovarium. Ligaments Cardinal ligament – Transverse Cervical Ligament – Mackenrodt ligament • anchors medially to the uterus and upper vagina. • Parametrium is the connective tissues adjacent and lateral to the uterus within the broad ligament. • Paracervical tissues are those adjacent to the cervix • Paracolpium is that tissue lateral to the vaginal walls. water over the bridge- ureter above the ovary PELVIC BLOOD SUPPLY spiral artery chuchu leads to preeclampsia PELVIC BLOOD SUPPLY Moore, K. et. al. Moore Clinically Oriented Anatomy. 7th Edition. Lippincott Williams & Wilkins, Venous drainage • the right ovarian vein empties into the vena cava • left ovarian vein empties into the left renal vein Cunningham, et. al. Williams Obstetrics, 24th Edition. McGraw-Hill Education, New York, 2014 Lymphatics • Cervix: internal iliac nodes • Uterine corpus: internal iliac nodes, paraaortic lymph nodes uterine part - instertitial Fallopian Tubes (Oviducts) • 8–14 cm from the uterinecornua Moore, K. et. al. Moore Clinically Oriented Anatomy. 7th Edition. Lippincott Williams & Wilkins, 2014. Fallopian Tubes (Oviducts) • Mesosalpinx • Myosalpinx • Endosalpinx progesterone - slows down uterine contractions a. isthmus b. ampulla c. infundibulum Cunningham, et. al. Williams Obstetrics, 24th Edition. McGraw-Hill Education, New York, 2014 Ovaries • Rests at the ovarian fossa of Waldeyer. • Sympathetic nerves: ovarian plexus (originates in the renal plexus) • Parasympathetic input: vagus nerve Ovaries • Sympathetic nerves: ovarian plexus (originates in the renal plexus) • Parasympathetic input: vagus nerve • Sensory afferents follow the ovarian artery and enter at T10 spinal cord level. What internal generative organ is unchanged during pregnancy? • • • • Cervix Uterus Fallopian Tubes Ovaries What internal generative organ is unchanged during pregnancy? • • • • Cervix Uterus Fallopian Tubes Ovaries Derivatives of Embryonic genital Structures Structure Undifferentiated Gonad Female Ovary Male homologue Testis FT Mullerian Duct Uterus Appendix of testes Cervix Vagina Prostatic utricle Hymen Seminal colliculus Phallus Clitoris Penis Labioscrotal swelling Labia majora Scrotum Urogenital Folds Labia minora Ventral part penis Urogenital sinus FEMALE REPRODUCTIVE TRACT Lining Epithelium Vulva Vagina Cervix Uterus FT Stratified Stratified Ectocervix: Simple Simple squamous squamous stratified squamous columnar columnar keratinizing non- non-keratinizing Ovary cuboidal ciliated keratinizing Endocervix: simple columnar mucin-producing Transformation zone: squamo-columnar junction inlet, midpelvis outlet PELVIC BONES Cunningham, et. al. Williams Obstetrics, 24th Edition. McGraw-Hill Education, New York, 2014 anything above pelvic brim - false p PELVIC BONES Pelvic Joints • Anteriorly: the symphysis pubis • Posteriorly: the sacroiliac joints ✓limited degree of mobility ✓during pregnancy: upward gliding of the sacroiliac joint (dorsal lithotomy) increase the diameter of the outlet by 1.5–2.0 cm Planes and Diameters of the Pelvis 1. The plane of the pelvic inlet—the superior strait 2. The plane of the pelvic outlet—the inferior strait 3. The plane of the midpelvis—the least pelvic dimensions 4. The plane of greatest pelvic dimension—of no obstetrical signifcance sacral promontory Pelvimetry Cunningham, et. al. Williams Obstetrics, 24th Edition. McGraw-Hill Education, New York, 2014 obstetric minus 1.5 to 2 we only need 10cm equals diameter of head Pelvic Inlet • True conjugate • Obstetric conjugate – 10cm or more – Shotest distance between the sacral promontory and SP – Cannot directly measured • Diagonal conjugate – Can be assessed clinically – DC – 1.5 or 2cm = OC Pelvimetry Midpelvis • Cannot be directly measured • Contracted if: ✓ Ischial spines prominent ✓ Sacrum concavity is shallow ✓ Sidewalls converge Pelvic Outlet • Diameter between the ischial tuberosities (normal: 8cm) • Measurement can be estimated by putting a closed fist again the perineum between the ischial tuberosities. • Pubic arch (wide) anthropoid = monkey Pelvic Shapes android = male platy = flat • Caldwell-Moloy anatomical classifcation of the pelvis: based on shape Cunningham, et. al. Williams Obstetrics, 24th Edition. McGraw-Hill Education, New York, 2014 Congenital Genitourinary Abnormalities ABEGAIL A. LAMAYRA, MD, FPOGS