Gynecology [PELVIC ANATOMY]
Ovarian Blood Supply:
The Aorta feeds the major tributaries to the body. The
ovarian arteries both exit from the aorta - they are their
own branches. The uterine arteries are discussed below.
The venous drainage of the ovaries mimics the venous
drainage of the kidneys and adrenals. On the left side the
vena cava is far away. Thus, like the kidneys and adrenals
the ovarian vein joins the renal vein on the left.
Conversely, since the vena cava is so close to the left
ovary, like the kidneys and adrenals the ovarian vein joins
the vena cava directly on the right.
Both the artery and vein pass through the suspensory
ligament of the ovary (in green)
Clinical Correlate: Ovarian Torsion. The ovary can spin
around. This twisting cuts off the arterial supply much
like kinking a hose. This happens when the ovary is
weighed down, such as by a cyst. The surgeon would
have to go in to the pelvis and untwist the ovary to see if
revascularization can save the ovary or if it needs to be
removed because of necrosis. Ovarian Torsion
Path Twists about the suspensory ligament
Uterine Supply Pt Spontaneous, Sudden onset pelvic pain
The aorta first branches into the common iliac arteries. Dx Clinical --> Ultrasound --> Surgery
The common iliac arteries then split into the external Tx Untwist ovary during Ex-Lap
iliacs (which will become the femoral arteries as they - Pinks up, leave it in
exit the pelvis under the inguinal ligament). The arteries - Stays grey, take it out
we REALLY care about are the internal iliacs that then
give rise to the uterine arteries. Deep down in the pelvis
are these arteries that feed the uterus and supply the
blood. This matters when mom bleeds. What’s important
to see is that the external iliacs can’t be cut off as that will
lead to death of the legs. We CAN ligate the uterine
arteries and even the internal iliacs without affecting a
whole lot of organs other than the uterus.
Clinical Correlate: In post-partum bleeding the goal’s to
do everything possible to preserve mom's ability to
reproduce. Start with uterine massage, trying to get the
uterus to contract down. If that fails, try medications -
oxytocin and methergine. Of course keep her tanked up
with blood if mom loses A LOT of it. But ultimately there
will be surgery. Staying closest to the uterus is best, so as
to not compromise the blood supply of nearby structures.
Management of Post-Partum Hemorrhage
Start with the uterine arteries, then internal iliacs, but
1) Physical Definition
don't go farther than that. If it still can't be kept under Uterine Massage 500 cc Vaginal
control a total abdominal hysterectomy is what she gets; 2) Medications 1000 cc C-Section
her life is worth more than preserving her ability to Oxytocin
reproduce. Methergine
Transfuse prn
3) Surgery = Ex-Lap
Uterine Arteries
Internal Iliacs
TAH
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Gynecology [PELVIC ANATOMY]
Ligaments
There are three ligaments that must be worried about.
They keep everything in place in the pelvis; failure to do
so can result in pathology.
1) Suspensory ligament of the ovary we talked about
above. See clinical correlate with ovarian torsion.
2) Uterosacral Ligament. This is the ligament that keeps
the uterus tacked down to the sacrum and contained in the
pelvis. To get the uterus out of the pelvis they must be
cut. But they’re in the same place as and look very similar
to the ureters. Yes, cut the uterosacral ligament. No, don't
cut the ureters. This would be a urologic emergency.
3) Cardinal Ligament of the Uterus. This is a ligament
that comes off the pelvic side walls and keeps the uterus
in place left to right, side to side. But it also has bands
that branch forward and backwards, attaching to the
bladder and the rectum. When young, prior to children,
these ligaments are tight and keep everything in place as
they should be. But this ligament can be tugged and
pulled in all three directions. So these ligaments can get
stretched out as a woman goes through pregnancy and
birth.
Pelvic Floor Relaxation (Clinical Correlates)
1) Uterine Prolapse: The uterus is no longer held in the
pelvis and begins to literally fall out, to invert, and come
out the vaginal opening. Cervical exam reveals a
prolapsed uterus or a shortened vagina with the cervix too
close to the opening.
Uterine Prolapse
2) Cystocele / Stress Incontinence: see the urinary
Grade I In vaginal canal
incontinence lecture. The bladder falls into the vagina and Grade II At the vaginal opening
allows urine to leak with increased intrabdominal pressure Grade III Out of vagina but not inverted
(sneezing, coughing, tennis). Cervical exam shows a Q-tip Grade IV Inverted and out of vagina
sign or an anterior prolapse (the bladder falling in).
Pelvic Floor Relaxation
3) Rectocele / Constipation: the rectum falls forward into Path: Multiple births, stretched ligaments
the space occupied by the vagina. The patient can relieve Pt: Vaginal Fullness, Chronic Back Pain,
Speculum exam shows prolapse
the constipation by inserting fingers into her vagina and
Dx: Clinical, Physical exam
pressing. Cervical exam shows a posterior prolapse (the Tx: Vaginal Hysterectomy (prolapse)
rectum). Colporrhaphy (Cystocele, Rectocele)
Sling / Reconstruction (Cystocele)
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