• Ninevah university • Ninevah college of medicine • Obstetric &Gynecology department • Theoretical lectures- 1 & 2 • Dr- Shayma Hazim Al-tayar Lec (1)

Clinical anatomy of the female reproductive system

The anterior abdominal wall Beneath the skin and the fat of the superficial anterior abdominal wall lies a sheath and combination of muscles including the rectus abdominus, external and internal oblique and tranversalis muscle The aponeuroses of the external & internal oblique, and tranversus abdominis muscles (flank muscles) conjoin to create the rectus sheath Blood Supply FEMORAL BRANCHES The superficial epigastric, superficial circumflex iliac, and external pudendal EXTERNAL ILIAC BRANCHES inferior "deep" epigastric vessels

Nerve Supply 1. The iliohypogastric nerve provides sensation to the skin over the suprapubic area. 2. The ilioinguinal nerve supplies the skin of the lower abdominal wall and upper portion of the majora and medial portion of the thigh Epithelium of the genital tract • The anterior abdominal wall including the , and perineal areas are lined with squamous epithelium. • The epithelium lining the endocervix and is columnar and the squamocolumnar junction usually arises at the ectocervix in women of reproductive age. External genitalia

Are commonly called the vulva ; includes  Labia Vestibule  Greater vestibular gland escutcheon Vulva the are areas of skin with underlying fat pads which bound the vagina. Medial to these are the . Anteriorly they come together to form the prepuce of the clitoris and posteriorly they divide form a fold of skin called the forchette at the back of the vagina. The vestibule Is the cleft between the labia minor contains the opening of the , the Bartholin's gland and the vagina. The Bartholin's glands are bilateral about the pea size opens via 2 cm ducts into the vestibule below the . Has lubricating action. The hymen is a fold of vaginal mucosa at the entrance to this organ. It usually has a small opening in virgins and is only seen as an irregular remnant after marriage . The area of the perineum is outlined by the vaginal fourchette anteriorly And the anus posteriorly . Deep to it, is perineal body which lies between the anal canal and the lower one- third of the posterior vaginal wall . The vulval blood supply comes from the pudendal artery and lymphatic drainage inguinal lymph N. nerve supply : the pudendal nerve and  pelvic plexus with branches of the • Perineal nerves and • posterior cutaneous nerve of the thigh Bony Pelvis and Pelvic Joints The bony pelvis is comprised of  (1) the two hip bones, termed the inominate bones;  (2) the sacrum; and  (3) the coccyx The innominate bones consist of the ilium, ischium, and pubis,

synovial

cartilaginous

The ischial spines are clinically important bony prominences

There are 4 types of pelvis •Classified according to the shape of the inlet •Gynecoid •Android •Anthropoid •Platypelloid The pelvic brim or inlet The pelvic brim is the inlet of the pelvis and is bounded in front by the symphysis pubis, on each side by the upper margin of the pubic bone, the ileopectineal line and the ala of the sacrum, and posteriorly by the promontory of the sacrum. transverse diameter in this plane is 13.5 cm and is wider than the anterior–posterior (AP) diameter which is normally 11 cm The pelvic mid-cavity An area bounded in  front by the middle of the symphysis pubis, laterally by the pubic bones, the obturator fascia and the inner aspect of the ischial bone and spines, and  posteriorly by the junction of the second and third sections of the sacrum. The midpelvis is almost round, as the transverse and anterior diameters are similar at 12 cm. The ischial spines are palpable vaginally The pelvic outlet • The pelvic outlet is bounded • anteriorly by the lower margin of the symphysis pubis, • laterally by the descending ramus of the pubic bone, the ischial tuberosity and the sacrotuberous , and • posteriorly by the last piece of the sacrum. • The AP diameter of the pelvic outlet is 13.5 cm and the transverse diameter is 11cm

Pelvic floor pelvic floor itself is a sling of various muscles which are pierced by the urethra, the vagina and the anal canal .

LEVATOR ANI MUSCLES

•constant state of contraction. •The most important parts are : pubococcygeus, •puborectalis, and •iliococcygeus The urogenital diaphragm This is a triangular-shaped diaphragm through it pass the urethra and vagina.0n its deep aspect are 2sets of muscles the constrictor of the urethra and vagina,& the deep transverse perinei. Superficially,there are the ischiocavernosus muscle ,the bulb (erectile tissue) with the bulbocavernosus muscle, the superficial perineal muscle,& bartholin glands.

Pelvic Viscera The uterus is a fibromuscular hollow organ situated between the bladder and the rectum. The uterus is divided structurally and functionally into two portions: an upper muscular body, the corpus , and a lower fibrous The portion of the corpus that extends above the level of entry of the fallopian tubes into the endometrial cavity is known as the fundus rugae • The shape, weight, and dimensions of the uterus vary according to parity and estrogen stimulation. Before menarche and after menopause, the corpus and cervix are approximately equal in size, but during the reproductive years, the uterine corpus is • significantly larger. • In the adult, non pregnant woman, the uterus measures approximately 7 cm in length and 5 cm in width at the fundus and weighs 30 to 50 g. and Serosa • . The endometrium consists of columnar epithelium and specialized stroma.The superficial portion of the endometrium undergoes cyclic changes with the menstrual cycle • Peritoneal serosa overlays the outer wall except for the anterior portion of the cervix and the lateral walls

Fallopian Tubes The fallopian tubes are tubular structures that measure 7 to 12 cm in length. Each tube has four identifiable portions. 1)The interstitial portion passes through the body of the uterus at the region known as the cornua. 13)The isthmic portion begins adjacent to the uterine corpus. It consists of a narrow lumen and a thick muscular wall. . Fallopian tubes 4)The fimbriated portion is the distal continuation of the ampullary segment. The fimbriated end has many frond-like projections that provide a wide surface area for ovum pickup. 3)The ampullary portion is recognized when the lumen widens. In addition to a wider lumen, this segment has a more convoluted mucosa Fallopian blood supply

• The ovarian artery • The venous plexus, lymphatic drainage, and nerve supply of the fallopian tubes follow a similar course tothat of the .