GENITOURINARY TRACT DEVELOPMENT Females: • external genitalia, gonads, and müllerian ducts each derive from different primordia and in close association with the urinary tract and hindgut. • Abnormal embryogenesis • multifactorial and can create sporadic anomalies • can lead to infertility, subfertility, miscarriage, or preterm delivery. Embryology of the Urinary System • 3-5 wks AOG - elevation of intermediate mesoderm on each side of the fetus—the urogenital ridge—begins development into the urogenital tract. • urogenital ridge divides into : • the genital ridge = ovary • nephrogenic ridges = mesonephros (mesonephric kidney) and paired mesonephric ducts, also termed wolfian ducts, which connect to the cloaca. A. Cross-section of an embryo at 4 to 6 weeks. B. Large ameboid primordial germ cells migrate (arrows) from the yolk sac to the area of germinal epithelium, within the genital ridge. C. Migration of sympathetic cells from the spinal ganglia to a region above the developing kidney. • early urinary tract develops from the mesonephros and its mesonephric ducts • 4-5 weeks AOG - each mesonephric duct gives rise to a ureteric bud, which grows cephalad toward its respective mesonephros • As each bud lengthens, it induces differentiation of the metanephros which will become the final kidney • Each mesonephros degenerates near the end of the first trimester • without testosterone the mesonephric ducts regress Embryonic development of the female genitourinary tract • The cloaca begins as a common opening for the embryonic urinary, genital, and alimentary tracts • 7th week it becomes divided by the urorectal septum to create the rectum and the urogenital sinus • The urogenital sinus is considered in three parts: • (1) the cephalad or vesicle portion, which forms the urinary bladder; • (2) the middle or pelvic portion, which creates the female urethra; • (3) the caudal or phallic part, which gives rise to the distal vagina and to the greater vestibular (Bartholin) and paraurethral glands Embryology of the Genital Tract • müllerian ducts or paramesonephric ducts • the fallopian tubes, uterus, and upper vagina are derive from • form adjacent to each mesonephros • These ducts extend downward and then turn medially to meet and fuse together in the midline. • The uterus is formed by this union of the two müllerian ducts at approximately the 10th week • Fusion to create the uterus begins in the middle and then extends both caudally and cephalad. Embryology of the Genital Tract • With cellular proliferation at the upper portion, a thick wedge of tissue creates the characteristic piriform uterine shape. • dissolution of cells at the lower pole forms the first uterine cavity • As the upper wedge-shaped septum is slowly reabsorbed, the final uterine cavity is usually formed by the 20th week. • If the two müllerian ducts fail to fuse, then two separate uterine horns remain • resorption failure of the common tissue between them results in various degrees of persistent uterine septum. Embryology of the Genital Tract • As the distal end of the fused müllerian ducts contacts the urogenital sinus, this induces endodermal outgrowths from the sinus termed the sinovaginal bulbs. • These bulbs proliferate and fuse to form the vaginal plate, which later resorbs to form the vaginal lumen. • This vaginal canalization is generally completed by the 20th week. • the lumen remains separated from the urogenital sinus by the hymeneal membrane. This membrane further degenerates to leave only the hymeneal ring. cryptocordism Diagnosis • the urinary system can be evaluated with magnetic resonance (MR) imaging, sonography, or intravenous pyelography • With müllerian anomalies, ovaries are functionally normal but have a higher incidence of anatomical maldescent into the pelvis • the mesonephric ducts usually degenerate, however, persistent remnants may become clinically apparent. Mesonephric or wolffian vestiges can persist as Gartner duct cysts. • These are typically located in the proximal anterolateral vaginal wall but may be found at other sites along the vaginal length. • They can be further characterized by MR imaging, which provides excellent image resolution at soft tissue interfaces. • Most cysts are asymptomatic and benign and usually do not require surgical excision. • Intraabdominal