Presentation on theme: "Reference TEXT BOOK Williams Obstetrics Berek & Novak's Gynecology"— Presentation transcript:
1 Reference TEXT BOOK Williams Obstetrics Berek & Novak's Gynecology Obstetrics & Gynecology (fifth edition)Author: Tamara L. Callahan, Aaron B .CaugheyWilliams ObstetricsBerek & Novak's GynecologySource: Lippincott Williams & Wilkins (LWW)
2 Anatomy of the Female Reproductive System Ai-Xia LiuWomen’s Hospital, School of Medicine,Zhejiang University
4 External Genital Organs(vulva) Mons pubisLabia majoraLabia minoraClitorisVestibule of the vaginaExternal urethral orificeVestibule glandsparaurethral glands (Skene’s glands)Bartholin's glandvagina openinghymenthe skin of the mons pubis is covered by hair after puberty. as one of the female sencondary sex characteristics,The normal pubic hair in the female is distributed in an inverted triangle. The labia majora are composed of 2 rounded mounds of tissue, originating in the mons pubis and terminating in the perineum. The labia minora are 2 folds of skin medially to the labia majora. Clitoris is the principal female erogenous organ. vestibule: the area that is bordered by the labia minora laterally. In the area of vestibule, we can see 6 opening.External genitalia of adult female (parous)
8 Internal Genital Organs Vagina: extend from the uterus to the vestibuleThe wall is composed of a mucosal and a muscular layerFunction: sexual intercourse organ, the passage way of labor and menstrual bloodFornix: divided into 4 regionsPosterior fornixThe vagina is a strong canal of muscle approximately 7.5cm long that extends from the uterus to the vestibule ['vestibju:l] of the external genitalia[.dʒeni'teiliə] , where it opens to the exterior. Fornix is the upper end of the vagina which is around the cervix, we can divide it into 4 portions. Anterior, posterior and two lateral fronices. The posterior fronix provides surgical access to the periptoneal cavity. Toward its lower end, the vagina pierces[piəs] the urogenital diaphragm['daiəfræm ] and is surrounded by the 2 bulbocavernosus muscles and bodies, which act as a sphincter['sfiŋktə] . In the virginal['və:dʒinl] state, an incomplete fold of highly vascular tissue and mucous membrane, the hymen, partially['pɑ:ʃəli] closes the external orifice.Fornix
9 Uterus A pear shaped, thick walled, muscular organ Situated between bladder and rectum7-8 cm long, 4-5 cm wide, 2-3 cm thickThe uterus is a pear-shaped, thick walled, muscular organ, situated between the base of the bladder and the rectum. Covered on each side by the 2 layers of the broad ligament.isthmus
10 Uterus Divided into 2 main portions Body/Cervix Ratio: adult, 2:1, infant, 1:2isthmusa transitional zone between body and cervixSpecial obstetrical significance (lower uterine segment)Internal orifice(os)anatomical internal os: narrowest position of the cavityhistological internal osthe columnar epithelium changes into endometriumisthmusThe uterus is divided into 2 main portions, the larger portion or body above and the smaller cervix below, connected by a transverse constriction, the isthmus. The body is flattened so that the side-to-side dimension is greater than the anteroposterior dimension and larger in women who have borne children. The communication of the cavity below with the cavity of the cervix corresponds in position to the isthmus and forms the internal orifice. It can be divided into anatomical [ænə'tɔmikəl] internal os and histological internal os. The cervix is somewhat barrel-shaped['bærəl ], its lower end joining the vagina at an angle varying 45 to 90 degrees. It projects into the vagina and is divided into a supravaginal and a vaginal portion by the line of attachment. At the extremity[iks'tremiti ] of the vaginal portion is the opening leading to the vagina, the external orifice, which is round before parturition but takes the form of a transverse slit in women who have borne children.
11 This slide shows the changes of isthmus during pregnancy and labor This slide shows the changes of isthmus during pregnancy and labor. The isthmus can extend from 1cm to 10cm.in the prepubertal period, it is considerably smaller. In women who have borne children, it is larger. Its shape, size, and characteristics in the pregnant state become considerably modified depending on the stage of gestation.
