SURFACE ANATOMY - ABDOMEN

The abdomen is divided into 9 regions:

 Right hypochondrium, Epigastrium, left hypochondrium
 Right lumbar, umbilical, left lumber
 Right iliac, hypogastrium, left iliac; by:

1) Two vertical planes through the mid-point between the anterior superior iliac spine and the symphysis pubis and

2) Two horizontal planes:

 The sub-costal plane - joins lowest points of costal margin on both sides (inferior margin of 10th costal cartilage; level
L3)
 The inter-tubercular plane - joins tubercles of iliac crests (level L5)
 Trans-pyloric plane -Through tips of 9th costal cartilages (point where linea semilunaris intersects with costal margin).
Passes through the pylorus, nexk of pancreas, hili of kidneys and duodeno-jejunal junction.

Abdominal wall

Dermatomes
 Xiphoid process - T7
 Umbilicus - T10
 Pubis - L1

Blood supply
 Medial aspects - Superior epigastric artery (above umbilicus - continuation of the internal thoracic artery, branch of
the first part of the subclavian artery. Enters the rectus sheath between the sternal and costal origins of the
diaphragm and descends behind rectus muscle)
 Inferior epigastric artery (below umbilicus - branch of external iliac artery just above inguinal ligament. It pierces the
transversalis fascia to enter the rectus sheath anterior to the arcuate line; runs behind rectus muscle). There is no
anastomosis between the arteries of the left and right side
 Lateral aspects - intercostals, lumbar arteries and deep circumflex iliac artery (branch of external iliac artery above
the inguinal ligament).

Venous drainage
 Above umbilicus - axillary vein via lateral thoracic and superficial epigastric veins
 Below umbilicus - femoral vein via superficial epigastric and great saphenous vein
 Few para-umbilical veins drain into the portal vein via the ligamentun teres, forming a portal-systemic anastomosis.
Distended veins may indicate portal hypertension *
 Deep veins follow the arteries with the posterior intercostals veins draining into the azygous vein and the lumbar
veins into the inferior vena cava
Caput medusae, also known as palm tree sign, is the appearance of distended and engorged superficial epigastric
veins, which are seen radiating from the umbilicus across the abdomen (MRCOG 1 2015)
Lymphatics
 Above umbilicus - anterior axillary nodes
 Below umbilicus - superficial inguinal nodes
 Deep lymphatics follow the arteries into the internal thoracic, external iliac, posterior mediastinal and para-aortic
nodes

HERNIAS

INGUINAL
 Indirect commoner than direct
 Indirect more common in males and on the right side (right testis descends later than the left)
 Direct hernias commoner in (old) males
 Indirect: Enters inguinal canal through deep inguinal ring, lateral to inferior epigastric vessels. Can descent into the
scrotum or labia majora. Sac is formed by the remains of the processus vaginalis
 The sac of all inguinal hernias lies above and medial to the pubic tubercle
 FEMORAL
 Commoner in females protrudes through the femoral canal medial to the femoral vein, below and lateral to the pubic
tubercle.

UMBILICAL
 Congenital - exomphalos
 Acquired infantile - weakness in scar of umbilicus
 Acquired adult - para-umbilical, weakness in linea alba above or below umbilicus, commoner in females

EPIGASTRIC
 Weakness in linea alba above umbilicus

RICHCTER’S
 A knuckle of the side-wall of the bowel is incarcerated in the sac but the continuity of the bowel is maintained and
there is no obstruction.
ABDOMINAL WALL MUSCLES

ANTERIOR ABDOMINAL WALL

External oblique
 ORIGIN: Outer surface of lower 8 ribs
 INSERTION: Xiphoid process, linea alba, pubic crest and pubic tubercle and the anterior half of the iliac crest

Internal oblique
 ORIGIN: Lumbar fascia, anterior 2/3 of iliac crest and lateral 2/3 of inguinal ligament
 INSEROTION: Lower border of lower 3 ribs and costal cartilages, xiphoid process, linea alba and symphysis pubis
 Lower free border gives rise to cremasteric fascia

Transversus abdominis
 ORIGIN: Deep surface of lower 6 costal cartilages, lumbar fascia, anterior 2/3 of iliac crest and lateral 1/3 of inguinal
ligament
 INSERTION: Xiphoid process, linea alba and symphysis pubis
 Conjoint tendon formed by insertion of internal oblique and transversus abdominis onto pubic crest and pectineal line

Rectus abdominis
 ORIGIN: Symphysis pubis and pubic crest
 INSERTION: 5th,6th and 7th costal cartilages and xiphoid process
 Lateral margins form the Linea semilunaris

Pyramidalis
 ORIGIN: Anterior surface of pubis
 INSERTION: Linea alba

NERVES
 External oblique, internal oblique and transversus: Lower 6 thoracic nerves and L1 (ileoinguinal and ileohypogastric
nerves)
 Rectus abdominis: Lower 6 thoracic nerves
 Pyramidalis: T12

FUNCTION
 External / internal oblique / transversus - laterally flex and rotate the trunk, relax during inspiration to accommodate
abdominal viscera, contract during micturiction, defecation and vomiting.
 Rectus abdominis - flexes the trunk and stabilises the pelvis

RECTUS SHEATH

Above costal margin

 Anterior wall: Aponeurosis of external oblique
 Posterior wall: thoracic wall.

Between costal margin and anterior superior iliac spine

 Anterior wall: Aponeurosis of external and internal oblique
 Posterior wall: Aponeurosis of internal oblique and transversus abdominis
 Note that the aponeurosis of the internal oblique splits to enclose the rectus abdominis

Between anterior superior iliac spine and pubis

 Anterior wall: Aponeuroses of external, internal oblique and transversus
 Posterior wall: Transversalis fascia
 Arcuate line : Site where the aponeuroses of the posterior wall pass anterior to the rectus at the level of the anterior
superior iliac spine. The inferior epigastric artery enters the rectus sheath at this point and lies posterior to the rectus
abdominis. Pyramidalis lies within the rectus sheath.

POSTERIOR ABDOMINAL WALL

PSOAS MAJOR
 Origin: Roots of transverse processes, sides of vertebral bodies and inter-vertebral discs T12 - L5
 Insertion: Lesser trochanter of the femur
 Nerve: Lumbar plexus
 Action: Flexes thigh on trunk. If thigh if flexed, flexes trunk on thigh.

ILIACUS
 Origin: Iliac fossa
 Insertion: Lesser trochanter of the femur
 Nerve: Femoral nerve
 Action: Flexes thigh on trunk. If thigh is flexed, flexes trunk on thigh

QUADRATUS LUMBORUM
 Origin: Iliolumbar ligament, iliac crest and tip of transverse processes of lower lumbar vertebrae
 Insertion: Lower border of 12th rib and transverse processes of upper 4 lumbar vertebrae
 Nerve: Lumbar plexus
 Action: Laterally flexes spine to same side, fixes or depresses 12th rib during respiration

The Pfannestiel incision cuts through

 Skin and superficial fascia including Scarpa’s fascia
 The rectus sheath which is formed at this level by the aponeuroses of the external, internal oblique and transversus
abdominis
 The linea alba is split to separate the recti abdominis which are NOT cut
 The transversalis fascia
 ?The parietal peritoneum
 Incisions should be made along Langer’s lines which run horizontally in the lower abdomen
INGUINAL LIGAMENT
 Formed by the aponeurosis of the External oblique muscle
 Attached medially to the pubic tubercle
 Forms the inferior wall or floor of the inguinal canal
INGUINAL CANAL
 4cm long in adults
 Deep ring: - oval shaped hole in transversalis fascia, 1.3cm above inguinal ligament, mid-way between anterior
superior iliac spine and symphysis pubis. Medial relation - inferior epigastric vessels. Gives rise to the internal
spermatic fascia or the internal covering of the round ligament of the uterus
 Superficial ring:- triangular in shape, defect in external oblique aponeurosis, base formed by pubic crest, gives rise to
external spermatic fascia
 The following pass through the superficial ring: round ligament, ilioinguinal nerve, genital branch of the genitofemoral
nerve, lymphatics and sympathetic plexus
 Anterior wall - aponeurosis of external oblique, reinforced laterally by origin of internal oblique
 Posterior wall - transversalis fascia, reinforced medially by conjoint tendon - common insertion of internal oblique and
transversus to the pubic crest and pectineal line
 Floor - Inguinal ligament
 Roof - internal oblique and transversus abdominis
 The femoral neurovascular bundle and lateral cutaneous nerve of the thigh pass beneath the inguinal ligament.
 The femoral branch of the genitofemoral nerve enters the thigh behind the middle of the inguinal ligament.
 The ilioinguinal nerve enters the thigh through the superficial inguinal ring.
 The superficial epigastric vessels cross the inguinal ligament

Inguinal canal in male contains:

 Vas deferens
 Testicular vessels
 Lymphatics
 Sympathetic fibres from the renal or aortic sympathetic plexuses
 Remains of the procesus vaginalis
 Cremasteric artery - branch of the inferior epigastric artery
 Artery to the vas - branch of inferior vesical artery
 Genital branch of genitor-femoral nerve - supplies cremaster muscle

Inguinal canal in the female contains:

 Round ligament of the uterus
 Lymphatics
 Remains of the processus vaginalis
 Genital branch of the genitofemoral nerve
 The ilio-inguinal nerve

Cremaster muscle / cremasteric reflex

 Derived from internal oblique
 Supplied by cremasteric artery - branch of inferior epigastric
 Supplied by genital branch of genitor-femoral nerve
 Cremasteric reflex - cremaster muscle contracts when skin on medial aspect of thigh is stroked. Afferent - femoral
branch; Efferent - genital branch of genitor-femoral nerve

SCROTUM
 Made up of following layers (superficial - deep):
 Skin
 Dartos muscle - smooth muscle, continuous with fatty / membraneous layer of superficial fascia of anterior abdominal
wall; innervated by sympathetic fibres and responsible for wrinkling of overlying skin
 Colles- fascia? continuous with Scarpa’s fascia
 External spermatic fascia - external oblique
 Cremasteric fascia - internal oblique
 Internal spermatic fascia - transversalis fascia
 Tunica vaginalis - procesus vaginalis - covers anterior and lateral BUT NOT posterior aspect of testis
 Tunica albuginea - fibrous capsule of testis - covers entire testis
 Both Dartos muscle and Colles - fascia contribute to median partition of scrotum.

Lymphatic drainage
 Skin and superficial fascia (including tunica vaginalis) - Superficial inguinal nodes
 Testis / epididymis - para-aortic nodes (L1)
 For successful spermatogenesis, the temperature of the testis is maintained at 3C below body temperature by
various mechanisms including a counter-current heat exchange system formed by the pampiniform plexus (testicular
vein).

Blood supply to testis

 Testicular artery - leaves aorta at L1
 Right testicular vein - drains into IVC
 Left testicular vein - drains into left renal vein
 Epididymis - testicular artery

Umbilical folds
Located anterior to the bladder on the inner aspect of the abdominal wall. Typically visualised during laparoscopy.
 one median umbilical fold on the median umbilical ligament (which in turn, contains the urachus)
 two medial umbilical folds on the occluded umbilical artery.
 two lateral umbilical folds on the inferior epigastric vessels (MRCOG 2015)

Femoral canal (MRCOG 1 2015)

 Located in the anterior thigh within the femoral triangle
 Smallest and most medial part of the femoral sheath
 1.3cm long
 Four borders and an opening:
1. Medial border – Lacunar ligament.
2. Lateral border – Femoral vein.
3. Anterior border – Inguinal ligament.
4. Posterior border – Pectineal ligament, superior ramus of the pubic bone, and the pectineus muscle
 The opening to the femoral canal is located at its superior border, known as the femoral ring. The femoral ring is
closed by a connective tissue layer – the femoral septum. This septum is pierced by the lymphatic vessels exiting the
canal.

The femoral canal contains:

1. Lymphatic vessels – draining the deep inguinal lymph nodes.

2. Deep lymph node – the lacunar node.
3. Empty space.
4. Loose connective tissue.

 The femoral canal is a common site of bowel herniation through the femoral ring
 Presents as a lump situated inferolaterally to the pubic tubercle
 More common in women, due to wider bony pelvis.

The borders of the femoral canal are tough and can compress the hernia, interfering with its blood supply causing
strangulation
PERITONEUM
 The central part of the diaphragmatic peritoneum is supplied by the phrenic nerve while the peripheral parts are
supplied by the lower intercostals nerves
 The parietal peritoneum of the anterior and lateral abdominal wall is supplied segmentally by the lower six thoracic
and first lumbar nerve. It is sensitive to pain, temperature, touch and pressure while the visceral peritoneum is
supplied by autonomic nerves and is sensitive to stretch
 The pelvic parietal peritoneum is supplied by the obturator nerve.
 The ureters are retro-peritoneal throughout their course

PERITONEAL LIGAMENTS
 Falciform ligament - anterior surface of liver to anterior abdominal wall and diaphragm
 Ligamentum Teres - free border of falciform ligament, contains obliterated umbilical VEIN
 Median umbilical ligament - urachus (remnant of the allantois), apex of bladder to umbilicus
 Lateral umbilical ligament - INTERNAL iliac artery to umbilicus, obliterated umbilical ARTERY
 Gastrosplenic ligament - greater curvature of stomach to spleen

GREATER OMENTUM
 Anterior layer attached to the greater curvature of the stomach
 Posterior layer attached to the inferior border of the transverse colon
 The lower part of the lesser sac lies within it
 The right gastro-epiploic artery runs along the greater curvature of the stomach in the upper border of the greater
omentum

LESSER OMENTUM
 Runs from the lesser curvature of the stomach to the porta hepatis
 Its right free border forms the ANTERIOR margin of the opening into the lesser sac (epiploic foramen) and contains
the RIGHT gastric artery

Boundaries of the epiploic foramen

 Anterior - right free border of LESSER omentum (containing bile duct to the right and in front, hepatic artery to the left
and in front and portal vein posteriorly)
 Posterior - inferior vena cava
 Superior - caudate lobe of liver
 Inferior - first part of duodenum

PARACOLIC GUTTERS
 There are 4 paracolic gutters - left and right medial / lateral
 The right lateral extends from the pelvis to the right posterior sub-phrenic space
 The right medial is closed off from the pelvis by the mesentry of the small intestine
 The left lateral is separated from the spleen by the phrenicocolic ligament extending from the left colic flexure to the
diaphragm
STOMACH
 Lies in the left HYPOCHONDRIUM extending onto the epigastric and umbilical regions
 Has a fundus, body, antrum and pylorus
 Body extends from the level of the cardiac orifice to the incisura angularis on the lesser curvature
 Connected to the liver by the lesser omentum
 Three muscle layers - outer longitudinal, inner circular and innermost oblique. Intra-peritoneal (has peritoneum on all
surfaces)
 The pyloric sphincter is an anatomical sphincter but a physiological sphincter only exists at the cardiac orifice

RELATIONS OF THE STOMACH

Anterior
 Anterior abdominal wall, left costal margin, diaphragm, left lung and pleura, left lobe of liver
Posterior
 Lesser sac, diaphragm, spleen, splenic artery, pancreas, left suprarenal gland and upper part of left kidney,
transverse colon and transverse mesocolon

BLOOD SUPPLY
 Left gastric artery - branch of celiac artery - lower third of oesophagus and upper RIGHT part of stomach
 Right gastric artery - branch of hepatic artery - lower right part of stomach
 Short gastric arteries - branches of splenic artery - fundus
 Left gastro-epiploic - branch of splenic artery - runs along GREATER curvature
 Right gastro-epiploic - branch of gastroduodenal artery - lower part of greater curvature
 Left / right gastric veins - drain into portal vein directly
 Short gastric and left gastro-epiploic veins - drain into the splenic vein
 Right gastro-epiploic vein - drains into the superior mesenteric vein

NERVES AND LYMPHATICS

 Lymphatics follow arteries, all drain into celiac nodes. Those from the fundus of the stomach initially drain into nodes
in the hilus of the spleen then to the celiac nodes
 Nerves: Anterior vagal trunk - Left vagus nerve mainly; has hepatic branch to the liver from which the pyloric branch
arises
 Posterior vagal trunk - Right vagus mainly; has branch to celiac and superior mesenteric plexuses which supply
foregut and mid-gut (splenic flexure)
 Vagal impulses are secretomotor to the glands and motor to the muscle (but inhibitory to the pyloric sphincter)
 Sympathetic supply - from celiac plexus - motor to the pyloric sphincter
 DUODENUM
 25cm long, first 2.5cm are intra-peritoneal. Divided into 4 parts
 First part - 5 cm long on transpyloric plane
 Anterior: quadrate lobe of liver and gall bladder
 Posterior: Lesser sac, gastroduodenal artery, bile duct, portal vein, inferior vena cava
 Superior: Epiploic foramen
 Inferior: Head of pancreas
 Second part - 8cm long
 Anterior: gallbladder, right lobe of liver, transverse colon and small intestine
 Posterior: Hilus of right kidney and right ureter
 Lateral: Ascending colon, right colic flexure, right lobe of liver
 Medial: Head of pancreas
 Pancreatic and bile ducts open into second part of duodenum
 Third part - 8cm long
 Anterior: Superior mesenteric vessels, root of mesentery of small intestine and jejunum
 Posterior: Right ureter, right psoas, inferior vena cava and aorta
 Superior: Head of pancreas
 Inferior: Jejunum
 Fourth part - 5cm long
 Anterior: Jejunum
 Posterior: Aorta and left psoas
 Ligament of Trietz attaches the duodeno-jejunal junction to the right crus of the diaphragm
SMALL INTESTINE
 Jejunum and Ileum, 6m long
 Attached to the posterior abdominal wall by a mesentery
 Mucosa has CIRCULAR folds called plicae circularis which are more prominent in the jejunum
 Aggregations of lymphoid tissue are present in the mucous membrane of the lower ileum along the antimesenteric
border (Payer’s patches)
 Blood - Superior mesenteric vessels
 Lymphatics - superior mesenteric nodes
 Nerve - sympathetic and parasympathetic (vagus) from the superior mesenteric plexus
CECUM
 6cm long, intra-peritoneal
 Has 3 bands of outer longitudinal muscles (Tenia coli) which converge on the base of the appendix
 Appendix arises from its postero-medial aspect and its lumen is in direct communication with the cavity of the cecum
 Related anteriorly to coils of small intestine, greater omentum and anterior abdominal wall
 Related posteriorly to the psoas, iliacus, femoral nerve and lateral cutaneous nerve of the thigh (and usually the
appendix)
 Blood supply - anterior and posterior cecal arteries - branches of the ileocolic artery which arises from the superior
mesenteric artery
 Nerves- sympathetic and parasympathetic (vagus) from the superior mesenteric plexus
 Lymphatics - superior mesenteric nodes

