uterus and cervix

Question 1

describe shape and size of uterus ?

Answer 1

3 PARTS:

Fundus –> dome shaped, muscular portion above the opening of the fallopian tubes , it doesnt contain a cavity

Body –> Central, hollow portion of uterus where implantation occurs

Cervix –> Narrow , lower part that extends into vagina

Before puberty

Cervix and body of uteterus are 1:1

After puberty , cervix and body become 1:2

Lvl of fundus change during pregnancy :

Week 12 at the pubic symphysis

Week 24 at the umbilicus

Wekk 36 subcosta/epigastric region

Question 2

what is fornix ?

Answer 2

gap surrounds the cervix

between it and the upper part of vaginal wall

3 parts as well:

Anterior fornix

Posterior fornix deeper

Lateral fornices on each side

Question 3

describe isthmus ?

Answer 3

between the body and the cervix of the uterus

during pregnancy

the junction increases in length, sensitivity and become softer

CALLED HEGAR SIGN OF EARLY PREGNANCY

Question 4

describe cavity of cervix? CERVICAL CANAL

Answer 4

Internal opening and external opening

Internal: upper opening of the cervical canal connecting the uterine cavity with cervical canal , its located at the junction between the uterine body and the cervix also called isthmus, its usually narrow and tightly closed in non pregnant women, helping maintaining pregnancy by keeping uterus sealed (aka isthmus )

External opening :

Lower opening of the cervical canal which connects the cervical canal with the vaginal lumen , visible during examination using speculum

In nulliparous woemn ( hasnt given birth), the external opening appear small and round

in parous women ( after birth ), becomes wider and more transverse slit like due to the stretching of childbirth almost appearing like it has lips

Question 5

position of uterus ?

Answer 5

in the erect posture with bladder empty

the uterus lies in almost horizontal plane

The body of the uterus is freely mobile hence as the bladder fills with urine , the uterus rises

the cervix of the uterus is not mobile because its held in position by several ligaments

Question 6

position in most women?

Answer 6

Anteverted and Anteflexed ( tilting on the bladder)

Anteverted :

Long axis of the uterus is bent forward on the long axis of the vagina is -90 degree

Anteflexed :

Long axis of the body of the uterus is bent foreword at the lvl of internal opening with long axis of cervix 170 degree

the anteverted and anteflexed uterus is pressed against the bladder when intra-abdominal pressure is increased

Question 7

position in some women?

Answer 7

Retroversion: ( instead of tilting on the bladder it tils back to the sacrum )

Cervix and body of uterus are bent backward on the vagina

Retroflexion :

Body of uterus is bent backward ( not the cervix )

Increased intra-abdominal pressure tends to push the retroverted uterus into vainga –> PROLAPSE

Question 8

what is the anterior relation of the body uterus ?

Answer 8

Covered by peritoneum

Which reflects forward into the superior surface of the bladder forming –> UTEROVESICAL POUCH

Question 9

posterior surface relation of body of uterus?

Answer 9

Covered by peritoneum which extends over the posterior fornix of the vagina then back up the RECTUM

forming –> RECTOUTERINE POUCH ( OF DOUGLAS)

Question 10

superior relation of cervix?

Answer 10

Supra vaginal part anteriorly —>

NON PERITONEAL, RELATED TO BASE OF BLADDER

Question 11

Posterior relation of cervix?

Answer 11

covered with peritoneum

sigmoid colon

Question 12

muscular /active support of uterus ?

Answer 12

1- Pelvic diaphragm :( levator ani )

Musculo fascial partition between pelvic cavity and perineum

Pubovaginalis part of pubococcygeus-main support

2- Perineal body - fibromusucular node

3- Urogenital diaphragm – Musculo fascial partition

Question 13

visceral support of uterus ?

Answer 13

Urinary bladder

Vagina

Uterine axis

Question 14

fibro-muscular support of uterus ?

Answer 14

Ligaments of the cervix –> all attached to the certiv –> IMMOBILE CERVIX

1- PUBO-CERVIAL – anterior pelvic wall

2- Sacro-cervical - post pelvic wall

3- Transverse cervical/cardinal /mackenrodts –> LATERAL PELVIC WALL

4- Round ligament ( around fallopian tubes )

Question 15

what lies in the upper part of the cardinal ligament ?

Answer 15

Ureter

uterine vessels

Question 16

peritoneal folds?

Answer 16

Broad ligament

Utero-vesical pouch ( between anterior wall of uters and bladder )- Can collect fluid , pus, blood, in PID, less deep compared to the other one

Recto-uterine/vaginal pouch –> Between rectum and posterior wall of uterus–> COMMON SITE for fluid accumulation , blood, pus , ascites–> ACCESSIBLE VIA POSTERIOR FORNIX

Question 17

describe broad ligament?

Answer 17

Suspensory ligament of the ovaries/infundibulopelvic ligament :

Lateral quarter of the upper edge of the broad ligament , contain the ovaries vessels and lymphatics

MESOVARIUM :

Mesosalpinx

Memometrium

Question 18

describe mesovarium ?

Answer 18

suspends the ovary from the POSTERIOR surface of the broad ligament

Question 19

describe mesosalpinx ??

