FEMALE REPRODUCTIVE ANATOMY - Located at the superior portion of the vulva,

between the labia minora

External Genitalia
- Composed of:
Pudenda/ Vulva o Glans clitoris
o Corpus cavernosum
- Collective term to describe the external female o Two crura (crus clitoris)
genitalia - Lined with stratified squamous epithelium
- Boundaries - Prepuce: describes the point where the labia
o Anterior: Mons pubis minora fuses anteriorly (clitoris hood)
o Posterior: Perineum - Frenulum: posterior fusion of the labia minora
- Structures within the pudenda
o Labia majora/minora Vestibule
o Urethral opening - Almond-shaped area enclosed by the labia minora
o Clitoris - Structures within the area are part of the
o Hymen vestibule
o Mons pubis
- Boundaries
o Vestibule o Anterior: clitoris
o Glandular and vascular structures o Posterior: Fourchette
Mons Pubis - Openings:
o Urethral opening
- Mons veneris counterpart in males o Clitoris
- Escutcheon in females once pubic hair develops o Two Bartholin glands
- Triangular in females; not well-circumscribed in o Two paraurethral glands (Skene’s
males glands)
- Primarily composed of adipose tissue - Represents the functionally mature female
structure of the urogenital sinus
Labia majora
Bartholin’s Glands
- Scrotum counterpart in males
- Rich in sebaceous glands and adipose tissue - Located at either side of the vaginal opening
- Dimensions: o At 5 o’clock and 7 o’clock positions of the
o Length: 7-8 cm vaginal opening
o Width: 2-3 cm - Major vestibular glands
o Thickness: 1.5 cm - Gland size: 0.5 – 1 cm in length
- No muscular elements - Duct size: 1.5 – 2 cm in length
- Posterior commissure: describes the area where - Risk of enlargement due to accumulation of
the left and right labia are joined posteriorly abscess
o Incision and drainage
Labia minora
Urethral opening
- Thin, moist mucus membrane
- Between the labia majora and vaginal opening - Located at the midline of the vestibule
- Lined by stratified squamous epithelium - 1-1.5 cm below the pubic arch
- No hair follicles - Skene’s duct open on either side of the urethral
- Contains few sweat glands opening
- Extremely rich in nerve endings → highly - Bartholin’s gland is located below the urethral
sensitive opening
- Fourchette: describes the area where the labia
minora joins posteriorly Vestibular bulbs

Clitoris - Anlage of the corpus spongiosum of the penis

- Aggregation of veins beneath the mucous
- Principal female erogenous organ membranes on either side of the vestibule
o Erectile organs rich in nerve endings o Higher risk of producing hematoma
o Rich in genital corpuscles during episiotomy if failed to be ligated
- Homologous to the male penis
Vaginal opening and Hymen ▪ Vestibular bulbs
▪ Clitoral body and crus
- Composed of elastic and connective tissue
▪ Branches of the pudendal vessels
- Lined with stratified squamous epithelium and nerves
- Contains no glandular or muscular elements o Deep
- No nerve fibers ▪ Compressor urethrae
- Hymen characteristics
▪ Urethrovaginal sphincter
o NB – vascular ▪ External urethral sphincter
o Pregnant – thicker epithelium rich in ▪ Branches of the internal
glycogen pudendal A.
o Menopause – thinner with focal
▪ Dorsal nerve and vein clitoris
cornification - Posterior
o Adult women – surrounds the vaginal o Ischiorectal fossa anal canal
opening more or less completely o Anal sphincter complex
Vagina o Branches of the internal pudendal vessels
o Pudendal nerve
- Musculomembranous structure
- Connects the vulva and uterus Internal Reproductive Organs
o Passageway between the external
Uterus
genitalia to the internal reproductive
organs - Boundaries:
- Boundaries: o Anterior: Urinary bladder
o Anterior: urinary bladder o Posterior: Rectum
o Posterior: rectum - Non-pregnant: flat pear-shaped
- Walls: - Isthmus
o Anterior: 6-8 cm in length o Located between the body of the uterus
o Posterior: 7-10 cm in length and cervix
- Development: o Transforms to become the lower uterine
o Upper: Mullerian ducts segment during pregnancy
o Lower: Urogenital sinus - Cervix
- Vagina fornices o Mucosa: ciliated columnar epithelium
o Upper part of the vagina allows access to - Endometrium
the internal pelvic organs o Lines the uterine cavity
o Provides access to the intraperitoneal o Contains uterine glands, which are
cavity tubular in structure
- Rugated o Lined with high columnar ciliated
o Has inner circular and outer longitudinal epithelium
layer of smooth muscle o Layers:
- No vaginal glands ▪ Stratum basalis (1/3)
o Lubrication is attributed to cervical glands • Remains during menses
- Blood supply • Supplied by straight
o Upper 1/3: cervicovaginal branch of the arteries
uterine A. • Not sloughed off
o Middle 1/3: inferior vesical A. • Not responds to
o Lower 1/3: middle rectal A., internal hormones
pudendal A. • Replenishes cells of the
stratum functionalis
Perineum
▪ Stratum functionalis (2/3)
- Consists of muscles responsible in supporting the • Compactum: sloughed
structures bounded within it off during menses
o Issues can lead to pelvic organ prolapse • Spongiosum
- Anterior triangle • Supplied by coiled A.
o Superficial • Responsive to hormones
▪ Ischiocavernosus M. • Sloughed off
▪ Bulbocavernosus M.
 - Contained inside the Infundibulopelvic ligament

