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The folds causes the uterus to decrease in length by around have a cellular stroma. These changes affect the cervix endometrium undergoes cyclical changes during men. Due to anti- flexion or retroflexion.

The ureter runs about 1 cm lat. This passes into the widest and longest portion. The endometrial layer is and the size ratio reverses. The tively less m uscular. This 4. This in turn terminates in the extremity known as the infundibulum.

The interstitial portion lies within the wall of the formation zone and is an area of rapid cell division. After the menopause. There is no submucosa and there. Each tube is about secrete a clear alkaline mucus. The cervix is only separated from the muscle by a very scanty is then twice the length of the uterus.

At the abdominal uterus. The inner right-angles to the vagina and normally tilts forwards. It has numerous deep glandular follicles that strip along this inferior aspect. The mucous membrane of margin of the broad ligament.

One of these fimbriae is longer than the In around 20 per cent of women. The uterus is usually also lium. Th e pouch of Douglas. The vaginal portion towards the uterus. This does not have a pathological significance. Anterior and lateral to the supravaginal por. They have a smooth surface and suspensory ligament of the ovary with folds of peri- at birth contain between 1 and 2 million primordial toneum' which become continuous with that over- follicles.

Cortex pink and approximately 3 cm long. The ovaries The size and appearance of the ovaries depend on both age and the stage of the menstrual cycle. The ovaries increase to Anterior to the ovary lie the Fallopian tubes. This con. Anatomy 13 Figu re 2. Isthmus Ampulla are no glands. In the child. Structure The ovary is the only intra-abdominal structure The ovary Fig.

The epithelium of the Fallopian tubes Mesovarium Hilum contains two functioning cell types: It has an ligament. Each ovary is consisting of loose connective tissue containing many attached to the cornu of the uterus by the ovarian elastin fibres and non-striated muscle cells.

Changes occur under the influence of the menstrual cycle. In the young adult they are almond shaped. The smooth muscle of its wall is arranged uterus. It is atretic follicles. The epoophoron.

Between the muscular coat and the epithelium is a The bladder.. With puberty. There are a number of tubular mucous glands and. Situated in lower and middle thirds. The bands of fibrous tissue called the pubourethralliga- involuntary muscle of its wall is arranged in an inner ments. It is lined with transitional the broad ligament. The tubules The female urethra is about 3. At the internal meatus. The urethra leaves the bladde r in front of the gle layer of cuboidal cells.

Trigone Pubourethral. The upper part of the urethra is mobile. As the tubules. The surface of the ovaries is covered by a sin. Vestigial remains of the mesonephric duct and tubules are always present in young children. Figure Posteriorly it is related to the anterior vaginal longitudinal layer.

In its upper two- The bladder thirds the urethra is separated from the symphysis by loose connective tissue. In a few individuals. External sphincter the two. The attached to the pubic ramus on each side by strong bladder is lined with transitional epithelium..

This the striated fibres of the deep transverse perineal muscle is the duct of Gartner. The front and sides of the upper third are covered As the ureter crosses the brim of the pelvis it lies in by the peritoneum of the rectovaginal pouch. It next passes forwards through a ments.

The two muscle. On volun- tary voiding of urine. Because of its close relationship to the cervix. The levator ani muscles are inserted into: It may be displaced upwards downwards and inwards. It was formerly claimed that absence of this posterior angle was the cause of stress inconti- nence. When they contract. The the layers of the broad ligament. Apart from being cut or tied. Fi gure 2. Finally it runs close to the lat- eral vaginal fornix to enter the trigone of the bladder. In the lower third there is no peritoneal cover- the pelvis to reach the pelvic floor.

The ureter's blood supply is derived from small branches of the ovarian artery. Medial fibres of the pubococcygeus of the levator ani muscles are inserted into the urethra and vaginal wall. Its direction follows the curve of the sacrum and it is about 11 cm in length. Th e ureter continuous with the anal canal. It middle third only the front is covered by the peri- runs downwards and forwards on the lateral wall of toneum.

The rectovaginal pouch has already been described. They thus embrace the vagina.

Its apex is at the lower end of the rectovaginal septum. Its base is covered with skin and extends from the fourch ette to the an us. The deep transverse perineal the peritoneum and thin fascia.

The nerve ment which lies above the ovary. The part of the posterior part of the tendinous arch and the the broad ligament that is lateral to the opening is ischial spine. This is not a liga- The muscle is described in two parts: The perineal body This is the perineal mass of muscular tissue that lies between the anal canal and th lower third of the vagina.

Below the ovary. The medial ligament widens out and contains a considerable edge passes beneath the bladder and runs laterally to amount of loose connective tissue.

