Ovaries

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A. General features. The ovaries are almond-shaped structures located posterior to the broad ligament. They are attached to the lateral pelvic wall by the suspensory ligament of the ovary (a region of the broad ligament), which contains the ovarian artery, vein, and nerve. The surface of the ovaries is not covered by peritoneum; they are covered by a simple cuboidal epithelium called the germinal epithelium. The arterial supply is from the abdominal aorta via the ovarian arteries. Venous drainage is to the right ovarian vein, which empties into the inferior vena cava, and the left ovarian vein, which empties into the left renal vein. Right-sided hydronephrosis in a female may indicate thrombosis of the right ovarian vein that is constricting the ureter, because the right ovarian vein crosses the ureter to enter the inferior vena cava. Ovarian pain often is referred down the inner thigh through the obturator nerve.

B. Clinical considerations

1. Ovarian cancer. The most common type is an epithelial tumor, which is a malignant transformation of the germinal epithelium that covers the ovary. The main lymphatic drainage of the ovary is to the deep para-aortic lymph nodes near the renal artery. The incidence of ovarian cancer is increased in women with hereditary nonpolyposis colorectal cancer (HNPCC; Lynch syndrome II). Ovarian cancer is associated with mutations of the p53 tumor suppressor gene. The tumor markers CEA and CA-125 are useful in diagnosis. A palpable ovary or adnexal mass usually suggests an ovarian neoplasm rather than an ovarian cyst.

2. Ovarian cysts. A functional cyst is a physiologically and hormonally active cyst that has not yet involuted. There are three types: follicular cyst, corpus luteum cyst, and theca lutein cyst (caused by elevated levels of (3-human chorionic gonadotropin). Clinical findings include: sudden, extreme pelvic pain, especially in an adolescent girl. Functional cysts usually resolve spontaneously.

UTERINE (FALLOPIAN) TUBES

A. General features. The uterine tube has four divisions: the infundibulum, which opens into the peritoneal cavity; the ampulla, which is the site of fertilization; the isthmus; and the intramural section, which opens into the uterine cavity. The uterine tubes are supported by the mesosalpinx, which is a region of the broad ligament.

B. Clinical considerations

1. Salpingitis probably is the most common cause of female infertility. It is a bacterial infection (most commonly gonococcal) of the uterine tube, with inflammation that leads to scarring. This condition predisposes affected women to an ectopic tubal pregnancy.

2. Ectopic tubal pregnancy most often occurs in the ampulla of the uterine tube. Risk factors include: salpingitis (see II B 1), pelvic inflammatory disease, pelvic surgery, and exposure to diethylstilbestrol in utero. Clinical findings include: sudden onset of abdominal pain, which may be confused with appendicitis in a young woman; last menses 60 or more days ago; positive result on human chorionic gonadotropin test; and intraperitoneal blood seen on culdocentesis.

III. UTERUS (Figure 14-1)

A. Regions. The uterus is divided into four regions.

1. The fundus is located superior to the cornua and contributes largely to the upper segment of the uterus during pregnancy. At term, the fundus may extend as high as the xiphoid process (vertebral level T9).

2. The cornu is located near the entry of the uterine tubes.

3. The body of the uterus is located between the cornu and the cervix. The isthmus, which is part of the body of the uterus, is the dividing line between the body of the uterus and the cervix. The isthmus is the preferred site for a surgical incision during cesarean delivery.

4. The cervix is located inferior to the body of the uterus. It protrudes into the vagina. It contains the internal os, cervical canal, and external os.

In a nulliparous woman, the external os is round. In a parous woman, it is transverse.

B. Support. The uterus is supported by the following structures:

1. Pelvic diaphragm (levator ani muscles)

2. Urogenital diaphragm

3. Urinary bladder

4. Round ligament of the uterus, which is a remnant of the gubernaculum in the embryo

5. Transverse cervical ligament (cardinal ligament of Mackenrodt), which extends laterally from the cervix to the side wall of the pelvis. It is located at the base of the broad ligament and contains the uterine artery, which is a branch of the internal iliac artery.

6. Uterosacral ligament, which extends posteriorly from the cervix to the sacrum and is responsible for bracing the uterus in its normal anteverted position

7. Pubocervical ligament, which extends anteriorly from the cervix to the pubic symphysis and helps to prevent a cystocele (herniation of the urinary bladder into the anterior wall of the vagina)

8. Broad ligament, a double fold of parietal peritoneum that extends laterally from the uterus to the side wall of the pelvis a. The broad ligament is divided into four regions: the mesosalpinx, which supports the uterine tubes; the mesovarium, which supports the ovary; the mesometrium, which supports the uterus; and the suspensory ligament of the ovary.