wolffian remnants in the female include a few blind tubules in the mesovarium—the epoöphoron—and similar ones adjacent to the uterus— paroöphoron • The epoöphoron or paroöphoron may develop into clinically identifiable cysts in the adult. Embryology of the gonads • 4 weeks, gonads derive from coelomic epithelium covering the medial and ventral surface of the nephrogenic cord at a site between the eighth thoracic and fourth lumbar segments. • Because of this separate gonadal and müllerian derivation, women with müllerian defects typically have functionally normal ovaries and are phenotypic females. Embryology of the gonads • The coelomic epithelium thickens to form the genital ridge, also known as the gonadal ridge. • Strands of these epithelial cells extend into the underlying mesenchyme as the primary sex cords. By the sixth week, primordial germ cells have migrated from the yolk sac to enter the genital ridge mesenchyme • The primordial germ cells are then incorporated into the primary sex cords. 14th week can distinguish sex organs • In the seventh week, the sexes can be distinguished, and testes are recognized during microscopic sectioning by their well-defined radiating testis cords. • The testis cords develop into the seminiferous tubules and rete testis. • The rete testis establishes connection with small tubes arising off the mesonephric duct. • These small tubes become the efferent ducts that drain into the epididymis and then into the vas deferens, which are main mesonephric duct derivatives • In the female embryo, the primary sex cords give rise to the medullary cords, which persist only for a short time. • The coelomic epithelium again proliferates into the underlying mesenchyme, and these strands are the cortical cords. • By the fourth month, the cortical cords begin to form isolated cell clusters called primordial follicles. • These follicles contain the oogonia, which derive from primordial germ cells and are surrounded by a single layer of flattened follicular cells derived from the cortical cords. • Follicular cells serve as supporting nutrient cells. • By 8 months, the ovary has become a long, narrow, lobulated structure that is attached to the body wall by the mesovarium. • The coelomic epithelium has been separated by a band of connective tissue—tunica albuginea—from the cortex. • At this stage, the cortex contains follicles and is well defined from the inner medulla, which is composed of abundant blood vessels, lymphatic vessels, and nerve fibers. Embryology of the External Genitalia • Early development of the external genitalia is similar in both sexes. • By 6 weeks’ gestation, three external protuberances have developed surrounding the cloacal membrane. • These are the left and right cloacal folds, which meet ventrally to form the genital tubercle • With division of the cloacal membrane into anal and urogenital membranes, the cloacal folds become the anal and urethral folds, respectively. Embryology of the External Genitalia • Lateral to the urethral folds, genital swellings arise, and these become the labioscrotal folds. • Between the urethral folds, the urogenital sinus extends onto the surface of the enlarging genital tubercle to form the urethral groove. • By week 7, the urogenital membrane ruptures, exposing the cavity of the urogenital sinus to amnionic fluid. Development of the external genitalia. A. Indifferent stage. B. Virilization of external genitalia. C. Feminization. • The genital tubercle elongates to form the phallus in males and the clitoris in females. • Still, it is not possible to visually differentiate between male and female external genitalia until week 12. • In the male fetus, dihydrotestosterone (DHT) forms locally by the 5-α reduction of testosterone. • DHT prompts the anogenital distance to lengthen, the phallus to enlarge, and the labioscrotal folds to fuse and form the scrotum. • In the female fetus, without DHT, the anogenital distance does not lengthen, and the labioscrotal and urethral folds do not fuse • The genital tubercle bends caudally to become the clitoris, and the urogenital sinus forms the vestibule of the vagina. • The labioscrotal folds create the labia majora, whereas the urethral folds persist as the labia minora. • Female external genital differentiation is complete by 11 weeks, whereas