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Anatomia Dell'apparato Genitale Femminile

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Anatomia Dell'apparato Genitale Femminile Facoltà di Medicina e Chirurgia Università degli Studi di Foggia “Ginecologia ed Ostetricia” Prof. Felice Pietropaolo Prof. Pantaleo Greco D.ssa M. Matteo 1 Programma di Ginecologia ed Ostetricia Anatomia e Fisiologia dell’Apparato Genitale Femminile ─ Anatomia apparato genitale femminile. ─ Embriologia dell’apparato genitale femminile e malformazioni genitali. ─ Fisiologia dell’apparato genitale femminile: gli ormoni steroidei, l’asse ipotalamo- ipofisi-ovaio, il ciclo ovarico e il ciclo mestruale. ─ Fisiologia della funzione riproduttiva femminile. Ginecologia Benigna: ─ Alterazioni del ciclo mestruale: oligo-amenorrea, ipermenorrea, polimenorrea, menorragia, metrorragia, spotting intermestruale. Dismenorrea. ─ Climaterio e Menopausa: definizione, sintomatologia, indicazioni ed effetti collaterali della terapia ormonale sostitutiva. ─ Contraccezione: metodi naturali, metodi di barriera, dispositivi intra-uterini, metodi ormonali e intercezione post-coitale. ─ Sterilità ed infertilità: eziopatogenesi, classificazione e diagnosi. Cenni sulle tecniche di riproduzione assistita. ─ Infezioni dell’apparato genitale: infezioni della vulva, vaginiti, endometriti, malattia infiammatoria pelvica. ─ Endometriosi: epidemiologia, eziopatogenesi, anatomia patologica, sintomatologia, diagnosi e terapia. ─ Alterazioni della statica pelvica: anomalie di posizione dell’utero, il prolasso genitale. ─ Incontinenza urinaria femminile: classificazione, eziopatogenesi, diagnosi e cenni di terapia medica e chirurgica. Oncologia Ginecologica: - Procedure diagnostiche in ginecologia oncologica. - Prevenzione e diagnosi precoce dei tumori dell’apparato genitale femminile. - I tumori della cervice uterina. - I tumori dell’endometrio. - I tumori dell’ovaio e della salpinge. - I tumori della vulva e della vagina. - I sarcomi ginecologici. - Le neoplasie del trofoblasto (tumori trofoblastici gestazionali). 2 Ostetricia ─ Fisiologia della gravidanza: fecondazione dell’uovo, impianto dell’embrione, sviluppo dell’embrione e del feto, placenta, liquido amniotico, membrane e funicolo ombelicale. ─ Diagnosi di gravidanza, Modificazioni materne in gravidanza e Igiene della gravidanza. ─ Semeiologia feto-placentare: Diagnosi Prenatale con ecografia, amniocentesi, villocentesi, fetoscopia. Valutazione Maturità Fetale e Benessere Fetale (profilo biofisico e comportamentale fetale, conteggio dei movimenti fetali attivi). Sofferenza Fetale Acuta (cardiotocografia, amnioscopia, flussimetria Doppler). ─ Fisiologia del parto: fattori del parto (canale, feto, forza), cause del parto, evoluzione del parto normale (periodo prodromico, dilatante, espulsivo, secondamento, post-partum), fenomeni del parto (dinamici, meccanici, plastici). Assistenza alla gestante in travaglio di parto. ─ Il neonato: adattamento neonatale, prime cure, punteggio di Apgar. ─ Puerperio e Lattazione. ─ Patologie del secondamento, post-partum e puerperio. ─ Anomalie del concepimento: gravidanza multipla. ─ Anomalie di sede della gravidanza: gravidanza extrauterina e gravidanza intrauterina ectopica. ─ Anomalie di durata della gravidanza: Aborto, Morte endouterina del feto, Parto post- termine e Gravidanza protratta. Interruzione volontaria della gravidanza. ─ Patologia degli annessi fetali: patologia placentare (distacco e placenta previa), patologia funicolare (nodi, torsione, prolasso), patologia del liquido amniotico e delle membrane (oligo-anidramnios, polidramnios, rottura tempestiva delle membrane, corioamnionite). ─ Patologia del parto: distocie del canale del parto, distocie della forza, distocie del corpo mobile e anomalie di presentazione. ─ Malattie infettive in gravidanza. ─ Il diabete in gravidanza. ─ La gestosi EPH. Testi consigliati: - Pescetto, Pecorari, De Cecco, Ragni. “Manuale di Ginecologia ed Ostetricia” Vol. I e II, Società Editrice Universo, Roma. - Wierdis, Mollica, Montoneri, Romanini, Volpe. “Ginecologia ed Ostetricia” Edizioni Minerva Medica. 3 Anatomia Apparato Genitale Femminile L’Apparato Genitale Femminile è costituito da organi genitali interni ed esterni: ─ organi genitali interni: ovaie, vie genitali cioè tube uterine, utero e 3° superiore della vagina. ─ organi genitali esterni: monte di Venere, grandi e piccole labbra, organi erettili, vestibolo della vagina, ghiandole vestibolari maggiori del Bartolini. Le Ovaie o gonadi femminili sono organi pari, simmetrici, situate sulla parete laterale della piccola pelvi, hanno forma a mandorla di piccole dimensioni, consistenza dura delimitate da una faccia mediale rivolta verso la cavità pelvica, una faccia laterale accolta nella fossetta ovarica di Krause cioè una depressione della parete postero-laterale della piccola pelvi, un margine