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When preparing raw food it's important to be hygienic and store your edibles safely. Using a big tablespoon, By eati DC Dutta's Textbook of Gynecology. TEXTBOOK OF. DC DUTTA's. GYNECOLOGY including. Contraception. Book Donated by: tvnovellas.info Please Donate to keep us alive and let us keep. DC DUTTA's TEXTBOOK OF GYNECOLOGY including Contraception OTHER BOOKS BY THE SAME AUTHOR yy Textbook of Obstetrics yy A guide to Clinical .
Overseas Offices J. All rights reserved. No part of this publication may be reproduced, stored or transmitted in any form or by any means, elec- tronic, mechanical, photocopying, recording or otherwise, without the prior permission in writing of the publishers. All brand names and product names used in this book are trade names, service marks, trademarks or registered trademarks of their respective owners. Information contained in this book is uptodate, believed to be reliable when checked with the sources and is in accordance with the accepted standard, at the time of publication. However, with ongoing research and passage of time, new knowledge may modify some of it.
The fascia is very tough and membranous. The deep endopelvic connective to the margins of the bone. It contains fatty and connective is situated inferior to the uterosacral ligament with tissues and unstriped muscle fibers.
Condensation occurs especially near the cervicovaginal junction to form ligaments. Condensation of parietal fascia covering the to merge with the visceral layer of the pelvic fascia obturator internus.
It covers which extend from the viscera to the pelvic walls the obturator internus and pyriformis and gets attached on either side. Distal The cellular tissue lies between the pelvic peritoneum part of ureter passes under the uterine artery and the pelvic floor.
Lateral supravaginal cervix and upper fascia Covering the pelvic Viscera part of lateral vaginal wall in a fan-shaped manner. The main supporting ligaments of the uterus viewed from above fascia on the pelvic Wall called parametrium. Uterosacral plexus of autonomic nerves.
It extends is suspended over the levator plate. They serve mainly as vascular conduit and provide x infection spreads along the track. Arcus tendinous fascia white line and widen up the spaces. These ligaments are poorly developed. It supports the posterior vaginal wall.
These are the primary proximal suspensory ligaments. After traversing through the inguinal It extends between the posterior vaginal wall canal. It is continuous with Content: Pericervical ring see Fig.
Vesicovaginal septum: It is a fibroelastic connective to the thigh along the external iliac vessels and tissue with some smooth muscle fibers. It is located between the posterior Uterus is thus maintained anteflexed and the vagina surface of the cervix and the rectum behind. Smooth muscle and minimal vessels. During its course. It is also a fibroelastic connective tissue with It courses beneath the anterior leaf of the broad few smooth muscle fibers.
Anterolateral supravaginal cervix and condensation blends with the pericervical ring of endopelvic fascia and the cardinal ligaments. Here it blends with the endopelvic supravaginal part of the cervix.
Artery and veins of the bladder pillar. Each measures vaginal wall.
These are formed by condensation of peritoneum. This fibroelastic anterior third of the labium majus. They hold the cervix posteriorly at the level of the ischial spines. Back of the pubic bone and the arcus Clinical significance of the tendinous fascia laterally. It is a circular band Insertion: Posterolateral surface of the cervix at the of fibromuscular connective tissue that encircles the level of internal os.
It is an extension of endopelvic fascia. It is hypertrophied posteriorly with the uterosacral ligaments. Periosteum of sacral vertebra 2. It supports the bladder and the anterior These are paired. It contains plain arcus tendineus fascia. It corresponds developmentally in length. In the fetus. The lymphatics from the body of the uterus pass along it to reach the inguinal group of nodes.
Paravagial defect may be due to: Defect in the Posterior Compartment see p. The blood to the gubernaculum testis. It is lined by ciliated columnar epithelium.
The glands are simple tubular. The cortex is studded with follicular structures and the medulla contains hilus cells which are homologous to the interstitial cells of the testes. It lies close to the supravaginal part of the cervix 1.
The deep perineal pouch is formed by the inferior and superior layer of the urogenital diaphragm. The duct is lined by columnar epithelium except near the opening. The ovarian fossa is related posteriorly to ureter. The glycogen content is highest in the vaginal fornix being 2. The cervical glands are compound racemose type. Doderlein bacillus is gram-positive anaerobic organism. The duct measures 2 cm.