male external genital • differentiation is complete by 14 weeks. SEXUAL DIFFERENTIATION • Defining gender incorporates genetic gender, gonadal gender, and phenotypic gender. Genetic gender—XX or XY—is established at fertilization. • For the first 6 weeks, development of male and female embryos is morphologically indistinguishable. SEXUAL DIFFERENTIATION • Gonadal gender is heralded by the differentiation of the primordial gonad into a testis or an ovary. • If a Y chromosome is present, the gonad begins developing into a testis. • Testis development is directed by a protein called the testis-determining factor (TDF), which modulates the transcription of several genes involved in gonadal differentiation. • TDF is encoded by the sex-determining region (SRY) gene, located on the short arm of the Y chromosome. • But testis development is much more complex and requires other autosomal genes SEXUAL DIFFERENTIATION • The importance of the SRY gene is demonstrated in several paradoxical conditions. • First, 46,XX phenotypic males can result from translocation of the Y chromosome fragment containing SRY to the X chromosome during meiosis of male germ cells • Similarly, 46,XY individuals can appear phenotypically female if they carry a mutation in the SRY gene SEXUAL DIFFERENTIATION • Last, phenotypic gender begins at 8 weeks’ gestation. • Before this, urogenital tract development in both sexes is indistinguishable. • Thereafter, differentiation of the internal and external genitalia to the male phenotype is dependent on testicular function. • In the absence of a testis, female differentiation ensues irrespective of genetic gender SEXUAL DIFFERENTIATION • In males, the fetal testis secretes a protein called müllerian-inhibiting substance (MIS), also called antimüllerian hormone (AMH). • It acts locally as a paracrine factor to cause müllerian duct regression. • Thus, it prevents the development of uterus, fallopian tube, and upper vagina. AMH is produced by the Sertoli cells of the seminiferous tubules. • Importantly, these tubules appear in fetal gonads and secrete AMH before differentiation of Leydig cells, which are the cellular site of testosterone synthesis. SEXUAL DIFFERENTIATION • AMH is secreted as early as 7 weeks, and müllerian duct regression is completed by 9 to 10 weeks. • Because AMH acts locally near its site of formation, if a testis were absent on one side, the müllerian duct on that side would persist, and the uterus and fallopian tube would develop on that side. • Apparently through stimulation initially by human chorionic gonadotropin (hCG), and later by fetal pituitary luteinizing hormone (LH), the fetal testes secrete testosterone. SEXUAL DIFFERENTIATION • This hormone acts directly on the wolffian duct to effect the development of the vas deferens, epididymis, and seminal vesicles. • Testosterone also enters fetal blood and acts on the external genitalia anlage. • In these tissues, testosterone is converted to 5α-DHT to cause virilization of the external genitalia. Embryonic Urogenital Structures and Their Adult Homologues DISORDERS OF SEX DEVELOPMENT Definitions • abnormal sex development may involve the gonads, internal duct system, or external genitalia. • 1 in every 1000 to 4500 births • The nomenclature used to describe disorders of sex development (DSDs) has evolved. • Current classification of these disorders include: • (1) sex chromosome DSDs • (2) 46,XY DSDs • (3) 46,XX DSDs Disorders of Sex Development (DSD) Classification DISORDERS OF SEX DEVELOPMENT Gonadal dysgenesis • disorders of sexual development associated with abnormal, underdeveloped gonads Dysgenetic testis • testis is poorly formed Streak gonad • an ovary is poorly formed ➢affected patients: the underdeveloped gonad ultimately fails, which is indicated by elevated gonadotropin levels. ➢patients bearing a Y chromosome are at high risk of developing a germ cell tumor in the dysgenetic gonad DISORDERS OF SEX DEVELOPMENT Ambiguous genitalia • genitalia that do not appear clearly male or female. Abnormalities may include hypospadias, undescended testes, micropenis or enlarged clitoris, labial fusion, and labial mass Ovotesticular • characterized by ovarian and testicular tissue in the same individual. • It was formerly termed true hermaphroditism. • In these cases, different