Uterus anatomy embryology, and clinical aspects
- 2. Introduction Uterus, also called womb, an inverted pear-shaped muscular organ of the female reproductive system. • It is responsible for many functions in the processes of implantation, gestation, menstruation, and labor. • The main function of the uterus is to provide nourishment and a conducive environment for the developing foetus until it is developed and delivered.
- 3. Embryology • Uterus develops from the Paramesonephric duct. • It is also called as Mullerian duct. • Uterus develops on 10th week but uterine cavity develops on 20th week.
- 5. MAYER-ROKITANSKY-KUSTER-HAUSER SYNDROME In this Mullerian Agenesis occurs as a result- • Fallopian tubes • Uterus • Upper part of vagina are absent. • While Ovary and lower part of vagina are present.
- 6. Morphology The uterus is a hollow pyriform muscular organ situated in the pelvis between the bladder in front and the rectum behind. PARTS OF UTERUS- 1. Body or Corpus 2. Isthmus 3. Cervix
- 7. 1) Body or corpus: The body is further divided into fundus—the part which lies above the openings of the uterine tubes. The body proper is triangular and lies between the openings of the tubes and the isthmus. The superolateral angles of the body of the uterus project outwards from the junction of the fundus and body and is called cornua of the uterus .The uterine tube, round ligament and ligament of the ovary are attached to it. 2) Isthmus is a constricted part measuring about 0.5 cm, situated between the body and the cervix. 3) Cervix is cylindrical in shape and measures about 2.5 cm. It extends from the isthmus and ends at the external os which opens into the vagina after perforating its anterior wall. The part lying above the vagina is called supravaginal and that which lies within the vagina is called the vaginal part .
- 8. Relations of Uterus • Anteriorly • The body of uterus is related to the uterovescical pouch and the superior surface of urinary bladder . • The supravaginal portion of cervix related to the posterior surface of urinary bladder. • The vaginal portion of cervis in related to the anterior fornix of the vagina.
- 9. • Posteriorly • The body of uterus and supravaginal portion of cervix is related to the rectouterine pouch. • The vaginal portion of cervix is related to poster fornix. • Laterally • The body of uterus is related to the broad ligament and uterine artery and vein. • The supravaginal portion of uterus is related to the ureter and uterine artery. • The vaginal portion of cervix is related to the lateral forces of the vagina.
- 11. Normally the uterus lies in position of anteversion and anteflexion. • Anteversion The long axis of the cervix is normally bent forward on the long axis of vagina forming an angle of about 90. • Anteflexion. The long axis of the body of uterus bent forward at the level of isthmus (internal os)on the long axis of cervix forming an angle of 170 . Normal position & axis of uterus
- 12. The backward tilting of the uterus relative to vagina is known as retroversion.
- 13. • The uterus is kept in position and prevented from sagging down by a number of structures providing support to it. • The supports of the uterus are subdivided into two types, chief or primary supports andaccessory or secondary supports Supports of the Uterus
- 14. Primary Supports Muscular or active supports 1 Pelvic diaphram 2.Perineal body 3. Distal urethral sphincter mechanism Fibromuscular or mechanical supports 1. Uterine axis 2. Pubocervical ligaments 3. Transverse cervical ligaments of Mackenrodt 4. Uterosacral ligaments 5. Round ligaments of utterus
- 17. Secondary Supports These are of doubtful value and are formed by peritoneal ligaments. 1 Broad ligaments 2 Vesicouterine pouch and fold of peritoneum 3 Rectovaginal or rectouterine pouch and fold of peritoneum
- 19. Prolapse of Uterus • Downward displacement of the Uterus due to damage of Ligaments of uterus and Levator ani muscles during childbirth or general poor body muscular tone is called Prolapse of uterus.
- 20. Blood Supply of Uterus
- 21. Lymphatic Supply of Uterus
- 22. Histology of Uterus • Uterus wall is made up of 3 layers 1. Perimetrium 2.Myometrium 3.Endometrium • Perimetrium:It is the Outermost layer of Uterus.It is either serosa or adventitia.It remains unchanged through out the menstrual cycle.
- 23. MYOMETRIUM: It is middle of the uterus consisting three layers of smooth muscles 1. Thin outer longitudinal layer. 2. Middle layer of circularly disposed musclefibres called STRATUM VASCULARE 3.Inner longitudinal layer • During pregnancy this layer undergoes hypertrophy under the effect of progesterone.
- 24. ENDOMETRIUM: It consists of two layers: 1. Epithelium (Simple columnar) 2. Lamina propria. EPITHELIUM:-It consists of two types of cells: a) Ciliated cells b) Secretory cells (Non-ciliated ) LAMINA PROPRIA : 1.It is also called Endometrial stroma. 2. It is highly cellular. 3. It lodges uterine glands. • In secretory phase of menstrual cycle it is divided into two zones :- • 1. Stratum functionalis2. Stratum basalis (It consists of distal part of uterine glands and proximal part of spiral arteries)
- 26. Menstrual cycle • Beginning with puberty and ending at menopause, the endometrium of the body of uterus passes through cyclic structural modifications which constitute the menstrual cycle. • The duration of a menstrual cycle is variable but averages 28 days.
- 29. HISTOPATHOLOGY: ECTOPIC PREGNANCY a) Fertilized ovum implants other than uterus for example in ovary, uterine tube or abdomen. b) Management :- 1. Methotrexate. 2. 2. Surgery.