APPENDIX
 8-13cm long
 Arises from the postero-medial aspect of the cecum
 Lies in RIF with its base located 1/3 of the way up the line joining the anterior superior iliac spine to the umbilicus
(McBurney’s point)
 Identified within the abdomen by followint the Tenia coli of the caecum to its base
 Arterial supply - appendicular artery, branch of posterior cecal artery
 Lymphatics - superior mesenteric nodes
 Nerve - parasympathetic (vagus) and sympathetic from superior mesenteric plexus
 Fibres transmitting visceral pain signals enter the spinal cord at T10 (dermatome is in the region of the umbilicus, the
site of referred pain during acute appendicitis)

ASCENDING COLON
 13cm long, from the cecum to the inferior surface of the right lobe of the liver
 Retro-peritoneal
 Related anteriorly to coils of small intestine, the greater omentum and the anterior abdominal wall
 Related posteriorly to the psoas, iliacus, quadratus lumborum, origin of the right transversus abdominis muscle;
iliohypogastric and ilioinguinal nerves; lower pole of RIGHT kidney
 Blood supply - right colic and iliocolic branches of the SUPERIOR mesenteric artery
 Lymphatics - superior mesenteric nodes
 Nerves - parasympathetic (vagus) and sympathetic from the superior mesenteric plexus

TRANSVERSE COLON
 38cm long, from the right colic flexure to the left colic flexure, which is attached to the diaphragm by the phrenico-
colic ligament
 Intra-peritoneal - transverse mesocolon is attached to its SUPERIOR border

 The POSTERIOR layer of the greater omentum is attached to its inferior border
 Typically hangs down into the pelvis
 Related posteriorly to the second part of the duodenum, head of pancreas, coils of jejunum and ileum
 Blood - proximal 2/3 - middle colic artery (superior mesenteric); distal 1/3 - left colic (inferior mesenteric
 Lymphatics - proximal 2/3 - superior mesenteric nodes; distal 1/3 - inferior mesenteric nodes
 Nerves - proximal 2/3 - superior mesenteric plexus (vagus - parasympathetic); distal 1/3 - inferior mesenteric plexus
(sympathetic) and pelvic splanchnic nerves (parasympathetic)
 NOTE that the junction between the proximal 2/3 and distal 1/3 of the transverse colon is the junction between the
mid-gut and the hind-gut, hence the arrangement of blood, nerve supply and lymphatics.

DESCENDING COLON
 25cm long, retroperitoneal, extends from left colic flexure to pelvic brim
 Related anteriorly to greater omentum, coils of small intestine and the anterior abdominal wall
 Related posteriorly to the lateral border of the left kidney, LEFT psoas, iliacus, iliac crest, quadratus lumborum and
origin of the left transversus abdominis; iliohypogastric, ilioinguinal and femoral nerves and lateral cutaneous nerve of
the thigh
 Blood - left colic artery and sigmoid arteries (inferior mesenteric)
 Lymphatics - inferior mesenteric nodes
 Nerves - sympathetic - inferior mesenteric plexus; parasympathetic - pelvic splanchnic nerves

DIFFERENCES BETWEEN SMALL AND LARGE BOWEL

 Longitudinal smooth muscle - continuous in small bowel, 3 bands (teniae coli) in large bowel
 Fatty tags - appendices epiploicae - present in large bowel, absent in small bowel
 Payer’s patches - lymphoid tissue within mucosa - present in small bowel, absent in large bowel
 Plicae circularis - folds of mucous membrane - present in small bowel, absent in large bowel
 Muscle wall - smooth in small bowel, sacculated in large bowel

LIVER
 The falciform ligament divides the liver into right and left lobes and splits on the superior surface of the liver, the right
layer forming the upper layer of the coronary ligament while the left layer forms the upper layer of the left triangular
ligament
 The peritoneal layers forming the coronary ligaments are widely separated, leaving part of the liver devoid of
peritoneum – the - bare - area
 The ligamentum teres (remnant of umbilical vein) runs from the umbilicus to the left branch of the portal vein
 The ligamentum venosum (remnant of ductus venosus) runs from the left branch of the portal vein to the inferior vena
cava
 The right lobe is further divided into the quadrate lobe (between the ligamentum venosus and inferior vena cava,
superior to the gall bladder) and the caudate lobe (between the ligamentum teres, porta hepatis and gall bladder
 The quadrate and caudate lobes are functionally part of the left lobe and there is very little overlap in the blood supply
of the two sides
 The hepatic artery (30%, oxygenated) and the portal vein (70%, de-oxygenated) supply blood to the liver. Venous
drainage (right and left hepatic vein) is into the inferior vena cava.
 Although anatomically part of the right lobe, the caudate and quadrate lobes are supplied by the LEFT hepatic artery
 The hepatic lobule contains a central vein (tributary of the hepatic vein) while the spaces between the lobules (portal
canals) contain branches of the hepatic artery, portal vein and a tributary of a bile duct
 Lymphatic drainage of most of the liver is to the celiac nodes but the bare area drains into posterior mediastinal
nodes

The porta hepatis contains the following structures

 Right and left hepatic arteries
 Right and left branches of the portal vein
 Right and left hepatic ducts
 The upper part of the free edge of the lesser omentum is attached to the liver at this point
 Sympathetic and parasympathetic nerves
 Lymphatics and nodes draining the gall bladder

BILIARY TREE
 The bile canniliculi drain into interlobular ducts located at the periphery of the hepatic lobule. The interlobular ducts
join to form larger ducts and eventually form the right and left hepatic ducts at the porta hepatis
 The caudate and quadrate lobes are functionally part of the left lobe of the liver and are drained by the left hepatic
duct
 The common hepatic duct is formed from the left and right hepatic ducts
 The cystic duct runs from the gall bladder to join the RIGHT side of the common hepatic duct, forming the common
bile duct
 The common bile duct is located in the right free edge of the lesser omentum, anterior to the epiploic foramen, in front
of the portal vein and to the right of the hepatic artery
 The common bile duct then runs behind the first part of the duodenum (to the right of the gastro-duodenal artery) then
behind the head of the pancreas to open half way down the second part of the duodenum into the ampulla of Varter
 The common bile duct is usually joined by the main pancreatic duct close to its opening into the duodenum. The
opening has a smooth muscle sphincter - the sphincter of Oddi

GALL BLADDER
 Has a fundus, body and neck which is continuous with the cystic duct
 The fundus is at the level of the tip of the 9th right costal cartilage
 Related anteriorly to the anterior abdominal wall and the visceral surface of the liver
 Related posteriorly to the transverse colon and the first and second parts of the duodenum
 Arterial supply - cystic artery, branch of the right hepatic artery
 Venous drainage - cystic vein, into the portal vein
 Lymphatics - cystic lymph node located near the neck, then to the celiac nodes
 Nerves - celiac plexus
THE PANCREAS
 Exocrine (acini) and endocrine (islets of Langerhans) gland
 Head, neck, body and tail. The uncinate process of the head lies posterior to the superior mesenteric vessels. The
neck lies anterior to the origin of the superior mesenteric artery and portal vein
 Related anteriorly to the transverse colon and mesocolon, lesser sac and stomach
 Related posteriorly to the bile duct, portal vein, splenic vein, inferior vena cava and aorta, origin of superior
mesenteric artery, left psoas, left suprarenal gland, left kidney and hilus of spleen
 The splenic artery runs along the upper border of the pancreas
 Drained by main pancreatic duct, opening half way down the second part of the duodenum. The accessory pancreatic
duct, where present, opens above the opening of the main duct
 Arterial supply - splenic, superior and inferior pancreatico-duodenal arteries
 Lymphatics - celiac nodes
 Nerves - parasympathetic (vagus) and sympathetic from the celiac plexus

SPLEEN
 Lies in the left hypochondrium under the 9th, 10th and 11th ribs with its long axis along the shaft of the 10th rib.
Extends to the mid-axillary line and the normal spleen is not palpable. It is intra-peritoneal
 Has a notched anterior border
 Anterior relations: stomach, tail of pancreas and left colic flexure
 Medial relation: left kidney
 Posterior relations: diaphragm, left costo-diaphragmatic recess, left lung, 9th,10th and 11th ribs
 Blood supply - splenic artery, branch of celiac artery
 Lymphatics - celiac nodes
 Nerves - celiac plexus
THE RIGHT KIDNEY
 Lower level than the left due to the bulk of the right lobe of the liver
 Anterior relations: suprarenal gland, liver, second part of duodenum, right colic flexure
 Posterior relations:
Diaphragm, costo-diaphragmatic recess
12th rib. Psoas, quadratus lumborum and transversus abdominis
Sub-costal (T12), iliohypogastric and ilioinguinal nerves

LEFT KIDNEY
 Descends 2.5cm on INSPIRATION
 Anterior relations: LEFT suprarenal gland, spleen, stomach, left colic flexure and coils of jejunum
 Posterior relations:
11th and 12th ribs, diaphragm and costo-diaphragmatic recess. Psoas, quadratus lumborum and transversus
abdominis
Sub-costal, iliohypogastric and ilioinguinal nerves

KIDNEY - BLOOD SUPPLY

 Renal artery - branch of abdominal aorta. Enters the hilus of the kidney behind the renal vein; has 5 segmental
branches at the hilus, four in front and one behind the renal pelvis
 Subsequent branches are as follows: segmental - lobar - interlobar - arcuate - interlobular arteries - afferent
glomerular arterioles
 Renal vein drains y into the inferior vena cava directly

THE URETER
 25cm long, leaves renal pelvis behind the renal vein and descends on psoas major which separates it from the tips of
the transverse processes of the lumbar vertebrae
 Adherent to parietal peritoneum
 Enters the pelvis in front of the sacro-iliac joint and the bifurcation of the common iliac artery
 Supplied by the renal, testicular / ovarian and superior vesical arteries
 Lymphatic drainage is to the para-aortic and iliac nodes
 Nerve - renal, testicular / ovarian and hypogastric plexuses. Afferent (sensory) fibres travel with the sympathetic
nerves and enter the spinal cord at L1&2
 Within the pelvis, the ureter runs at first downward on the lateral wall of the pelvic cavity, along the anterior border of
the greater sciatic notch and under cover of the peritoneum.
 It lies in front of the internal iliac artery and medial to the obturator nerve obturator, inferior vesical, and middle rectal
arteries
 In the female, the ureter forms the posterior boundary of the ovarian fossa, in which the ovary is situated and is
separated from the ovary by pelvic peritoneum
 In the region of the ischial spine, it runs medially and forward beneath the base of the broad ligament on the lateral
aspect of the cervix and upper part of the vagina to reach the bladder.
 It is crossed by the uterine artery ~2cm lateral to the supra-vaginal cervix and the lateral vaginal fornices
 At the bladder base, the ureters are ~5 cm apart in the full bladder and 2.5cm apart when the bladder is empty. The
ureter lies anterior to the anterior vaginal fornix as it reaches the bladder
 Finally, the ureters run obliquely for about 2 cm. through the wall of the bladder and open by slit-like apertures into
the cavity of the viscus at the lateral angles of the trigone.
 The ureter is narrowed at the pelvi-ureteric junction, where it bends into the pelvis at the pelvic brim and where it
passes into the bladder wall - renal calculi are likely to lodge at these points *

During pelvic surgery, the ureters can be injured at the following points
 The ureteric tunnel where it is crossed by the uterine artery during clamping & ligation of the uterine artery pedicle
 At the bladder base during vaginal surgery - anterior colporrhaphy / vaginal hysterectomy or during colpo-suspension
 Anterior to the vagina as it courses forward to enter the bladder and can be injured while excising the upper vagina
during radical hysterectomy
 At the ovarian fossa where it may be involved in an ovarian mass
 At the pelvic brim where it may be confused with the infundibulo-pelvic ligament *

RIGHT URETER
Anterior relations include: second part of duodenum, terminal ileum, right colic and ileocolic vessels, right testicular /
ovarian vessels and the root of the mesentery of the small intestine.

LEFT URETER
Anterior relations: sigmoid colon, sigmoid mesocolon, left testicular / ovarian vessels, left colic vessels
Medial relation: inferior mesenteric vessels

Structure
 Three coats - fibrous, muscular and mucosa
 The fibrous coat is continuous with the renal capsule and the fibrous structure of the bladder
 Muscular coat arranged in two layers- outer longitudinal and inner circular
 The mucosa is smooth lined by transitional epithelium *

SUPRARENAL GLANDS
 Right - pyramidal, Left - crescenteric in shape
 Right related anteriorly to: right lobe of liver and lateral border of inferior vena cava
 Left related anteriorly to: pancreas, lesser sac and stomach
 Both glands rest posteriorly on the diaphragm
 Blood - suprarenal branches of aorta, inferior phrenic and renal arteries
 Single suprarenal vein drains into renal vein on the left or inferior vena cava on the right
 Lymphatics - para-aortic nodes
 Nerves - predominantly sympathetic pre-ganglionic fibres derived from the splanchnic nerves *

ABDOMINAL BLOOD VESSELS & NERVES » Notes

 BLOOD VESSELS

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ABDOMINAL AORTA
 Enters the abdomen through the aortic opening of the diaphragm at the level of T12
 Bifurcates into the right and left common iliac arteries at L4 (MRCOG 1 2015)
 The inferior vena cava, cysterna chyli and the beginning of the azygos vein lie to the right of the aorta
BLOOD SUPPLY TO GI TRACT
 Celiac artery - fore-gut (lower 1/3 of oesophagus to proximal half of second part of duodenum. Gives off left gastric,
splenic and hepatic arteries
 Superiormesenteric -mid-gut (distal half of second part of duodenum to junction between proximal 2/3 and distal 1/3 of
transverse colon. Gives off inferior pancreatico-duodenal, middle colic, right colic, ileocolic arteries and 12-15 jejunal and ileal
branches
 Inferior mesenteric - hind-gut (distal 1/3 of transverse colon to upper half of anal canal). Gives off left colic and sigmoid
branches and continues as superior rectal artery.
CELIAC ARTERY
 Artery of the fore-gut
 Branch of abdominal aorta at T12
 Posterior to lesser sac
 Three terminal branches: LEFT gastric, splenic and hepatic arteries
 The splenic artery has the following branches: Pancreatic branches, left gastro-epiploic and short gastric arteries
(Common) HEPATIC ARTERY
 Branch of the celiac artery
 Runs within the lesser sac ANTERIOR to the opening into the lesser sac
 Lies INFRONT of the portal vein and to the LEFT of the bile duct
 Has 4 branches: RIGHT gastric, gastroduodenal and left and right hepatic arteries
 The left gastro-epiploic artery is a branch of the splenic artery while the right gastro-epiploic is a branch of the
gastroduodenal artery
PORTAL VEIN
 5cm long, formed behind the neck of the pancreas from the splenic and superior mesenteric veins
 Posterior to the first part of the duodenum, then enters the lesser omentum, lying anterior to the epiploic foramen and
posterior to the hepatic artery and bile duct
 Divides into RIGHT and LEFT terminal branches
 Drains blood from the lower third of the oesophagus to the upper half of the anal canal (the inferior mesenteric vein drains
into the splenic vein)
INFERIOR VENA CAVA
 Formed by the union of the left and right common iliac veins (and median sacral vein) behind the right common iliac artery
at the level of L5
 Pierces central tendon of the diaphragm at the level of T8 to drain into the right atrium
 Lies to the right of the aorta, cysterna chyli
 Lies to the left (medial) of the right ureter
 Lies posterior to the opening into the lesser sac and the pancreas
 The left suprarenal, testicular / ovarian vein drain initially into the left renal vein then into the IVC *
 Left and right renal veins, hepatic veins, right ovarian / testicular and right suprarenal vein drain directly into the IVC
PORTAL-SYSTEMIC ANASTOMOSES
 Lower third of oesophagus - LEFT gastric vein and azygos vein
 Half way down anal canal - superior rectal vein and middle (internal iliac) and inferior rectal (internal pudendal) veins
 Umbilicus - veins of anterior abdominal wall and left branch of portal vein, travel within the falciform ligament *
 Veins of the ascending and descending colon, duodenum and pancreas anastomose with renal, lumbar and phrenic veins
LYMPHATICS
 The GI tract drains into pre-aortic (celiac, superior and inferior mesenteric) nodes and the efferent lymph vessels form the
intestinal trunk
 The para-aortic nodes drain lymph from the kidneys, suprarenal glands, testes / ovaries, fallopian tubes, uterine fundus,
common iliac nodes and deep lymphatics from the posterior abdominal wall. Efferent lymphatics form the right and left lumbar
trunks
 The cisterna chyli is an elongated lymph sac located below the diaphragm anterior to L1&2 and to the right of the aorta. It
receives the intestinal, right and left lumbar trunks and continues into the thorax as the thoracic duct.
ABDOMINAL BLOOD VESSELS & NERVES » Notes