types of gonads can be paired DISORDERS OF SEX DEVELOPMENT • Pairing: a normal testis, a normal ovary, a streak gonad, dysgenetic testis, or an ovotestis. • In the latter, both ovarian and testicular elements are combined within the same gonad • With ovotesticular DSDs • the internal ductal system structure depends on the ipsilateral gonad and its degree of determination. Specifically, the amount of AMH and testosterone determines the degree to which the internal ductal system is masculinized or feminized. • External genitalia are usually ambiguous and undermasculinized due to inadequate testosterone Sex Chromosome Disorders of Sex Development Turner and Klinefelter Syndromes - arise from an abnormal number of sex chromosomes Turner syndrome • caused by de novo loss or severe structural abnormality of one X chromosome in a phenotypic female. • Most affected fetuses are spontaneously aborted • in girls with Turner syndrome who survive, phenotype varies widely, but nearly all affected patients have short stature. • Associated problems include cardiac anomalies (especially coarctation of the aorta), renal anomalies, hearing impairment, otitis media and mastoiditis, and an increased incidence of hypertension, achlorhydria, diabetes mellitus, and Hashimoto thyroiditis. • It is the most common form of gonadal dysgenesis that leads to primary ovarian failure. In these cases, the uterus and vagina are normal and capable of responding to exogenous hormones Klinefelter syndrome (47,XXY) • These individuals tend to be tall, undervirilized males with gynecomastia and small, firm testes. • They have significantly reduced fertility from hypogonadism due to gradual testicular cell failure. • These men are at increased risk for germ cell tumors, osteoporosis, hypothyroidism, diabetes mellitus, breast cancer, cardiovascular abnormalities, and cognitive and psychosocial problems • Gonads → Testis or ovary • Ducts → Mesonephric or paramesonephric • External Genitalia → Male or female genitalia Undifferentiated gonads Y chromosome No Y SRY gene No SRY TDF No TDF Testis formation Ovary formation Testosterone + AMH Estrogen Mesonephric “wolffian” duct Paramesonephric “mullerian” duct Congenital anomalies of ovaries and fallopian tubes • Duplication • Absence • Ectopic ovarian tissue : Accessory or supernumerary ovaries are extremely rare, and may also be associated with other congenital genitourinary abnormalities • Sexual bipotentiality “Ovotestis “true hermaphrodite” - combined ovarian and testicular tissues seen “ • Genetic chromosomal disorders : • 1. Turner syndrome (45 XO) “streaked ovaries that are a hallmark of the disorder ” Fallopian tube • Aplasia or atresia “ almost always associated with absence of the uterus as well as with other anomalies” • Complete duplication Congenital anomalies of the uterus and cervix The most common anomalies of the uterus result from either : 1.Incomplete fusion of the paramesonephric Ducts. 2.Incomplete dissolution of the midline fusion of those ducts 3. formation failures EPIDEMIOLOGY • Are extremely rare • increased incidence of müllerian anomalies in women who were exposed in utero to diethylstilbestrol (DES) from 1940 to 1971 • DES - synthetic nonsteroidal estrogen that was indicated for gonorrheal vaginitis, atrophic vaginitis, menopausal symptoms, postpartum lactation, miscarriage prevention, and for advanced prostate and breast cancer. CLINICAL MANIFESTATIONS • Discovered incidentally in the workup for common obstetrical and gynecologic complaints at the onset of menache, onset of coitus, or attempts at childbearing. • Menstrual abnormalities • Dysmenorrhea • Dyspareunia, cyclic and noncyclic pelvic pain, infertility, and recurrent miscarriage Uterus didelphys Two separate uterine bodies, each with its own cervix and attached fallopian tube and vagina Represents a fusion failure A bicornuate uterus with a rudimentary horn bicornuate uterus with or without double cervices • Bicornuate and unicornuate uteri are associated with second-trimester pregnancy loss, malpresentation, and preterm labor and delivery Septate uterus • Incomplete dissolution of the midline fusion of the paramesonephrica • 25% of women with uterine septa may suffer from recurrent first-trimester pregnancy loss. Unicornuate uterus Failure of formation • Normal