Session 5 - Group Work

Question 1

The uterine tubes lie in the free edge of which ligament?

Answer 1

Broad

Question 2

List the mechanisms, which facilitate movement of an ovum along the duct?

Answer 2

Cilia and smooth muscle contraction (peristalsis)

Question 3

Explain how infection may spread to the peritoneum from the female reproductive
tract

Answer 3

The opening of the uterine tube at the infundibulum into the peritoneal cavity allows infection
such as gonorrhea to spread from the vagina and cervix, via the uterus and uterine tubes
into the peritoneal cavity.

Question 4

What may be the consequence of infection in the uterine tubes?

Answer 4

Adhesions, which do not allow an ovum to pass through to the uterus. Hence, this may
cause infertility or an ectopic pregnancy.

Question 5

List two common and two very rare sites of implantation of an ectopic pregnancy.

Answer 5

Common: fimbrial, ampullary, isthmic or interstitial (of the uterine tubes); ovary Rare: Pouch of Douglas, abdominal viscera

Question 6

Where would pain be felt with an ectopic pregnancy implanted in the ampulla of the
uterine tubes? Explain why pain may be felt at the shoulder tip following rupture of an
ectopic pregnancy?

Answer 6

Pain from an ectopic pregnancy is felt in the lower abdominal quadrants

If lying down blood in the peritoneal cavity may collect beneath the diaphragm irritating the
phrenic nerve. Since this nerve originates with cutaneous nerves from C3, 4 and 5, pain may
be referred to the dermatomes for these segments; i.e. shoulders. Pain felt in the lower
quadrants is due to stretching and tearing of the peritoneum.
Blood passing from the vagina is usually withdrawal bleeding (not a result of bleeding at the
site of the rupture), caused by reduction in the hormone hCG which maintains the corpus
luteum and hence prepares the endometrium for implantation.

Question 7

A ruptured ectopic pregnancy at this site may cause a dangerous haemorrhage.
Describe the arterial blood supply to the uterine tubes?

Answer 7

It is an anastomotic system of the ovarian and uterine arteries.

Question 8

The lateral reflection of the peritoneum off the body of the uterus forms which
ligament?

Answer 8

Broad ligaments (which also contain uterine vessels)

The broad ligament may be subdivided. The mesentery of uterus is also called the
mesometrium. The mesosalpinx is mesentery of the uterine tube, whilst the mesovarium is
that part of the broad ligament that suspends the ovary.

Question 9

Histologically, what are the three layers of the uterus and which of these layers is
shed during menstruation?

Answer 9

Perimetrium (outer)
Myometrium (consisting of three muscle layers)
Endometrium (inner) (consisting of the stratum functionalis - shed during menstruation) and
the stratum basalis (which produces new stratum functionalis after each menstruation)

Question 10

The endometrial lining of the uterus is of which type of epithelial cells?

Answer 10

Simple columnar epithelium (either are ciliated or have microvilli) with glycogen producing
glands changing from simple to highly coiled over the course of the uterine cycle.

Question 11

How does this compare to the cervical canal epithelium?

Answer 11

Tall columnar cells, with branched glandular cells, which form an alkaline mucus.

Question 12

How does the epithelium of the body of the uterus change during the menstrual
cycle?

Answer 12

menses days 1 – 4 : desquamation of 2/3, bleeding
days 5 – 7 : rapid re-growth from remaining epithelial cells
days 7 – 14 : endometrial re-growth is completed
This concludes the proliferative phase
days 14 – 28 : Secretary phase includes endometrial thickening, enlargement of
glandular cells, oedematous, proliferation of white cells.
3 layers : compact superficial zone spongy middle zone (glandules) inactive
basal layer

As menses approach the arteries go in to spasm, retracting back to the deeper layers
evoking ischaemia.

Question 13

Explain why the ureter is in danger of being damaged during hysterectomy.

Answer 13

In clamping off the uterine artery, the ureter may be accidentally damaged (remember :
water (urine) under the (arterial) bridge).

Question 14

List the lymphatic drainage of the following structures.

Answer 14

Fundus of uterus - aortic nodes (lesser to inguinal lymph nodes)
Body of uterus - external iliac nodes
Cervix - external and internal iliac nodes, sacral nodes.

Question 15

In what position does the uterus usually lie ?

Answer 15

anteverted and anteflexed

Question 16

What is assessed in a bimanual examination?

Answer 16

Insertion of one or two fingers into the vagina to examine the cervix. The external hand
palpates the uterus (and ovaries if enlarged) from the anterior surface of the body to assess
for pregnancy or irregularity.

The uterus is assessed for mobility, consistency, pain, regularity, position, size (usually of a
plum, 10weeks pregnancy it is the size of an orange), etc

Question 17

If the uterus is retroverted, which structure would be the presenting part on a
speculum or vaginal examination?

Answer 17

Os or the posterior lip (rather than the anterior lip) of the cervix.

Question 18

Secretory cells of the cervix produce a cervical mucus. Comment on how the mucus
changes during the uterine cycle.

