Relevant anatomy

Uterus derived from Mllerian duct aka para mesonephric ducts

They appear at 6 weeks of POG

They appear in both male and female

Degenerates in males at the 8-9 weeks of POG

Remnants of this duct are called Utriculus Masculinus and appendix of

testes

Fusion of the two ducts begins centrally and then goes caudal and cranial

Uterus is formed by 10 weeks of POG

Facts about uterus

Nulliparous. Multiparous

Weight is 50-70 gms 80 gm

6-8 cm in length. 9-10 cm

Shape of cavity : triangular in coronal section

Cleft like in saggital section

Wt of pregnant uterus at term: 1000 gm

Wt of uterus immediately after the delivery of the baby: 1000 gm

Volume of pregnant uterus at term: 5 liters

Volume of non pregnant uterus: 10 ml

Pregnant uterus undergoes both Hypertrophy and hyperplasia

If one has to be chosen: Hypertrophy

fundus is the part which lies above the attachment of the Fallopian tubes

Isthmus in the pregnancy forms the lower uterine segment(LUS)

LUS begins to form in the second trimester

Well developed LUS( late in pregnancy, third trimester) : now it's

Isthmus(70%) and cervix( 30%)

Internal Os lies between isthmus and cervix

Two types of internal Os

Histological internal Os lies below the anatomical internal Os

Three structures at upper end of uterus

Round ligament

Fallopian tubes

Ovarian ligament

Relationship

Antero posterior

RFO

Supero inferior relationship

Fallopian tube

Round and ovarian at the same level

All these are covered by broad ligament

It's a fold of peritoneum

Anterior leaf and posterior leaf

Contents of broad ligament

RFO

Connective tissue

Blood vessels

Nerves

Ovary and it's ligaments

Remnants of wollfian ( Mesonephric duct)

This relation is useful for tubal ligation

One of the main reason for failed tubal ligation

Wollfian duct:Mesonephric duct

Disappears in female fetus at 8-9 weeks

Remnants

Epoophoron

Paroopharon

Gartners duct

Cranial remnant of wollfian duct is epoophoron

Caudal is paroopharon

Epoophoron has 15-20 tubules which join to form the Gartners duct

Supports of uterus

1. Utero sacral ligament

2. Mackenrodt ligaments aka transverse ligament aka cardinal ligament

3. Pubocervical ligaments

4. Levator Ani

If have to choose one: mackinrodts

Which ligament keeps the uterus antiverted: round ligament

Which ligament prevents the retro version of uterus: uterosacrals

Anti Version
Angle between the Uterus and the Vagina
90 degrees

Anti flexion

Angle between the uterus and cervix

Always obtuse: 120-170 degrees

Lining of the uterus

Single layered columnar epithelium and ciliated only near glands

Thickness immediately after menstruation

0.5 mm

Thickness in the proliferative phase at mid cycle

2-3 mm

Thickness in luteal phase

5-6 mm

At the time of implantation will be same as in luteal phase

Cervix

Cervix to corpus ratio

At birth: 1:1

Pre menarche : 2:1

Post menarche : 1:2

Reproductive life : 1:3

Menopause: 1:1

Cervix is made up more of connective tissue and very less muscle tissue

External Os

Shape in nulliparous: circular

Multiparous: transverse slit( after delivery)

Cervix
Gross shape: conical

Shape of cavity: fusiform or spindle shaped

Glands of cervix

Arbor vitae appearance

Blood supply to uterus

Uterine artery

It is a branch of anterior division of the internal iliac artery

Most common site of injury

the uterine artery crosses over the ureter two cm lateral to the cervix

Or 1.5 cm lateral to the fornix

Ka water under the bridge

Second most common site

Pelvic brim

Crossed by ovarian vessels

Cervix is also derived from Mllerian duct

Supplied by descending cervical artery which are branches of uterine

artery

They are present at 3 o'clock and 9 o'clock position

Therefore cervical block given at 2 or 4 o'clock and 8 or 10 o'clock

Branches of uterine artery

U: uterine artery

A: arcuate

R: radial

B: basal: supplies basal endometrium

S: spiral : supplies superficial endometrium( functional endometrium)