NERVES

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THE LUMBAR PLEXUS

 Formed within psoas major from the ANTERIOR rami of L1,2,3&4
 Receives grey rami communicantes from the sympathetic trunk
 L1&2 give off white rami communicantes to the sympathetic trunk
 Branches emerge from the lateral and medial borders and the anterior surface of psoas major

LATERAL BRANCHES
 Iliohypogastric - L1; skin of lower part of anterior abdominal wall
 Ilioinguinal - L1; enters inguinal canal and supplies skin of groin, scrotum / labium majus
 Lateral cutaneous nerve of the thigh - L2&3; crosses iliac fossa anterior to iliacus, supplies skin on lateral aspect of thigh
 Femoral nerve - L2,3&4; enters thigh behind inguinal ligament lateral to femoral sheath and canal

The ilioinguinal nerve (MRCOG 1 2015)

 Branch of the first lumbar nerve (L1)
 merges from the lateral border of psoas major and passes obliquely across the quadratus lumborum and iliacus
 Perforates the transversus abdominis and communicates with the iliohypogastric nerve between the transversus and the internal
oblique muscle
 Pierces the internal oblique muscle, distributing filaments to it, and then accompanies the spermatic cord through the superficial
inguinal ring
 Its fibres are then distributed to the skin of the upper and medial part of the thigh, and to the following locations in the male and
female:

1. In the male ("anterior scrotal nerve"): to the skin over the root of the penis and upper part of the scrotum.
2. In the female ("anterior labial nerve"): to the skin covering the mons pubis and labia majora.
 Note that the ilioinguinal nerve does not pass through the deep inguinal ring, and therefore it only travels through part of the
inguinal canal

The iliohypogastric nerve

 Arises with the ilioinguinal nerve as a single trunk from the anterior ramus of L1
 Enters the abdomen behind the medial arcuate ligament and runs anterolaterally parallel and superior to the iliac crests and
divides in to iliohypogastric and ilioinguinal nerves at the lateral edge of the psoas muscle
 Continues along the anterior surface of the quadratus lumborum muscle posterior to the kidney
 Pierces the transversus abdominis muscle coursing anteriorly between the transversus abdominis and internal oblique muscles
 Above the iliac crest the iliohypogastric nerve gives off a lateral cutaneous branch to supply the posterolateral gluteal skin
 The remaining anterior cutaneous branch courses anteriorly to pierce the internal oblique muscle just above the anterior superior
iliac spine before turning obliquely downwards and medially becoming increasingly more superficial as it descends. Just superior
to the superficial inguinal ring the anterior branch pierces the aponeurosis of the external oblique to distribute multiple cutaneous
branches to the skin of the pubic region

Femoral nerve (MRCOG 1 2015)

 Nerve Roots: L2, 3, 4

 Motor: Innervates the anterior thigh muscles that flex the hip joint (pectineus, iliacus, sartorius) and extend the knee (quadriceps
femoris: rectus femoris, vastus lateralis, vastus medialis and vastus intermedius),
 Sensory: Supplies cutaneous branches to the anteromedial thigh (anterior cutaneous branches of the femoral nerve) and the
medial side of the leg and foot (saphenous nerve)
 Largest branch of the lumbar plexus
 Descends from the lumbar plexus in the abdomen through the psoas major muscle and travels through the pelvis to the mid-point
of the inguinal ligament. It then traverses behind the inguinal ligament into the thigh and splits into an anterior and posterior
division
 Passes through the femoral triangle lateral to the femoral vessels (enclosed within the femoral sheath) and gives off articular
branches to the hip and knee joints
 The terminal cutaneous branch is the saphenous nerve which continues, with the femoral artery and vein, through the adductor
canal.

Motor Functions

Hip Flexors

 Pectineus – adducts and flexes the thigh, assists with medial rotation of the thigh
 Iliacus – acts with psoas major and psoas minor (forming iliopsoas) to flex the thigh at the hip joint and stabilise the hip joint
 Sartorius – flexes, abducts and laterally rotates the thigh at the hip joint. Flexes the leg at the knee joint.

Knee Extensors

 Quadriceps femoris (rectus femoris, vastus lateralis, vastus intermedius) – extends the leg at the knee joint. Rectus femoris also
steadies the hip joint and assists iliopsoas in flexing the thigh.
Sensory Functions

 Anterior cutaneous branches arise in the femoral triangle and supply the skin on the anteromedial thigh
 Saphenous nerve supplies the skin on the medial side of the leg and the foot

MEDIAL BRANCHES (MRCOG 1 2015)

 Obturator nerve - L2,3&4; crosses pelvic brim in front of sacro-iliac joint and behind common iliac vessels
 4th lumbar root of the lumbosacral trunk contributes to the sacral plexus

ANTERIOR BRANCH
 Genito-femoral nerve - L1&2; genital branch enters spermatic cord and supplies cremaster muscle; femoral branch supplies skin
on medial aspect of thigh

ABDOMINAL SYMPATHETIC TRUNK

 Enters the abdomen through the medial arcuate ligament and runs downwards along the medial border of psoas major and enters
the pelvis behind the common iliac vessels. The right trunk lies posterior to the inferior vena cava
 Made up of 4 segmentally arranged ganglia; the upper two ganglia receive white ramus communicans from the 1st and 2nd
lumbar nerves
 Give off grey rami communicans to the lumbar spinal nerves
 Also gives off branches to the aortic sympathetic plexuses and the hypogastric plexus

CELIAC PLEXUS
 Two celiac ganglia and a network of fibres surrounding the origin of the celiac artery
 Receive sympathetic pre-ganglionic fibres from the greater and lesser splanchnic nerves and gives off POST-ganglionic fibres to
the fore-gut
 Receives parasympathetic pre-ganglionic fibres from the vagus and these form synapses within the wall of the organs supplied
 The proximal 2/3 of the transverse colon is mid-gut (superior mesenteric plexus)
ABDOMINAL BLOOD VESSELS & NERVES » Notes

AUTONOMIC NERVOUS SYSTEM

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AUTONOMIC NERVOUS SYSTEM

 Provides the efferent (motor) pathway linking areas of the brain concerned with the regulation of the internal environment to
specific effectors such as blood vessels, glands and the heart

SYMPATHETIC DIVISION

 EFFERENT fibres originate in cells in the inter-mediolateral column of T1 - L2/3 segments of the spinal cord - pre-ganglionic
neurons

 Axons of pre-ganglionic fibres emerge via the ventral root of the spinal cord together with somatic motor fibres

 Shortly after the dorsal and ventral roots of the spinal cord fuse, sympathetic pre-ganglionic fibres leave the spinal nerve trunk
and travel to sympathetic ganglia via white rami communicantes

 Sympathetic pre-ganglionic fibres synapse with post-ganglionic neurons in the sympathetic ganglia

 Fibres entering the sympathetic ganglia high up in the thorax may travel up the sympathetic trunk to cervical ganglia where they
 synapse with post-ganglionic neurons

 Pre-ganglionic fibres may pass through the sympathetic ganglia without synapsing - these myelinated fibres form splanchnic
nerves of which there are three - greater splanchnic nerve (5th - 9th thoracic ganglia - pierce the diaphragm and synapse in the
celiac ganglion), lesser splanchnic nerve (10thand 11th thoracic ganglia, pierce the diaphragm and synapse with cells in the lower
part of the celiac plexus) and lowest splanchnic nerve (12th thoracic ganglion, may be absent, pierces the diaphragm and synapses
with cells in the renal plexus)

 A few pre-ganglionic fibres travelling in the greater splanchnic nerve synapse directly with cells in the adrenal medulla

 Sympathetic post-ganglionic fibres travel to target organs via grey rami communicantes and segmental spinal nerves

 Sympathetic pre-ganglionic fibres may therefore terminate in the ganglion of the same segment or pass to another ganglion in the
sympathetic chain or to pre-vertebral ganglia such as the celiac ganglion

 Sympathetic pre-ganglionic fibres are myelinated (white) while post-ganglionic fibres are non-myelinated (grey)

 With the exception of the cervical region, sympathetic ganglia are distributed segmentally as far as the coccyx

 The cervical sympathetic chain is represented by the superior, middle and inferior cervical ganglia which supply the eyes,
lacrimal, salivary glands (superior), heart and respiratory tract (middle & inferior plus upper 3-4 thoracic ganglia)

 Sympathetic pre-ganglionic fibres to the abdominal organs form the splanchnic nerves which are distributed to the celiac,
superior and inferior mesenteric plexuses

 All pre-ganglionic fibres secrete acetylcholine

 AFFERENT myelinated fibres travel from the viscera through the sympathetic ganglia without synapsing, enter the spinal nerve
via the white rami communicantes and reach their cell bodies in the posterior (dorsal) root ganglion of the corresponding spinal
nerve. The central axon then enters the spinal cord and may form the afferent component of a local reflex arc or pass to higher
autonomic centres in the brain

CHROMAFFIN CELLS
 Derived embryologically from the neuro-ectoderm (neural crest). During development, chromaffin cells are widely scattered
within the embryo but in the adult can only be found in the adrenal medulla
 Innervated by pre-ganglionic fibres from the thoracic spinal cord via the splanchnic nerves. These fibres synapse directly with the
chromaffin cells which are homologous to sympathetic post-ganglionic neurons and can generate action potential
 Sympathetic pre-ganglionic fibres are myelinated while post-ganglionic fibres are non-myelinated. All pre-ganglionic fibres
secrete acetylcholine *

Synthesis of adrenaline in adrenal medulla

 Tyrosine converted to dihydrophenylalanine (DOPA) by tyrosine hydroxylase

 DOPA converted to dopamine by DOPA decarboxylase

 Dopamine converted to noradrenaline by dopamine-beta-hydroxylase

 Noradrenaline converted to adrenaline by phenylethanolamine-N-methyltransferase

PELVIC WALL » Notes

 BONY STRUCTURES

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TRUE PELVIS
 That part of the pelvis between the pelvic inlet and the pelvic outlet
 The pelvic inlet is oval in shape in the Gynaecoid pelvis and has the following borders:
1) Posterior: Sacral promontory
2) Lateral: Iliopectineal lines
3)Anterior: Symphysis pubis
The pelvic outlet is diamond shaped with the following borders:
 Posterior: Coccyx
 Lateral: Ischial tuberosities
 Anterior: Pubic arch formed by the simphysis pubis and the ischio-pubic rami
 Part of the lateral border is formed by the sacro-spinous and sacro-tuberous ligaments which convert the greater and lesser sciatic
notches into the greater and lesser sciatic foramina
 The pelvic cavity has a shallow anterior wall and a deeper posterior wall. The ischial spines are at the level of the mid-cavity
 The acetabulum is formed from the ilium, ischium and pubic bones
 In the up-right position, a line drawn from the sacral promontory to the symphysis pubis will meet the horizontal plane at 50 - 60
degrees (MRCOG 1 2015)

THE SACRUM
 5 rudimentary vertebrae
 The anterior and upper margin of the first sacral vertebra bulges forward as the posterior margin of the pelvic inlet and forms the
sacral promontory
 Articulates with innominate bone at the sacro-iliac joint, with the 5th lumbar vertebra superiorly (where it is tilted forwards at the
lumbo-sacral angle) and with the coccyx inferiorly
 The laminae of S5 and occasionally S4 fail to fuse in the mid-line, forming the sacral hiatus
 The vertebral foramina form the sacral canal which contains the cauda equine, filum terminale and meninges as far as the lower
border of S2 while the rest of the canal contains the filum terminale and lower sacral and coccygeal nerves
 The anterior / posterior surfaces contain 4 foramina for the anterior and posterior rami of the upper 4 sacral nerves respectively
 The piriformis muscle arises from the front of the lateral mass of the sacrum and leaves the pelvis through the greater sciatic
foramen to insert onto the greater trochanter

THE SACRO-ILIAC JOINT (MRCOG 1 2015)

 Synovial joint - the irregular articular surfaces of the joint make a contribution to joint stability but this is mainly maintained by
the very strong posterior and inter-osseous sacro-iliac ligaments.
 The sacro-spinous and sacro-tuberous ligaments also contribute to joint stability
 Supplied by branches of the sacral plexus and POSTERIOR rami of S1

Differences between the Male and Female Pelvis

The female pelvis:
 Less massive
 The anterior iliac spines more widely separated - greater lateral prominence of the hips.
 Wider pelvic inlet - both antero-posterior and transverse diameters
 Pelvic inlet more circular
 More shallow
 The sacrum is shorter wider, and its upper part is less curved
 The obturator foramina are triangular in shape and smaller in size
 The outlet is larger and the coccyx more movable.
 The sciatic notches are wider and shallower
 The ischial spines are less prominient.
 The pubic symphysis is less deep, and the pubic arch is wider and more rounded than in the male

The deep circumflex iliac artery (MRCOG 1 2015)

 Arises from the lateral aspect of the external iliac artery
 Ascends obliquely and laterally, posterior to the inguinal ligament, contained in a fibrous sheath formed by the junction of the
transversalis fascia and iliac fascia
 Travels to the anterior superior iliac spine, where it anastomoses with the ascending branch of the lateral femoral circumflex
artery
 Then pierces the transversalis fascia and passes medially along the inner lip of the crest of the ilium to a point where it perforates
the transversus abdominis muscle. From there, it travels posteriorly between the transversus abdominis muscle and the internal
oblique muscle to anastomose with the iliolumbar artery and the superior gluteal artery.
 Opposite the anterior superior iliac spine, it gives off a large ascending branch. This branch ascends between the internal oblique
muscle and the transversus abdominis muscle, supplying them, and anastomosing with the lumbar arteries and inferior epigastric
artery
 Serves as the primary blood supply to the anterior iliac crest bone flap
PELVIC WALL » Notes

MUSCLES

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PYRIFORMIS (MRCOG 1 2015)

 Origin: Lateral mass of sacrum
 Leaves pelvis through greater sciatic foramen
 Insertion: Upper border of greater trochanter
 Action: Laterally rotates femur at hip joint
 Nerve: Sacral plexus
OBTURATOR INTERNUS
 Origin: Pelvic surface of obturator membrane and adjoining part of the hip bone
 Leaves pelvis through Lesser sciatic foramen
 Covered by the obturator fascia which gives rise to the origin of the levator ani muscle
 Forms the lateral wall of the roof of the ischio-rectal fossa (medial wall of the roof formed by the levator ani)
 Insertion: Greater trochanter of femur
 Action: Laterally rotates femur at hip joint
 Nerve: nerve to obturator internus from sacral plexus
 LEVATOR ANI MUSCLE
 Origin: Back of body of pubis, obturator fascia and ischial spine
 Insertion: Anterior fibres (sphincter vaginae) - perineal body
 Intermediate fibres (puborectalis) - median raphe and anococcygeal body
 Posterior fibres (iliococcygeus) - anococcygeal body and coccyx
 Action: Support pelvic viscera and resist rise in intra-pelvic pressure during straining; sphincter action at anorectal junction and
vagina
 Nerve: Perineal branch of S4 and perineal branch of the pudendal nerve

COCCYGEUS
 Origin: ischial spine
 Insertion: lower end of sacrum and upper part of coccyx
 Action: supports pelvic viscera, flexes coccyx
 Nerve: branch of S4 and S5
PELVIC WALL » Notes

NERVES

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SACRAL PLEXUS
 Formed from anterior rami of L4&5 (lumbosacral trunk) and anterior rami of S1,2,3&4
 Related anteriorly to internal iliac vessels + branches and the rectum
 Related posteriorly to the piriformis muscle

Branches
To lower limb - leave the pelvis through GREATER sciatic foramen
 Sciatic nerve - L4,5, S1,2&3; largest nerve in the body
 Superior gluteal nerve - gluteus medius, minimus and tensor fascia lata
 Inferior gluteal nerve - gluteus maximus
 Nerve to obturator internus - also supplies superior gamellus muscle
 Nerve to quadratus femoris - also supplies inferior gamellus muscle
 Posterior cutaneous nerve of the thigh

Branches to pelvic organs

 Pudendal nerve - S2,3&4 - leaves the pelvis through the greater sciatic foramen and enters the perineum through the lesser sciatic
foramen
 Nerve to piriformis
 Pelvic splanchnic nerves - S2,3&4 - sacral part of parasympathetic system
 Perforating cutaneous nerve - skin of lower medial part of buttock
 PELVIC SYMPATHETIC TRUNK
 Continuous with the abdominal part behind the common iliac vessels
 Lies posterior to the rectum
 Lies anterior to the sacrum
 Lies medial to the anterior sacral foramina
 Has 4-5 segmentally arranged ganglia
 Gives off grey rami communicantes to the sacral and coccygeal spinal nerves
 Gives off fibres to the pelvic (hypogastric) plexuses
 No white rami communicantes join this part of the sympathetic trunk

HYPOGASTRIC PLEXUSES
 Superior hypogastric plexus
 Retroperitoneal, between common iliac arteries and in front of the sacral promontory
 Formed from aortic sympathetic plexus and branches from the lumbar sympathetic ganglia
 Parasympathetic fibres from the pelvic splanchinc nerves join the inferior hypogastric plexus and ascend to the superior
hypogastric and eventually inferior mesenteric plexus to supply the hind gut
 Right and left inferior hypogastric plexuses
 Branches of superior hypogastric plexus
 Descend medial to internal iliac artery
 Descend lateral to rectum
 Receive parasympathetic fibres from the pelvic splanchnic nerves
 The descending colon (hindgut) is supplied by the inferior mesenteric plexus