There is no submucous layer. Ureter lies about 2 cm from the lateral fornix. Isthmus is bounded above by the anatomical internal os and below by the histological internal os. This prevent pelvic organ prolapse see Table Mucous coat is lined by transitional epithelium. It has no glands. One end is attached to cornu of the uterus and the other end terminates in the anterior third of the labium majus.
Broad ligament contains Fallopian tube. Uterine artery crosses the ureter anteriorly from above. The ureter is likely to be damaged during hysterectomy at the infundibulopelvic ligament. The pH ranges between 4 and 5. The epithelium. The labia minora are devoid of fat and do not contain hair follicle. Normal length of uterine cavity is 6—7 cm.
It is comparatively constricted i where it crosses the brim. The tube measures 10 cm. Isthmus measures 0.
Cervical canal is lined by tall columnar epithelium. The gland is compound racemose and lined by columnar epithelium. It measures about 2 cm. Only the anterior division supplies the arise almost at right angles. These common iliac artery. The branches are schematically the entire length of the myometrium.
It ultimately anastomoses Vaginal artery end on with the tubal branch of the ovarian artery in Origin: The vaginal artery arises either from the the mesosalpinx.
Uterine artery a Short basal artery—supplies the basal endo- Origin: The uterine artery arises either directly metrium. It runs downwards and forwards along the finally in extensive capillary plexuses Figs lateral pelvic wall almost in the same direction as the 2.
The bifurcation occurs over anastomose with the corresponding branches of the sacroiliac articulation. It soon divides into anterior and posterior the arcuate arteries. Near the mentioned overleaf. From posteriorly. These pierce about Internal iliac artery one-third of the myometrium and then divide Internal iliac artery is one of the bifurcations of the into anterior and posterior branches.
A Showing pattern of basal and spiral arteries in the endometrium. Lymphatic Drainage and Innervation of Pelvic Organs 27 the internal iliac artery. Numerous transverse branches are sent the cervix. It is in relation to the lateral Other arteries contributing to azygos arteries fornix and then runs down along the lateral wall of are: A B Fig.
B Internal blood supply of the uterus Ch They arteries of the vagina—one anterior and one posterior. These are variable in number.
Higher up. Each ovarian artery arises from the front of the aorta. It supplies the lower-third The ovarian veins on each side begin from the of the vagina. As it enters the hilum of the ovary. It then divides into two and each courses hypotension syndrome in late pregnancy. This will help Venous drainage from the rectal plexus drains via in maintaining the blood supply of the bladder when superior rectal vein into the inferior mesenteric the vesical branch of the internal iliac artery is ligated.
The middle and inferior rectal veins drain into the internal pudendal vein and thence to the internal Ovarian artery iliac vein. It enters the pelvic cavity Applied Anatomy after crossing the external iliac vessels. This teric artery and descends down to the base of pelvic collateral pathway is also related with supine mesocolon.
It then runs medially along the infundibulopelvic ligament to enter the mesovarium. It is one of the parietal of broad ligament near the mesovarium. It leaves the pelvic cavity along with its of the corresponding artery.
The terminal branches of the artery anastomose with superficial and deep pudendal Rectum arteries—branches of the femoral artery. Middle rectal: It arises either directly from the anterior division of the internal iliac or in common Ovarian veins with inferior vesical artery.
Beyond the branches of the anterior division of the internal infundibulopelvic ligament. Superficial group receive afferents from gluteal Internal iliac nodes receive afferents from all the region. Sacral group It consists of two sets of glands.
One lying hori. These two groups receive all the lymph from the pelvic organs. Afferents are from internal iliac. Schematic representation of the lymphatic opens into the left subclavian vein at its junction drainage of the body of uterus with left internal jugular vein.
Common iliac lymph nodes are arranged in three groups: Lymphatic Drainage and Innervation of Pelvic Organs 29 specially in malignant diseases.
In carcinoma cervix. They receive afferents from external and internal iliac nodes and send efferents to the lateral aortic nodes. The following groups Efferents from the deep nodes pass through the femoral of nodes are involved. It is of small size. There are three groups: These nodes receive iliac artery.
They are 5—6 in These glands receive drainage from the cervix. Inguinal nodes Fig. The lymph is finally carried upwards via the thoracic duct which Fig.