- Myometrium Oviducts (Fallopian Tube)

o Muscular layer of the uterus
- Undergo rhythmic contractions
o Number of muscles decrease caudally
- Parts:
o Undergoes hypertrophy during
o Interstitial: found embedded in the
pregnancy
uterus; forms attachment between the
Ligaments tubes and the uterus;
o Isthmus: the narrowest part of the
Broad ligaments oviduct; common site of ectopic
- Wing-like structure consisting of a fold of pregnancy
peritoneum extending from the lateral margin of o Ampullary: widest area
the uterus o Infundibulum: fimbriated ends; catches
- Divides the pelvic cavity into anterior and the ovum
posterior compartments Ovaries
- Divisions
o Mesosalpinx/mesovarium - Located in the ovarian fossa of Waldeyer
▪ Inner 2/3 - Appearance:
▪ Fallopian tube attaches o Young: smooth
o Infundibulopelvic/ suspensory ligament o Childbearing years: corrugated
of the ovary o Elderly: markedly convoluted
▪ Outer 1/3
Bony pelvis
▪ Fimbriated end to pelvic wall
▪ Contains ovarian blood vessel - Consist of 4 bones
(ovarian A.) o Sacrum: posterior
o Coccyx
Cardinal ligament
o 2 innominate bones
- Densest portion of the broad ligament ▪ Ilium
- Continuous with the connective tissue of the ▪ Ischium
pelvic floor - Pelvic joints
- Other names o Symphysis pubis: joins the pelvic bone
o Transverse cervical ligament anteriorly
o Mackenrodt ligament o Sacroiliac joints: joins the pelvic bones
posteriorly
Round ligament - Planes and diameter of the pelvis
- Below and anterior to the origin of the oviducts o 3 planes – inlet, midplane, outlet
- Gubernaculum testis in men o Diameters
▪ AP diameter: shortest distance
Uterosacral ligament between promontory of the
sacrum and symphysis pubis –
- “V-like” structure found posterolateral at the
Diagonal conjugate
supravaginal portion of the cervix
▪ Obstetric conjugate: estimated
- Forms the lateral boundaries of the Pouch of
indirectly by subtracting 1.5 –
Douglas
2cm from the diagonal conjugate
Blood Supply of the Uterus ▪ Normal obstetric conjugate –
10cm, allowing for normal
Uterine A. delivery
- Branch of the anterior part of the internal iliac A. o Ischial spines
(hypogastric A.) ▪ Shortest diameter of the pelvic
- Enters the uterus at the supravaginal portion, cavity
lateral to the cervix as it crosses over the ureter ▪ Landmark for descent of the
presenting part into the true
Ovarian A. pelvis
- Direct branch of the abdominal aorta
 o Criteria for ideal vaginal delivery based Phases
on bone structure/position
1. Follicular phase (ovarian)
▪ Curved sacrum
▪ Non-converging sidewalls − Goal: develop a mature/viable egg
(dominant follicle)
▪ Non-prominent ischial spines
▪ Wide suprapubic angle (difficult − Stimulus: ↑ GnRH → ↑ FSH and LH
to assess) − Events:
▪ Sacrosciatic notch able to ▪ FSH stimulates follicles to grow
accommodate 2 fingers (difficult ▪ One follicle becomes dominant –
to assess) Graafian follicle
▪ Granulosa cells in the follicle
MENSTRUAL CYCLE produce estrogen
▪ Estrogen initially inhibits FSH/LH
Overview
via negative feedback
- Duration: average of 28 days (may range from 21 ▪ Around day 12-14: estrogen
– 35 days) surge leads to positive feedback
- Main players: Hypothalamus → pituitary gland → − Products
ovaries → uterus ▪ Estrogen: thickens
- Two major aspects: endometrium, promotes cervical
o Ovarian cycle mucus thinning (for sperm entry)
▪ Follicular phase: days 1-14 ▪ Inhibin: inhibits further FSH
▪ Luteal phase: days 15-28 secretion to prevent multiple
o Uterine cycle dominant follicles
▪ Menstrual phase: days 1-5 2. Menstrual phase (uterine)
▪ Proliferative phase: days 6-14 − Event: shedding of the functional layer of
▪ Secretory phase: days 15-28 endometrium
- Hormones involved − Cause: drop in estrogen and
o GnRH progesterone (due to degeneration of
▪ Produced by the hypothalamus corpus luteum from previous cycle)
▪ Stimulates pituitary to release 3. Proliferative phase (uterine)
FSH and LH − Occurs alongside with the follicular phase