Uterine muscle fibers

Outer longitudinal

Middle criss cross: acts as a living ligature( vessels running through and
prevent blood loss post partum)

Inner circular layer: arranged in sphincteric fashion at 3 points

2 at Cornu

1 at internal Os

Q. Which part of the Fallopian tube act as sphincters: intramural or

interstitial part

Lymphatic drainage

From the fundus of the uterus: para aortic lymph nodes

Rest of the uterus: internal iliac LN

Nerve supply

Q. Which nerve fibre carry the pain sensations during labor

T11- T 12

Q. Indirectly the level of spinal anesthesia can be asked

Answer is T4( coz the peritoneum is to be blocked as well)

Q. Level for operative vaginal delivery

T10

What carries the painful fibers from cervix and upper genital tract

S2,3,4

From vagina and lower genital tract: pudendal nerve

This nerve is blocked in operative vaginal delivery

Pudendal nerve is present behind the sacro spinous ligament in the

pudendal canal

Thus this ligament is pierced

Fallopian tubes

Derived from Mllerian duct

Length is 10 cm

Parts

Medial to lateral

Intramural aka interstitial (2 cm), narrowest part: 0.7 mm

Isthmus (3 cm), diameter is 1 mm

Ampulla (5 cm), diameter is 6 mm

Fimbrial end aka infundibulum

Lining epithelium

Single layer ciliated columnar epithelium

Cell types found in the Fallopian tubes

1. Ciliated cells: cilia beat asynchronously, towards the uterus

2. Secretory cells: secretions are rich in pyruvate

3. PEG cells characteristic of Fallopian tubes

Movement of conceptus is majorly by the muscular contractions of the

Fallopian tube and not the ciliary movements

Q. Early conceptus derives it's nutrition from pyruvate secreted by

secretory cells

PEG cells are the resting cells of the Fallopian tubes, no important
function

Blood supply of Fallopian tube

Dual supply

Medial half:

Lateral half: ovarian artery

Lymphatic drainage of FT

Major drainage in Para aortic LN

Some also drain into superficial inguinal LN

Nerve supply

T11,12, L1

Vagina

7-10 cm long

Three walls

Posterior wall is longer than the anterior wall by 2 cms

Shape on cut section is H shaped

Anterior and posterior wall stick to each other

Embryo logically it has a dual origin

Upper 2/3: Mllerian ducts

Lower 1/3: Uro genital sinus

Germ layer

Upper 2/3: mesoderm of Mllerian ducts

Lower 1/3: endoderm of Uro genital sinus

Ante version angle is 90 degrees

Angle with horizontal is 45 degrees

Vagina lacks glands

Secretions come from the cervical glands

pH

During menstruation: 6.5-7.5

In other phases of cycle: 4-4.5

Pregnancy: 4-4.5

After menopause: 6.5-7.5

Doderlein bacilli keep the vaginal pH acidic to protect against infections

Blood supply

Upper 1/3: uterine artery

Middle 1/3: inferior vesicle artery

Lower 1/3: middle rectal artery

Lymphatic drainage

Upper 1/3: external iliac LN

Middle 1/3: internal iliac LN

Lower 1/3: superficial inguinal LN

External genitalia

Genital tubercle: clitoris and penis

Genital fold: labia minora and penile urethra

Genital swelling : labia majora and scrotum

Bartholin glands: male counterpart is Cowpers glands aka bulbourethral

glands

These are responsible for secretions during coitus and secretions are
alkaline

Bartholin present in superficial perineal pouch while Cowper in deep

Gland is lined by columnar epithelium

Duct by transitional

Duct open at junction of anterior 2/3 and posterior 1/3 of faucet and open
in the groove between labia minora and majora

Thus 5 o'clock and 7 o'clock positions

These glands form cysts and abscess

treatment of abscess

I and D and placement of a WORD catheter to prevent recurrence

Treatment of recurrent cysts

Marsupialization

Relevant embryology

Gonads

Testes and ovaries

Arise from genital ridge aka gonadal ridge

Arise at 5 weeks of POG

Testes appear at 7 weeks

Ovary appear at 8 weeks

SRY gene located on the short arm of Y chromosome determine the

gonads towards testes

Sertoli cells: release MIS( Mllerian inhibiting substance)