Answer 19

Between the uterine tube mesovarium and mesometrium

Question 20

describe mesometrium?

Answer 20

Broad ligament - mesovarium- mesosalpinx

Question 21

content of broad ligament ?

Answer 21

Areolar tissue

The ligament of the ovary and round ligament of uterus

Uterine and ovarian vessels and lymphatics

Embyronic renmants : May accumulate fluid and form cysts like gartner duct cysts

Question 22

ligaments of the ovary?

Answer 22

1- Ligament of the ovary –> holds ovary to the uterus ( from the uterine pole of the ovary the cornu of the uterus )

VISIBLE AS A RIDGE ON THE POSTERIOR LAYER OF THE BROAD LIGAMENT

2- Suspensory ligament which holds the ovary to lateral pelvic wall

Suspensory ligament is not within the broad ligament but continuous with it

Question 23

parts of fallopian tube ?

Answer 23

Infundibulum– > Trumpet like expansion of lateral end –>frimbae are finger like projections from it and one prominent frimae is attached directly to the ovary called Fimbria OVARICA and it help guide the oocyte

Ampulla –> Median continuation of the infundibulum ( SITE WHERE FERTILIZATION OCCUR )

Isthmus

Intramural part : narrowest part of the uterine tube –> pass through the uterine wall

the infudibulum opens into the greater sac

Question 24

describe tubal pregnancy?

Answer 24

Delay in transport –> embedding of zygot of the wall of the tubue

Ligation and division of the tubes is a common method of birth control

Question 24

how does fallopian tube cause peritonitis ?

Answer 24

Uterine tube allow communication between the peritoneal cavity and the exterior of the body through uterus and vagins Thus infection of the vagina , uterus and tube may result into PERITONOTIS in ectopic pregnancy in tube ---> The tube is thin and narrow and is not deigned support a growing embryo , the developing pregnancy can lead to progressive distension of the tube , this cause rupture ---> The contents of the tube including blood and embryonic tissue will be released into greater sac via fimbrial end of the tube into peritoneal space this could be misdiagnosed as acute appendicitis

Question 25

what is salpinigtis ?

Answer 25

inflammation of the tube - > Blocks the uterine tube major cause of infertility

Question 26

describe hysterosalpinogography?

Answer 26

Injection of a radiopaque materal into the uterus and tubes to study the patency of the tube and abnormalities of uterus

Question 27

situation of ovary in newborn ?

Answer 27

above pelvic brim

Question 28

situation in nulliparous ?

Answer 28

lies in the ovaries fossa External iliac vessels anteriorly Internal iliac vessels and ureter posteriorly The OBTURATOR nerve crosses the floor of fossa

Question 29

situation of ovary after pregnancy ?

Answer 29

Position of the ovary before pubert is smooth but after pregnancy is become scarred due to degeneration of corpora lutea

Question 30

what happens in irritation of obturator nerve?

Answer 30

Diseased ovary may cause pain along the medial side of the thigh ---> Irritation of the obturator nerve in the ovarian fossa The obturator nerve sends cutaneous branch to the medial thigh

Question 31

ovarian pain?

Answer 31

originally an abdominal organ --> sensory innervation IS SYMPATHETIC

Question 32

Describe mittelschmerz? Middle pain ?

Answer 32

Para-umbilical pain experienced by some woman at ovulation Stretching of the ovarian wall Afferent impulses reach the central nervous system at T10 segment the pain is referred to dermatone of T10

Question 33

arterial supply of ovary?

Answer 33

ovarian arteries --> abdominal aorta

Question 34

venous drainage of ovaries ?

Answer 34

Ovaries vein

Question 35

innervation of ovaries?

Answer 35

sympathetic fibers from T10

Question 36

describe vagina ?

Answer 36

Extends upward and backwards from vulva its 8 cm long Has opposed anterior and posterior walls The urethra is embedded in the anterior wall the posterior wall is longer than the anterior wall --> THE POSTERIOR FORNIX IS DEEPER cuz no peritoneum intervenes between the anterior cervix and base of the bladder , cervical cancer may spread by continguity to the bladder UPPER PART --> ABOVE PELVIC FLOOR LOWER HALF --> WITHIN THE PERINEUM

Question 37

Anterior relation of the vagina?

Answer 37

base of the bladder and urethra below

Question 38

posterior relation of vagina ?

Answer 38

Upper third = peritoneum + rectouterine pouch of douglas middle third --> rectal ampulla Lower third -->perineal body separating vagina from anal canal

Question 39

lateral relation of vagina ?

Answer 39

Upper part --> above diaphragm --> URETER, UTERINE ARTERY AND LATERAL CERVICAL LIGAMENT ( artery inside ligament ) Middle part --> Levator ani Lower part : Urogenital diaphragm, bulb of vestibule and greater vestibular glands ( content of the deep perineal pouch and under it the superifical pouch )

Question 40

structures felt during vaginum exam?

