OBGYN! Repo Anatomy Flashcards
What are the muscles of the pelvic diaphram
Levator ani
Coccygeus muscle
What is the “HART” line
“Hart Line:” demarcation between skin and mucous membrane on inner surface of labia minora
Outer surface to Hart Line: keratinized stratified squamous epithelium
Medial to Hart Line: nonkeratinized squamous epithelium
Where are bartholin glands
4 and 8 o’clock
Below hymenal ring; lubrication
Where are skenes glands
(largest paraurethral glands)
Fluid secretion to lubricate urethral opening
Near urethral meatus
Anterior wall of vagina
What are the anatomical borders of the vagina
Musculomembranous tube from hymenal ring to uterus
What is the cell type in the vagina
Nonkeratinized stratified squamous epithelium
What are the fornixes of the vagina
Recessed areas bordering cervix, “arch”
There are 4
What is the pouch of Douglas
AKA rectouterine pouch
Lowest point in abdominal cavity: fluid accumulation
-?Ectopic pregnancy
Procedure to drain fluid: Culdocentesis
What is Chadwick’s sign
early; blue tint (inc. vascularity)
What is Goodell Sign
cervical softening d/t edema
What is Hegar sign
isthmus (uterus) softening
What cells cover the ectocervix
Squamous epithelium
What are the cells of the Endo cervix
Columnar epithelium
What happens to the cervix under the influence of life
Everts
What is the most common site of fertilization
The Ampullla
What is the most common site for ectopic pregnancy
Ampulla
How does the fimbriae grab an egg from the ovarie
Salivary sweeping action
The Ovaries secrete what ?
Estrogen and progesterone in response to FSH and LH
What is the most common site for ovarian cancer
The outer epithelium of the ovary
Where do the L and R ovaries drain into
L ovary drains into L renal vein
R ovary drains into IVC
What is the línea terminalis
Linea terminalis is the boundary between the greater pelvis and lesser pelvis as well as the plane of the pelvic inlet. “pelvic brim”
Thelinea terminalisorinnominate lineconsists of the pubic crest,pectineal line(pecten pubis), thearcuate line, the sacral ala, and thesacral promontory.
What is the difference between the true and false pelvis
“True:” important in childbearing
Immobile; constrains delivery of fetus
“False:” above linea terminalis
Physically supports pregnant uterus
What is vertex presentation of a baby
Chin tucked small diameter
Good for baby and mom
What is sinciput and brow presentation of baby
Larger diameter of head and neck flexion
Not great for mom or baby
What are the two most favorable hip anatomies for birth
Gynecologist and Anthropoid
What is the in utero gonadal development
Begins at 5w; committed by ~7w
Testes develop: ~7w
Ovaries develop: ~12w
Decided by TDF and MIF
What is the dif between Mesonephric and Paramesonephric ducts
Mesonephric (Wolffian) ducts: male reproductive development
Paramesonephric (Mullerian) ducts: female reproductive development
What is the ovarian development at 16 weeks gestation
~16w: cortical cords break into cell clusters: “primordial follicles”
Each primordial follicle contains an oogonium (primordial germ cell → egg)
What is important about anti-mullarian hormone in utero in males
STOPS female sex anatomy production in developing baby
AMH suppresses development of paramesonephric (Mullerian) ducts, which form uterus and uterine/fallopian tubes
Paramesonephric ducts are responsible what development of what anatomy
Fallopian tubes, uterus, and upper third of vagina
What is ovotesticular DSD
Rare -Chromatin-positive nuclei (typically) ~70%: 46XX ~20% mosaic: 46XX/46XY ~10%: 46XY
Most will have “ovotestis” (both testicular & ovarian components present)
Phenotype: male or female
External genitalia are always ambiguous
A pt presents with presetn and normal ovaries with ambitious external genitalia.
Think
Female fetal exposure to excess androgens -external genital
Virilization
Clitoral hypertrophy, partial fusion of labia majora, persistent urogenital sinus
46XX DSD
Most common CAH or tumors
A baby is supposed to look male however they have underveloped testicles
Think
46XY DSD
Caused by inadequate production of testosterone and MIS by the fetal testes
“Chromatin-negative” nuclei (no sex chromatin)
Testicular tissue present
Could be visible, undescended, or present with ovarian tissue
What are the features of AIS
Androgen Insenitivity syndrome
46XY
Normal external genitalia
+cryptorchid testes
Blind vaginal pouch
With testicles that are resistant to testosterone
Define the syndrome :
Hypogonadotropic hypogonadism
Anosmia
Infertile, poorly defined 2ndary sexual characteristics
Typically born with normal sexual differentiation!