PELVIC SPLANCHNIC NERVES (MRCOG 1 2015)

 Formed from the ventral (anterior) primary rami of S2 through S4.
 These are the ways in which parasympathetic neurons reach the hypogastric plexus, and therefore the pelvic viscera and distal
colon.
 The parasympathetic part of the autonomic nervous system is the "craniosacral" part. Parasympathetic innervation to most of the
gut comes from the "cranio-" half of that, i.e., the vagus nerve. The rest, to colon distal to the splenic flexure and to pelvic
viscera, is from the "-sacral" half, via the pelvic splanchnic nerves
 There are thoracic, lumbar, sacral, and pelvic splanchnic nerves.
 "Splanchnic" refers to nerves that supply viscera.
 Thoracic, lumbar and sacral splanchnic nerves emerge from sympathetic ganglia and carry sympathetic fibers
 Pelvic splanchnic nerves are parasympathetic
 Contain pre-ganglionic fibres
 Join inferior hypogastric plexus
 Some fibres ascend to the superior hypogastric and eventually inferior mesenteric plexus and supply the hind-gut
 Provide parasympathetic supply to the pelvic viscera
 Afferent impulses from the pelvic viscera are transmitted mainly by the sympathetic pathway
 Parasympathetic nerves innervate detrusor and internal sphincter via the pelvic splanchnic nerves (S2,3,4) and also innervate the
external sphincter via the pudendal nerve - initiate micturiction by inhibiting internal sphincter activity and stimulating detrusor
contraction (MRCOG 1 2015)
 Parasympathetic supply to the ovary is from the vagus nerve. Sympathetic innervation is from the L1/2 segment
 Pain from uterine contractions goes back to T10-L1. This means that uterine contraction pain is sympathetic. But for the lower
portion of the uterus and upper vagina (the cervix) - it is parasympathetic back to the pelvic splanchnic nerves

OBTURATOR NERVE
 Branch of lumbar plexus - L2,3,4 - anterior divisions
 Descends through psoas major and emerges on its medial border to enter the pelvis anterior to the sacro-iliac joint
 Passes behind the common iliac vessels and on the lateral side of the internal iliac vessels and the ureter. Separated from the
ureter by the internal iliac vessels
 Runs on the lateral wall of the pelvis above and infront of the obturator vessels
 Separated from the ovary within the ovarian fossa by parietal peritoneum only
 Leaves pelvis to enter the thigh through the obturator foramen, accompanied by the obturator artery and vein
 Supplies parietal peritoneum on lateral pelvic wall
 Splits into anterior and posterior divisions
 Anterior division supplies gracilis, adductor brevis, adductor longus, the hip joint and occasionally pectineus. Also supplies skin
on medial aspect of thigh (MRCOG 1 2015)
 Posterior division supplies obturator externus, adductor part of the adductor magnus, the knee joint and occasionally adductor
brevis
PELVIC ORGANS » Notes

SIGMOID & RECTUM

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SIGMOID COLON
 Continuous with the descending colon in front of the LEFT external iliac artery, and with the rectum at the level of S3
 Intra-peritoneal with an inverted V-shaped mesentery - one limb running on the medial side of the left external iliac artery and
the other from the bifurcation of the left common iliac artery to S3. The recess of the pelvic mesocolon is located at the apex of
the V and the left ureter lies beneath it
 Related anteriorly to the bladder in the MALE and the uterus and upper part of the vagina in the female
 Related posteriorly to the sacrum and rectum
 Blood supply - inferior mesenteric artery (MRCOG 1 2015)
 Venous drainage - inferior mesenteric vein - to portal vein
 Lymphatics - inferior mesenteric plexus (MRCOG 1 2015)
 Nerve - inferior hypogastric plexuses

THE RECTUM
 ~13cm long
 Upper third - covered by peritoneum on its anterior and lateral surfaces, middle third covered by peritoneum on the anterior
surface only and lower third devoid of peritoneum
 The three teniae coli of sigmoid colon come together to form a broad band of longitudinal smooth muscle on its anterior and
posterior surfaces
 Three transverse folds, two on the left and one on the right
 Anterior relations: sigmoid colon and small intestine within pouch of Douglas (upper third); Posterior surface of vagina (lower
third)
 Posterior relations: sacrum, coccyx, piriformis and coccygeus muscles, lavatory ani, sacral plexus and pelvic sympathetic trunk
Blood supply
 Superior rectal artery - continuation of inferior mesenteric artery - main blood supply to mucosa
 Middle rectal artery - branch of internal iliac artery - muscular coat mainly
 Inferior rectal artery - branch of internal pudendal artery
 Veins correspond to arteries and form an important portal-systemic anastomosis
 Lymphatic drainage: Upper two thirds - inferior mesenteric nodes; lower third - internal iliac node
 Nerve supply - inferior hypogastric plexus
 REPRODUCTIVE ORGANS

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THE OVARY
 4x2 cm, attached to the posterior aspect of the broad ligament by a mesentery - the mesovarium
 Attached to the lateral pelvic wall by the suspensory ligament of the ovary (infundibulo-pelvic ligament)
 Attached to the upper part of the lateral uterine wall by the round ligament of the ovary (remnant of upper part of the
gubenaculum)
 Position variable, but usually lies within ovarian fossa in lateral pelvic wall. The ovarian fossa is bounded superiorly by the
external iliac vessels, inferiorly by the ureter and internal iliac vessels and its floor is crossed by the obturator nerve
 The ovary is surrounded by a thin fibrous capsule - the tunica albuginae
 Blood supply - ovarian artery - branch of abdominal aorta at L1 (MRCOG 1 2015 and 2016)
 Venous drainage - LEFT -left ovarian vein drains into left renal vein; RIGHT - right ovarian vein drains into inferior vena cava
Lymphatics - para-aortic nodes
Nerve - aortic plexus

FALLOPIAN TUBES
 ~10cm long, 4 parts
 Infundibulum - funnel-shaped lateral end, projects beyond the broad ligament with fimbriae at its free end
 Ampulla - widest and longest part, site of fertilisation
 Isthmus - narrowest part, just lateral to the uterus
 Intra-mural part - pierces uterine wall
 Three coats: serous, muscular, and mucous.
 The external or serous coat is peritoneal. The middle or muscular coat consists of an external longitudinal and an internal circular
layer of smooth muscle fibers continuous with those of the uterus
 The mucosa is thrown into longitudinal folds, which in the ampulla are much more extensive than in the isthmus. Lined by
ciliated columnar epithelium
 Blood - ovarian and uterine arteries
 Lymphatics - aortic and internal iliac nodes (follow arteries)
 Nerves - inferior hypogastric plexus

THE UTERUS
 8cm long x 5cm wide x 2.5cm thick
 Covered by peritoneum except anteriorly below the reflection of the utero-vesical fold of peritoneum and laterally between the
layers of the broad ligament
 Fundus - that part of the uterus above the entrance of the uterine tubes
 Cavity - triangular in coronal section, cleft in saggital section
 Anteverted uterus - long axis of uterine body at 90degrees to long axis of vagina
 Ante-flexed uterus - long axis of the body of the uterus bent forward at the level of the internal os
 Retroverted uterus - body and fundus bent backwards on the vagina to lie within the pouch of Douglas
 Anterior relations: utero-vesical pouch and superior surface of bladder
 Posterior: Pouch of Douglas, sigmoid colon and coils of ileum
 Laterally: uterine vessels, ureter
 Nerve - inferior hypogastric plexuses (Parasympathetic via the pelvic splanchnic nerves, sympathetic via the lumbar splanchnic
nerves). Pain sensation is transmitted via the sympathetic nerves and the lumbar splanchnic nerves

Age-related changes (MRCOG 1 2016)

 In female neonates, the uterus is larger due to the influence of maternal and placental hormones
 The uterine body is larger than the uterine cervix
 Between the age of two and six years, the size and morphology of the uterus and ovaries remain relatively stable
 The prepubertal uterus is a tubular structure (uterine cervix = uterine body), but sometimes the uterine cervix thickness may be
larger than the uterine body
 From the beginning of puberty, there is a progressive growth of uterus and ovaries. The uterine body becomes wider and thicker
than the uterine body, assuming the piriform shape observed in adult women, with an increase in the uterine body/cervix ratio
from 1/2 to values between 2/1 and 3/1
 The uterine body-to-cervix ratio in postmenopause approaches 1:1

Lymph
 Fundus - accompany ovarian artery to para-aortic nodes at the level of L1
 Body and cervix - internal and external iliac nodes

THE UTERINE ARTERY

 Branch of the anterior division of the internal iliac artery
 Runs medially in the base of the broad ligament
 Reaches the cervix at the level of the internal os
 Crosses the ureter
 Ascends within the broad ligament on the lateral aspect of the uterus
 Gives off descending branch to the cervix and vagina
 Supplies uterus and fallopian tube

LIGAMENTS
 Transverse cervical ligament: fibro-muscular condensations of pelvic fascia pass from the cervix and upper end of the vagina to
the lateral pelvic wall
 Utero-sacral ligament: cervix and upper end of vagina to the lower end of the sacrum - form two ridges on either side of the
pouch of Douglas
 Pubo-cervical ligament: cervix to posterior surface of pubis
 Round ligament: Of the ovary - from medial margin of ovary to upper part of lateral wall of uterus. Of the uterus - from upper
part of lateral uterine wall to deep inguinal ring
 The uterus is supported mainly by the tone of the pelvic floor muscles (levator ani) which are partly inserted onto the perineal
body and condensations of pelvic fascia forming the transverse cervical, pubo-cervical and utero-sacral ligaments.

THE BROAD LIGAMENT

 Two layered fold of peritoneum extending from the lateral uterine wall to the lateral pelvic wall
 Has an upper free edge which contains the fallopian tube
 The layers of peritoneum separate inferiorly to cover the pelvic floor
 Has ovary attached to its posterior surface by the mesovarium
 Uterine artery crosses the ureter at the base (lower attached border)
 Round ligament of the uterus forms a ridge an the anterior surface
 Contains vestigial structures: epoophron and paroophron (remnant of the mesonephric system)
 Uterine and ovarian blood vessels and lymphatics run within it

ROUND LIGAMENT
 Originates at the uterine horns, in the parametrium, enters the pelvis via the deep inguinal ring, passes through the inguinal canal
and continues on to the labia majora where its fibers spread and mix with the tissue of the mons pubis.
 Blood supply is from Sampson’s artery, an anastomosis of the ovarian and uterine arteries. The distal part of the round ligament
(within the inguinal canal) is supplied by a branch of the inferior epigastric artery (equivalent to the cremasteric artery in the
male) (MRCOG 1 2015)

CERVIX
 Lower, narrow portion of the uterus, connected to the uterine fundus by the uterine isthmus - upper limit is the internal os. Made
 up mainly of fibrous tissue with very little smooth muscle
 Protrudes through the upper anterior vaginal wall
 Approximately half its length is visible in the vagina (vaginal cervix), the rest being above the vagina (supra-vaginal cervix)
 The vaginal cervix ~3 cm long and 2.5 cm wide. Size and shape varies widely with age, hormonal state, and parity - bulkier and
the external with a wider and more slit-like external os in multiparous women.
 Ectocervix - portion of the cervis beyond the external os - lined by stratified squamous non-keratinising epithelium(MRCOG 1
2015)
 Endocervical canal - links external and internal os - lined by columnar epithelium
 The squamo-columnar junction - variable location - high up the endocervical canal before puberty and in the post-menopausal
women. Site of origin of squamous cell carcinoma of the cervix (MRCOG 1 2015)
 The external os is bounded by two lips, an anterior and a posterior, of which the anterior is the shorter and thicker, although due
to the slope of the cervix, it projects lower than the posterior. Both lips are in contact with the posterior vaginal wall
 The supravaginal cervix is separated in front from the bladder by fibrous tissue (parametrium), which extends also on to its sides
and laterally between the layers of the broad ligaments. Not covered by peritoneum on the anterior aspect
 The uterine arteries reach the margins of the cervix within the parametrium
 The ureter runs downward and forward 2 cm lateral to the supravaginal cervix
 Posteriorly, the supravaginal cervix is covered by peritoneum, which extends on to the posterior vaginal wall, when it is reflected
on to the rectum, forming the Pouch of Douglas which may contain coils of small intestine.
 The vaginal cervix projects free into the anterior wall of the vagina between the anterior and posterior fornices.

Blood supply
 Uterine artery, branch of internal iliac
 Cervical and vaginal branches supply the cervix and upper vagina.
 The cervical branches of the uterine arteries descend on the lateral aspects of the cervix at 3 and 9 o'clock. Venous drainage
parallels the arterial supply, eventually emptying into the hypogastric venous plexus.

Lymphatics
 Regional lymph nodes for the cervix include: paracervical, parametrial, presacral, sacral, external iliac, common iliac,
hypogastric (obturator), internal iliac..

Support
 Mainly the cardinal (transverse cervical) and uterosacral ligaments.
 These attach to the lateral and posterior aspects of the supra-vaginal cervix and extend laterally and posteriorly bony pelvis.
 The uterosacral ligaments are the conduits of the main nerve supplying to the cervix, derived from the hypogastric plexus.

Autonomic Innervation of the Uterus and cervix (MRCOG 1 2015)

 The uterovaginal plexus originates from the intermediate part of the inferior hypogastric plexus and innervates the uterus, uterine
tube, cervix and upper vagina
 Sympathetic innervation originates in segments of the lower thoracic spinal cord (T11 and T12) and passes through lumbar
splanchnics and the inferior mesenteric/hypogastric plexuses and finally to the uterovaginal plexus
 Parasympathetic innervation originates in the S2 through S4 spinal cord segments and passes through pelvic splanchnics to the
inferior hypogastric plexus and then into the uterovaginal plexus
 The pudendal nerve (S2-S4) does not carry parasympathetic fibers
 Visceral afferent fibers originating in the fundus and body of the uterus travel retrograde with sympathetics along the hypogastric
nerves and superior hypogastric plexus to reach the lower thoracic segments of the spinal cord.
 Afferent fibers of the upper vagina and cervix travel back along the pelvic splanchnics (S2-S4) and on the pudendal nerve.
 Sensory, sympathetic, and parasympathetic fibers are present in the cervix
 Sensory fibres travel via the parasympathetic nerves (S2,3,4 - pelvic splanchnic nerves)
 Dilatation of the cervix using dilators may result in a vasovagal attack with reflex bradycardia
 The endocervix has a plentiful supply of sensory nerve endings, while the ectocervix is relatively lacking in these. Small cervical
biopsies and cryotherapy can be performed in most patients without the use of anaesthesia

THE VAGINA
 ~8cm long, axis directed upwards and backwards from the vulva. Posterior wall longer than anterior wall
 Lined by stratified squamous epithelium which undergoes changes during the menstrual cycle. Does not secrete mucus
 Has anterior and posterior walls which are normally in apposition, and four fornices (anterior, posterior, left and right lateral)
 Upper half lies above the level of the pelvic floor

Relations
 Anterior: bladder, urethra
 Posterior: upper third - pouch of Douglas; middle third - ampulla of the rectum; lower third - perineal body
 Lateral: upper part - ureter, middle part - anterior fibres of levator ani; lower part - uro-genital diaphragm and the bulb of the
vestibule

 Blood: vaginal artery, branch of internal iliac artery

 Lymphatics: upper third - internal and external iliac nodes; middle third - internal iliac nodes; lower third - superficial inguinal
nodes
 Nerve:Upper two thirds -? inferior hypogastric plexuses. Parasympathetic from pelvic splanchnic nerves, sympathetic from
lumbar splanchnic nerves (L1 & 2)
 Autonomic innervation to the lower third - pudendal nerve
 Somatic sensation is present mainly in the lower thirs and is carried by the pudendal nerve

VAGINAL SUPPORT
 The vagina is supported by
 Levator ani muscles, transverse cervical, pubo-cervical and utero-sacral ligaments in its upper part
 The uro-genital diaphragm in its middle part
 The perineal body in its lower part
URINARY BLADDER

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THE URINARY BLADDER

 Lined by transitional epithelium - the upper part is derived from the yolk sac and is continuous with the urachus
 The trogone is derived from the mesonephric duct and is lined by cells of mesodermal origin. It is believed that these are later
replecad by cells of endodermal origin
 The bladder wall is made up of a syncytium of smooth muscle fibres called the detrusor - contraction results in simultaneous
reduction in all dimensions of the bladder
 The extrinsic sphincter mechanism is made up of the striated muscles of the levator ani - mainly fast twitch fibres
 Main nerve supply to the detrusor is parasympathetic - causes contraction (S2,3 4) (MRCOG 1 2015)
 Beta-sympathetic innervation causes relaxation (L 1&2) (MRCOG 1 2015)
 The urethral smooth muscle has alpha sympathetic innervation which causes contraction - there is however, significant overlap
 The rhabdosphincter is supplied by somatic nerves (S2,3,4) via the pelvic splanchnic nerves
 Levator ani supplied by S2,3,4 through the perineal branch of the pudendal nerve
 Sensory innervation (stretch) is via both sympathetic and parasympathetic pathways
 The female urethra has an intrinsic and an extrinsic component: the intrinsic component is made up of epithelial, vascular and
connective tissue and the rhabdosphincter which is a circular ring of striated muscle with slow twitch fibres. The ring is well
developed anteriorly, thins laterally and is virtually absent posteriorly. It is l lined by transitional cell epithelium
proximally and by nonkeratinizing stratified squamous epithelium distally (MRCOG 1 2015)

PHARMACOLOGY
 INHIBIT DETRUSOR CONTRACTILITY - Anti-cholinergic agents, calcium channel blockers, beta-agonists, CNS depressants
like chlorpromazine cause voiding dysfunction
 STIMULATE DETRUSOR CONTRACTILITY - Cholinergic agonists
 INCREASE URETHRAL RESISTANCE - alpha agonists

URODYNAMIC PARAMETERS
 MAXIMUM FLOW RATE - measured with a full bladder - at least 15ml/s. Reduced with hypotonic detrusor, outflow
obstruction or an inadequate voided volume
 A graph of flow rate against time is bell-shaped
 BLADDER CAPACITY - 400 - 600ml
 First sensation to void occurs at 150 - 250ml - decreased in sensory urgency and detrusor instability; increased in overflow
incontinence
 Detrusor pressure rise should be less than 15cm H2O during filling - increased pressure occurs in low compliance bladder and
detrusor instability
 Leakage occurs if detrusor pressure exceeds urethral pressure. If there is no abnormal pressure rise on filling and the woman
leaks because of a rise in intra-abdominal pressure without a rise in detrusor pressure then a diagnosis of URODYNAMIC
STRESS INCONTINENCE is made. Leakage with a rise in detrusor pressure occurs in detrusor instability and fistulas
 Cystometry is required for a diagnosis of detrusor instability - detrusor contraction associated with symptoms during bladder
filling when the individual is trying to inhibit micturiction
 High urethral pressure profile occurs in outflow obstruction. Low pressure in USI.