karyotypic and phenotypic females + anomalies of the urinary system such as a horseshoe or pelvic kidney Clinical significant • • • • Woman’s risk for infertility Early pregnancy Loss Dysmenorrhea and dyspareunia Anomalies within uterine vascular system, such as an AVM • Spontaneously Always .. But may also be caused by early maternal exposure to certain drugs • The most notable of these drugs is diethylstilbestrol (DES) (is a synthetic nonsteroidal estrogen that was first synthesized in 1938 ) DES-exposed female’s infant • T-shaped endometrial cavity • cervical collar deformity Diagnostic Evaluation • pelvic ultrasound, CT, MRI, sonohistogram, hysterosalpingogram, hysteroscopy, and laparoscopy • Keep in mind that uterine septa and bicornuate uteri may appear identical on hysteroscopic evaluation • Because there is an increased incidence of renal anomalies (unilateral renal agenesis, pelvic or horseshoe kidneys, or irregularities in the collecting system), additional radiologic evaluation should be pursued in the setting of a congenital Müllerian anomaly Septate Uteri Unicornuate Treatment • Many uterine anomalies require no treatment. • When the defect causes significant symptoms such as pain , menstrual irregularities, or infertility, treatment options should be explored. • Uterine septa can be excised with operative hysteroscopy once bicornuate uterus has been ruled out • Many women with a bicornuate uterus are able to carry a pregnancy to delivery, although preterm labor and delivery is a significant risk • When a viable pregnancy cannot be achieved in a patient with a bicornuate uterus, viable pregnancies have been achieved with surgical unification procedures. External genitalia CONGENITAL ANOMALIES OF THE VULVA Ambiguous genitalia: ▪ may appear as a large clitoris or a small penis. Thus a child may be born with a typically female appearance, but with a large clitoris (clitoral hypertrophy ) or typically male with a small penis that is open on its ventral surface (hypospadius). CONGENITAL ANOMALIES OFTHE VULVA • Clitoral agenesis : failure of the genital tubercle to develop • IMPERFORATE HYMEN • Vaginal agenesis, also known as Mayer-RokitanskyKuster-Hauser syndrome (MRKH). • Vaginal atresia (also known as agenesis of the lower vagina) is often confused with imperforate hymen or transverse vaginal septum. Ambiguous genitalia • • • • Physical examination Pelvic ultrasonography Hormonal studies Examination of a buccal smear for sex chromatin • Karyotyping • And consultation with specialists l Female pseudohermaphroditism • Genetic females (45,XX) • Ovaries but with secondary sexual characteristics or external genitalia resembling those of a male • Caused by masculinization occurring in utero (Androgens) • Presenting with ambiguous genitalia. Female pseudohermaphroditism • Ex. Congenital adrenal hyperplasia ➢ Defect in production of cortisol. ➢ Excessive adrenal androgens must be produced to overcome the decrease in cortisol production. ➢ Enlargement of the clitoris is the most conspicuous abnormality ➢ the diagnosis is not suspected until signs of salt-wasting develop a week later, due in particular to the lack of aldosterone. ➢ When the external genitalia are ambiguous is necessary to investigate for the presence of a uterus and ovaries. ➢ The diagnosis can be confirmed when levels of serum testosterone result to be extensively increased while anti mullerian hormone is not present. Male pseudohermaphroditism Androgen insensitivity • Genetic males (45,XY) • Deficit in testosterone production oraction • These individuals have testes, but their genital ducts and external genitalia are female • Occur with varying degrees of virilization and müllerian development • Ex. 5-alpha-reductase deficiency Quigley scale • • Grade 1 includes individuals whose external genitalia are fully masculinized, condition that correspond to mild androgen insensitivitysyndrome. Grade 6 and 7 includes individuals whose external genitalia are fully feminized. i True hermaphroditism • Dual gonadal development occurs, either in the form of an ovotestis or as a separate ovary and testis • Most true hermaphrodites have some degree of both female and male development internally and externally • The extent to which masculinization occurs depends on the relative amount of testicular tissue and