Lumbar group It consists of two sets of glands— 1 Inferior group. The lymphatics from these groups pass on either to the inferior lumbar group or to the common iliac group. The efferents ultimately drain into the common iliac group.
There are two groups. The efferents from the superficial along the median and lateral sacral vessels. Internal iliac group. The afferents from these plexuses pass up along with ovarian lymphatics Extrinsic drainage to superior lumbar group. Sacral group. Obturator group. External iliac—anterior and medial group.
Parametrial group—inconsistent. Two plexuses are demonstrated: Schematic representation of the lymphatic drainage of the cervix Ch Levator ani. Node of Cloquet: It was previously thought to be the main relay node through which the efferents from the superficial inguinal nodes pass to the external iliac nodes.
The efferents from the superficial inguinal may reach the external iliac group bypassing the node of Cloquet. Lymphatics intercommunicate with the opposite side iv Posterior cutaneous nerve of thigh.
Labia majora anterior half iii Genital branch of genitofemoral nerve—L1. The motor fibers supply all the Labia majora posterior half voluntary muscles of the perineal body. Lymphatic Drainage and Innervation of Pelvic Organs 31 Labia minora and prepuce of clitoris Intercommunicating with the lymphatics of the opposite side in the vestibule and drains into superficial inguinal nodes.
Glans of clitoris: Drains directly into the deep inguinal and external iliac glands. The lymphatics drain into superficial inguinal and anorectal nodes. Pudendal nerve Thus. Recent study shows its insignificant involvement in vulval malignancy. Upper half drains like that of bladder. Diagram showing nerve supply of the internal genital organs While the anterior half of vulval skin is supplied by of 5th lumbar vertebra and more often wrongly called the ilioinguinal and genital branch of genitofemoral presacral nerve.
The fibers are mainly sensory to the superior hypogastric plexus. The pelvic plexus then continues along the course of the uterine artery as paracervical plexus Fig. The fibers from the preaortic plexus of the hypogastric nerve of the corresponding side to form sympathetic system are continuous with those of the pelvic plexus.
This The autonomic supply is principally from the plexus lies in the loose cellular tissue. The motor fibers arise from the segments The parasympathetic fibers nervi erigentes are D5 and D6 and the sensory fibers from the segments derived from the S2. Sympathetic The sympathetic system carries both the sensory and Parasympathetic motor fibers. The hypogastric nerve joins the pelvic of thigh. This plexus lies in front cervix. While passing over the bifurcation nerves. Levator ani muscle supports the pelvic viscera and prevents pelvic organ prolapse see p.
The azygos arteries two are formed by vaginal. The sensory supply of the tube and ovary is from D10 to D The sensory supply of the tube and ovary is sympathetic fibers. S3 and S4 nerves. The ovarian veins drain into inferior vena cava on the right side and into the left renal vein on the left side. Fallopian tube and the fundus of the impulses carried via sympathetic or para. The endodermal cloaca is divided by a coronally oriented vertical partition.
This eleva- Fig. The external genital organs start developing almost c. It contributes to vestibule of vagina. When the urogenital membrane rupt- The ventral portion. The urorectal septum contains a the cloacal membrane is the primitive perineal body. The lower phallic part of the urogenital sinus: Diagrammatic representation showing differentiation of the female external genitalia Ch Upper vesicourethral part forms the mucous persists as vestibule.
The ectodermal swelling. Eventually they form the labia majora. The site of origin is from the urogenital see below. Middle pelvic part of urogenital sinus: It The genital folds meet at the cephalic end of the receives the united caudal end of the two para. They persist as labia minora. The the primitive perineal body is called urogenital dorsal part of the endodermal cloaca.
The perineal cleft a. It also contributes to the major part of side and lateral to the genital fold is called labioscrotal female urethra. Vestigial structures are also shown. B Newborn female Ch Diagrammatic representation showing development of female reproductive systems from the primitive genital ducts. A Female fetus at 12 weeks. It receives the openings of urethra. The ingrowth forms a groove male and the female 50 mm CR length.
The inferior portion of the pelvic part Fig. The duct forms one on tion is known as genital tubercle. If the gonads become ovaries. Myometrium and in the urorectal septum and meet each other. Around endometrial stroma are developed from the meso.
The coelomic opening of the duct becomes the pronephric origin Fig. The corresponding mesonephric duct and then meets its intervening septum disappears during the 5th counterpart from the opposite side in the midline month of intrauterine life.