The mesosalpinx. The ureter is attached to the posterior leaf Together with fibres from the opposite muscle.

The Fallopian tube runs in the upper free anterior part of the tendinous arch of the pelvic fascia edge of the broad ligament as far as the point at which white line. The peritoneal cavity muscle compressor urethrae lies between the two can be opened by posterior colpotomy at this point. It is the point of insertion of the superficial perineal muscles and is b ounded above by the levator ani muscles where they come into contact in the midline between Figure 2.

Urogenital diaphragm It will be noted that while the vagina does not have any The urogenital diaphragm triangular ligament lies peritoneal covering in front. Various the base of the broad ligament. It is here that This vessel is about 4 cm in length and begins at the the levator ani muscle arises and the cardinal ligament bifurcation of the common iliac artery in front of the gains its lateral attachment.

It also forms the upper layer of viscera are all from the anterior division. The artery divides into branches that sup- cervix and vagina. Where the parietal pelvic sacroiliac joint. Much of it is loose cellular The ovarian artery tissue. It then turns inwards and forwards. The cardinal ligaments transverse cervical liga- The ovarian ligament lies beneath the posterior layer ments provide the essential support of the uterus and of the broad ligament and passes from the medial vaginal vault.

It soon divides into anteriq! The artery first runs downwards on the the case of the vagina and cervix and at the base of the lateral wall of the pelvis.

The uterine artery provides the main blood supply Each viscus has a fascial sheath. By this change of processes of the visceral pelvic fascia pass inwards direction the artery crosses above the ureter.

The pelvic ply the ovary and tube and then run on to reach the fascia may be regarded as a specialized part of this uterus. The bla dder is supported laterally by cond nsa - the ovarian and round ligaments are analogous to the tions of the vesical pelvic fascia one each side. The parietal pelvic fascia lines the wall of the pelvic cavity. In the erect position they peritoneum to enter the inguinal canal.

The round ligament is the continuation of the same The uterosacral ligaments ru n from the cervix and structure and runs forwards under the anterior leaf of vaginal vault to the sacrum. The pelvic arteries. The ovarian artery arises from the aorta just extraperitoneal tissue of the abdominal wall. The pelvic fascia and pelvic ce llu lar tissue Arteries supplying the pelvic organs Connective tissue fills the irregular spaces between the various pelvic organs.

There is a brim. These are two strong. Anatomy 17 The ovarian ligament and round ligament parts of the visceral fascia are of particular import- ance. There is a thickened tendinous arch or white line on the side wall of the pelvis. On reaching the wall of the uterus. Anatomists describe parietal and branches of the uterine artery. This artery is the continuation of the inferior mesen. Lymph draining from the lower extremities and the The artery supplies a branch to the ureter as it vulval and perineal regions is all filtered through crosses it.

The vesical arteries are variable in number. The vulva and the perineum medial to the Venous drainage from the uterine.

Lymphatic drainage from the genital tract The pelvic veins The lymphatic vessels from individual parts of the genital tract drain into this system of pelvic lymph The veins around the bladder. At first there are two veins on low the vulval drainage to the superficial inguinal each side accompanying the corresponding ovarian nodes.

One deep chain passes upwards lateral iliac artery that runs at a lower level to supply the to the m ajor blood vessels. It leaves the pelvic cavity through the ing the upper vagina.

One usually deep femo ral nodes through the femoral canal to the runs in the roof of the ureteric canal. It terminates in branches finally all the lymphatic drainage from the legs and that supply the perineal and vulval structures. In this part of its course it sends many branches into the substance of the uterus. It divides into two branches. From here. They Medially.

Drainage from these is through the fossa ovalis and the middle and inferior rectal veins to the internal into the deep femoral nodes. Tumour cells that penetrate or bypass the pelvic teric artery and descends in the base of the pelvic and para-aortic nodes are rapidly disseminated via mesocolon.

Higher up. The largest of these. These last The middle rectal artery often arises in common nodes are interspersed among the origins of the with the lowest vesical artery. On the sensory supply to the vulva. Most of the vessels drain to the internal iliac. The pudendal nerve arises from the second.

A few vessels at the fundus follow the ovarian chan. The main nerve supply of the levator ani muscles der of the rectal drainage follows pararectal channels comes from the third and fourth sacral nerves.

The posterior femoral cutaneous nerve nodes. As it passes along the outer wall round ligament to the inguinal nodes. The dorsal intervening before the lymph flows into the thoracic nerve of the clitoris is sensory.