its relative contribution of testosterone MATERNAL PHYSIOLOGY Abegail A. Lamayra, MD, FPOGS INTRODUCTION ▪ In all mammalian species, there are extensive biochemical, physiological and structural changes during pregnancy: ▪ Any female of reproductive age could be pregnant ▪ Virtually every organ system affected ▪ The causes of these changes are: 1. To provide a suitable environment for nutrition, growth and development of fetus 2. To prepare the mother for the process of parturition and subsequent support of the newborn baby. FETAL DEVELOPMENT 9 – 12 weeks crown rump length is 6 – 7 cms 13 – 20 weeks skin is covered with vernix caseosa 21 – 29 weeks fingernails are present and eyelids are open 30 - 34 weeks weight is about 1800 grams 35 – 38 weeks have firm grasp and with spontaneous light orientation 40 weeks testes are in the scrotum MATERNAL ADAPTATIONS TO PREGNANCY Presumptive Evidence of Pregnancy Presumptive symptoms 1. Nausea with or without vomiting 2. Disturbances in urination 3. Fatigue 4. Perception of fetal movement 5. Breast symptoms Presumptive signs 1. Cessation of menstruation 2. Anatomical Breast changes 3. Changes in the vaginal mucosa 4. Skin pigmentation changes 5. Thermal signs positive hcg = choriocarcinoma Probable Evidence of Pregnancy Probable signs 1. Enlargement of the abdomen 2. Changes in the size, shape, consistency of the uterus 3. Anatomical changes of the uterus 4. Braxton-Hicks contractions 5. Ballottement 6. Physical outlining of the uterus 7. Positive results of endocrine test normal hr mother = 115 baby hr = 110 Positive signs of Pregnancy 1. Identification of the fetal heart action separately and distinctly from the mother 2. Perception of active fetal movement by the examiner 3. Recognition of the embryo or fetus by ultrasound or by radiological methods Objectives ▪ Understanding the adaptations to pregnancy ➢Anatomical ➢Physiological Anatomical adaptations • Uterus • Cervix • Ovaries • FallopianTubes • Vagina & Perineum • Breast Physiological adaptations • CardioVascular • Musculoskeletal • Hematologic • Endocrine • Respiratory • Metabolic • Gastrointestinal • WeightChange • Hepatobiliary • Dermatological • Urinary • Ophthalmological • Neurological • Dental UTERUS Non Pregnant Uterus Muscular Structure weight Volume Almost Solid Pregnant Uterus Mechanism Of Uterine Enlargement Stretching & marked hypertrophy & hyperpalsia myometrial cells (d/t high level of maternal estradiol & progesterone Individual muscle fibres increasing in length by 15 fold along with specialized cellular connections (gap junctions); spiral arteries changed into floppy thin-walled vessel. Accumulation of elastic tissue & fibrous tissue, particularly in the external muscle layer. Bartholomews Uterine size, shape & position dextro rotation more on right ▪ First few weeks, original peer shaped organ ▪ As pregnancy advances, corpus & fundus assumes a more globular form. ▪ By 12 weeks, the uterus becomes almost spherical . ▪ Subsequently, uterus increases rapidly in length than in width & assumes an ovoid shape. ▪ With ascent of uterus from pelvis, it usually undergoes Dextrorotation (caused by the rectosigmoid colon on the left side) mucus plug - indication of 1cm dilation mucus with blood Cervix ▪ As early as 1 month after conception the cervix begins to undergo profound swelling, softening &cyanosis due to : (estradiol & progesterone) ➢Increased vascularity & edema of the entire cervix. ➢Hypertrophy & hyperplasia of the cervical glands. ➢Endocervical mucosal cells produce copious amounts of a tenacious mucus that obstructs the cervical canal soon after conception(mucus plug) ➢Estradiol stimulates growth of the columnar epithelium of cervical canal that becomes visible on ectocervix called ectropion Changes that occur due to increased vascularization: Hegars sign • Non-sensitive indication of pregnancy • Pertains to the features of the cervix and the uterine isthmus • As softening in the consistency of the uterus such that the uterus and cervix seem to be two separate regions due to increased blood supply. Goodell’s sign • Significant softening of the vaginal portion of the cervix from increased vascularization due to hypertrophy and engorgement of the vessels below the growing uterus Chadwick’s sign • Blue/violet discoloration of the cervix and