Normal Pelvic Anatomy and Mullerian Anomalies Flashcards by Samuel Latham

What is the cervix?

The inferior most part of the uterus

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What is the corpus?

The body of the uterus - between the cervix and the fundus

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What is the fundus?

The superior most part of the uterus

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What is the cornua?

Part of the uterus where the Fallopian tubes enter the uterine cavity

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What do internal organs develop from?

Paramesonephritic (Mullerian) Ducts and Mesonephritic (Wolffian) Ducts

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What do both Wolffian and Mullerian ducts lead to?

Formation of a cloaca in a urogenital sinus

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What determines if Wolffian or Mullerian ducts develop?

Hormones

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What determines the development/progression of Wolffian ducts?

Testosterone and DHT

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What do Sertoli Cells produce that causes regression of Mullerian Ducts?

AMH - Anti Mullerian Hormone

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What produces AMH?

Sertoli Cells

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What leads to the development of external femal genitalia?

Nothing - absence of androgen/AMH all that is required

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What develops from the Mullerian ducts?

Tubes, Uterus, Cervix, Upper 2/3 of the Vagina

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What develops from the urogenital sinus?

Lower 1/3 of the Vagina

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Where is the hymen located?

At the junction of the Upper 2/3 of the Vagina from the Mullerian Ducts and the Lower 1/3 of the Vagina from the Urogenital Sinus

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When does fusion of the Mullerian Ducts begin?

8-9 weeks post gestation

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What follows fusion?

Canalization

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When is Canalization Complete?

20 weeks

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What happens to any anomalies of canalization at 20 weeks?

They stay but aren’t easily seen on U/S

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What forms male internal genitalia and parts of the external genitalia?

Wolffian duct

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What does the Umbilical vein become in adults?

Falciform Ligament

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What does the Umbilical Artery become in adults?

Lateral suspensory ligaments of bladder

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Where do you insert the laparoscope?

Umbilicus

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What do you inflate the abdominal wall with?

CO2

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What do you inflate the abdominal wall with CO2?

CO2 will dissolve, and be exhaled

- Room air –> Air embolism

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What can be seen during a laparoscopy?

1. Fundus of uterus, ovaries, and tubes 2. Retroperitoneal vessels 3. Utero-ovarian ligament (contains a vessel) 4. Uterine Ligaments 5. Infundibulopelvic ligaments (AKA Suspensory Lifgament of ovary) at pelvic brim 6. Other abdominal Organs

What do the pelvic organs look like during a laparoscopy?

Upside down as you are looking at them from above instead of from below

What does the infundibulopelvic ligament (suspensory ligament of the ovary) contain?

Ovarian Artery, Veins, and Nerves

What can PID lead to?

Fitz-Hugh-Curtis Syndrome | - Adhesion of liver to diaphragm

What is endometriosis?

Discolorization of all pelvic organs due to intra-pelvic bleeds (rust-colored)

What is a hysteroscopy?

Used to look inside the uterus and to operate inside the uterus

What do you fill uterus with during hysteroscopy?

Saline - Allows operations - NOT CO2

What is the main etiology of Mullerian anomalies?

Environment + Genetics + Epigenetics

What happens when you karyotype a woman with an Mullerian anomaly?

Karyotype is normal

What are the classifications of Mullerian Anomalies?

1. Hypoplasia/Agenesis 2. Unicornuate 3. Didelphus 4. Bicornuate 5. Septate 6. Arcuate 7. DES Drug Related

Subclasses of Hypoplasia/Agenesis

a. Vaginal b. Cervical c. Fundal (aka uterine) d. Tubal e. Combined

What is agenesis?

No fusion of Mullarian duct --> no development of female tract

Presentation of Hypoplasia/Agenesis?

Primary amenorrhea w/ cyclic pain , normal secondary sex characteristics

Possible anomalies in hypoplasia/agenesis?

No uterus No uterus + no tubes No uterus + no tubes + no cervix/upper vagina

What is the etiology of unicornuate uterus?

Failure of one of the Mullerian Ducts to develop/elongate

Subclasses of unicornuate uterus?

Communicating Non-communicating No Cavity True Unicornuate Uterus

What is a communicating unicornuate uterus?

Rudimentary horn w/ a cavity and its communicating with uncornuate cavity

What is a non-communicating unicornuate uterus?

Rudimentary horn w/ a cavity but its not communicating with uncornuate cavity

What is a No cavity unicornuate uterus?

Rudimentary horn w/o a cavity

What is a true unicornuate uterus?

No rudimentary horn --> Very rare

Etiology of Uterine didelphys?

Failure of Mullerian ducts to fuse --> two seperate uterine horns --> each with endometrial cavity and its own cervix

Subclasses of bicornuate uterus?

a. Complete Septum | b. Partial Septum

Etiology of bicornuate?

Incomplete fusion | - Walls of Mullerian ducts don't fuse properly, so you end up with a kind of Y-shaped uterus

How many cervices do you have in a bicornuate uterus?

One Cervix with two separate but communicating endometrial cavities

What happens during pregnancy with a bicornuate uterus?

Increased incidence of preterm delivery

Subclasses of Septate uterus?

a. Complete Septate Uterus | b. Partial septate (subseptate) uterus

Etiology of Septate uterus?

Incomplete canalization

Where in the uterus are bicornuate and septate uterus similar? different?

Inside the uterus | Outside the uterus

What does the outside of the uterus look like in a septate uterus?

Normal

What are the risk with septate uterus?

Infertility and early pregnancy loss

How do you differentiate between a bicornuate uterus and a septate uterus?

Measuring depth of outside indentation - >1 cm = bicornuate - <1 cm = septate

How do you distinguish between arcuate uterus and septate uterus?

Measuring length of inside indentation - >1 cm = septate - <1 cm = arcuate

What does DES make the uterus look like?

T-Shaped Uterine Cavity

DDx of agenesis?

1. Meyer-Rokitansky-Kuster-Hauser (MRKH) Syndrome | 2. Androgen insensitivity (AI) Syndrome

How do you tell MRKH from AI?

Karyotype - MRKH = 46 XX - AI = 46 XY

Genetics of MRKH?

46 XX

Phenotype of MRKH?

Female

What is absence in MRKH?

Vagina, Cervix, Uterus

Do pts with MRKH have ovaries?

Yes - leads to normal pubetal secondary sex characteristic development

Genetics of AI?

46 XY

Phenotype of AI?

Female

Why do pts with AI present as females?

Androgen receptors do not respond to androgen leading to no Wolffian duct development so they default to female external genetalia

Do pts with AI produce AMH?

yes

The production of AMH in pts with AI leads to what?

The regression of the Mullerian Ducts --> No vagina, uterus, cervix, fallopian tubes

How to pts with AI go thru female puberty?

High levels of androgen get converted to estrogen via aromtase

Do pts with AI have testes?

Yes