- 30. Uterine changes in Pregnancy • There is enormous growth of the uterus during pregnancy. • BODY OF THE UTERUS: There is increase in growth and enlargement of the body of the uterus. • CHANGES IN THE MUSCLES: 1.Hypertrophy and hyperplasia – under the influence of oestrogen & progesterone. 2.Stretching – as a result the wall becomes thinner.
- 31. Arrangement of the muscle fibers: Three distinct layers of muscle fibers are evident: (1)Outer longitudinal (2) Inner circular (3) Intermediate—It is the thickest and strongest layer arranged in crisscross Fashion through which the blood vessels run. Vascular system—Whereas in the nonpregnant state, the blood supply to the uterus is mainly through the uterine and least through the ovarian but, in the pregnant state, the latter carries as much the blood as the former. • Uterine artery diameter doubles & blood flow is increased 8 folds. • This vasodilatation is mainly due to estradiol and progesterone.
- 32. • Weight: The increase in weight is due to the increased growth of the uterine muscles, connective tissues and vascular channels. • Shape:Nonpregnant pyriform shape is maintained in early months. It becomes globular at 12 weeks. As the uterus enlarges, the shape once more becomes pyriform or ovoid by 28 weeks and changes to spherical beyond 36th week . • Position: Normal anteverted position is exaggerated up to 8 weeks. Thus, the enlarged uterus may lie on the bladder rendering it incapable of filling, clinically evident by frequency of micturition. • Lateral obliquity: As the uterus enlarges to occupy the abdominal cavity, it usually rotates on its long axis to the right (dextrorotation).
- 33. Contractions (Braxton-Hicks): The contractions are irregular,infrequent, spasmodic and painless without any effect on dilatation of the cervix. UTERINE SIGNS OF PREGNANCY • Hegar’s sign: . It can be demonstrated between 6 and 10 weeks.This sign is based on the fact that: • upper part of the body of the uterus is enlarged by the growing fetus • lower part of the body is empty and extremely soft and • the cervix is comparatively firm • Palmer’s sign: Regular and rhythmic uterine contraction can be elicited during bimanual examination as early as 4–8 weeks.
- 34. Fundal height is increased with progressive enlargement of the uterus. Approximate duration of pregnancy can be ascertained by noting the height of the uterus in relation to different levels in the abdomen
- 35. Cesarean Section • DEFINITION: It is an operative procedure whereby the fetuses after the end of 28th weeks are delivered through an incision on the abdominal and uterine walls. • INCIDENCE: The incidence of cesarean section is steadily rising. • TYPES OF OPERATIONS: 1) Lower segment 2) Classical or upper segment • Lower segment cesarean section(LSCS): In this operation, the extraction of the baby is done through an incision made in the lower segment through a transperitoneal approach.
- 36. Classical:In this operation, the baby is extracted through an incision made in the upper segment of the uterus.
- 38. Pathology of Uterus • ENDOMETRITIS & MYOMETRITIS • ADENOMYOSIS • ENDOMETRIOSIS • TUMOURS • ENDOMETRIAL CARCINOMA • LEIOMYOMA • LEIOMYOSARCOMA • CERVICITIS • CERVICAL POLYP • CERVICAL CARCINOMA
- 39. Endometritis and Myometritis • Inflammation of Endometrium and myometrium. • Two forms: • ACUTE FORM- causes-1.purperal 2.IUCD 3.Extension of gonorrheal infection from cervix and vagina • CHRONIC FORM-Above+tuberculosis endometritis
- 40. Adenomyosis • Also called as endometriosis interna. • It is due to Abnormal distribution of histologically benign endometrial tissue within the myometrium along with myometrial hypertrophy. • Aetiology: Metaplasia or oestrogen simulation due to dysfunction of the ovary. • Clinical features:Menorrhagia,Colicky dysmenorrhea, Menstrual pain
- 42. Endometriosis • Presence of endometrial glands and stroma in Abnormal locations outside the Uterus. • CHIEF LOCATIONS: Ovaries ,Uterine ligaments,Rectovaginal septum,Pelvic peritoneum,Laprotomy scars. • CLINICAL FEATURES:Intrapelvic bleeding, Dysmenorrhea ,Pelvic pain,Dyspaeunia,Infertility
- 44. Endometrial carcinoma • Carcinoma of the endometrium, commonly called uterine cancer. • ETIOLOGY • 1. Chronic unopposed oestrogen excess • 2. Obesity • 3. Diabetes mellitus • 4. Hypertension • 5. Nulliparous state • 6. Heredity.
- 46. Leiomyoma • Leiomyomas or fibromyomas, commonly called fibroids by the gynaecologists, are the most common uterine tumours of smooth muscle origin, often admixed with variable amount of fibrous tissue component. • Leiomyosarcoma is an uncommon malignant tumour as compared to its rather common benign counterpart.
- 49. Cervical Carcinoma • It is the most common cancer in females (11%). • It is rare before 20 years of age and reaches its peak between the ages 45 and 55 years. • 80% cervical cancers are squamous cell carcinomaand are related to sexual activity. • Early sexual exposure and promiscuity are prominent factors. • It spreads directly to adjacent structures and metastasizes via lymphaticsto pelvic lymph nodes and then to the preaortic and para- aortic lymph nodes.
- 51. Hysterectomy Hysterectomy is the total or partial removal of the uterus, is indicated in a woman over 40 years of age, multiparous woman or when associated with malignancy. Types of hysterectomy • Abdominal hysterectomy • Vaginal hysterectomy • Laparoscopic hysterectomy