Cervix 2-4 cm in length. The wall of the cervix consists primarily of fibrous tissue and a smaller amount (approximately 10 percent) of smooth muscle. The endocervical canal is lined by columnar, mucus-secreting epithelium. The transformation zone • The lower border of the canal, called the external cervical os, contains a transition from squamous to columnar epithelium of the . • . At the upper border of the endocervical canal is the internal cervical os, where the narrow cervical canal becomes continuous with the wider endometrial cavity. Uterine Lymphatic Drainage

• Lymphatic drainage of the uterus is primarily to the obturator and internal and external iliac nodes • superficial inguinal nodes • lateral sacral nodes. Round They extend laterally to the pelvic sidewall. They enter the retroperitoneal space and enter the inguinal canal through the internal inguinal ring. After coursing through the inguinal canal, the round ligaments exit through the subcutaneous tissue of the labia majora. The round ligaments do not contribute significantly to uterine support.

Broad Ligaments

• The broad ligaments are double layers of peritoneum that extend from the lateral walls of the uterus to the pelvic walls . • Within the upper portion of these two layers lie the fallopian tubes and the ovarian and round ligaments. • The fallopian tubes, ovaries, and round ligaments each have their separate mesentery, called the mesosalpinx, mesovarium, and mesoteres,respectively, that carries nerves and vessels to these structures. Vagina is a distensible muscular 8-12 cm tube passes from the introitus to the cervix. anteriorly, is related to the base of the bladder and the urethra, and posteriorly, to the pouch of Douglas, rectum and anal canal . the uterine cervix project into the top of the vagina deviding it into 4 fornices and are labelled as anterior,posterior, right or left The epithelium contains no glands but is rich in glycogen in the premenopausal woman. The normal commensal, Doderleins bacillus, breaks down this glycogen to create an acid environment vaginal arteries which arise from the internal iliac arteries uterine arteriers (descending branches)  aided by the arteries to the bladder above , middle rectal & internal pudendal arteries.  There is a profuse network of veins accompanying the arteries. The ovaries • The ovaries and fallopian tubes constitute the uterine adnexa . The size and hormonal activity of the ovaries depend on age, time of the menstrual cycle, and exogenous hormonal suppression. During reproductive years, the ovaries measure • 2.5 to 5 cm in length, • 1.5 to 3 cm in thickness, and • 0.7 to 1.5 cm in width.

Ovaries • consist of an outer cortex and an inner medulla. Ovarian cortex is comprised of a specialized stroma punctuated with follicles, corpora lutea, and corpora albicantia. • A single layer of mesothelial cells covers this cortex as a surface epithelium( the germinal epithel ium) • The medullary portion of the consists primarily of fibromuscular tissue and blood vessels. Ovaries • are attached to the posterior leaf of the broad ligament by the mesovarium. • In addition they are fixed in position by the (to the uterus medially) and the infundibulopelvic ligament which contains the ovarian blood supply direct from the aorta. • Laterally, each ovary is attached to the pelvic wall by an infundibulopelvic ligament , also termed suspensory ligament of the ovary, that contains the ovarian vessels and nerves Ovarian Blood Supply, Lymphatics, and Innervation The blood supply to the ovaries comes from the ovarian arteries, which arise from the and from the ovarian branches of the uterine arteries The right ovarian vein drains into the inferior vena cava. However, the left ovarian vein drains into the left renal vein. Lymphatic drainage to the para-aortic nodes . Innervation to the ovaries are supplied by extensions of the renal plexus that course along the ovarian vessels in the infundibulopelvic ligament.

The skull bones, sutures and fontanelles vault, the face and the base. The sutures are the lines formed where the individual bony plates of the skull meet one another. sagittal, frontal, coronal and lambdoidal At thetime of labour, the sutures joining the bones of the vault are soft, unossified membranes, whereas the sutures of the fetal face and the skull base are firmly united The fontanelles are the junctions of the various sutures .The anterior fontanelle,also known as bregma, is at the junction of the sagittal, frontal and coronal sutures, and is diamond shaped. The posterior fontanelle lies at the junction of the sagittal suture and the lambdoidal sutures between the two parietal bones and the occipital bone, and is smaller and triangular shaped. • that the sutures are not fixed It allows the bones to move together and even to overlap. • The parietal bones usually slide over the frontal and occipital bones. • Furthermore, the bones themselves are compressible. • these characteristics of the fetal skull allow a process called ‘moulding’ to occur, • which reduces the diameters of the fetal head and encourages progress through the • bony pelvis, while still protecting the underlying brain vertex The area of the fetal skull bounded by the two parietal eminences and the anterior and posterior fontanelles . Sinciput:-the part of the head in front of the anterior fontanell .It is subdevided into the brow and the face Occiput:-the back of he head,lies behind the posterior fontanelle.