Anatomy embryology

Question 1

1. Regarding transverse vaginal septum choose the correct option.

a) occurs at the junction of lower 2/3 and upper 1/3 of vagina
b) occurs commonly with abnormalities of upper Mullerian system
c) associated with in utero DES exposure
d) autosomal recessive inheritance
e) treated with Tompkin’s procedure

Answer 1

Answer b) but not commonly
I reckon c (which is true, but is it truer?)

Tompkins procedure is removal of uterine septum (open procedure)

Transverse vaginal septum results from failure of cannalisation of the distal one third of vagina. Patients usually present with symptoms of menstrual obstruction and/or urinary frequency. There is no introital distension with Valsalva manoeuver and it may be accompanied by anomalies of upper reproductive tract.

Question 2

23 year old lady has premature labour at 23 weeks after a 10 hr labour. Later it is discovered the she has a vertical uterine septum. You recommend before her next pregnancy:

a) reassurance. No intervention recommended
b) cervical suture required for next pregnancy
c) recommend metroplasty before next pregnancy
d) elective LUSCS next pregnancy

Answer 2

Answer c ?metroplasty. hysteroscopic resection now.

Question 3

Where does the paravaginal fascia insert?

a) arcus tendineus
b) iliopectineal ligament
c) urogenital diaphragm
d) perineal body
e) sacrospinous ligament

Answer 3

a) arcus tendineus

Question 4

4. What structures would you not meet when repairing a third degree tear?
   a) bulbospongiosus
   b) ischiocavernosus
   c) external anal sphincter
   d) superficial transverse perinei
   e) deep transverse perinei

Answer 4

Answer b
Muscles running into perineal body - external anal sphincter, pubovaginalis, deep and superficial transverse perinei and bulbospongiosis

Question 5

5. During a radical hysterectomy the uterine artery is divided at which of the following:
   a) at its origin adjacent to the hypogastric artery (aka internal iliac a)
   b) adjacent to the ureter
   c) where it meets the uterus
   d) in the wall of the uterus

Answer 5

a) at its origin adjacent to the hypogastric artery (aka internal iliac a)

Question 6

34 yo, 165 cm, 52 kg. Hysterectomy for adenomatous atypical hyperplasia. No technical difficulties. Self-retaining retractor used. Next day weakness of left leg, unable to weight bear, reduced sensation anterior thigh, no patellar reflex. Which of the following has been injured:

a) sciatic nerve
b) femoral nerve
c) obturator nerve
d) pudendal nerve
e) sacral plexus

Answer 6

b) femoral nerve

Question 7

The structure posterior to the external iliac artery and vein and would dissect medially off the psoas muscle is:

a) superior gluteal artery
b) obturator nerve
c) ureter
d) uterine artery

Answer 7

b) obturator nerve

Question 8

8. Which group of lymph nodes drain the vulva initially?
   a. superficial inguinal
   b. deep inguinal
   c. femoral
   d. obturator

Answer 8

Answer a
Spread – inguinal -> femoral-> pelvic (external iliac in particular), pelvic lymph nodes only positive is inguinal nodes are

Question 9

9. Muscles that are cut with a midline episiotomy?
   a) pubococcygeus and ischiocavernosus
   b) bulbocavernosus and ischiococcygeus
   c) superficial transverse perinei and ischiocavernosis
   d) bulbocavernosus and superficial transverse perinei
   e) superficial transverse perinei and coccygues

Answer 9

d) bulbocavernosus and superficial transverse perinei

Bulbocavernosus
• origin – perineal body
• posterior aspect of the clitoris, some fibres pass above the dorsal vein of the clitoris in a sling like fashion
• ie from perineal body curves around vaginal and urethral opening to clitoris
Superficial transverse perinei
• origin – ischial tuberosity
• insertion – central perineal body
• action – fixes the perineal body
• ie runs straight across from sides of pelvis ie tuberosity to perineal body
NB other muscle in perineal body is external anal sphincter

Question 10

10. What structures would you not meet when repairing a 3rd degree tear?
    i. bulbocavernosus
    ii. ischiocavernosus
    iii. external anal sphincter
    iv. superficial transverse perinei
    v. deep transverse perinei

Answer 10

Answer b)

Ischiocavernosus goes from ischial tuberosity to ischiopubic bone (i.e. nowhere near the perineal body/anal sphincter

Question 11

12. At what week post-conception does the neural tube close?
    a. 2 weeks
    b. 4 weeks
    c. 6 weeks
    d. 8 weeks

Answer 11

Answer b)

D26

Question 12

Where does the paravaginal fascia insert?

a. arcus tendineus
b. iliopectineal ligament
c. urogenital diaphragm
d. perineal body
e. sacrospinous ligament

Answer 12

a. arcus tendineus

Question 13

Placentation. Which is true?

a. complete fetoplacental circulation established by 5-6 weeks post conception
b. two waves of endothelial cytotrophoblast invasion is finished by 10/40
c. of uterine blood flow 55% is to placenta, rest to myometrium/endometrium/decidua
d. blood leaves fetus to go to placenta via 2 arteries and 1 vein and flow is 350 ml/min
e. flow in cord is 150 ml/min

Answer 13

Answer a)
Two waves finished by 14/40
85 % of uterine blood flow to placenta
blood leaves placenta to go to fetus not fetus to placenta
blood flow in cord is 350 ml/min