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 ve in on the th e left. the ovarian vein joins the renal vein 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. Uterine Supply The aorta first branches into the common iliac arteries. The common iliac arteries then split into the external iliacs (which will become the femoral arteries as they exit the pelvis under the inguinal ligament). The arteries 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. Start with the uterine arteries, then internal iliacs, but don't go farther than that. If it still can't be kept under control a total abdominal hysterectomy is what she gets; her life is worth more than preserving her ability to reproduce.
Path Pt Dx Tx
Ovarian Torsion Twists about the suspensory ligament Spontaneous, Sudden onset pelvic pain Clinical --> Ultrasound --> Surgery Untwist ovary during Ex-Lap - Pinks up, leave it in - Stays grey, take it out
Management of Post-Partum Hemorrhage 1) Physical Definition Uterine Massage 500 cc Vaginal 2) Medications 1000 cc C-Section Oxytocin 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 t hey 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 chil dren, 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 t hese 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. 2) Cystocele / Stress Incontinence: see the urinary incontinence lecture. The bladder falls into the vagina and allows urine to leak with increased intrabdominal pressure (sneezing, coughing, tennis). Cervical exam shows a Q-tip sign or an anterior prolapse (the bladder falling in). 3) Rectocele / Constipation: the rectum falls forward into the space occupied by the vagina. The patient can relieve the constipation by inserting fingers into her vagina and pressing. Cervical exam shows a posterior prolapse (the rectum).
Grade Grade Grade Grade
Path: Pt: Dx: Tx:
I II III IV
Uterine Prolapse In vaginal canal At the vaginal opening Out of vagina but not inverted Inverted and out of vagina
Pelvic Floor Rel axation Multiple births, stretched ligaments Vaginal Fullness, Chronic Back Pain, Speculum exam shows prolapse Clinical, Physical exam Vaginal Hysterectomy (prolapse) Colporrhaphy (Cystocele, Rectocele) Sling / Reconstruction (Cystocele)
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