Low FSH, LH, and estrogen
Failure in production/activity of GnRH (lack of GnRH, LH, FSH surge in infancy)
Kallman!
Define the syndrome:
47XXY
Low T, elevated FSH, elevated LH; FSH > LH
Presentation varies, but may include micropenis, hypospadias, cryptorchidism
Often not diagnosed, or diagnosed in adulthood d/t incomplete virilization
May present with s/sx of androgen deficiency, infertility
Klinefelter
Define the syndrome
45 XO
Hypergonadotropic hypogonadism
Elevated FSH and LH
Low estrogen
“Streak” gonads, short stature, webbing of neck, low hairline, short stature
“gonadal dysgenesis”
Turner Syndrome
Haploid vs Diploid cells
Diploid 46XY
Haploid 23
What is the purpose of the acrosome on a sperm
Enzymes to penetrate zona pellucida and dispersion of follicular cells of corona radiata
What is the difference between Spermatogenesis and Spermiogenesis
Spermatogensis is development of spermatocytes
Spermiogensis is transition into sperm
What is sperm capacitation
Physiologic process by which sperm acquire ability to fertilize ova
Occurs right after ejaculation
What is the role of prostaglandins in sperm transport
Prostaglandins (in semen)
- Stimulate uterine motility at time of intercourse
- Aid in movement to site of fertilization in ampulla
What hormones surges right before ovulation
LH
What hormone causes proliferation of the endometrium
Estrogen
This phase of the reproductive cycle is when estrogen proliferates endometrial glands and endometrial growth is maximized
Proliferative phase
This phase of the reproduction cycle is when progesterone stimulates glands to secrete glycogen and mucus
Secretory phase
What are the effects of high estrogen at ovulation
Increase amount of mucus that is alkaline and not viscous
With a favorable electrolyte content
Making it more favorable for sperm motility
How many days post ovulation is the hCG starting to be secreted in a fertilization
8 days
What is the acrosomal reaction of sperm and egg
enzymatic penetration of zona pellucida
What is the zona reaction of the sperm and egg
change in solubility and binding of zona pellucida: ovum now impermeable to other sperm
What is a morula
16-cell stage of a Zygote
What does the trophoblast become
Placenta
When does the Blastocyst make it to the endometrial cavity s/p ovulation
4 days
What are the 3 phases of implantation
Apposition
(Contact with the uterine wall)
Adhesion
(Contact between the blastocyst and uterine epithelium)
Invasion
(Penetration of the uterine vasculature)
What is the maternal component of the placenta
Decidua
How does maternal blood get to the baby
Decidua
3 parts of the Decidua
Decidua basalis
Decidua capsularis
(separates conceptus from uterine cavity)
Decidua parietalis
When you think chorion
Think
Baby contribution to the placenta
What two layers does the chorion turn into by day 8
Cytotrophoblast (inner layer)
Syncytiotrophoblast (outer layer)
What is Nitabuchs Layer
Maintains maternal/placental separation
Zone of fibrinoid degeneration in decidua basalis
What is placenta increta
When the placenta invades the myometrium
BAD!
What is placenta percreta
When the placenta perforates through the myometrium
What is placenta accreta
When the placenta adheres to the myometrium
BAD!
IN a normal pregnancy what is the rate of hCG production
Doubles every 2 days
When does hCG peak in a normal pregnancy
Peaks at around 60-70 days
Is thought to be a contributor to N/V in pregnancy
What is the peak of hCG in a normal pregnancy
Peaks by 60-70 days
Then declines to plateau for remainder of pregnancy
Abnormally low in ectopic & spontaneous abortion
What are is the HPO axis generally repressed?