o FSH − Event: regeneration and thickening of
▪ Anterior pituitary gland endometrial lining
▪ Stimulates follicle development − Stimulated by estrogen developing from
in ovaries follicles
o LH − Results in:
▪ Anterior pituitary ▪ Increase endometrial gland size
▪ Triggers ovulation and corpus ▪ Development of spiral arteries
luteum 4. Ovulation (transition)
o Estrogen − Triggered by LH surge
▪ Ovarian follicles (granulosa cells) − Events:
▪ Promotes endometrial growth, ▪ LH causes completion of meiosis
inhibits FSH/LH (early), then I in oocyte → becomes
surges LH (late) secondary oocyte
o Progesterone ▪ Proteolytic enzymes digest
▪ Corpus luteum follicular wall → follicle ruptures
▪ Maintains endometrium for ▪ Secondary oocyte is released
implantation into fallopian tube (viable for 24
o Inhibin hours)
▪ Granulosa cells and corpus 5. Luteal phase (ovarian)
luteum − Corpus luteum appears
▪ Inhibits FSH ▪ Secretes: progesterone,
estrogen, and inhibin
− Events:
 ▪Progesterone prepares endometrium and facilitate
endometrium for possible invasion
implantation − Secretes hCG to
▪ if no fertilization: corpus luteum maintain corpus luteum
degenerates into corpus albicans → maintains
▪ progesterone and estrogen progesterone secretion
levels fall → triggers → maintain vascularity
menstruation of the functionalis layer
6. Secretory phase (uterine)
Early placental development (Week 2-4)
− Occurs alongside with luteal phase
− Stimulated by progesterone 5. Lacunar stage (Day 9-12)
− Changes: − Lacunae (spaces) form in the
▪ Endometrial glands become syncytiotrophoblast and fill with maternal
coiled and secrete glycogen-rich blood – early uteroplacental circulation
fluid to nourish embryo begins (diffusion)
▪ Increased blood supply to 6. Primary villi formation (End of Week 2)
support implantation − Proliferating cytotrophoblasts form
finger-like projections into the
IMPLANTATION AND PLACENTAL DEVELOPMENT
syncytiotrophoblast
Implantation (6-10 days after fertilization) 7. Secondary and Tertiary villi (Week 3-4)
− Extraembryonic mesoderm
1. Fertilization (Day 0)
(splanchnopleuric) invades the primary
− Occurs in the ampulla of the fallopian villi → secondary villi
tube
− Fetal blood vessels develop within the villi
− Forms the zygote → morula → blastocyst
→ tertiary form
2. Blastocyst formation (Day 5-6)
− Establishment of chorionic villi which
− Composed of: form the functional unit of the placenta
i. Trophoblast: outer layer: future
placenta Placental maturation (Week 5 onwards)
ii. Inner cell mass: forms the
embryo; differentiates into the 8. Chorion development
three layers (ectoderm, − Differentiates into:
mesoderm, endoderm) i. Chorion frondosum: forms the
fetal part of the placenta
− Zona pellucida sheds to allow
ii. Chorion leave: degenerates
implantation
9. Decidua formation (Maternal contribution)
3. Apposition and adhesion (Day 6-7)
− Blastocyst aligns and attaches to the − Decidua basalis: under implantation site;
forms maternal part of the placenta
endometrium (usually posterior uterine
wall) − Decidua capsularis: covers the embryo
− Microvilli on the surface of the blastocyst − Decidua parietalis: lines the rest of the
will anchor itself to the pinopods of the uterus
surface of the endometrium → loose 10. Placental barrier establishment
attachment − Formed by layers of syncytiotrophoblast,
− Integrins (trophoblast) + selectins (and cytotrophoblast, connective tissue, and
collagens) (endometrium) → strong fetal capillary endothelium
11. hCG peaks (Week 9-10)
attachment → trophoblast will release
chemokines → stabilizing the attachment − supports the corpus luteum, which
secretes progesterone and estrogen
4. Invasion (Day7-9)
− Placenta takes over in the production of
− Trophoblast differentiates into:
progesterone by the end of the 1st
i. Cytotrophoblast: inner
trimester
mitotically active layer
ii. Syncytiotrophoblast: outer
invasive layer that secretes
enzymes (hydrolytic) to digest
 Maternal Adaptations to Pregnancy Fat metabolism