12 uterus body (superior 2/3s) Fundus: the widest place of the corpus Lined with endometriumcervix (inferior 1/3)Supravaginal portionVaginal portionExternal cervical osSquamocolumnar junctionThe cervical canal is coveredby columnar epitheliumThe surface of vaginal portion iscovered by squamous epitheliumThe round portion that extends above the plane pass through the points of attachment of the tubes is termed the fundus. The cavity of the body is lined with endometrium. The cervix projects into the vagina and is divided into 2 part. At the extremity of the vaginal portion is the opening to the vagina, the external os, which is round before vaginal delivery. Transverse slit because of cervical laceration. Squamocolumnar[kə‘lʌmnə] junction: a region of transition from stratified[’strætifaid]分层的 squamous epithelium to columnar[kə'lʌmnə] epithelium in the cervix.:External cervical os
13 fundus cavity isthmus corpus Anatomical os. cervix Histologic os. fornixSupra-vaginalExternal osReview the anatomy of uterus. There is a bend in the area of the isthmus, at which the cervix then faces downward. This position is the normal anteversion of the uterus, although it may be placed backward, without angulation, or to one side. There is no sharp line between the normal and pathologic state of anterior angulation.Vaginal partvaginaSagittal viewCoronary viewuterus
14 Position and Axis Direction retroversiontipped backwardsanteversion:tipped forwardThe position and axis direction of the uterus varies greatly. Normally , the uterus forms a angle with the vagina, there is a bend in the area of isthmus.retroflexion: the fundus is pointing backwards. Anterior of uterus is convex.anteflexion: the fundus is pointing forwards. The isthmus is bend.
15 perimetrium (serous): peritoneal covering The wall of the uterusperimetrium (serous): peritoneal coveringmyometrium (muscular): the out layer, the inner layerthe endometrium(mucous): soft and spongythe uterine wall consists of 3 layers:serous, muscular and mucous. The serous layer is simply the peritoneal covering. The muscular layer is extremely thick. The outer layer is weaker and composed of vertical fibers and inner layer, the fibers is interlace.12The myometrium of the uterus:1. the out layer, 2. the inner layer
16 Ligaments 4 pairs of ligaments ligaments Round ligamentUterosacral ligamentCardinal ligament(transverse ligament of cervix)Broad ligamentligaments1. round ligament - attaches anterior-inferiorly to uterotubal junctions, pass in the broad ligaments, end in labia majora. They help to keep uterus in the position of anteversion.Broad lig.Round lig.Cardinal lig.Although the cervix of the uterus is fixed, the body is free to rise and fall with the filling and emptying of the bladder. The so called ligaments supporting the uterus consist of the uterosacral ligaments, the transverse ligaments of the cervix(cardinal ligaments), the round ligaments, and the broad ligaments.The round ligaments of the uterus may assist in maintaining the body of the uterus in its typical position over the bladder.they consist of fibrous cords containing smooth muscle from the outer layer of the corately below that the ovarian ligament, each round ligament extends downward, laterally,and forward between the 2 layer of the mesometrium, toward the abdominal inguinal ring.Ligments of uterus
17 Ligaments2. Broad ligament – arise from the side of the uterus to the lateral pelvic wall, provide minimal support.Between two leaves of ligaments there lies round ligaments,fallopian tube, ovarian ligament, mesosalpinx,infundibulum ligament, bloodvessles and nerves3. Cardinal ligaments - extend from cervix and lateral parts of vaginal fornix to lateral walls of pelvis.Chief means of support and suspends the uterus from the lateral walls of the pelvis minorBroad lig.Round lig.Cardinal lig.The broad ligment, consisting of a transverse fold of peritoneum that arises from the floor of the pelvis between the rectum and the bladder,provides minimal support.The cervix is embedded in tissue called the parametrium. There are 2 pairs of structures continuous with the parametrium and with the wall of the cervix:the uterosacral ligaments and the cardinal ligament of the neck, the latter is the chief means of support and suspends the uterus from the lateral walls of the pelvis minor..Ligments of uterus
18 Ligaments4.Uterosacral ligaments – arise from the sacral fascia, and insert into the posteroinferior portion of the uterus at about the level of the isthmus. They provide important support for the uterus.The uterosacral ligaments are the inferior posterior folds of peritoneum from the broad ligamentIn addition to the static support of these ligament, the pelvic diaphragm provides an indirect and dynamic support.