vagina caused by increased vascularity prominent at 4th week AOG. Ovaries ▪ Cessation of ovulation & arrest of maturation of new follicles. ▪ Single corpus luteum is found in ovaries of pregnant women that contributes to progesterone production maximally during the first 6 to 7 weeks of pregnancy ▪ This explains the rapid fall in serum progesterone & the occurrence of spontaneous abortion upon removal of the corpus luteum before 7 wks. Fallopian Tubes ▪ The musculature of the fallopian tubes undergoes little hypertrophy ▪ The epithelium of the tubal mucosa becomes somewhat flattened Vagina & Perineum ▪ Increased vascularity prominently affects the vagina resulting in the violet color (chadwick sign). ▪ Considerable increase in the thickness of the vaginal mucosa, loosening of the connective tissue, hypertrophy of smooth muscle cells. ▪ Vaginal epithelium = thicker = desquamation = acidic discharge Breast changes • Increased size and vascularity warm, tense & tender • Increased pigmentation of the nipple & areola • Secondary areola appear (light pigmentation around the 1ry areola) • Montgomery tubercules appear on the areola (dilated sebaceous glands) • Colostrum like fluid is expressed at the end of the 3rd month Breast changes Volume haemostasis ▪ Fluid retention = 8-10 kg of average maternal weight ▪ Some innrease in intracellular water, but most marked expansion occurs in ECF (↑by 7 liter,~40% above prepregnant), especially plasma volume - 70% increase in blood volume ▪ Factors contributing to fluid retention: ➢ Na & H2O retention: 900 mmol (3-4 mmol/day), ↑anti- natriuretic hormone (aldosterone & deoxycorticosterone) ➢ Plasma osmolality – resetting osmostat ➢ Decrease thirst thresold ➢ Decrease in plasma oncotic pressure by 20%: major contributing to starling mechanism & peripheral edema HEMATOLOGY ▪ ↑ Erthropoietin & hPL in pregnancy = stimulate hemopoiesis ▪ Erythrocytes rises (no. & size) by 20-30% after 16 wks ▪ ↑ in RBC mass is slower & lesser than the ↑ in plasma volume = hemodilution = physiological anemia of pregnancy ▪ Total WBC count ↑ due to ↑ed polymorphonuclear leukocytes (due to ↑ estrogen) ▪ T & B lymphocytes counts do not change rather their function is suppressed = pregnant women more suceptible to viral infections, malaria & leprosy HEMATOLOGY COAGULATION • Several procoagulent factors (factors VII, VIII & X, & Plasma fibrinogen doubles) rise from the end of 1st trimester = hypercoagulable state (advantage or disadvantage??) • Anti-thombin III (inhibitor of coagulation) falls • ESR rises due to increase in fibrinogen - favors rouleaux formation • Protein C (inactivates factor V & VIII) = unchanged but protein S fall during 1st two trimesters • Plasma fibrinolytic activity is decresed map = impt tool to detect pre eclampsia CardioVascular ▪ Elevated progesterone & estrogen vasodilation ▪ Endothelium derived vasoactive (eg.NO) ▪ Vasodilation ▪ ▪ ▪ ▪ ↓TPR ↓afterload & BP, & perceived as circulatory underfilling that activates RAS= ↑Ald = ↑CO Probably fall in baroreflex sensitivity as pregnancy progresses & HRV falls & HR increases = ↑CO Small fall in SBP but greter fall in DBP. The BP then rises steadly in parallel with ↑sympthetic activity (thus, ↑in Pulse Pressure). MAP usually decreases during mid pregnancy & rises in 3rd trimester = remains at or below normal No change in pressureintherightventricle CardioVascular ▪ Stroke volume ▪ Heart rate ▪ CO ▪ SVR ▪ Systolic BP ▪ Diastolic BP ▪ Mean BP ▪ O2 Consumption •( •( •( •( •( •( •( •( 10%) 15%) 35%) 35%) 5-10 mmHg) 15 mmHg) 10%) 20%) CardioVascular ECG Changes ▪ Increased heart rate ( 15%) ▪ 15° left axis deviation. ▪ Inverted T-wave in lead ІІІ. ▪ Q in lead ІІІ & AVF ▪ Unspecific ST changes Pulmonary Function ▪ ↓RV & FRC - due to elevation of diaphragm. No change in VC, pulmonary compliance, FEV1 & PEFR. ▪ Though respiratory rate is little changed, TV↑(~40%)---> ↑alveolar ventilation. TV is ↑ as progesterone,↓ the thresold & the sensitivity of medulla oblongata to CO2 ↑ ▪ Pco2 is lowest in early gestation (↑ Va + ↑CA in RBC) - facilitates CO2 transfer from fetus to mother; ↓maternal plasma osmolaity (due to ↓HCO3- ) ▪ ↑2,3 DPG in maternal RBCs Gastrointestinal ▪ Due to relaxation of smooth muscle (due to high progesterone level) ▪ Pyrosis (heartburn) is common &is caused by reflux of acidic