Metabolic changes - Increased:

o Lipolysis
Weight gain
o Lipid mobilization
- Normal o Fatty acid synthesis
- Average weight gain: 12.5 kg or 27.5 lbs o Lipid, lipoprotein, and apoliprotein
- Higher risk of: concentration in plasma during
o Gestational diabetes mellitus pregnancy
o Hypertension - This ensures available fats for energy production
o Preeclampsia at times of prolonged starvation and hard
o CS delivery physical exertion
o Postpartum weight retention Electrolyte and mineral metabolism
Water metabolism - Decreased
- Changes include o Total serum Ca2+
o ↑ water retention o Serum Mg2+ level
o Changes in osmoregulation o Serum Na+ level
o Impaired urine concentration by the o Serum K+ level
kidneys → ↑ urine production - Increased:
o ↑ GFR to support metabolic demand of o Iron requirement – meet the expansion
pregnancy of maternal Hgb mass
- At term volume: o Iodine requirement – maintain
o Placenta, fetus, and amniotic fluid: ~ euthyroidism and transfer of thyroid
3.5L hormones to the fetus
o Uterus and breast growth: ~3 L Hematologic changes
o Extra water: ~6.5 L
- Edema in pregnancy Blood volume
o Due to the compression of the veins and
- 32 – 34 weeks AOG: 40-45% increase in blood
lymphatic system by the growing fetus
volume
→ ↑ venous pressure below the level of
o Meet metabolic needs of the growing
the uterus → ↓ interstitial colloid
fetus
osmotic pressure
o Provide nutrients to support growing
Protein metabolism placenta and fetus
o Protect against the effects of:
- Increased: ▪ Impaired venous return in the
o Protein synthesis supine and erect position
o Amino acid uptake ▪ Parturition-associated blood loss
o Protein catabolism to meet the demands
of the fetus Red blood cells
- Dietary protein requirement: 15 – 20g/day
- Mass increase at around 8-10 weeks AOG
Carbohydrate metabolism - ↑ in mass < ↑ plasma volume → physiologic
anemia of pregnancy
- Changes include: o Plasma volume: 40-50%
o Mild fasting hypoglycemia o RBC: 20-30%
o Postprandial hyperglycemia - Total iron requirement increases to 1000 mg
o Hyperinsulinemia o 300 mg: transferred to the fetus
o ↑ insulin resistance o 200mg: lost through normal excretion
- Human placental lactogen (GIT)
o ↑ during 24th-28th week AOG o 500 mg: incorporated to RBCs due to
o Produced by syncytiotrophoblasts increased blood volume
o Responsible for ↑ insulin resistance - After mid-pregnancy iron requirement: 6-7
o Utilization of stored fat mg/day
o Leads to diabetogenic state
White blood cells ▪ Brachial and central systolic
pressure
- Leukocytosis (↑ WBC)
▪ Diastolic pressure
- Labor and early puerperium: 15,000 – 25,000
Heart
Platelets
- Displaced to the left and upward
- Thrombocytopenia due to hemodilution and - Apex is moved laterally → large cardiac
increased platelet consumption and
silhouette in CXR on latter half of pregnancy
sequestration
- Return to normal levels 4-12 weeks postpartum Heart sounds