EXTERNAL GENITALIA & ANAL CANAL

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EXTERNAL GENITALIA
 Labia majora: prominent hair-bearing folds of skin extending from the mons pubis to fuse posteriorly in the mid-line
 Labia minora: hairless folds of skin within the labia majora; unite posteriorly to form the fourchette; split anteriorly to enclose the
clitoris, forming an anterior prepuce and a posterior frenulum
 Vestibule: triangular area bounded laterally by the labia minora with the clitoris at its apex and the fourchette at its base
 The urethra opens within the vestibule posterior to the clitoris

THE ANAL TRIANGLE

 Bounded posteriorly by the tip of the coccyx and laterally by the ischial tuberosities
 Skin supplied by inferior rectal nerve
 Lymphatic drainage is to the medial group of superficial inguinal nodes

THE ANAL CANAL

 ~4cm long, extends downwards and backwards from the rectal ampulla to the anus
 LATERAL walls kept in apposition by the levator ani and anal sphincter except during defecation
 Anterior relations: perineal body, urogenital diaphragm and perineal body
 Posterior relations: anococcygeal body and the coccyx

UPPER HALF
 Derived from hind-gut endoderm
 Lined by columnar epithelium
 Thrown into vertical folds called anal columns
 Autonomic supply from the inferior hypogastric plexus, sensitive to stretch only
 Blood - superior rectal branch of inferior mesenteric artery (MRCOG 1 2015)
 Lymphatics - inferior mesenteric nodes
 Dentate line - boundary between endodermal and ectodermal origin of anal canal

LOWER HALF
 Derived from the ectoderm of the proctodeum
 Lined by stratified squamous epithelium
 No anal columns
 Blood - inferior rectal artery, branch of internal pudendal artery
 Lymphatics - medial group of superficial inguinal nodes
 Nerve - inferior rectal nerve - sensitive to temperature, pain, touch and pressure

ANAL SPHINCTER (MRCOG 1 2015)

Internal
 Thickening of the inner circular layer of smooth muscle in the upper half of the anal canal
 Lies deep to the outer layer of longitudinal smooth muscle

External
 Skeletal muscle
 Sub-cutaneous part - lower half of anal canal, no bony attachments
 Superficial part - attached to the perineal body anteriorly and the anococcygeal body posteriorly
 Deep part - no bony attachments, blends with puborectalis

ISCHIO-RECTAL FOSSA (MRCOG 1 2015)

 Wedge shaped space filled with dense fat
 Base formed by skin
 Medial wall formed by anal canal and levator ani muscles
 Lateral wall formed by lower part of obturator internus muscle
 Contains the pudendal nerve and internal pudendal vessels within the pudendal canal on the lateral wall
PERINEAL POUCHES

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PUDENDAL NERVE
 Branch of sacral plexus (S2,3,4)
 Leaves pelvic cavity through greater sciatic foramen
 Enters perineum through lesser sciatic foramen
 Enters perineum below and medial to the ischial spine
 Lies medial to the internal pudendal artery as it exits from the pelvis into the perineum

Branches
 Inferior rectal nerve - supplies external anal sphincter and mucous membrane of the lower half of the anal canal
 Dorsal nerve of the clitoris (penis)
 Perineal nerve - supplies muscles of the urogenital triangle and the skin on the posterior surface of the labia majora

Internal pudendal artery

 Leaves the pelvis through the greater sciatic foramen, and emerges between the Piriformis and Coccygeus
 Crosses the ischial spine, and enters the perineum through the lesser sciatic foramen.
 Then crosses the Obturator internus, along the lateral wall of the ischiorectal fossa, ~ 4 cm above the lower margin of the ischial
tuberosity.
 Passes forward between the two layers of the fascia of the urogenital diaphragm
 Runs forward along the medial margin of the inferior ramus of the pubis behind the pubic arcuate ligament
 Pierces the inferior fascia of the urogenital diaphragm
 Branches include the inferior rectal artery (supplies lower half of anal canal) and branches to the penis or labia and clitoris
The Dorsal Artery of the Penis (MRCOG 1 2015)
 Branch of the internal pudendal artery
 Ascends between the crus penis and the pubic symphysis, and pierces the inferior fascia of the urogenital diaphragm
 Passes between the two layers of the suspensory ligament of the penis, and runs forward on the dorsum of the penis to the glans,
where it divides into two branches, which supply the glans and prepuce.

SUPERFICIAL PERINEAL POUCH

 Bounded inferiorly by the membranous layer of the superficial fascia
 Bounded above by the urogenital diaphragm
 Closed posteriorly by the fusion of its upper and lower walls
 Communicates anteriorly with the potential space between the superficial fascia of the anterior abdominal wall and the abdominal
wall muscles
 Contains the structures forming the root of the clitoris: the bulb of the vestibule, bulbospongiosus and ischiocavernosus muscles;
superficial transverse perineal muscle with their nerve supply (perineal branch of the pudendal nerve), blood supply (branches of
the internal pudendal artery) and the perineal body
 The superficial perineal pouch is seperated from the deep perineal pouch by the inferior fascial layer of the urogenital
diaphragm. (MRCOG 1 2015)

SUPERFICIAL TRANSVERSE PERINEAL MUSCLE

 Located in the posterior part of the superficial perineal pouch
 Origin: ischial ramus
 Insertion: perineal body
 Action: fixes perineal body in the centre of the perineum
 Nerve: perineal branch of the pudendal nerve

BULBOSPONGIOSUS MUSCLE
 Surrounds vaginal orifice and covers the bulb of the vestibule
 Origin - perineal body
 Inserted onto the corpus spongiosus of the clitoris
 Compresses dorsal vein of the clitoris and assists in erection

ISCHIOCAVERNOSUS MUSCLE
 Origin - ischial tuberosity
 Insertion - fascia covering corpus cavernosus
 Nerve - perineal branch of the pudendal nerve
 Action - assists in erection of the clitoris

UROGENITAL DIAPHRAGM
 Musculo-fascial diaphragm with a superior and inferior fascial layer containing the deep transverse perineal muscle and the
sphincter urethrae
 The two layers fuse anteriorly, leaving a gap beneath the simphysis pubis
 The two layers fuse posteriorly with the perineal body
 The two layers are attached laterally to the pubic arch
 The enclosed space between the two fascial is the deep perineal pouch

DEEP PERINEAL POUCH

 Enclosed space between superior and inferior fascial layers of the urogenital diaphragm
 Contains:
1) The sphincter urethrae and the deep transverse perineal muscle
2) Part of the vagina
3) Part of the urethra
4) Internal pudendal vessels
5) Dorsal nerve of the clitoris

MUSCLES OF THE DEEP PERINEAL POUCH

Deep transverse perineal muscle

 Origin - ischial ramus
 Insertion - perineal body
 Nerve - perineal branch of pudendal nerve
 Action - fixes perineal body

Sphincter urethrae
 Origin - pubic arch
 Insertion - surrounds urethrae
 Nerve - perineal branch of pudendal nerve
 Action - voluntary control of micturiction

THE CLITORIS
 Located at the apex of the vestibule anterior to the opening of the urethra
 Has a root made up of three masses of erectile tissue - the bulb of the vestibule (divided into two by the vaginal orifice) and the
left and right crura
 The bulb is covered by the bulbospongiosus muscle and becomes the corpus spongiosus and the glans clitoris anteriorly
 The crura are covered by the ischiocavernosus muscles and form the corpora cavernosa anteriorly
THORACIC WALL and ORGANS » Notes

RIB CAGE

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 THORAX - SURFACE ANATOMY
 Supra-sternal notch: Upper margin of manubrium sterni, palpable in mid-line between medial ends of clavicles
 Sternal angle (angle of Louis): angle between manubrium and body of sternum; lies at the level of the second costal cartilage
opposite the intervertebral disc between the 4th and 5th thoracic vertebrae
 Xiphisternal joint: lies opposite the body of the 9th thoracic vertebra
 Costal margin: formed from costal cartilages of 7th ? 10th ribs and the ends of the 11th and 12th cartilages. Lowest point formed
by the 10th rib and lies at the level of L3
 The first rib is not palpable
 The apex beat of the heart is located in the 5th left intercostal space 9cm from the mid-line
 The first spinous process that is palpable is that of the 7th cervical vertebra (vertebra prominens)
 The superior angle of the scapula lies at the level of the spine of the 2nd thoracic vertebra while the inferior angle lies at the level
of the spine of the 7th thoracic vertebra. The root of the spine of the scapula lies at the level of the spine of the 3rd thoracic
vertebra

THE RIB
 A typical rib has a head which articulates with the body of the corresponding vertebra and the vertebra immediately above; a
neck between the head and the tubercle; a tubercle which articulates with the transverse process of the corresponding vertebra; a
shaft or body and an angle where the shaft turns sharply forwards.
 The costal groove is located on the inferior border of the shaft

FIRST RIB
 Has the scalene tubercle on its medial border for the attachment of the scalenus anterior muscle
 The subclavian vein crosses the rib anterior to the scalene tubercle
 The subclavian artery and brachial plexus lie posterior to the scalene tubercle
 Has a head which articulates with the body of the 1st thoracic vertebra. Unlike other ribs, the first rib does not articulate with the
body of the vertebra above it (7th cervical)
 Has a tubercle which articulates with the transverse process of the 1st thoracic vertebra
 Is not palpable - lies deep to the clavicle

INTERCOSTAL MUSCLES
 EXTERNAL - fibres directed downwards and forwards from the inferior border of the rib above to the superior border of the rib
below; extends from the tubercle to the costochondral junction where it is replaced by the anterior intercostal membrane
 INTERNAL - fibres directed downwards and backwards, extends from the sternum to the angle of the rib posteriorly where it is
replaced by the posterior intercostal membrane
 TRANSVERSUS THORACIS - extends over more than one intercostal space

INTERCOSTAL NEUROVASCULAR BUNDLE

 Runs within the costal groove between the internal thoracic and transversus thoracis muscles
 Arranged from above downwards: Vein, Artery and Nerve (VAN)

INTERCOSTAL VESSELS
 Each intercostal space has two anterior and one posterior arteries
 1st and 2nd posterior intercostal arteries are branches of the superior intercostal artery, a branch of the costocervical trunk of the
subclavian artery
 Lower 9 posterior intercostal arteries - branches of the thoracic aorta
 Upper 6 anterior intercostal arteries - branches of the internal thoracic artery
 Lower 5 anterior intercostal arteries - branches of the musculophrenic artery (terminal branch of the internal thoracic artery)
 Intercostal arteries supply parietal pleura, intercostal muscles and skin of thoracic wall
 Posterior intercostal veins drain into azygos or hemiazygos veins
 Anterior intercostal veins drain into musculophrenic and internal thoracic veins
 INTERCOSTAL NERVES
 Anterior rami of upper 11 thoracic spinal nerves
 Enter intercostal space between the parietal pleura and the posterior intercostal membran
 Run in the subcostal groove between the internal intercostal and transversus thoracis muscles and inferior to the intercostal vein
and artery (VAN)
 Upper 6 supply intercostal spaces
 Lower 5 also supply anterior abdominal wall

Branches
 Rami communicantes - give white rami and receive grey rami from the sympathetic trunk
 Lateral cutaneous branch - divides into anterior and posterior branches and supplies the skin
 Anterior cutaneous branch - divides into medial and lateral branches
 Collateral branch - runs forward below the main nerve
 Muscular, pleural and peritoneal branches
 First intercostal nerve - the equivalent of the lateral cutaneous branch joins the brachial plexus. There is no anterior cutaneous
branch
 Second intercostal nerve - the equivalent of the lateral cutaneous branch forms the intercostobrachial nerve which joins the
medial cutaneous nerve of the arm to supply the skin of the armpit and medial side of the arm
THE DIAPHRAGM
 Has a peripheral muscular part and a central tendon
Three origins:
 Sternal - from the posterior surface of the xiphoid process
 Costal - from the deep surfaces of the lower 6 ribs and their costal cartilages
 Vertebral - right crus from the sides of the bodies and inter-vertebral discs of the upper 3 lumbar vertebrae; left crus
from the sides of the bodies and intervertebral disc of the first 2 lumbar vertebrae. Also has an origin from the medial
and lateral arcuate ligaments. The median arcuate ligament joins the crura
Insertion - central tendon
Action
 Contracts during inspiration - most important muscle for inspiration
 Contraction raises intra-abdominal pressure during micturiction, defecation or parturition
 Thoraco-abdominal pump - contraction lowers intra-thoracic and raises intra-abdominal pressure, aiding venous
return from the inferior vena cava to the right atrium
Nerve supply - motor : phrenic nerve. Sensory supply to parietal pleura and peritoneum covering the central tendon is
from the phrenic nerve. Sensory supply to the peripheral part is from the lower 5 intercostal nerves

OPENINGS
 Aortic - anterior to T12 between the crura, transmit the aorta, thoracic duct and azygos vein
 Oesophageal - level of T10, also transmits right and left vagi, oesophageal branch of the left gastric vessels and
lymphatics from the lower third of the oesophagus
 Caval - level of T8 in the central tendon, also transmits terminal branch of the right phrenic nerve
 The superior epigastric vessels pass between the sternal and costal origins ; the left phrenic nerve pierces the left
dome; the greater, lesser and lowest splanchnic nerves pierce the crura and the sympathetic trunk lies posterior to
the medial arcuate ligament.

THE MEDIASTINUM

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THE MEDIASTINUM
 Divided into superior and inferior mediastinum by a plane passing from the sternal angle to the lower border of T4
 Inferior mediastinum divided into middle mediastinum containing the heart, posterior and anterior mediastinum posterior and
anterior to the heart respectively
 Superior mediastimun has the following structures from front to back: thymus, large veins, large arteries, trachea, oesophagus +
thoracic duct, sympathetic trunk
 Inferior mediastinum has the following structures from front to back: thymus, heart + phrenic nerves, oesophagus + thoracic duct,
descending aorta, sympathetic trunk

TRACHEA
 13cm tube with a fibro-elastic wall within which are embedded U-shaped bars of hyaline cartilage
 Commences in the neck below the cricoid cartilage of the larynx (C6) and ends at the level of the angle of Louis (lower border of
T4)
 Anterior relations: sternum, thymus, left brachiocephalic vein, arch of the aorta and the origins of the brachiocephalic and left
common carotid arteries
 Posterior relations: oesophagus, left recurrent laryngeal nerve
 Right side: azygos vein, right vagus nerve
 Left side: arch of the aorta with left common carotid and subclavian arteries, left vagus and left phrenic nerves.