The lining epithelium Fig. The cervix Each paramesonephric duct passes ventral to the is differentiated from the corpus by 10th week. B Earliest development of vaginal plate and mesonephric duct. The mesonephric tubules.
The united lower vertical parts ducts up to the lateral pelvic walls. These endodermal cells further ducts and partly from the urogenital sinus. The tissue at the Vaginal introitus is developed from the ectoderm periphery persists as hymen. It is lined by sinus of the genital folds after rupture of the bilaminar epithelium endodermal origin on either side with a urogenital membrane.
Site and the majority enter into the prophase of the first The ovary is developed on either side from the genital meiotic division and are called primary oocytes. This ridge is formed in a four-week These are surrounded by flat cells granulosa cells embryo between the dorsal mesentery medially and and are called primordial follicles. At birth, there is no the mesonephric ridge laterally by the multiplication more mitotic division and all the oogonia are replaced of the coelomic epithelium along with condensation by primary oocytes.
The estimated number at birth of the underlying mesenchyme Fig. Sources Indifferent or Primitive Gonad The cortex and the covering epithelium are developed Initially, the gonads do not acquire male or female from the coelomic epithelium and the medulla from morphological characteristics until the seventh week the mesenchyme.
The germ cells are of endodermal of development. Around the time of arrival of germ origin. They migrate from the yolk sac to the cells, the coelomic epithelium of the genital ridge genital ridge along the dorsal mesentery by ameboid proliferates. The irregular cords of cells primitive sex movement between 20 and 30 days. The germ cells cords invaginate the underlying mesenchyme. These undergo a number of rapid mitotic divisions and cords of cells surround the primordial germ cells and differentiate into oogonia.
The number of oogonia still have connection with the surface epithelium. It reaches its maximum at 20th week numbering is difficult at this stage to differentiate between an about 7 million. The mitotic division gradually ceases ovary and testis. Schematic representation of the development of the reproductive system in the male and female.
Derivatives Embryonic structure Male Fig. Definitive Gonad cords of cells into the mesenchyme cortical cords , In a XX individual, without the active influence of Y but unlike testis, maintains connection with the sur- chromosome, the bipotential gonad develops into face epithelium. In the fourth month, these cords split an ovary about two weeks later than testicular into clusters of cells, which surround the germ cells.
SRY gene located on the short arm The germ cells will be the future oogonia and the of Y chromosome directly controls the differ- epithelial cells will be the future granulosa cells. Apart From 20th week, the oocytes that are not surrounded from SRY, autosomal genes are also essential for by the granulosa cell envelope, are destroyed.
The differentiation of the gonads. Absence of SRY gene leads to female sex differentiation Fig. Thus, a basic Genetic control is of prime importance for differentiation of bipotential gonad. Genes that regulate the process are: DAXI gene expression is involved in ovarian differentiation. The cranial part of the genital ridge becomes the The surface becomes thicker and continues to infundibulopelvic ligament Fig. From the lower proliferate extensively. It sends down secondary pole of the ovary, genital ligament gubernaculum.
Gubernaculum is a fibromuscular band. The and the part between the cornu of the uterus to genital ligament gets an intermediate attachment the end is the round ligament. The part between the ovary and they are situated at the pelvic brim. Testicular development is an active event whereas ovarian development is a default pathway due to absent SRY gene. The cortex and the covering epithelium are developed from the coelomic epithelium and the medulla from the mesenchyme.
The germ cells are endodermal in origin and migrate from the yolk sac to the genital ridge. The number of oogonia reaches its maximum at 20th week numbering about 7 million.
The estimated number at birth is about 2 million. The mesonephric duct in male gives rise to epididymis, vas deferens and seminal vesicles. The sinovaginal bulbs, which grow out from the posterior aspect of the urogenital sinus, differentiates into vagina. The genital tubercle differentiates into clitoris female or penis male. The urinary bladder develops from the urogenital sinus. Introduction main symptom is uncontrollable wetness.
Partial nephrectomy and ureterectomy may be indicated or From the embryological considerations, the following implantation of the ectopic ureter into the bladder facts can be deduced.
The existence is revealed after marriage. Dyspareunia may be the first complaint, or it may be detected during investigation of infertility.