Inhibits the ipsilateral Mllerian duct

Leydig cells: secrete testosterone

These act on wollfian ducts to form the male internal genitalia

Therefore sequential action of MIS and testosterone needed for male

genitalia formation

Testosterone converts into di hydro testosterone with the help of 5 alpha

reductase which help in making of male like genitalia

If 5 alpha reductase absent: genitalia is female like

Thus male pseudohermaphrodite

If female pseudohermaphrodite : karyotype female but external genitalia

male like

True hermaphrodite: both gonads are present but non functional and
external genitalia is ambiguous

Ovaries

Arises from gonadal ridge or genital ridge at 8 weeks

Follicles are present only in the cortex of the ovary

Medulla only has blood vessels and compnmective tissue

Primordial germ cells arise first in the yolk sac at 3 weeks of POG

They arise from Epiblast which arises from ectoderm

PGC Reach the gonads at 6 weeks of POG

At 9 weeks, the PGC form oogonia

At 12 weeks, oogonia form the primary oocyte

At 14 weeks, follicle formation begins

At 24 weeks, follicle formation completes

Granulosa cells

Derived from the germinal epithelium

Epithelial lining of Ovary: single layer cuboidal epithelium

Theca cells

Derived from

Mesoderm gives rise to ovarian stroma

Ovarian stroma has intermediate cells

Which give rise to

Theca cells

Hilar cells( resemble leydig cells of the ovary, produce androgen and thus
Hilus cell tumor is a virilizing tumor of the ovary

Max no. Of oogonia are found at 20 weeks of POG

No. is 7 million

After this they show atresia

At birth : 2 million

At puberty: 400,000

Of all, only 400 will ovulate

Oogenesis

Begins in utero

Oogonia divides by mitosis

Primary oocyte

First meiotic division

Arrested in the dictyotene phase of prophase 1

Meiosis 1 resumes at

Meiosis releases the secondary oocyte and first polar body

First polar body is formed 3-4 hours before/ or at ovulation

Cytoplasm

Secondary oocyte as soon as it is formed enters into meiosis and

arrested into metaphase

Meiosis 2 completed after fertilization

Producing female pronucleus

Spermatogenesis

Begins at puberty

72 days

Spermatogonia( diploid)

Mitosis

Primary spermatocyte( diploid)

Meiosis 1

No arrest

Two Secondary spermotocytes( haploid)

Meiosis 2

No arrest

Two spermatids

Process of spermiogenesis

Nuclear material forms the head of the sperm

Golgi body forms the acrosomal cap

Mitochondria forms the middle piece

Micro tubules form the tail

These are still non motile

Attain motility in epididymis

Fertilizable life span of a sperm is 72 hours

Fertilizable life span of an uvum is 24 hours

Capacitation: change in sperm before fertilization

It takes place in female genital tract

Begins in cervix

Major part in Fallopian tubes

Process takes 6 hours

It has to take place within 6 hours of ejaculation

Only acrosomal part and head enter the ovum

They have to pierce the zona pellucida

Function of Zona pellucida is to prevent polyspermy

It undergoes cortical reaction after it is penetrated

Releases granules which prevent other sperms from entering

Aka zona reaction

Fertilization takes place in the ampulla of the FT

Conceptus is formed

For how long conceptus remains in FT: 3 days

Enters the uterine cavity on day 4

Implantation takes place on day 6 to day 7

In what form does it enter the uterine cavity: Morula

Blastocyst is formed on day 5

Zona pellucida is lost just before implantation which is day 5

Implantation completed on day 10 to day 11

Decidua Vera: capsularis and parietalis fuse

Happens at 14-16 weeks of POG

Clinical relevance: twining theoritacally can occur till this happens

trophoblast: appears at day 8

Cyto trophoblast gives rise to syncitiotrophoblast

Trophoblast forms the placenta and the fetal membranes

Amnion

Chorion

Yolk sac

Allantois: outpouching from the hind gut which grows into the connecting
stalk

Inner cell mass forms the embryo proper

first germ layer to appear is endoderm on day 8

All three layers are formed on day 21

placenta
Human placenta is hemo chorial

500 gms at term

Volume at term is 500 ml

Placenta: fetal wt at term is 1:6

Total villous surface area: 12 meter square

It has

Primary villi: day 13

Secondary villi: day 16

Tertiary villi: day 21

Has two surfaces

Maternal, faces the decidua

Fetal, faces the baby

Maternal side is divided into 15-20 lobes or cotyledons

Each lobe further has 3-5 lobules

Thus lobules is the functional unit of placenta

Fetal side is smooth and shiny because covered by fetal membrane and
cord is attached