19 Fallopian tubeserves to convey the ova to the uterus, running in the superior border of the broad ligments (mesosalpinx).divided into 4 parts:interstitial portion: embodied within the muscular wall of uterusisthmus: narrowest portionampulla: wide and tortuousinfundibulum: fringed by numerous diverging processes (open to cavity).The fallopian tubes serve to convey the ova to the uterus. They extend from the superior angles['æŋglz] of the uterus to the region of the ovaries, running in the superior border of the broad ligament(mesosalpinx).Each tube is 7-14 cm long and may be divided into 4 parts: interstitial portion, isthmus, ampulla and infundibulum.Interstitial portion: embodied within the muscular wall of uterusThe isthmus is the anrrowest portion.Following the isthmus is the wider, more tortuous ampulla. It terminates in a funnel like dilatation, the infundibulum.The margins of the infundibulum are fringed[frindʒd] by numerous diverging processes, the fimbriae['fimbriə] , the longest of which is attached to the ovary. The funnel shaped mouth of the infundibulum, the abdominal ostium['ɔstiəm ] is about 3mm in diameter and actually leads into the peritoneal cavity.
20 mucous: ciliated columnar epithelium Layers of the tube wallseroussubserousmuscularmucous: ciliated columnar epitheliumThe wall of the tube has 4 coats: serous, subserous , muscular, and mucous.After ovulation, the egg goes into the fallopian tube. Frequently at the portion of ampulla, the egg meets with sperm and become fertilization. Then the zygote['zaigəut] passes through the tube to the uterine cavity, where the zygote develops into blastocyst and implant into the uterus.
21 Left and right tube uterine ostium in the hysteroscopy Hysteroscopy [histə'rɔskəpi]Ostium ['ɔstiəm]Left and right tube uterine ostium in the hysteroscopy
23 Ovary: Oval shaped, 2.5-5 cm long, 1.5-3 cm wide, 0.7-1.5 cm thick Covered by cuboid or low columnar epithelium and white fibrial tissue, no peritoneum corveredConsists of cortex and medullacortex: contains oocytes in various stages of maturitymedulla: made up of blood vessels, nerves, lymphatic vessels, and supporting tissue.ligamentssuperior (tubal) end of ovary is connected to lateral wall of pelvis by suspensory ligament of the ovary (infundibulum ligament)contains ovarian vessels and nervesligament of ovary - connects inferior (uterine) end of ovary to lateral angle of uterusMesovarium: attach to the posteroanterior layer of the broad ligament, connected with suspensory ligamentHilum: vessels , nerves and lympatics enter the ovaryThe ovaries are paired organs situated close to the wall on either side of the pelvis minor, a little below the brim. Each measures 2.5-5cm in length, 3 cm in breadth, and 1.5cm in width.
24 The ovary is covered by cuboid['kju:bɔid] or low columnar[kə'lʌmnə ] epithelium and consists of a cortex['kɔ:teks] and a medulla[mi'dʌlə] . The medulla is made up of connective tissue fibers, smooth muscle cells, and numerous blood vessels, lymphatic vessels, and supporting tissue. The cortex is composed of a fine areolar stroma, with many vessels and scattered follicles of epithelial cells with which are the oocytes in various stages of maturity. The more mature follicles enlarge and project onto the free surface of the ovary, where they are visible to the naked eye. They are called graafian follicles. When fully mature, the follicle bursts, releasing the ovum and becoming transfromed into a corpus luteum. The corpus luteum, in turn, is later replaced by scar tissue, forming a corpus albican.