MAIN BRONCHI
RIGHT
 Shorter, wider and more vertical than the left
 Gives off the superior lobar bronchus before entering the hilum of the lung where it divides into the middle and inferior lobe
bronchus
LEFT
 Passes to the left below the aortic arch, anterior to the oesophagus
 At the hilum of the left lung divides into superior and inferior lobe bronchi
THE PLEURA
 Parietal - lines the thoracic wall, thoracic surface of the diaphragm and lateral aspect of mediastinum
 The cervical pleura extends ~3cm above the medial third of the clavicle to line the under surface of the suprapleural
membrane
 Supplied by the intercostal nerves (costal pleura and peripheral part of diaphragmatic pleura); phrenic nerve
(mediastinal pleura and diaphragmatic pleura over dome of diaphragm)
 Visceral - surrounds the lungs and receives autonomic supply

THE LUNGS
 Right - three lobes with a horizontal and an oblique fissure
 Left - two lobes only, with an oblique but no horizontal fissure. Has a cardiac notch
 Blood supply to the bronchi and connective tissue of the lung is from the bronchial arteries, branches of the
descending aorta
 Alveoli receive de-oxygenated blood from the pulmonary arteries and oxygenated blood leaves via the pulmonary
veins
 Lymphatic drainage is to the pulmonary nodes close to the hilum and then into the bronchomediastinal lymph trunks.
These two trunks ascend on either side of the trachea and drain into the brachiocephalic vein (left) or the thoracic or
right lymphatic duct
 Parasympathetic supply is from the vagus nerve - produce bronchoconstriction, vasodilation and increased glandular
secretion
 Sympathetic supply is from the thoracic sympathetic trunk, cause bronchodilation, vasoconstriction and decreased
glandular secretion
 THE HEART

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THE RIGHT ATRIUM

 Has a main cavity and an auricle
 The superior and inferior vena cava and coronary sinus open into the right atrium
 Drains into right ventricle via the tricuspid valve
 Fetal remnants include the fossa ovalis (on the atrial septum, remnant of foramen ovale); annulus ovalis (upper margin of fossa
ovalis, lower edge of septum secundum)

THE RIGHT VENTRICLE

 Communicates with the right atrium (tricuspid valve) and the pulmonary artery (pulmonary valve with three semilunar cusps).
Pumps de-oxygenated blood to the lungs
 Cavity contains muscular projections called trabeculae carneae:
a) Papillary muscles - connected by chordae tendinae to the cusps of the?? tricuspid valve
b) Muscular projections, one of which traverses the cavity and transmits the right branch of the atrio- ventricular bundle
(moderator band)

THE LEFT ATRIUM

 Has a main cavity which is smooth and an auricle with muscular ridges
 Lies posterior to the right atrium and forms the base of the heart. Separated from the oesophagus by the pericardium
 Receives 4 pulmonary veins and opens into the left ventricle via the mitral (bicuspid) valve

THE LEFT VENTRICLE

 Communicates with the left atrium (mitral valve, two cusps) and with the aorta through the aortic valve (three cusps)
 Myocardium is three times thicker than that of the right ventricle
 Has trabeculae carneae and two large papillary muscles
 There is no moderator band (right ventricle only)

CONDUCTING SYSTEM OF THE HEART

Sino-atrial node
 Specialised cardiac muscle of the right atrium to the right of the opening of the superior vena cava
 Pacemaker
 Supplied by the left and right coronary arteries
Atrio-ventricular node
 Situated in the lower part of the atrial septum
 Supplied by the right coronary artery
Atrio-ventricular bundle
 Conducts impulses from the atrio-ventricular node to the ventricles
 Only muscular connection between atrial and ventricular myocardium
 Descends to reach the inferior border of the membranous part of the inter-ventricular septum
 Supplied by the right coronary artery
Right and left atrio-ventricular bundles
 Formed from the atrio-ventricular bundle in the upper border of the muscular part of the ventricular septum
 Right branch enters the moderator band
 Continuous with the Purkinje plexus
 Right branch is supplied by the right coronary artery, left branch by the left and right coronary arteries

BLOOD SUPPLY TO THE HEART

Right coronary artery
 From anterior aortic sinus
 Descends in the atrio-ventricular groove, supplying right atrium and ventricle
 Gives off marginal branch at the inferior border of the heart and a posterior interventricular branch
Left coronary artery
 From the left posterior aortic sinus
 Gives off anterior interventricular and circumflex branches
 Anterior interventricular branch supplies right and left ventricles and interventricular septum
 Circumflex branch supplies left atrium and ventricle
Venous drainage
 Coronary sinus, a continuation of the great cardiac vein. Drains into the right atrium
 Small cardiac and middle cardiac veins drain into the coronary sinus
 The anterior cardiac vein drains directly into the right atrium
BLOOD VESSELS & LYMPHATICS

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AORTIC ARCH
 Runs upwards, backwards and to the left, initially anterior then to the left of the trachea
Branches
 Brachiocephalic artery which divides into the right common carotid and right subclavian arteries
 Left common carotid artery
 Left subclavian artery

DESCENDING THORACIC AORTA

 Begins on the left side of the lower border of T4
 Descends in the posterior mediastinum and ends at the aortic opening of the diaphragm at the level of T12 where it continues as
the abdominal aorta

Branches
 Posterior intercostal arteries
 Subcostal artery
 Pericardial, oesophageal and bronchial arteries

THE PULMONARY TRUNK

 5cm long begins at the pulmonary valve, runs upwards, backwards and to the left, terminating in the concavity of the aortic arch
 by dividing into the left and right pulmonary arteries. Lies anterior to the trachea
 Connected to the aortic arch by the ligamentum arteriosum (remnant of the ductus arteriosus)
 The left recurrent laryngeal nerve hooks around the ligamentun arteriosum

INTERNAL THORACIC ARTERY

 Branch of the first part of the subclavian artery
 Supplies the anterior wall of the body from the clavicle to the umbilicus
 Descends on the pleura deep to the costal cartilages
 Ends at the 6th intercostal space dividing into the superior epigastric and musculophrenic arteries
 Gives off two anterior intercostal arteries to the upper 6 intercostal spaces
 Pericardiophrenic artery to the pericardium
 Mediastinal arteries to the anterior mediastinum including the thymus
 Perforating arteries to thoracic and anterior abdominal wall
 The internal thoracic vein drains into the brachiocephalic vein

SUPERIOR VENA CAVA

 Formed from the left and right brachioceplalic veins (which are formed from the subclavian and internal jugular veins)
 Receives the azygos vein just before piercing the pericardium
 Lies anterior to the trachea and aorta in the superior mediastinum

THORACIC DUCT
 Begins in the abdomen as the cysterna chyli
 Enters thorax through aortic opening of the diaphragm on the right side of the descending aorta
 Crosses the mid-line posterior to the oesophagus
 Ascends on the left side of the oesophagus within the superior mediastinum
 Drains into the left brachiocephalic vein
 Receives the LEFT bronchomediastinal, jugular and subclavian lymph trunks
 Conveys lymph from the lower limbs, pelvis, abdomen, left side of the thorax, left side of the head and neck and left upper limb
into the blood stream
 Lymph from the right side of the head and neck, right upper limb and right side of the thorax is drained by the right jugular,
subclavian and bronchomediastinal trunks respectively. These may unite to form the right thoracic duct which drains into the
right brachiocephalic vein or drain independently in to the vain.
THE OESOPHAGUS

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THE OESOPHAGUS
 25cm long, continuous with the laryngeal part of the pharynx opposite C6
Relations in the neck
 Posterior: vertebral column
 Anterior: trachea and recurrent laryngeal nerves
 Lateral: lobes of thyroid gland
Relations in the thorax
 Anterior: trachea, left recurrent laryngeal nerve, left main bronchus, left atrium separated by pericardium
 Posterior: thoracic vertebral bodies, thoracic duct, azygos vein, descending thoracic aorta
 Right side: terminal part of azygos vein and mediastinal pleura
 Left side: left subclavian artery, aortic arch, thoracic duct and mediastinal pleura
Blood supply
 Upper third: inferior thyroid artery / vein
 Middle third: descending thoracic aorta / azygos vein
 Lower third: left gastric artery / vein (portal vein)
Lymphatic drainage
 Upper third: deep cervical nodes
 Middle third: posterior mediastinal node
 Lower third: celiac nodes

Oesophageal opening of the diaphragm

 Level T10
 Left vagus (anterior), right vagus (posterior)
 Transmits left gastric vessels and lymphatics
THE VAGUS NERVES
Right
 Enters the thorax posterior-lateral to the brachiocephalic artery
 Descends lateral to the trachea and medial to the terminal part of the azygos vein
 Passes posterior to the root of the right lung
 Descends onto the posterior surface of the oesophagus to enter the abdomen and posterior surface of the stomach
Left
 Enters the thorax between the left common carotid and left subclavian arteries
 Crosses the left side of the aortic arch
 Is crossed by the left phrenic nerve
 Descends posterior to the root of the left lung
 Then passes onto the anterior surface of the oesophagus to enter the abdomen

Branches
 Both nerves contribute to their respective pulmonary and oesophageal plexuses
 The right vagus gives off a cardiac branch
 The left vagus gives off the left recurrent laryngeal nerve at the level of the ligamentum arteriosum. The nerve hooks
around the ligament to ascend between the trachea and the oesophagus on the left side and supplies all the muscles
of the left vocal cord except the cricothyroid muscle (external laryngeal branch of the vagus)

THE PHRENIC NERVES

Right
 Arises in the neck from the anterior rami of C3,4,5
 Enters the thorax on the right side of the right brachiocephalic vein and inferior vena cava
 Descends anterior to the root of the right lung
 Is separated by the pericardium from the right atrium
 Leaves the thorax through the caval opening of the diaphragm on the right side of the inferior vena cava
Left
 Enters the thorax on the left side of the left subclavian artery
 Crosses the left side of the aortic arch and the left vagus nerve
 Descends anterior to the root of the left lung
 Is separated from the left ventricle by the pericardium
 Terminal branches pierce the muscle of the diaphragm and supply the central part of the peritoneum on its under
surface
 Provide motor supply to the diaphragm and sensory supply to the pericardium, mediastinal pleura, the central part of
the diaphragmatic pleura and peritoneum.
 THORACIC SYMPATHETIC TRUNK
 Continuation of the cervical sympathetic trunk, descends on the head of the ribs
 Arranged in 11 to 12 segmental ganglia
 Enters the abdomen on the side of the body of T12 by passing behind the medial arcuate ligament
 First ganglion often fused with the inferior cervical ganglion to form the stellate ganglion
 Gives grey rami communicantes to the thoracic spinal nerves
 Receives white rami communicantes from the thoracic spinal nerves
 Upper five ganglia give POST-ganglionic fibres to the heart, lungs, oesophagus and aorta
 Lower eight ganglia give PRE-ganglionic fibres which form the greater (5th-9th), lesser (10th & 11th) and lowest
(12th) splanchnic nerves

GAMETOGENESIS & FERTILIZATION

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SPERMATOGENESIS
 Begins at puberty under the influence of testosterone
 Sertoli cells differentiate and the sex cords become canalised and converted into seminiferous tubules
 The dormant primordial germ cells divide by mitosis and then differentiate into spermatogonia located immediately beneath the
basement membrane of the seminiferous tubules
 Germ cells are translocated from the basement membrane to the lumen of the seminiferous tubule as spermatogenesis progresses
 Spermatogonium - (mitotic division) - primary spermatocyte - (first meiotic division) - secondary spermatocyte - (second meiotic
division) - spermatid - (spermiogenesis) - spermatozoon
 Spermatozoon obtain full motility in the epididymis
 Spermatogenesis takes 64 days
 Primordial germ cells - diploid (2N)
 Spermatogonia - diploid (2N)
 Primary spermatocytes - diploid (4N)
 Secondary spermatocytes - haploid (2N)
 Spermatides - haploid (N)

Spermiogenesis (MRCOG 1 2015)

 The final stage of spermatogenesis when maturation of spermatids into mature, motile spermatozoa occurs
 The spermatid is a circular cell containing a nucleus, Golgi apparatus, centriole and mitochondria
 Spermiogenesis is divided into four stages

Golgi phase
 The spermatids begin to develop polarity with a head at one end while the Golgi apparatus produces enzymes that will become
the acrosome
 At the other end, a thickened mid-piece develops, where the mitochondria
 Spermatid DNA undergoes packaging, becoming highly condensed

Cap/Acrosome phase
 The Golgi apparatus surrounds the condensed nucleus, becoming the acrosomal cap.

Formation of Tail
 One of the centrioles of the cell elongates to become the tail of the sperm. A temporary structure called the "manchette" assists in
this elongation
 The developing spermatozoa orient themselves so that their tails point towards the center of the lumen

Maturation phase
 The excess cytoplasm, known as residual bodies, is phagocytosed by surrounding Sertoli cells

Spermiation
 Mature spermatozoa are released from the protective Sertoli cells into the lumen of the seminiferous tubule and a process called
spermiation then takes place, which removes the remaining unnecessary cytoplasm and organelles
 The resulting spermatozoa are mature but lack motility and cannot fertilise an oocyte. The non-motile spermatozoa are
transported to the epididymis in testicular fluid secreted by the Sertoli cells with the aid of peristaltic contraction
 Spermatozoa acquire motility in the epididymis
 Transport of the mature spermatozoa through the remainder of the male reproductive system is achieved via muscle contraction
rather than the spermatozoon's motility
 A glycoprotein coat over the acrosome prevents the sperm from fertilizing the egg prior to traveling through the male and female
reproductive tracts. Capacitation of the sperm by the enzymes FPP (fertilization promoting peptide, produced by the male) and
heparin (in the female reproductive tract) remove this coat and allow sperm to bind to the oocyte

SPERMATOZOON
 Head - contains a condensed nucleus capped by the acrosome which contains hydrolytic enzymes
 Middle-piece - contains large helical mitochondria which generate the power for swimming
 Tail - contain microtubules forming part of the propulsion system
 Sperm morphology is not important in determining fertility and abnormal spermatozoa are commonly present in fertile semen
 Capacitation - changes in the acrosome in preparation for release of hydrolytic enzymes required to penetrate the zona pellucida -
occurs in the female genital tract

OOGENESIS (MRCOG 1 2015)

 Begins during intra-uterine life. The primordial germ cells undergo mitosis and then differentiate into oogonia
 By the 5th month in-utero, the number of oogonia is at a maximum - 7 million
 Oogonia enlarge into primary oocytes. These are surrounded by flattened follicular cells forming primordial follicles
 Primary oocyte enters prophase of meiosis I and becomes arrested at the dictyotene stage. Meiosis I is not completed until
puberty
 Primordial follicles begin to degenerate such that at birth, there are 700,000 - 2 million, and at puberty there are 40,000
 Several primordial follicles (10-12) begin to mature with each menstrual cycle and one dominant follicle becomes selected by
mechanisms which are not fully understood
 Follicular cells become cuboidal, forming the primary follicle. A layer of acellular mucopolysaccharide becomes deposited
between the developing oocyte and the follicular cells, forming the zona pellucida
 Resumption of meiosis is triggered by the ovulatory LH / FSH surge with formation of the secondary oocyte with most of the
cytoplasm and the first polar body
 Ovulation occurs the moment the secondary oocyte shows spindle formation and the second meiotic division is only completed if
fertilisation occurs. In a woman with a regular 28 days cycle, ovulation occurs on day 14. The oocyte is surrounded by a cluster
of cells called the cumulus oophorus (MRCOG 1 2015)
 The polar body also completes meiosis II, resulting in one definitive oocyte and three polar bodies

FERTILIZATION
 Occurs in the ampulla of the fallopian tube
 The second meiotic division in the oocyte is only completed if fertilization occurs
 The spermatozoan undergo capacitation within the female genital tract, during which seminal plasma proteins and a glycoprotein
 coat are removed from the plasma membrane overlying the acrosome
 The spermatozoan force their way through the cumulus oophorus to reach the zona pellucida to which they are attached aided by
sperm receptors
 The acrosome reaction results in the release of hydrolytic enzymes and one spermatozoan enters the oocyte. This causes
immediate release of cortical granules into the perivitelline space (between the oocyte cell membrane and the zona pellucida,
preventing penetration by other sperm *
PRE-IMPLANTATION DEVELOPMENT
 The Zygote begins a series of mitotic divisions within 24h of fertilization - cleavage. The number of cells increases but
the size of the embryo remains constant within the zona pellucida - results in a decrease in mean cell volume. By the
32 cell stage, the embryo is called a morula
 The cells (blastomeres) become segregated into the inner cell mass which forms the embryo proper and the outer
cell mass which forms the placenta and membranes
 Fluid collects between the cells of the inner cell mass, forming a blastocyst cavity - day 4 of development
 The blastocyst enters the uterine cavity ~day 4, hatches from the zona Pellucida
 Implantation occurs between days 5-12 (MRCOG 1 2015)

PRIMITIVE STREAK
 Appears during the third week and is clearly visible by day 15-16
 Narrow groove on the epiblast with slightly bulging sides
 Cephalic end forms primitive node - elevated area surrounding a small pit, the primitive pit
 Cells from the epiblast migrate towards the primitive streak, detach from and slip underneath the epiblast to form a
third layer between the epiblast and hypoblast - the intra-embryonic mesoderm
 These cells also form most, or all of the intra-embryonic endoderm
 This process is known as gastrulation, at the end of which the remaining epiblast forms the ectoderm
 The ectoderm and endoderm remain in contact, without intervening mesoderm in two regions - the buccopharyngeal
membrane and the cloacal membrane

NERVOUS SYSTEM
 Development begins during the third week
 A thickening of the ectoderm forms the neural plate with elevated lateral edges forming the neural folds and the
depressed mid-region forming the neural groove
 Fusion of the neural folds begins in the region of the future neck (4th somite) and proceeds in ceplalic and caudal
directions, forming the neural tube
 The neural tube remains temporarily open to the amniotic cavity at the anterior and posterior neuropores
 The anterior neuropore closes on day 25 and the posterior on day 27
 Abnormal fusion of the neural tube results in neural tube defects - spina bifide / anencephaly. Risk reduced by use of
folic acid 12 weeks before to 12 weeks after fertilisation

NEURAL CREST
 Ectodermal cells at the edge of the neural grove, become detached and located initially between the closed neural
tube and the overlying ectoderm
 Contribute to several important structures includig
a) The truncoconal septum of the heart - migrate via pharyngeal arches. Form the connective tissue , muscle and
parasympathetic ganglia
b) Dorsal root ganglia of spinal nerves
c) Sensory ganglia of 5th, 7th, 9th and 10th cranial nerves
d) Aortic sympathetic ganglia
e) Sympathetic chain
f) Parasympathetic ganglia
g) Melanocytes
h) Cartilage of pharyngeal arches
i) Odontoblasts
j) Schwann cells and meninges
 DEVELOPMENT OF THE GUT