Umbilical cord

30-100 cm

Average length: 55 cm

Short cord< 30 cm

Has all membranes except chorion

Has two arteries and one vein( left)

Umbilical vein is bigger in diameter than the umbilical artery

Secretes hormones

Progesterone

Source to produce it is maternal LDL cholesterol

Synthsizes on its own

But estrogen can not be produced by it as it lacks the enzyme 17

hydroxylase

It takes the help of the fetus , uses fetal DHEAS sulfate produced by fetal
adrenals

Sulphatase

Aromatase

Estrogen

Estrogen specific to pregnancy: E3 or estriol

Major estrogen produced by placenta: estradiol

Progesterone

What rescues luteolysis of the corpus luteum: HCG

When does placenta take over the function of corpus luteum: at 8-10
weeks of POG

Human placental Lactogen is produced by placenta

Levels Reach maximum at 36 weeks

Tells about functioning of placenta

It is not required for normal pregnancy

It prepares the breast tissue for lactation

Human chorionic gonadotropin

Secreted by syncitiotrophoblast

Two chains

Alpha chain is non specific

LH/ FSH/ TSH/HCG

Beta chain is specific

Can be identified at 8-9 days of fertilization

Max levels at 8-10 weeks

Then levels begin to fall and reaches nadir at 16 weeks after which it
plateaus

Doubling time of B-HCG

48 hours

1.4- 2 days

Rise of 66% is known as doubling( 55-66)

Is seen in live intrauterine pregnancies

Urine pregnancy test

Uses sandwich ELISA technique

Can detect 10-20 IU/L

Can be detected in serum

Qualitative test are no better than urine tests

Quantitative tests are the best , very low values can be detected(1-2 IU/L)

Cut o value

The lowest value at which the Sonologist will see the gestational sac

TVS: 1500 IU ( range is 1000-2000 IU)

TAS: 6500 IU ( no range)

HCG maintains the corpus luteum of pregnancy

Helps in testosterone production from testes

Produces immunological tolerance

Diagnosis of

Ectopic

Molar pregnancy and it's monitoring

Diagnosis of Down's syndrome

Down's syndrome

Trisomy 21

Three forms

Non disjunction( most common, 95%)

Translocation(4%)

Mosaicism(1%)

Non disjunction is not heritable therefore second baby after first baby is
down has a chance of 1 %( general population)

Translocation can be herited

Types of translocation

13,14,15,21 and mother is the carrier, risk is 10% and if father is the
carrier , risk is 3-5 %

21/21 or 21/22 will have risk of 100%

balanced robertsonian translocation: same amount of genetic material is

switched

ACOG guideline

All pregnant females should go for downs screening

Screening of Down's syndrome

1st trimester

USG: want to see nuchal translucency , ideal time is 11-13+6 weeks

Maternal serum markers :

Free B HCG + PAPPA

Increased. Decreased

Combined test

USG plus serum markers

2nd trimester

Serum screening(15-20 weeks)

Triple test: HCG + AFP + serum EsTRIOL

Quadruple test: HCG+ AFP + estriol + inhibin A

integrated test

First trimester serum markers

Second trimester

First trimester USG ????

Best test

Q. Anencephaly can be picked up at 10-12 weeks but confirmatory at 14

weeks

Confirmatory test for downs

Karyotyping

In the first trimester

Chorionic villus sampling: should be done after 10 weeks

Not done before or equal to 9 weeks: limb defects( also oro mandibular)

Second trimester

Amniocentesis

Anytime after 15 weeks

Usually 16-18 weeks

Less than 15 weeks, fetal loss

Cordocentesis

After 20 weeks

Karyotyping can be done by

CVS

Amniocentesis

Cordocentesis

Not skin biopsy