Answer 18

The mucus is a mixture of water, glycoprotein, lipids, other proteins, enzymes and inorganic
salts. Production of mucus is greatest during the follicular phase, in readiness for ovulation.
It changes from cloudy to clear. At ovulation it is a clear, acellular mucus with high
stretchability (spinnbarkeit). (Such characteristics may enable a women to self-assess the
time of ovulation - it dries in a glass slide with a characteristics fern-patterning). Following
ovulation (as progesterone increases), the mucus again becomes cloudy and more sticky
but in diminishing quantities.

A thick cervical mucus -plug forms during pregnancy - the loss of which may indicate labour.

Question 19

From what cells of the cervix do Nabothian cysts develop?

Answer 19

From the cervical glandular ducts.
Infection of the endocervical glands (as in chronic cervicitis) can result in blockage of the
ducts and hence cyst formation (between 2mm to 1cm). There presence, especially if
infected, can reduce chances of pregnancy by making the cervix inhospitable to sperm.

Question 20

What are the anatomical relations of the vagina?

Answer 20

Anteriorly – base of bladder and urethra (embedded in anterior vaginal wall)
Posteriorly – anal canal, rectum and most superiorly pouch of Douglas
Laterally – levator ani and ureters (lying just superior to lateral fornices) (A ureteric stone
can sometimes be palpated from the vagina)

Question 21

Which structures may be palpated in a vaginal examination?

Answer 21

Anteriorly – bladder, urethra and pubic symphysis
Posteriorly – rectum (prolapsed uterine tubes and ovary)
Laterally – ovary and uterine tube, sidewall of pelvis (ischial spines)
Apex – cervix (ante or retro-verted)

Question 22

In bimanual / pelvic examination, which of the cervical fornices is the usually largest
and why? What structures can be palpated from each fornix?

Answer 22

Since the uterus is usually anteverted and anteflexed, the posterior fornix is the deepest
(more of the posterior part of the cervix enters the vagina compared to anteriorly). The
fornices form a continuous recess around the cervix.

During bimanual examination, examination of the pelvis, the vaginal fingers should pass
through each of the four fornices. Palpation of the posterior fornix is used to assess posterior
fundus, uterosacral ligaments, posterior broad ligaments/ovaries and Pouch of Douglas.
Palpation of the anterior fornix might address bladder, recto-pubic space
Palpation of the lateral fornices might address broad ligaments and associated structures.
The Fallopian tubes and ovaries cannot normally be felt.

Question 23

Very generally, which lymph nodes drain the vagina?

Answer 23

Inguinal lymph nodes

Question 24

How does the epithelial lining of the vagina reflect its function?

Answer 24

Stratified squamous epithelia, hence external layers are shed with friction. Cells are swollen
due to glycogen production. Lubrication is via cervical mucus, shed vaginal cells.

Question 25

Which bony (and fibrous) structures form the boundaries of the perineum?

Answer 25

Pubic symphysis, inferior pubic rami, ischial rami, ischial tuberosity, sacrotuberous
ligaments, coccyx

Question 26

Hence, which structures are found within the urogenital and anal triangles in the
female and male perineum?

Answer 26

Urogenital triangle
Female - External genitalia
Male - Root of scrotum and penis

Anal triangle
Female - Anus
Male - ANus

Question 27

Which structure is found mid-point of the line joining the ischial tuberosities?

Answer 27

perineal body

Question 28

How is the bony pelvis assessed in early pregnancy?

Answer 28

Bimanual exam, palpate ischial spines, assess intertuberous distance, assess
subpubic arch, assess diagonal conjugate.

Question 29

What might an narrow pubic arch signify?

Answer 29

Possible small pelvic outlet

Question 30

Why is it important for the fetal head to rotate after it delivers?

Answer 30

lows the fetal shoulders to move into the long axis of pelvic outlet

Question 31

Which two muscles would you feel contracting when the patient squeezes on the
examining finger?

Answer 31

The external anal sphincter muscle tube squeezes and the puborectalis pulls the finger
anteriorly.

Question 32

What important role does the perineal body play in pelvic floor support?

Answer 32

In women, the fibro-muscular perineal body supports the lower posterior part of the vaginal
wall against prolapse and forms a dense attachment for the two halves of the levator
muscles in the midline. It acts as a tear-resistant body between the vagina and external anal
sphincter muscle tube during childbirth, but is now considerably stressed by the evolution of
large fetal head size.

Question 33

Which part of levator ani muscles can be torn or stretched during childbirth and with
what consequences?

Answer 33

Fibres of pubococcygeus can be damaged which may lead to prolapse or herniation of
bladder and / or urethra with subsequent incontinence. The medial fibres of pubo-rectalis
(which inserts into the perineal body as a pubo-vaginalis muscle) may be torn together with
the perineal body allowing herniation of the rectum to occur (the tear extending into the
external anal sphincter) leading to difficulty with defecation or faecal incontinence.

Question 34

What is an episiotomy?

Answer 34

A surgical cut in the perineum during childbirth to avoid tearing and damage to the perineal
body

Question 35

In general, what tissues need to be repaired after episiotomy?

Answer 35

Vaginal mucosa and submucosa, perineal skin, muscles and fascia of perineum

Question 36

What checks should you carry out after repair of an episiotomy?

Answer 36

Vaginal and rectal exam.