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The corpus uteri: In the Nerve fibres of the pre-aortic plexus of the sympa- non-pregnant uterus. The lower rectum join the plexus.

The main 'supports of the disturbed. The uterovaginal plexus con. The cellular tissue posterolateral to the cervix below the paramesonephric duct. It is lateral to the supravaginal cervix. Fibres from or to the bladder. The ureter runs about 1 cm ory or motor impulses. Clinical facts are few. Stimulation of the cut lower end of the hypo. The right ovarian sation because the sacral connections of the uterovagi.

If this is squamous epithelium and the junction between this and the divided during presacral neurectomy. Although it has been stated that the.

Parasympathetic fibres from the second. This plexus lies in the loose forms the urogenital ridge and the mesonephriC duct. TDF directly known as gonadal sex. Mullerian inhibitor. Following fertilization. Subsequent development of influences the undifferentiated gonad to become a the internal and external genitalia gives phenotypic testis. On the. In the developing embryo with a genetic complement trolled by the sex chromosomes.

Chapter 3 Normal and abnormal sexual development and puberty Sexual differentiation 21 Puberty 26 Genetic sex 21 Common clinical presentations Abnormal development 22 and problems 27 OVERVIEW Sexual differentiation and normal subsequent development are fundamental to the continuation of the human speci'es. The Wolffian ducts have the. The resulting development of the ticular development as it produces a protein known gonad will create either a testis or an ovary.

Sexual differentiation The means by which the embryo differentiates is con. The normal chromosome complement is determines that the undifferentiated gonad will become Cerebral differen. This chapter describes the processes involved and discusses the subsequent evolution to full maturation.

Absence of the Y chromosome will An embryo that contains 46 chromosomes and has result in the development of an ovary. This is known as of 46 XY. In recent years. This is as testicular determining factor TDF. Leydig unexpected developmental sequence of events may be cells and Sertoli cells. The Sertoli cells are responsible mediated in a number of ways.

In an embryo that loses one of its sex chromosomes. Figure 3. The gonad is. If the testis produces Mullerian inhibitor. Any aberration in development that results in an The testis differentiates into two cell types. The absence of testosterone means stroma of the ovary is present streak ovaries. The Leydig cells produce Chromosome abnormalities testosterone. Testosterone by itself does not have a different effect the total complement of chromosomes-will be reduced on the cloaca.

If the genetic abnormality leads ment of Mullerian structures. In the female. These individuals have been to Fig. This is an extrem ely rare The reason for th is remains speculative. The external genitalia will be fema le. In these leads to an abnormal testicular development.

The testis circumstances. H owever. In Leydig cell hypoplasia. The In XY gonadal dysgenesis. A range of abnormali ties m ay result. Gonadal abnormalities Therefore so me effect on the external genitalia may be p ossible an d a varying degree of virilism will occur.

In males. As the genes involved in achieving fin al height are shared by the sex chromosomes. Here again. The exter. In true hermaphrodites. Th is is the commonest type of XY female and the Wolffian ducts regress. If this enzyme is ponent. In the rare condition known as mixed gonadal dys.

Obstetrics by Ten Teachers 18th Edition

The chromosome complement is typically gene. At puberty. The first of these is androgen insens itivity Fig. Internal genitalia abnormalities tures remain and the Wolffian structures regress.

Girls with this ovotestis with a testis. The result here is t hat the fetus develops in the nal genitalia in this rare condition may be ambiguous. Failure to possess the receptor means that 46 XX or a mosaic with a Y component.

The M ullerian ducts Thus. In this condition the fetus fails to develop androgen genesis. Failure of development of Wolffian structures Ovotestis 2. No masculinization of cloaca Figure 3. As can be seen from As outlined above. The Mullerian struc. This usually results from a mosaic XX: XY puberty. These patients will present at puberty with No virilization either primary amenorrhoea or. Here the dias. This is the sec. Two other developmental abnormalities may occur. This is most commonly opment of the vagina without development of the seen in a condition known as congenital adrenal hyper- uterus.

The first of these is maldevelopment of the uterus. Sa-reductase deficiency. B XV female. This process can also fail. Mullerian development reductase These genes. These abnormalities have been classified and result from the failure of fusio n of the paramesonephric ducts at their lower border.

In the Figure 3. In hypospa- women.

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Variations on this may lead to devel. In this condition. The development of the vagina involves a down- growth of the vaginal plate and subsequent union of No Mullerian Wolffian Male external inhibitor development genitalia this with the cloaca and thereafter canalization. Mullerian regression the overall effect of this developmental abnormality is a failure of uterine and vaginal development. In 46 XX females. It is probably. The internal genitalia are either absent In females.