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DEVELOPMENT OF THE GUT

FOREGUT
 The pharynx extends from the buccopharyngeal membrane to the tracheo-bronchial diverticulum
 The tracheo-bronchial diverticulum develops on the ventral wall of the foregut during the 4th week and then becomes separated
from it by the tracheo-oesophageal septum. The respiratory primordium is therefore developed from the foregut
 The stomach develops as a dilatation and rotates 90 degrees clockwise along its longitudinal axis. The left side comes to lie
anteriorly such that the left vagus nerve forms the anterior vagal trunk
 Rotation of the stomach leads to the formation of the lesser sac
 The liver develops as an outgrowth of the endoderm of the distal foregut, as does the gall bladder, bile and cystic ducts. The
haemopoietic cells, Kupffer cells and connective tissue are derived from the mesoderm of the septum transversum
 The pancreas develops from a dorsal and a ventral pancreatic bud from the distal foregut. With rotation of the duodenum, the
ventral pancreatic bud migrates dorsally.
 The dorsal bud forms the head, body and tail while the ventral bud forms the uncinate process of the pancreas.
 The main pancreatic duct is formed from the distal part of the dorsal pancreatic duct and the entire ventral duct. Exocrine
pancreatic glands are derived from the foregut endoderm.
 Insulin secretion begins in the fifth month. The origin of the Islets is controversial
 The celiac trunk provides arterial supply to foregut structures

MIDGUT
 Begins distal to the entrance of the bile duct into the duodenum and ends at the junction between the proximal 2/3 and distal 1/3
of the transverse colon
 During the 6th week, the midgut herniated into the extra-embryonic coelom in the umbilical cord and rotates 90 degrees counter
clockwise along the axis of the superior mesenteric artery when viewed from in front
 The apex of the intestinal loop remains in open connection with the yolk sac through the vitelline duct, remnants of which form
the Meckel's diverticulum (MRCOG 1 2015)
 During the 10th week, the midgut retracts into the abdomen, undergoing a further 180 degrees rotation
 The superior mesenteric artery supplies midgut structures (MRCOG 1 2015)

HINDGUT (MRCOG 1 2015)

 Extends to the upper two thirds of the anal canal. The distal third of the anal canal is formed from the ectoderm of the cloaca and
the junction is marked by the pectinate line
 The terminal portion of the hindgut is enlarged as the cloaca. The cloaca develops into the rectum and upper 2/3 of the anal
canal, while its anterior subdivision, the urogenital sinus, develops into the bladder and in the female, the urethra and vestibule,
while in the male the prostatic urethra.
 The gut forms a solid cord during the 6th week with re-canalisation during the 7th - 8th weeks
 The smooth muscle and mesentery of the gut is derived from mesoderm
 The inferior mesenteric artery supplies hindgut structures

Ventral body wall defects

 Include ectopia cordis, bladder exstrophy, gastroschisis and exomphalos
 Exomphalos literally translated from the Greek means 'outside the navel'. Also called an omphalocele.
 The contents of the abdomen herniate into the umbilical cord through the umbilical ring – the contents fail to migrate back into
the abdominal cavity (MRCOG 1 2015)
 The viscera, which often includes the liver, is covered by a thin membrane consisting of peritoneum and amnion.
 Gastroschisis means 'stomach cleft'
 Congenital defect of the abdominal wall, usually to the right of the umbilical cord insertion. Abdominal contents herniate into the
amniotic sac, usually just involving the small intestine but sometimes also the stomach, colon and ovaries. Unlike exomphalos,
there is no covering membrane

Greater Omentum (MRCOG 2015)

 A peritoneal fold of splanchnic mesoderm extending from the greater curvature of the stomach and hanging ventrally down "like
an apron" in the peritoneal cavity over the small intestine
 Forms initially in the embryo and fetus as a loop of the dorsal mesentery (dorsal mesogastrium), which later fuses to form a
single sheet attached to the posterior body wall
 The lesser omentum is a smaller ventral peritoneal fold extending from lesser curvature of the stomach to liver.
URINARY TRACT

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KIDNEY AND URETER

Three overlapping systems

Pronephros
 Vestigial - develops from cervical nephrotomes, disappears by the end of the 4th week

Mesonephros
 Develops from the intermediate mesoderm on either side of the upper thoracic and lumbar vertebrae during the 4th week
 The mesonephric duct appears ~day 24 on the dorso-lateral aspect of the mesonephros and grows caudally to fuse with the cloaca
on ~day 26
 The mesonephros is functional between the 6th - 10th week, producing urine. The mesonephros regresses after 10 weeks in the
female
 In the male, the mesonephric duct and a few modified mesonephric tubules persist forming the ductus deferens and ductuli
efferentes of the testis. In the female, Gartner?s duct cysts, epoophron and paroophron are mesonephric remnants
 Mullerian remnants in the male include the appendix testis and the Utriculus prostaticus
 The developing gonad lies medial to the mesonephros
 The mesonephric ducts are derived from mesoderm

Metanephros - permanent kidney

 Develops in the 5th-15th week from the metanephric mesoderm in the sacral region
 Ureters - develop from the ureteric bud, an outgrowth of the mesonephric duct close to its opening into the cloaca(MRCOG 1
2015). Grows into the metanephric mesoderm, successive divisions forming the renal pelvis, major and minor calyces and
collecting tubules
 The metanephric mesoderm develops into the excretory units under inductive influence of the ureteric bud, forming the
Bowman’s capsule and excretory tubules. If the ureteric bud is missing, the kidney does not develop
 The metanephros is functional from the 10th week
 Metanephric development occurs in the pelvis and the kidney later ascends to its location in the abdomen by the 10th week.
Failure of this ascent leads to a pelvic kidney

LOWER URINARY TRACT

 The cloaca becomes divided into the anorectal canal and the primitive urogenital sinus during the 4th - 7th week by the urorectal
septum
 The cloacal membrane is divided into the anal and urogenital membranes
 The upper part of the primitive urogenital sinus forms the urinary bladder which is initially continuous with the allantois
 The obliterated allantois forms the urachus or median umbilical ligament
 The distal portions of the mesonephric ducts are absorbed into the urinary bladder such that the ureters come to open directly into
the bladder. With the ascent of the kidneys, the mesonephric ducts come to open into the prostatic urethra as the ejaculatory ducts
 The part of the mucosa of the bladder derived from the incorporation of the mesonephric ducts is mesodermal in origin and forms
the TRIGONE. The mesodermal lining of the trigone is later replaced by cells of endodermal origin such that at birth, the bladder
is completely lined by cells of endodermal origin (MRCOG 1 2015)
 The narrow pelvic part of the urogenital sinus forms the prostatic and membranous part of the urethra in the male (membranous
urethra in the female). Outgrowths of the endoderm of the prostatic urethra into the surrounding mesoderm form the prostate
gland (urethral and para-urethral glands in the female)
 The definitive urogenital sinus develops into the distal urethra and external genitalia
GONADAL DEVELOPMENT

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DEVELOPMENT OF THE TESTIS

 The gonads do not develop male / female differentiation until the end of the 6th week
 Primordial germ cells develop from the yolk sac endoderm and migrate via the dorsal mesentery of the hindgut to reach the
gonadal ridge in the 6th week (MRCOG 1 2015)
 Failure of migration results in gonadal agenesis
 The gonadal ridge develops medial to the mesonephros by proliferation of the coelomic epithelium and condensation of the
underlying mesenchyme, forming the primitive sex cords
 The sex-determining region of the Y chromosome has a testis determining factor, transcription of which triggers male
development
 Primitive sex cords proliferate into medullary cords with Sertoli cells which produce Mullerian Inhibiting Factor(MRCOG 1
2015) which acts on the ipsilateral Mullerian tube only, causing degeneration. Mullerian remnants in the male include the
appendix testis and the Utriculus prostaticus
 Leydig (Interstitial) cells develop from the mesenchyme and produce testosterone, influencing development of the duct system
and external genitalia. The enzyme 5-alpha reductase is essential for the development of the external genitalia but not for the
development of the duct system
 The distal excretory tubules of the mesonephros persist, forming the ductuli efferentes while the mesonephric duct elongates and
forms the eipdidymis and vas deferens
 The medullary cords remain solid until puberty when they become canalised, forming the seminiferous tubules
 The first meiotic division and spermatogenesis do not commence until puberty
 The seminal vesicles develop as outgrowth of the mesonephric duct while the prostate and bulbo-urethral glands develop from
the prostatic urethra
 DESCENT OF THE TESTIS
 During the 7th week, the testis begins to detach from the surrounding mesenchyme and develops a tough connective tissue coat -
tunica albuginae
 A thickening of mesenchyme, the Gubernaculum testis runs from the testis to the genital swellings
 As a result of the growth of the body relative to the gubernaculums, the testis descends to lie in the inguinal region during the
12th week
 During this process, an evagination of the coelomic epithelium forms the processus vaginalis which follows the descent of the
testis
 The final descent of the testis into the scrotum occurs in the 7th-9th months
 The processus vaginalis is obliterated during the first year of life, forming the tunica vaginalis

DEVELOPMENT OF THE OVARY

 The primitive sex cords disintegrate and the centre of the developing ovary becomes replaced by a vascular stroma, forming the
ovarian medulla
 The surface epithelium continues to proliferate, producing cortical cords which split into isolated cell clusters surrounding the
primitive germ cells
 The primitive germ cells differentiate into oogonia which undergo several mitotic divisions. The number of oogonia reaches its
maximum (~7 million) during the 5th month after which degeneration begins
 The oogonia become surrounded by a layer of follicular cells from the surface epithelium and develop into primary oocytes.
Primary oocytes surrounded by follicular cells form primordial follicles
 The primary oocytes duplicate their DNA and enter the first meiotic division and become arrested during Prophase I until puberty
 There are 700,000 - 2 million primary oocytes at birth and 40,000 at puberty
 The descent of the ovary is less extensive, coming to lie within the pelvis. The round ligaments of the ovary and uterus are the
equivalent of the gubernaculums testis (MRCOG 1 2015)
FETAL CIRCULATION

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FETAL ARTERIAL SYSTEM

 Each branchial arch receives its own artery during the 4-5th week - aortic arches
 The first aortic arch disappears apart from a small part - maxillary artery
 Second arch disappears - small hyoid artery
 Third arch - common carotid artery and first part of internal carotid artery
 The forth arch on the left forms part of the arch of the aorta. Right - proximal part of right subclavian artery
 Fifth arch is transient
 Sixth arch - pulmonary arch

FETAL VENOUS SYSTEM

 Three pairs of major veins develop in the 5th week:
 Vitelline veins - carry blood from the yolk sac to the sinus venosus - develops into the post-hepatic portion of the inferior vena
cava, the portal vein and superior mesenteric vein
 Umbilical veins - the proximal part of both umbilical veins and the remainder of the right vein later disappear so that the left vein
is the only one to carry blood from the placenta to the liver
 Cardinal veins: anterior cardinal veins anastomose to form the brachiocephalic vein. The superior vena cava is formed from the
right common cardinal vein and the proximal portion of the right anterior cardinal vein. Anastomosis of the sacrocardinal veins
forms the common iliac veins.

The developing umbilical cord contains the following

 Yolk sac stalk
 Two umbilical arteries and one umbilical vein
 The remnant of the allantois
 Small intestinal loops
 Extra-embryonic mesoderm
FETAL CIRCULATION
 Two umbilical arteries and one umbilical vein with in the umbilical cord
 The umbilical vein carries oxygenated blood from the placenta to the fetus
 Oxygenated blood in the umbilical vein bypasses the liver, draining into the inferior vena cava via the ductus venosus (MRCOG
1 2015)
 The obliterated umbilical vein forms the ligamentum teres while the obliterated ductus venosus forms the ligamentum venosum.
The ductus venosus is formed when a direct communication develops between the left umbilical vein and the hepatocardiac
channel
 Oxygenated blood entering the right atrium from the inferior vena cava is directed into the left atrium through the foramen ovale
 Desaturated blood from the superior vena cava flows via the right ventricle to the pulmonary artery
 Oxygenated blood then enters the aorta via the left ventricle
 Some blood from the right atrium leaves via the pulmonary artery - mainly return from the superior vena cava. As the pulmonary
circulation has high resistance, the blood enters the descending aorta through the ductus arteriosus which connects the pulmonary
artery to the aorta
 From the aorta, blood is supplied to the fetus, deoxygenated blood returns to the placenta via two umbilical arteries - oxygen
saturation here is ~58%
 The proximal part of the umbilical arteries form the superior vesical arteries. The obliterated distal part form the medial umbilical
ligaments
 Oxygenated and deoxygenated blood become mixed at the following points
a) The liver, mixing with blood returning via the portal system
b) The inferior vena cava, mixing with venous blood from the lower extremities
c) The right atrium, mixing with venous blood from the superior vena cava
d) The descending aorta, mixing with blood from the ductus arteriosus

 Blood in the ascending aorta has the highest oxygen saturation and supplies the heart and brain
 Blood in the right ventricle is therefore mostly de-oxygenated blood from the superior vena cava. Oxygenated blood passes
directly into the left atrium via the foramen ovale and does not enter the right ventricle

CIRCULATORY CHANGES AT BIRTH

 Placental blood flow ceases
 Respiration begins
 Pulmonary artery vasodilatation in response to falling PaCO2 and rising PaO2 - rapid fall in pulmonary vascular resistance in the
first few days of life
 Closure of the umbilical arteries - functionally closed within a few minutes of birth, obliteration takes 2-3 months. Distal part
forms the Medial umbilical ligaments while the proximal portion remains open as the superior vesical arteries
 Closure of the umbilical vein and ductus venosus - occurs shortly after closure of the umbilical arteries. The umbilical vein forms
the Ligamentum teres hepatis in the falciform ligament while the ductus venosus forms the ligamentum venosum
 Loss of umbilical blood supply reduces venous return via the inferior vena cava - fall in pressure
 Closure of the Ductus arteriosus - dependent on a rise in PaO2. Prostaglandin F, low calcium, low glucose and high pulmonary
pressure keep ductus arteriosus open in utero. Hypoxia can cause ductus to become patent
 Closure of the foramen ovale - caused by decreased right atrial pressure and increased left atrial pressure. Held shut by
haemodynamic forces only for the first few weeks. Remains potentially patent in 25-30% of normal adults
 PHARYNGEAL ARCHES & POUCHES

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PHARYNGEAL ARCHES
 First arch - cartilage forms incus and malleus, mesenchyme gives rise to the maxilla, mandible, zygomatic bone and part of the
temporal bone
 Second arch - cartilage forms the stapes and styloid process of the temporal bone and part of the hyoid bone
 Third arch - part of the hyoid bone
 Fourth to sixth arches - thyroid, cricoid, arytenoids and cuneiform cartilages
 Pharyngeal arches develop during the 4th-5th weeks. The arches receive neural crest cells which form the skeletal components
while the mesenchyme forms the muscle.

NERVE SUPPLY TO PHARYNGEAL ARCHES

 First arch - mandibular branch of the trigerminal nerve
 Second arch - facial nerve
 Third arch - glossopharyngeal nerve
 Fourth arch - superior laryngeal branch of the vagus
 Sixth arch - recurrent laryngeal branch of the vagus

PHARYNGEAL POUCHES
 First pouch - tympanic cavity and pharyngo-tympanic tube
 Second pharyngeal pouch - palatine tonsil
 Third pharyngeal pouch - inferior parathyroid gland and the thymus gland
 Fourth pharyngeal pouch - superior parathyroid gland
 Fifth pharyngeal pouch - parafollicular or C cells of the thyroid gland
 The thyroid gland develops from an epithelial proliferation in the floor of the pharynx (represented by the foramen cecum) and
subsequently descends in front of the pharyngeal gut, hyoid bone and laryngeal cartilages to reach its final position in the 7th
week.
 Thyroxine is produced from the 12th week.
 The first pharyngeal cleft forms the external auditory meatus. The others do not form any definitive structures.
GENITALIA

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GENITAL DUCTS IN THE FEMALE

 The Mullerian ducts persist in the female while the Mesonephric ducts degenerate. The Mullerian duct gives rise to the Fallopian
tube, body of the uterus, cervix and upper third of the vagina
 The Mullerian ducts fuse and grow into the urogenital sinus, forming the sinovaginal bulb which proliferates to form a solid plate
of tissue between the uterus and the urogenital sinus. This becomes canalised at the end of the 5th month to form the vagina
 The epoophron and paroophron and Gartner's cyst are remnants of the Mesonephric duct (MRCOG 1 2015)

BLADDER & URETHRA

 Development occurs in the 4th to 7th week
 Urogenital septum divides the cloaca into the anorectal canal and the primitive urogenital sinus - endodermal in origin
 Cloacal membrane divided into urogenital membrane and anal membrane
 The upper part of the urogenital sinus forms the bladder (except the trigone) which is initially continuous with the allantois
(obliterated to form the urachus)
 The trogone is formed from the mesoderm of the mesonephric ducts
 The narrow pelvic part of the urogenital sinus forms the prostatic and membranous urethra in the male
 The definitive urogenital sinus? which forms the external genitalia

EXTERNAL GENITALIA
 Cloacal folds develop on either side of the cloacal membrane during the 3rd week and fuse to form the genital tubercle cranial to
the cloaca
 With partitioning of the cloaca, the folds form the urethral folds anteriorly and the anal folds posteriorly
 The male / female genitalia are indistinguishable at the end of the 6th week
 Under the influence of testosterone (and 5-alpha reductase), the genital tubercle elongates rapidly in the male, forming the penis,
pulling the urethral folds forward forming the urethral groove
 The urethral groove closes over at the end of the 12th week, forming the penile urethra. The lining is endodermal in origin. The
external urethral meatus is formed from ectodermal cells from the tip of the glans which penetrate inwards, forming a cord which
is later canalised
 The genital swellings, which form on either side of the urethral swellings form the scrotum in the male and the labia majora in the
female
 In the female, there is only slight elongation of the genital tubercle, forming the clitoris. The urethral folds do not fuse and form
the labia minora. The urogenital groove is open to the surface and forms the vestibule
 The epithelium of the male and female urethra is endodermal (urogenital sinus) in origin apart from the most distal tip in the male
which is ectodermal in origin. The proximal part of the urethra in the female forms the urethral and paraurethral glands and
greater vestibular (Bartholin's) glands
 The vulval vestibule is the part of the vulva between the labia minora containing the urethral opening and the vaginal opening
open. It represents lower end of urogenital sinus (MRCOG 1 2015)