anteriore o mesovarico connesso al foglietto posteriore del legamento largo tramite il mesovario, breve piega peritoneale formata da 2 foglietti, attraverso cui passano vasi e nervi dell’ovaio (ILO ovarico), un margine posteriore o libero perchè non è connesso a strutture adiacenti, polo superiore o tubarico unito all’infundibolo della tuba uterina mediante la fimbria ovarica o legamento tuboovarico, polo inferiore o uterino unito all’angolo supero-laterale del corpo uterino mediante il legamento uteroovarico che decorre nello spessore del legamento largo dell’utero. Per cui i Mezzi di Fissità delle ovaie sono: mesovario, legamento tuboovarico, legamento uteroovarico e legamento sospensore dell’ovaio o legamento infundibolo-pelvico o lomboovarico. La Vascolarizzazione Arteriosa delle ovaie si deve all’arteria genitale o ovarica ramo dall’aorta addominale e al ramo ovarico dell’arteria uterina. Il Drenaggio Venoso si deve alla vena uterina e alle vene ovariche che formano il plesso pampiniforme da cui originano 2 tronchi venosi affluenti della vena cava inferiore a dx e vena renale a sx. Il Drenaggio Linfatico si deve ai linfonodi preaortici e paraortici. L’Innervazione si deve al plesso utero-ovarico e al plesso utero-vaginale. Dal punto di vista Istologico le ovaie sono costituite dalla zona midollare, centrale, costituita da tessuto connettivo ricco di vasi e nervi e zona corticale, periferica, costituita da epitelio germinativo o ovarico, follicoli ovarici e stroma ovarico. Dal punto di vista Fisiologico le ovaie hanno una duplice funzione: . funzione riproduttiva o gametogenetica: produzione dei gameti femminili o cellule uovo o ovociti. funzione endocrina: produzione degli ormoni steroidei sessuali femminili estrogeni e progesterone e una piccola quantità di ormoni androgeni. Le Tube Uterine, Salpingi o Trombe di Falloppio sono 2 canali muscolo-membranosi lunghi 12-18 cm che si estendono dal polo superiore o tubarico dell’ovaia all’angolo supero-laterale dell’utero con Ø che < progressivamente da 2 cm a 2-3 mm, costituite da 4 porzioni: . infundibulo: lungo 2 cm, molto frastagliata per la presenza di 12-15 fimbrie che muovendosi sulla superficie ovarica sono in grado di accogliere la cellula uovo dopo l’ovulazione. ampolla: lunga 7 cm, comunica con l’infundibolo mediante l’ostio addominale, presenta un decorso tortuoso formando l’ansa tubarica. Nell’ampolla avviene la fecondazione. istmo: lunga 3 cm di consistenza più dura. porzione interstiziale o intramurale: lunga 1 cm, decorre nello spessore della parete uterina e sbocca nella cavità uterina mediante l’ostio tubarico. La Parete della tuba uterina è costituita da: tonaca mucosa rivestita da epitelio cilindrico semplice con ciglia vibratili e cellule mucipare intercalate, irregolare per la presenza delle pieghe tubariche, sensibile all’azione degli ormoni durante il ciclo mestruale; tonaca muscolare, tonaca avventizia e tonaca sierosa peritoneale o mesosalpinge, piega peritoneale proveniente dal foglio posteriore del legamento largo che riveste le tube uterine favorendo la peristalsi tubarica. La Vascolarizzazione Arteriosa si deve ai rami tubarici dell’arteria uterina e ovarica. Il Drenaggio Venoso si deve alla vena uterina e alla vena ovarica. Il Drenaggio Linfatico si deve ai linfonodi paraortici, linfonodi ipogastrici e iliaci esterni. L’Innervazione si deve al plesso utero-vaginale e utero-ovarico che regolano la peristalsi tubarica. Le Funzioni delle tube uterine sono di accogliere l’ovocita espulso dal follicolo ovarico al momento dell’ovulazione, favorire il transito degli spermatozoi dall’utero verso l’ampolla dove avviene la fecondazione dell’ovocita e migrazione dell’uovo fecondato nella cavità uterina grazie all’azione delle ciglia vibratili, peristalsi tubarica e flusso sieroso endoluminale. 4 L’Utero è un organo muscolare cavo, impari, mediano, situato più o meno al centro della piccola pelvi, dietro la vescica e davanti al retto, in corrispondenza della parte superiore della sinfisi pubica e 1^-2^ vertebra coccigea. Presenta una forma di pera con base in alto e apice tronco in basso, appiattito in senso antero-posteriore, lungo 7-8 cm nella nullipara, anche se le dimensioni dell’utero variano in base all’età: dalla nascita fino all’età prepubere il collo è più lungo (4 cm) rispetto al corpo (2 cm), a partire dalla pubertà il corpo si accresce e nella donna adulta il collo rappresenta solo 1/3 dell’utero. L’utero è costituito da 3 porzioni: corpo, istmo e collo. corpo: è la parte più grande e robusta dell’utero caratterizzata dalla cavità uterina triangolare con apice inferiore. Il corpo è delimitato da: ─ faccia anteriore o vescicale: separata dalla vescica dal cavo peritoneale vescico-uterino. ─ faccia posteriore o intestinale: separata dal retto dal cavo retto-uterino del Douglas. ─ margini laterali dx e sx
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