The anal opening Gross hymenal abnormality of significance is situated either close to the posterior end of the is imperforate hymen. It is due to failure of vestibule or in the vestibule.
The eminence that projects into the urogenital sinus opening is usually sufficiently big and continence is see p. The existence is almost always unnoticed present. There is no problem in future reproduction.
As the The delivery should be by cesarean section see p. Depending upon the amount of is to be done bringing the anal end to the anal pit with blood so accumulated, it first distends the vagina prior colostomy. The uterus is next involved and the cavity is dilated hematometra. The Hematosalpinx Fig. Hematocolpos and hematometra due to Fig. Ultrasonographic view of hematometra and imperforate hymen. Note the elongation of the urethra hematocolpos in a girl with imperforate hymen due to distension of the vagina by blood.
Clinical features: The girl is aged about 14—16 years. In fact, in significant cases Cruciate incision is made in the hymen. The quadrants the presenting feature may be the retention of urine. Spontaneous escape of dark tarry urethra Fig.
Abdominal examination reveals a suprapubic Pressure from above should not be given. Internal swelling, which may be uterine or full bladder. Prior examination should not be done.
The patient is put catheterization reveals the true state. Antibiotic should be given. The residual pathology, if any, may be detected Vulval inspection reveals a tense bulging membrane by internal examination after the next period is over. Rectal examination reveals the bulged vagina.
Ultrasonography can make the diagnosis of Common variations of vaginal maldevelopments hematometra and hematocolpos Fig. Tense bulging of the hymen Fig. Spontaneous escape of dark tarry blood in hematocolpos following incision. The probable causes are: The principles of surgical polygenic, multifactorial, teratogens, or environmental. It may be often perforated. Incision of a complete imperforate due to failure of formation of the vaginal plate or due septum becomes easy when the upper vagina is to its failure of canalization or cavitation.
This reduces the risk of injury to adjacent organs. Otherwise abdominovaginal approach see Vertical fusion defects result in failure of fusion of p. It may be associated with double Disorders of lateral fusion are also due to failure uterus and double cervix. This results in needs no treatment. But it may cause dyspareunia or double uterovaginal canals. Such malformation may may obstruct delivery. In such circumstances, the be obstructive or nonobstructive.
Results of surgery are good Transverse vaginal septa are due to faulty fusion or in terms of achieving pregnancy. Septum A segment of vagina may be atretic in the upper-third. Uterus may be normal and functioning or hymen. Ultrasonography is a useful investigation to malformed.
Primary amenorrhoea cryptomenorrhea ,. During surgery VVF, pain and presence of lower abdominal mass as felt RVF, infection and bleeding are the important ones. Dyspareunia, restenosis are common late complications. Conventional treatment is hysterectomy.
Prosthesis is Associated abnormalities with: The result is, however, not a. When hysterectomy of the cloaca instead of the pelvic part of the is considered, ovaries should be conserved. This urogenital sinus see Fig. Assisted b.
Persistent urogenital sinus with various irregularities of urethral and vaginal orifices in Complete agenesis of the vagina is almost always the sinus. There is, however, presence of healthy gonads and fallopian tubes. Class I: Unicornuate uterus, Class III: Didelphys psychological counseling.
Often they are depressed uterus, Class IV: Bicornuate uterus, Class V: Septate concerning their sexual and reproductive life. Arcuate uterus, and Class VII: Treatment options are: Diethylstilbestrol DES -related abnormality.
Nonsurgical method: It varies vaginal dilators for a period of 6—12 months. The incidence is found to be high Presence of a vaginal dimple 1 cm is often in women suffering from recurrent miscarriage or seen.
McIndoe-Reed procedure A space is The absence of both ducts leads to absence of uterus, created digitally between the bladder and the including oviducts. There is absence of vagina as well. Split thickness skin graft is used over Primary amenorrhea is the chief complaint. This mould is kept in this neovaginal The absence of one duct leads to a unicornuate space.
Williams Vulvovaginoplasty Agenesis of the upper vagina or of the cervix—This c. Vaginoplasty with amnion graft may lead to hematometra as the uterus is functioning Chakraborty, Konar, see p.
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Next 37 years. Hormone in gynecology practice. Gynecological problems from birth to adolescence. Special topics. Operative Gynecology. Endoscopic surgery in gynecology. Current topics in gynecology.
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