Transverse vaginal septum (MRCOG 1 2015)

 Disorders of vertical (transverse) fusion result from abnormal canalization of the vaginal plate and, in some cases, failure of the
utero-vaginal promordium and the sinovaginal bulbs to fuse.
 These disruptions can result in the formation of a transverse vaginal septum, an imperforate hymen, and, in extreme cases,
vaginal atresia.
 Transverse vaginal septum is subdivided according to whether the defect is complete or partial and can be accompanied by
urinary tract anomalies. A partial septum may occur in females exposed to DES.
 Imperforate hymen and vaginal atresia result from structural defects involving derivatives of the urogenital sinus. Although not of
müllerian origin, these conditions can clinically mimic an obstructed TVS
 AXIAL SKELETON

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Development of the axial skeleton (MRCOG 1 2015)

 Begins during the third week with the appearance of the rod-like notochord along the dorsal length of the embryo
 Repeating, paired blocks of tissue called somites then appear along either side of notochord
 As the somites grow, they split into parts, one of which is called a sclerotome. This consists of mesenchyme which will become
the bones, cartilages, and connective tissues of the body - derived from mesoderm (MRCOG 1 2015)
 Mesenchyme in the head region will produce the bones of the skull via two mechanisms:
1. The bones of the brain case arise via intramembranous ossification in which embryonic mesenchyme tissue converts directly into
bone. At the time of birth, these bones are separated by fontanelles
2. The cranial base and facial bones are produced by endochondral ossification, in which mesenchyme tissue initially produces a
hyaline cartilage model of the future bone. The cartilage model allows for growth of the bone and is gradually converted into
bone over a period of many years
 The vertebrae, ribs, and sternum also develop via endochondral ossification. Mesenchyme accumulates around the notochord and
produces hyaline cartilage models of the vertebrae
 The notochord largely disappears, but remnants of the notochord contribute to formation of the intervertebral discs
 In the thorax region, a portion of the vertebral cartilage model splits off to form the ribs. These then become attached anteriorly to
the developing cartilage model of the sternum
 Growth of the cartilage models for the vertebrae, ribs, and sternum allow for enlargement of the thoracic cage during
childhood and adolescence. The cartilage models gradually undergo ossification and are converted into bone

DEVELOPMENT OF THE PLACENTA

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DEVELOPMENT OF THE PLACENTA

 Fetal weight is related to placental weight. The fetal:placental weight ratio increases with gestation age. At term, fetal weight is
5-6x placental weight. At 32 weeks gestation, fetal weight ~ 4x placental weight
 During implantation, the outer layer of the blastocyst proliferates to form the outer cell mass from which the trophoblast and the
 placenta develop
 The trophoblast differentiate into an inner layer of large clear mononuclear cells, the cytotrophoblast and an outer layer of multi-
nucleated cells, the syncytiotrophoblast which forms a true syncytium
 DNA synthesis and mitosis occurs only in the cytotrophoblast layer. The syncytiotrophoblast is formed by fusion of cells from
the cytotrophoblast layer
 Lacunae appear within the syncytiotrophoblast between days 10 - 13 post-ovulation and are the precursors of the intervillous
space. The lacunae are separated by columns of syncytiotrophoblast called primary villous stems (These are not villi)

DEVELOPMENT OF THE VILLOUS TREE

 Primary villous stems become infiltrated by cytotrophoblasts between days 13-21 post-ovulation
 Villous stems are subsequently infiltrated by extra-embryonic mysenchyme which differentiates into fetal blood vessels
 The distal parts of the villous stems are not vascularised. Here, cytotrophoblasts proliferate and spread laterally to form a
cytotrophoblastic shell, splitting the syncytiotrophoblast into a definitive syncytiotrophoblast on the fetal side and the peripheral
syncytium on the decidual side which degenerates and is replaced by fibrinoid material (Nitabuch's layer)
 Sprouts extend from primary villous stems, initially made up of syncytiotrophoblast and then infiltrated by cytotrophoblast and
mesenchyme - these are primary stem villi and the placenta is a true villous structure by day 21 of gestation. These villi grow and
divide into secondary, tertiary and terminal villi
 The villi oriented towards the uterine cavity degenerate between day 21 and the 4th month to form the chorion laeve. The
overlying decidua degenerates and the chorion laeve comes in contact with the deciduas of the opposite uterine wall
 The rest of the villi form the chorion frondosum which develops into the definitive placenta
 Division and modification of the villous tree continues until term. First trimester villi are larger, have a complete layer of
cytotrophoblasts and have a loose mysenchymal core which is vascularised towards the end of the first trimester
 At term, the villi are smaller, cytotrophoblasts are few in number, the syncytiotrophoblast is irregularly thinned. Fetal vessels are
sinusoidal and occupy most of the villous core and lie close to the syncytiotrophoblast, forming vasculusyncytial membranes
which maximise materno-fetal transfer.
 Sometimes, the syncytiotrophoblast nuclei appear in clusters called syncytial knots - more common in placentas from IUGR /
pre-eclamptic pregnancies
 Maternal blood is separated from fetal blood by the syncytiotrophoblast and the fetal capillary endothelium

TROPHOBLAST INVASION
 Extra-villous cytotrophoblast from the trophoblastic shell break through the outer syncytiotrophoblast layer and invade the
decidua
 Some of these cells invade the decidua (interstitial trophoblasts) and fuse to form multinucleat giant cells
 Endovascular trophoblasts invade the lumen of spiral arteries, destroying the muscular and elastic layers of the vessels, replacing
these with fibrinoid and replacing the vascular endothelium. The vessels are converted into wide, low resistance vascular
channels
 This invasion is initially restricted to the intra-decidual portion of the vessels and starts at 8-12 weeks. During the 4th month (16-
18 weeks), a second wave of invasion occurs, extending to involve the intra-myometrial segments of the spiral arterioles
 Extravillous trophoblasts invade through the decidua, followed by a second wave of migration ~18 weeks gestation to invade the
myometrium. Some differentiate and fuse into multinucleated giant cells within the decidua and myometrium
 Trophoblast cells stain positively for cytokeratin while decidual stromal cells are negative
 The basic structure of the placenta is formed by day 20 of pregnancy

PLACENTAL LOBES AND LOBULES

 LOBES: Placental septae develop during thr 3rd month as protrusions of the basal plate into the intervillous space, dividing the
maternal surface of the placenta into 15-20 lobes
 Lobes are not structural or functional units
 LOBULES: Each placental lobule is derived from a single secondary stem villus. A cotyledon is that part of the villous tree
which has arisen from a single primary stem villus and contains 2-5 lobules
 Each placental lobule is supplied by a single utero-placental artery

THE PLACENTAL BED

 Refers to the decidua and myometrium directly underlying the placenta
 The fetal component is made up of extra-villous trophoblast
 The maternal component is made up of decidualised endometrial stromal cells, macrophages and granular lymphocytes. Residual
endometrial glands are also present.
AMNIOTIC FLUID

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AMNIOTIC FLUID
 Initially produced by primitive cells around the amniotic vesicle
 Later formed from transudate from fetal skin and umbilical cord and diffusion across the amniotic membrane
 Fetal skin becomes keratinised in the second trimester and amniotic fluid is mainly formed from fetal urine and lung secretions.
The term fetus passes 500-700ml urine per day
 Fetal swallowing is a major route of amniotic fluid re-circulation and begins at 12 weeks. At term. ~500ml amniotic fluid is
exchanged / 24h
 Amniotic fluid volume = 50ml at 12 weeks, 150ml at 16 weeks gestation and ~1000ml at term. Peak volume is at 32-36 weeks
 Osmolarity: 275 mOsmol/l (lower than maternal or fetal), decreases as pregnancy progresses
 Cells: at term, contains fetal epithelial cells, amniocytes and dermal fibroblasts. Epithelial cells and amniocytes grow poorly in
culture. Glial cells present if neural tube defect
 Protein: concentration increases with gestation but plateaus after 30 weeks. Mainly albumin and globulins. Also contains AFP
(1/10TH concentration in fetal blood - rises until 12 weeks then declines). Virtually no fibrinogen.
 Urea, creatinine and urate concentration increases with gestation
 Amino acids: concentration similar to that in maternal plasma
 Lipids: mainly free fatty acids. Also contains phospholipids, cholesterol and lecithin (secreted by lungs during maturation)
 Carbohydrates: mainly glucose; concentration ~ half that of maternal serum
 PO2 = 2-15mmHg while PCO2 = 50-60mmHg
 pH = 7.0 (acidic relative to fetal blood)
 Bilirubin concentration falls in the third trimester (except in haemolytic disease)
PLACENTAL FUNCTION

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 PLACENTAL HORMONE PRODUCTION

OESTROGENS
 Mainly oestriol, but also oestradiol and oestrone in smaller amounts. Oestriol is produces from DHES-sulphate from fetal zone of
the fetal adrenal gland and also from the maternal adrenals. Fetal DHEA-S is initially hydroxylated by the fetal liver

PROGESTERONE
 Produced from maternal cholesterol. Pregnenolone is also produced and is converted by the fetal adrenals into androgens which
are then converted by the placenta into oestrogens.

HCG
 Produced by the syncytiotrophoblast. Cytotrophoblasts produce HCG in-vitro

Human Placental Lactogen - has growth-hormone -like effects and decreases insulin-sensitivity.
Human chorionic thyrotropin and virtually all of the hypothalamic releasing hormones

INHIBIN & ACTIVIN

 Produced by the feto-placental unit (mainly by the ovary in non-pregnant state)
 Inhibin-A levels peak in early pregnancy and rise again at term and are increased in pre-eclampsia
 Activin levels increase with gestation age and a marked increase occurs with the onset of labour and in pre-eclampsia

PLACENTAL TRANSFER
FACTORS AFFECTING PLACENTAL TRANSFER:
 Utero-placental blood flow - particularly important in the exchange of lipid soluble solutes such as O2, CO2
 Feto-placental blood-flow
 Surface area of placenta
 Activity of placental transport systems in the microvillous and basal plasma membranes of the syncytiotrophoblast
 Molecular weight and lipid solubility of solute
 Charge of solute
 Protein binding
 Placental metabolism of solute
 Concentration of solute in maternal and fetal plasma

PLACENTAL GAS TRANSFER

O2 / CO2
 Small lipid soluble molecules - transfer is by simple diffusion and rate of transfer is dependent on maternal / fetal concentrations
(partial pressure), rate of blood flow and surface area
 The fetal O2 - Hb dissociation curve lies to the left of the maternal curve - fetal red cells have greater affinity for O2 - see
respiratory physiology
 A hypoxic fetus develops both respiratory and metabolic acidosis ? CO2 excretion is impaired and anaerobic glucose metabolism
results in lactate production
 During acidosis, the fetal O2 - Hb dissociation curve is shifted to the right, decreasing oxygen binding for a given partial pressure
and releasing more O2 in fetal tissues. De-oxygenated Hb becomes available and acts as a better buffer than oxygenated Hb.

WATER TRANSFER
 3-4L of water is exchanged per hour between the mother and the fetus, placenta and amniotic fluid
 Net water accumulation by the fetus continues until delivery
 Water exchange is by perfusion transfer and osmosis
 Maternal dehydration / over-hydration will affect fetal water accumulation, although there is a time lag

CARBOHYDRATES & AMINO ACIDS

 Glucose transport across the microvillous and basal plasma membranes is by facilitated diffusion.
 This is dependent on glucose concentration gradient and the activity of transport proteins within the placenta. In theory,
facilitated diffusion can be saturated.
 In practice, the glucose transfer capacity (especially of the microvillous plasma membrane) is so large that it would not approach
saturation under in-vivo conditions
 Fetal amino acid concentrations are generally higher than maternal levels
 Transfer of amino acids from the mother to the fetus is therefore against a concentration gradient and energy (ATP) is required
for this process
 This energy is provided by coupling the transfer of amino acids (up a concentration gradient) to the transfer of sodium ions
(down a concentration gradient) - secondary active transport. These are called Na+-dependent transporters. The sodium
concentration gradient is maintained by Na+K+ATPase.
 Other amino acid transport systems are, however, Na+-independent.

PEPTIDES AND PROTEINS (MRCOG 1 2015)

 Peptides cross the placenta via active transport
 Maternal proteins do not traverse the placental barrier, with the exception of immunoglobulin (IgG) which is trensferred through
pinocytosis of syncitiothrophoblast cells
 This transfer occurs mainly towards the end of pregnancy. Thereby the fetus obtains a passive immunity that protects it against
various infectious diseases in the first six months of its life
 Transferrin is another important maternal protein that is transferred to the fetus by active transport
 Protein can also be transferred from the fetus to the mother; alpha-fetoprotein (the concentration of which is elevated in several
fetal abnormalities) can be detected in the maternal circulation system.
 Maternal or placental polypeptide hormones do not enter the fetal circulation system.
ELECTROLYTE TRANSFER
 Na+ concentration is low while K+ is high within the syncytiotrophoblast
 These concentrations are maintained by Na+K+ATPase which transfers 3Na+ out for 2K+ into the syncytiotrophoblast across the
microvillous plasma membrane
 Total and ionised calcium concentration - higher in fetal than maternal plasma. Calcium transfer across the microvillous plasma
membrane is magnesium dependent and dependent on 1,25-dihydroxycholecalciferol
 Phosphate transfer is Na+-dependent

Placental transfer
Molecule

Testosterone Minimal transfer - androgens aromatised by placenta. Very high maternal androgen

concentration may virilise female fetus

Ca2+, Mg2+ Active transfer against concentration gradient

PTH, Calcitonin Not transferred

Vitamin D Good transfer

IgA Minimal passive transfer

IgG Good active and active transfer from 7 weeks gestation

IgM No transfer

Glucose Fascilitated diffusion - excellent transfer

Amino acids Active transport - excellent transfer

Free fatty acids Very limited transfer - essential fatty acids only

Ketone bodies Excellent transfer – diffusion

 Insulin, glucagons No transfer

Thyroid hormone Poor transfer – diffusion

TRH Excellent transfer

Iodine and thioamides Excellent transfer

Cortisol & aldosterone Excellent transfer

ACTH No transfer

MULTIPLE PREGNANCY
Twins
 UK data 2007: ~ 1 in 65 (1.5%) pregnancies were twins
 Prevalence varies world-wide, being lowest in Japan and highest in Nigeria
 Incidence of monozygotic twins relatively constant world-wide at ~ 3.5 per 1,000 births
 Incidence of dizygotic twins varies widely
Dizygotic twins
 Fertilisation of two oocytes by different sperm
 Dizygotic twins have no more resemblance than brothers / sisters of different ages
 Both zygotes implant independently in the uterus and there are two separate placentas, amniotic and chorionic sacs
 The placentas and chorionic sacs may come into close approximation and fuse.
 Dizygotic twins cannot be monochorionic and cannot be identical. They are always dichorionic and diamniotic
Monozygotic twins
 A single ovum is fertilised and splits into two at different stages of development
 Earliest separation occurs at the 2 cell stage producing two zygotes which enter the uterus independently. Each
embryo would have its own placenta and chorionic sac, forming dichorionic diamniotic twins
 In the majority of cases, splitting occurs in the early blastocyst stage. The inner cell mass splits into two, producing
two embryos with a common placenta and a common chorionic cavity but separate amniotic cavities. These form
monochorionic diamniotic twins
 Rarely, splitting occurs at the stage of the bilaminar germ disc, resulting in two embryos with a common placenta,
common chorionic cavity and common amniotic cavity. These form monochorionic monoamniotic twins
 Splitting at later stages of development may result in incomplete splitting of the axial area of the germ disc, resulting
in conjoint twins
Monochorionic twins
 Both fetuses are dependent on a single shared placental mass
 One in 3 twin pregnancies have a monochorionic placenta
 Twin pregnancies are associated with an increased risk of maternal pregnancy symptoms, pre-term delivery, fetal
growth restriction, pre-eclampsia, and PPH. These risks are further increased in monochorionic twin pregnancies
 Additional problems associated with monochorionic twins include:
1) Feto-feto transfusion syndrome
 This is a complication of disproportionate blood supply to the fetuses in a monochorionic twin pregnancy, resulting in
one twin (the donor) being smaller with oligohydramnios and the recipient being bigger with polyhydramnios
 Associated with significant morbidity and morbidity with severe FFTS having a perinatal mortality rate of 60-100%
 Complicates 10-15% of monochorionic twin pregnancies but is less frequent in mono-amniotic compared to di-
amniotic twins
 Results from blood flow across the vascular anastomoses that connect the two umbilical circulations. Pregnancies
complicated by FFTS are more likely to have unidirectional artery-to-vein anastomoses and less likely to have bi-
directional artery-to-artery anastomoses.
 Artery-to-artery anastomoses can be identified antenatally using colour Doppler. Their absence is associated with an
increased risk of FFTS (61% Vs 15%)
2) Consequences to the co-twin of fetal death. Risk of death of surviving twin is ~12% and risk of neurological
abnormality ~18%
3) Management of discordant fetal malformation
4) Risk of cord entanglement in mono-amniotic twins
 As a consequence, monochorionic twin pregnancies have a higher fetal loss rate compared to dichorionic twins,
mainly due to second trimester loss. The risk of fetal loss after 24 weeks is also increased. There may also be an
increased risk of neuro-developmental delay