Answer 40

Anteriorly --> bladder , urethra, pubic symphysis Posteriroly --> you mainly feel the rectum and above it the pouch Laterally --> Pulsation of the uterine artery, rarely a stone in the ureter may be felt through the lateral fornix Apex : Cervix, cosnistency change in pregnancy and become soft and has lips ( isthmus ) degree of dilation during labor

Question 41

structures supports the vagina?

Answer 41

Upper part : Levator ani, transverse , cervical, pubocervical and sacrocervical ligaments Middle part --> UROGENITAL DIAPHRAGM Lower --> PERINEAL BODY

Question 42

describe vaginal fistula ?

Answer 42

Open communication between vagina and adjacent bladder, urethra, rectum, perineum Results from obstetrical trauma during long and difficult labor Vesicovaginal and urethrovaginal fistula --> URINE ENTER THE VAGINA Continues flow from vesicovaginal fistula Occurs only during micturition from URETHROVAGINAL FISTULA Rectovaginal fistula --> DISCHARGE FECAL MATTER FROM THE VAGINA

Question 43

Blood supply ?

Answer 43

Uterus: Uterine + ovarian artery and uterine plexus of vein Uterine tube: Ovarian and uterine arteries and ovarian and uterine plexus of vein

Question 44

relation of uterine artery and ureter?

Answer 44

Uterine artery Passes over the ureters like water under the bridge --> Water = ureter carrying urine Bridge = uterine artery

Question 45

describe hysterectomy ?

Answer 45

Surgical removal of uterus good regional knowledge is need cuz the uterine artery is ligated to remove the uterus Cuz the ureter passes so close underneath the artery so theres a risk of accidentally clamping , ligating or injuring the ureter will lead to urine leakage, fistula or loss kidney function if not detected

Question 46

Describe visceral afferent innervation in the pelvis ?

Answer 46

Pelvic pain like: Pelvic viscera that are in contact with peritoneum are superior to the pelvic pain line ( in contact with peritoneum = superior pelvic line _ Pain impusles from the viscera superior to the pain line --> TRANSMITTED BY SYMPATHETIC FIBERS --> ABDOMINOPELVIC SPLANCHNIC NERVE - T11-L2 Pain impulses from viscera inferior to the pain line are transmitted BY PARASYMPATHETICS FIBERS --> FIBERS SPLANCHNIC NERVES --> S2-S4 So if in contact with peritoneum = above the line = sympathetic pain fibers = abdominopelvic splanchnic = T11-L2 If not in contact with peritoneum = below the line = parasympathetic = pelvic splanchnic nerves = S2-S4

Question 47

Innervation of uterus ?

Answer 47

body and fundus Sympathetic fibers mainly through : Inferior hypogastric plexus T11-L1 may be motor to the uterine muscles Uterine muscles responds mainly to the hormonal changes Sensory --> PELVIC LINE ( above it )

Question 47

innervation of cervix ?

Answer 47

Dilation of cervix causes pain mediated by pelvic splanchnic S2-S4 ( below the line ) may be referred to these dermatomes posterior to the thigh and so resembles sciatica

Question 48

innervation of vagina ?

Answer 48

Upper part : Visceral sensation parasympathetic S2-S4 --> sensitive to distension ( below line ) Lower part : Somaticsensation pudendal nerve S2,3,4 --> SENSITIVE TO TOUCH AND TEMP

Question 49

1ST anesthesia for childbirth ?

Answer 49

Administered into the epidural spaces Affect S2-S4 spinal nerve roots including pain pain fibers from the UTERINE CERVIX, SUPERIOR VAGINA ( AUTONOMIC ) AND AFFERENT FIBERS FROM THE PUDENDAL NERVE ( SOMATIC ) Affected by aesthesia --> CERVIX, VAGINA , PELVIC FLOOR, MAJORITY OF PERINEUM NOT AFFECTED BY ANASTHESIA : Lower limbs, pain fibers from the uterine body --> mother is aware from uterine contraction Sciatic nerve = L4,5,S1,S2,3

Question 50

2nd anasthesia for childbirth?

Answer 50

Spinal block Administered into spina subarchnoid space at lvl L3-L4 vertebra COMPLETE ANESTHESIA INFERIOR TO THE WAIST LVL : birth canal, perineum, lower limbs the mother is conscious but must depend on electronic monitoring uterine contraction

Question 51

Lymphatic draiange?

Answer 51

Endo, myo, sub peritoneal plexus Uterine tube + Fundus and upper body --> PARA AORTIC LUMBAR LYMPH NODES Lower body --> EXTERNA ILIAC LYMPH NODES Cervix --> EXTERNAL, INTERNAL ILIAC AND SACRAL LYMPH NODES Cornu --> along the round ligament --> Superficial inguinal lymph nodes Cervix is drained by all 3 nodes so its serious in cancer spread

Question 52

Describe incomplete fusion of embryonic paramesonephric ducts?

Answer 52

Which uterus is formed resulsts in a vairety of congenital anomalies

Question 53

describe posterior vaginal fornix?

Answer 53

Covered by peritoneum of the rectouterine pouch : Rectouterine pouch can be drained through the posterior fornix Allows the insertion of instruments to the examine the ovaries and uterine tubes --> CULDOSCOPE Introducing sharp instruments or an intra uterine contraceptive device --> PERITONITIS