Crus Clitoris

Figure 14-1. (A) Anterior view of the female genital organs, with the anterior wall of the vagina opened to show the cervix. 1 = ovary; 2 = mesovarium; 3 = fundus of the uterus; 4 = vesicouterine pouch; 5 = cervix; 6 = vaginal part of the cervix; 7 = vagina; 8 = crus of the clitoris; 9 = labium minus; 10 = infundibulum of the uterine tube; 11 = ampulla of the uterine tube; 12= ovarian ligament of the uterus; 13= mesosalpinx; 14 = uterine tube; 15= suspensory ligament of the ovary (caudally displaced); 16= broad ligament; 17= round ligament of the uterus; 18 = corpus cav-ernosum of the clitoris; 19 = glans of the clitoris; 20 = hymen (vaginal orifice). (B) Anteroposterior radiograph of the female genital tract (hysterosalpingography). 1 = fundus of the uterus; 2 = uterine cavity; 3 = isthmus of the uterus; 4 = folds of the cervix; 5 = cervical canal (dilated and stretched); 6 = infundibulum of the uterine tube; 7= ampulla of the uterine tube; 8 = isthmus of the uterine tube; 9 = opening of the uterine tube; 10 = pecten of the pubis. (A reprinted with permission from Rohen JW, Yokochi C, Lutjen-Drecoll E: Color Atlas of Anatomy, 4th ed. Baltimore, Williams & Wilkins, 1998, p 336; B reprinted with permission from Fleckenstein P, Tranum-Jensen J: Anatomy in Diagnostic Imaging. Philadelphia, WB Saunders, 1993, p 291.)

Figure 14-1. (A) Anterior view of the female genital organs, with the anterior wall of the vagina opened to show the cervix. 1 = ovary; 2 = mesovarium; 3 = fundus of the uterus; 4 = vesicouterine pouch; 5 = cervix; 6 = vaginal part of the cervix; 7 = vagina; 8 = crus of the clitoris; 9 = labium minus; 10 = infundibulum of the uterine tube; 11 = ampulla of the uterine tube; 12= ovarian ligament of the uterus; 13= mesosalpinx; 14 = uterine tube; 15= suspensory ligament of the ovary (caudally displaced); 16= broad ligament; 17= round ligament of the uterus; 18 = corpus cav-ernosum of the clitoris; 19 = glans of the clitoris; 20 = hymen (vaginal orifice). (B) Anteroposterior radiograph of the female genital tract (hysterosalpingography). 1 = fundus of the uterus; 2 = uterine cavity; 3 = isthmus of the uterus; 4 = folds of the cervix; 5 = cervical canal (dilated and stretched); 6 = infundibulum of the uterine tube; 7= ampulla of the uterine tube; 8 = isthmus of the uterine tube; 9 = opening of the uterine tube; 10 = pecten of the pubis. (A reprinted with permission from Rohen JW, Yokochi C, Lutjen-Drecoll E: Color Atlas of Anatomy, 4th ed. Baltimore, Williams & Wilkins, 1998, p 336; B reprinted with permission from Fleckenstein P, Tranum-Jensen J: Anatomy in Diagnostic Imaging. Philadelphia, WB Saunders, 1993, p 291.)

b. The broad ligament contains the following structures: the ovarian artery, vein, and nerves; the uterine tubes; the ovarian ligament of the uterus, which is a remnant of the gubernaculum in the embryo; the round ligament of the uterus, which is a remnant of the gubernaculum in the embryo; the epoophoron, which is a remnant of the mesonephric tubules in the embryo; fhe paroophoron, which is a remnant of the mesonephric tubules in the embryo; the Gartner duct, which is a remnant of the mesonephric duct in the embryo; the ureter, which lies at the base of the broad ligament posterior and inferior to the uterine artery (during hysterectomy, the ureters inadvertently may be ligated along with the uterine artery because of their close anatomic relation); and the uterine artery, vein, and nerves, which lie at the base of the broad ligament within the transverse cervical ligament.

C. Position of the uterus. The uterus usually is in an anteflexed and anteverted position, which places it in a nearly horizontal position, lying on the superior wall of the urinary bladder. Anteflexed refers to the anterior bend of the uterus at the angle between the cervix and the body of the uterus. Anteverted refers to the anterior bend of the uterus at the angle between the cervix and the vagina.

D. Clinical considerations

1. Cervical carcinoma is the most common gynecologic malignancy. It may spread to the side wall of the pelvis, where the ureters may become obstructed, leading to hydronephrosis. The most common site of lymph node spread (i.e., sentinel nodes) is to the obturator lymph nodes.

2. Uterine fibrinoid (leiomyoma) is a common benign neoplasm that results from a proliferation of smooth muscle cells of the uterus; these smooth muscle cells may become calcified. Fibrinomas may be located within the myometrium of the uterus (intramural); beneath the endometrium (submucosa), where they may grow into the uterine cavity; or beneath the serosa (subserosal), where they may grow into the peritoneal cavity. They may cause infertility if they block the uterine tube or prevent implantation of the conceptus. They may be palpated as irregular, nodular masses that protrude against the anterior abdominal wall.

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Pregnancy Guide

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A Beginner's Guide to Healthy Pregnancy. If you suspect, or know, that you are pregnant, we ho pe you have already visited your doctor. Presuming that you have confirmed your suspicions and that this is your first child, or that you wish to take better care of yourself d uring pregnancy than you did during your other pregnancies; you have come to the right place.

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