25 Ligaments of ovaryThe ovary is suspended by means of the mesovarium[.mezə'vɛəriəm, .mezə'veriəm] , the suspensory ligament of the ovary, and the ovarian ligament. The mesovarium consists of 2 layers of peritoneum, continuous with both the epithelial coat of the ovary and the posterosuperior layer of the broad ligament. It is short and wide and contains branches of the ovarian and uterine arteries, with plexuses of nerves, the veins, and the lateral end of the ovarian ligament.the suspensory ligament of the ovary is a triangular fold of peritoneum and is actually the upper lateral corner of the broad ligament, which becomes confluent with the parietal peritoneum at the pelvic brim. It contains the ovarian artery, veins and nerves after they pass over the pelvic brim and before they enter the mesovarium.The ovarian ligament is a band of connective tissue, with numerous small muscle fiber, that lies between the 2 lays of the broad ligament on the boundary line between the mesosalpinx and the mesometrium, connecting the lower pole of the ovary with the lateral wall of the uterus. It is attached just below the uterine tube and above the attachment of the round ligament of the uterus and is continuous with the latter.
26 Neighbor organs Douglas pouch uterovesical pouch The organs that occupy the female pelvis are the bladder, ther ureters, the urethra, the uterus, the fallopian tubes, the ovaries, the vagina, and the rectum. With the exception of the inferior portion of the rectum and most of the vagina, all lie immediately beneath the peritoneum. The uterus, uterine tubes, and ovaries are almost completely covered with peritoneum and are suspended in peritoneal ligaments. The remainder are partially covered. These organs do not completely fill the cavity, the remaining space is occupied by ilium and sigmoid colon.The vesicouterine pouch [pautʃ] .the peritoneum passes onto the uterus at the junction of the cervix and corpus, continuing upward on the anterior surface of bladder to form the vesicouterine pouch.Rectouterine pouch or Douglas pouch:the entire posterior surface of the uterus is covered by peritoneum, and the convex posterior wall is separated from the rectum by the Douglas pouch.Neighbor organs
27 Water flows under a bridge ureterUterine arteryAbout 2cm lateral to the cervix,. The uterine artery crosses over the ureter, the proximity of the uterine vessels to the ureter at this point is of great surgical singnificance. The ureter may be injured or ligated during a hysterectomy.Water flows under a bridge
30 Blood supply for female genitalia Arterial systemOvarian artery: the chief source of the blood for ovaries.Uterine artery:corpus branchcervical-vaginal branch3. Vaginal artery: main source of the blood for the middle part of vagina4. Internal pudendal artery: supply for superficial perineum, labia majora, labia minora, lower part of the vagina, clitoris
31 The chief blood supply to the vagina is through the vaginal branch of the uterine artery. After forming the coronary or circular artery of the cerix, it passes medially, behind the ureter, to send 5 main branches onto the anterior wall to the midline.The blood supply to the uterus is from the uterine and ovarian arteries. As a terminal branch of the hypogastric artery, the uterine artery runs downward and medially to cross the ureter near the cervix. It then ascends along the lateral border of the uterus to join with the ovarian artery in the mesometrium.The blood supply to the tubes is derived from the ovarian and uterine arteries.The ovarian artery is the chief source of blood for the ovary. Though both arteries may originate as branches of the abdominal aorta, the left frequently originates from the left renal artery; the right, less frequently.
32 The lymphatic drainage of pelvis Internal iliac lymph nodeSurround internal iliac vesselsReceive afferents from pelvic viscera, perineum, buttock and back of thighExternal iliac lymph nodesLie along external iliac arteryReceive afferents from lower limb and some parts of pelvic visceraSacral lymph nodeCommon iliac lymph nodeLie along common iliac arteryReceive afferents from all the above nodesEfferents pass to lumbar lymph node
34 The nerve of external genitalia Pudendal nerveObstetric local anesthesiaDivided into 3 branches beside tuberosityInferior hemorrhoid nerveDorsal nervePerineal nerve
35 The nerve of internal genitalia Sympathetic and parasympathetic nerves from lumbar and sacral spinal cordSympathetic nerve are derived from PlexusSacral plexusOvarian plexusThe innervation of the vagina contains both sympathetic and parasympathetic fibers. Only occasional free nerve endings are seen in the mucosa.Genitalia [.dʒeni'teiliə ]