Abnormal development 25 Testis c:: A mal- Testis c:: The aetiology of this developmental abnormality remains to be clarified. The descrip- sex of rearing of those individuals who are uncertain tion of pubertal development is credited to Tanner. It is possible on the developing cloaca. The female child is then born with a degree of leptin.

The FSH. Theories exist that this is genetically predetermined and it is most likely that our sexual The sequence of events that occur in the physical orientation is in fact determined by our sexual make up. Puberty Five stages of puberty The hypothalamo-pituitary-ovarian axis is function- ally complete during the latter half of fetal life. The mech- precursors Enormous care growth. Failure of level then rises in response to the hypo-oestrogenic the production of cortisol means that the feedback state of the fetus and remains e eva ted for some mechanism on the hypothalamus leads to an elevation months after birth.

He has classified the stages of development into five stages for breast growth and pubic hai. During this time it is suppressed of adrenocorticotrophic hormone ACTH. The end result in both of these circumstances These spikes of FSH increase in frequency during the is known as the intersex state. This in due to the central inhib ition of the production of turn stimulates the adrenal gland to undergo a form of gonadotrophin. FSH pulses are almost undetect- perineum and hence a vaginal orifice is not apparent.

Brain sex The physiology of puberty The sex of orientation of a human is influenced by many factors. Although this is the sequence of events in 70 has to be taken before a final decision is made on the per cent of girls. Puberty therefo re occurs over a total of years.

Obstetrics by Ten Teachers 18th Edition

Menstrual oestradiol by the ovary. Common clinical presentations and problems 27 The breast bud responds to the production of menstrual cycles are commonly irregular. In the first few m onths of IS. In understanding the which leads to a pronounced areola in comparison menstrual difficulties that might arise d uring adoles- with the rest of the breast.

The mann er of presenta- fe mur causes fusion. In older children. Pubic hair growth begins on the labia and extends Common clinical presentations and gradually up onto the mons and then into the inguinal problems Table 3.

As one would imagine. Initially the body of the breast grows. Follicle-stimulating hormone. It takes between 5 and 8 years from grows in phases. It is perfectly normal for pubic hair to extend along the midline up towards the umbilicus. The growth spurt begins around the age of 11 years in girls. The breast turity of the axis. In order to ensure that secondary sexual char- acteristics appear n orm ally.

As pub rty itself takes 5 years to complete. These patients present at puberty with primary amen- stature. Patients with androgen insensitivity are sibility of a sex chromosome anomaly. If investigations reveal a diagnosis of 46 XX gonadal dysgenesis. As she is defi cient of oocytes. Pregnancy pro- gresses normally thereafter. The that pubic and axillary hair is either very scanty or hypothalamus and pituitary function normally and absent.

The vagina is short and. The second phase of treatment is at a time when the patient desires a pregnancy. The introduction of progesterone to th e regime usually occurs after 18 m onths to 2 years. XV females Figure 3. These girls may well have presented in childhood mal. It is this that suggests to the clinician the pos. The first phase is the induction of puberty.

As mentioned lower abdomen. Individuals occasionally have associ. The treatment of this condition falls into two phases. As the child phenotypically normal females with breast develop- grows.

The testes may be found in the levels are elevated due to ovarian failure. It is ated features such as colour blindness. As these of presentation. This situation is easily resolved by a cruciate incision. The first' of these is possibilities for this are outlined earlier in the chapter. In which will stretch the small vagina into a fully func- these circumstances.

The parents will obviously be anxious to successful. Initially the most important investigation the patient is in an established relationship and is karyotyping and. This may be achieved over a period of withheld until the infant can be fully evaluated. Clinical are still present. In order for this technique to be be taken. Common clinical presentations and problems 29 and the gonads will have been discovered at that stage otherwise.

An ultrasound examination of the pelvis sis straightforward. This may be created in one of two ways. For those patients the karyotype can be determined within 24 hours on for whom this cannot be successfully achieved. Teenage girls are emotionally labile durin g structures means pregnancy is impossible.

The most common cause of ambiguous genitalia is Several techniques have been described. The non-surgical tech- Ambiguous genitalia are usually diagnosed at birth nique involves the use of graduated glass dilators. A weeks of gradual dilatation. The simplest and most common is the imperforate hymen. It is impossible currently to offer any help for the absence of the uterus. These children fail to produce cortisol and have high levels of circulating hydroxyproges. The management of these patien ts is extremely women in order to maintain their fem ale body habitus.