Between age 4-10
What is the first indication of puberty in female pts
Thelarche
What is the association between obesity and early onset menarche
Leptin
Naturally found in adipocytes
What is the critical body mass for menarche
48kg (106 lbs)
What is the order of onset of puberty
Thelarche
Adrenal he
Pubarche
Peak Growth Velocity
Menarche
What is the Endo function for the onset of Puberty
PULSATILE exposure of GnRH causes anterior pituitary to release FSH/LH
(onset of puberty)
When is the onset of menarche after thelarche
Menarche typically ~2.5 years after thelarche
A pt presents with breast buds and straight pubic hair that appears of the labia majora
Think what tanner stage
Tanner stage II
What is early puberty (precocious puberty)
Onset before 8 yo
What is the tx approach to central precocious puberty
Treat w/ GnRH agonist to inhibit LH/FSH
Continuous GnRH exposure: negative feedback; inhibits LH/FSH
What are the defining traits of central vs peripheral puberty
Central: High LH/FSH → ↑ estrogen
Peripheral: Exogenous source → ↑ estrogen
FSH/LH suppressed (low)
What is the mean age of txt discontinuation for precocious puberty tx
11 y/o
What is the most common type of delayed puberty
lack of thelarche by 12 and no menses by 16
Constitutional Delay
What are the two presentations of delayed puberty
Due to gonads:
1° hypogonadism:
-High FSH/LH (hypergonadotropic)
Due to hypothalamus-pituitary: 2° hypogonadism:
-Low/nml FSH/LH (hypogonadotropic)
What is the difference betweeen primary and secondary amenorrhea
Primary (no prior menses):
-No menses by age 16 in presence of normal secondary sexual characteristics
- No menses by age 14 in absence of secondary sexual characteristics
- No menses w/in 3 yrs of thelarche
Secondary (cessation of menses)
-Absence of menses for at least 3 months in women who were previously menstruating regularly
-All causes of secondary amenorrhea can cause primary amenorrhea!
What is asherman syndrome
Intrauterine adhesions (cross links)
What is the appraoch to amenorrhea
Is there breast development
Consider outlet obstruction (XX, NML Test)
Is there a uterine and cervix?
(US)
Determine FSH level
What is the most common cause of secondary amenorrhea
Pregnancy
What are the primary tests for amenorrhea
β-HCG FSH Estradiol Prolactin TSH ± fT4
SLIDE 64 !
All the mysteries of Amenorrhea
(Mental cycle lecture)
What is PALM COIN for AUB
Polyps
Adenomyosis
Leiomyoma
Malignancy
Coag Ovulatory dysfunction Endometrial iatrogenic Not classified yet
Slide 74 MEntral bleed flow chart
What is the tx for AUB (ACUTE)
And stable
If stable:
Combined oral contraceptives (q6-8h x7d) or
Progestins: PO or IM
What is the tx for AUB Acute and UNSTABLE
If unstable OR no response in first 12-24 hrs → surgery
1st: Dilation & curettage (D&C)
Balloon tamponade (if surgery unavailable or surgery delayed or as adjunct)
Uterine artery embolization (if above not working)
Hysterectomy (rarely, last resort)
What is the Tx approach to chronic AUB
Normalize the prostaglandins
(if stable)
-NSAIDS
Use Medroxyprogesterone acetate (MPA) 10 mg daily for last 10 days of cycle Combined contraceptives (oral, ring, patch)
Can try endometrial suppression , —Levonorgestrel (LNG) IUD → most effective, often first line for chronic HMB
Or TXA
A Pt presents chronic pelvic pain, with pain during sex, and painful menses, and constipation + infertile
Think
Endometriosis
What are the “D” of endometriosis
Dysmenorrhea
Dyspareunia
Dyschezia
InfetilitD
Barbs located on uterosacral ligament …
Think
Endometriosis
What is the definitive Dx for endometriosis
Laparoscopy!
What is the tx for endometriosis
From watchful waiting to NSAIDs
If NSAIDs ineffective then cyclic hormones to suppress tissue growth
Can use Danzaol : analog that inhibits FSH./LH
GNRH agonistL Leuprolide
SRG Ablation (Fertility concerns and doesnt want OCP)
Refer to Chart in lecture 3 slide 103
What phase of the cycle does PMS effect
Luteal Phase
A pt presents with endometrial S.s during the luteal phase that is S/s free for 7 days in the first half of cycle x 3 consecutive cycles ..
think
PMDD
Think of mood charting for at least 2 cycles
What are the top three S.s of PMDD
Fatigue and loading with Labile mood
What is the primary tx for PMDD
SSRI
And An ovulatory agent (OCP)
What is required to Dx Menopause
When the last period is 12 months ago
What are the S/s of menopause
FSH,IUL!!
Flashes, Flushes Forgetfullness
Sad, Skin changes, Skeletaon, Stroke
headaches, HDz
Insomina
Urinary S/s
Libido Decrease