If this has not been the case and the testes with absence of the establishment of menses. The appearance. Obstructive outflow tract problems terone. Further investiga- developmental abnormalities observed by gynaeco- tion may be required if the karyotype is 46 XY. In fact. The periods may be irregular and very heavy and e. Cyclical early as 3 or 4 years of age. In some m en strual cycle control in the form of the oral contra- cases the vagina may distend to give a mass.

Knife cone biopsy is associated with an increased risk for both cervical incompetence weakness and stenosis leading to preterm delivery and dystocia in labour, respectively. There is probably a very small increase in the risk of preterm birth associated with large loop excision of the transformation zone LLETZ ; however, women who have needed more than one excision are likely to have a much shorter cervix, which does increase the risk for second and early third trimester delivery. Previous ectopic pregnancy increases the risk of recurrence to 1 in It is also important to know the site of the ectopic and how it was managed.

The implications of a straightforward salpingectomy for an ampullary ectopic are much less than those after a complex operation for a cornual ectopic. Women who have had an ectopic pregnancy should be offered an early ultrasound scan to establish the site of any future pregnancies.

Recurrent miscarriage may be associated with a number of problems. Antiphospholipid syndrome increases the risk of further pregnancy loss, FGR and pre-eclampsia. Balanced translocations can occasionally lead to congenital abnormality, and cervical incompetence can predispose to late second and early third trimester delivery.

Also, women need Taking the history a great deal of support during pregnancy if they have experienced recurrent pregnancy losses. Multiple previous rst trimester terminations of pregnancy potentially increase the risk of preterm delivery, possibly secondary to cervical weakness. Sometimes information regarding these must be sensitively recorded.

Some women do not wish this to be recorded in their hand-held notes. Previous gynaecological surgery is important, especially if it involved the uterus, as this can have potential sequelae for delivery. In addition, the presence of pelvic masses such as ovarian cysts and broids should be noted. These may impact on delivery and may also pose some problems during pregnancy.

A previous history of sub-fertility is also important. Donor egg or sperm use is associated with an increased risk of pre-eclampsia. The rate of preterm delivery is higher in assisted conception pregnancies, even after the higher rate of multiple pregnancies has been taken into account.

Women who have undergone fertility treatment are often older and generally need increased psychological support during pregnancy. Legally, you should not write down in notes that a pregnancy is conceived by IVF or donor egg or sperm unless you have written permission from the patient.

It is obviously a difcult area, as there is an increased risk of problems to the mother in these pregnancies and therefore the knowledge is important.

Generally, if the patient has told you herself that the pregnancy was an assisted conception, it is reasonable to state that in your presentation. Abdominal examination comprises quence of abdominal ascites. The next step should be to inspection, palpation, percussion andJ f appropriate, proceed to abdominal and pelvic examination. Inspection The contour of the abdomen should be inspected and noted. There may be an obvious distension or mass The patient should empty her bladder before the Fig.

She should be comfortable The presence of surgical scars, dilated veins or and lying semi-recumbent, with a sheet covering striae gravidarum stretch marks should be noted.

It her from the waist down, but the area from the is important specifically to examine the umbilicus for xiphisternum to the symphysis pubis should be left laparoscopy scars and just above the symphysis pubis Examination 3 to the exammer many pelvic m asses have disap- peared after catheterization. This method is not specifically useful for the gynaeco- logical examination.

Figure 1. The patient should be asked to Before proceeding to a vaginal examination, the raise her head or cough and any herniae or divarica- patient's verbal consent should be obtained and a tion of the rectus muscles will be evident. The external genitalia are first inspected under Palpation a good light with the patient in the dorsal position, First, if the patient has any abdominal pain, she the hips flexed and abducted and the knees flexed. This area should The left lateral position is used for examination not be examined until the end of palpation.

It is usual of prolapse or to inspect the vaginal wall with a to get the patient to cough, as she may show signs of Sims' speculum Fig. The patient is asked to peritonism. Palpation using the right hand is per- strain down to enable the detection of any prolapse formed, examining the left lower quadrant and pro- and also to cough, as this will show the sign of stress ceeding in a total of four steps to the right lower incontinence.

After this, a bivalve Cusco's speculum quadrant of the abdomen. Palpation should include is inserted to visualize the cervix Fig.This book owes a great debt to Professor Stuart Campbell who, along with the present editor Ash Monga, was responsible for introducing the concepts and features to the seventeenth edition that are continued here. The LH the corpus luteum derives its name. There is no submucosa and there.

One of these fimbriae is longer than the In around 20 per cent of women. As mentioned lower abdomen. The first of these is maldevelopment of the uterus. The two cell. The androgens to oestrogens aromatization Fig. Any aberration in development that results in an The testis differentiates into two cell types.

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