Coagulation and fibrinolysis - Exaggerated splitting of S1 and ↑ loudness of

both S1 and S2
- Increased coagulation factors:
- Loud S3
o Fibrinogen - Systolic murmur – 90% of cases
o Factor VII
- No diastolic murmur; if present, signals
o Factor X
pathology
o Plasminogen
- Decreased: ECG changes
o Plasminogen activator
- Slight LAD
o Antithrombin
o Protein C - Q waves in leads II, III
- Inverted T waves in leads III, V1-V3
o Total protein S
- Pregnancy is a procoagulant state Supine hypotensive syndrome
o ↑ risk of thrombosis
o ↓ fibrinolytic activity - Due to compression of major vessels,
o Favors clot formation particularly IVC
o ↓ venous return → ↓ preload
Cardiovascular changes o ↓ CO
Hemodynamic changes o ↓ BP
o ↓ uterine perfusion → fetal distress
- ↑ Cardiac output by 30-50%
o Up to 6L/min Pulmonary changes
- ↑ stroke volume - Attributed to progesterone
- ↑ HR - Physiological dyspnea due to elevation of the
- ↓ PVR and BP diaphragm
o Due to vasodilatory effects of - Key physiological changes
progesterone, relaxin, and NO o Mechanical effects of enlarging fetus
o BP decreases on 2nd to early 3rd ▪ Diaphragm rises approx. +4 cm
trimester ▪ Subcostal angle widens from
- Hypertension is never normal in pregnancy 68.5 cm to 103.5 cm
- Hemodynamic changes: ▪ Thoracic circumference
o Increased: increases by 6cm
▪ CO ▪ Thoracic diameter lengthens by
▪ SV 2cm
▪ Plasma intravascular volume o ↑ ventilatory requirement
▪ Cardiac preload o ↑ circulatory requirement
▪ End diastolic volume - Changes in lung physiology/volumes
▪ End systolic volume o Increased:
▪ Resting pulse rate ▪ IC
▪ Renin and angiotensin ▪ TV
o Decreased: ▪ Resting minute ventilation
▪ SVR ▪ Peak expiratory flow rate
▪ Total PVR ▪ Airway conductance
▪ Arterial pressure o Decreased:
▪ FRC
 ▪ ERV Gastrointestinal changes
▪ RV
- Stomach and intestines are displaced
▪ Pulmonary resistance
- Altered mobility of esophagus, stomach, SI,
o Unchanged
colon and biliary tree
▪ RR
- Impaired function of LES
▪ TLC
- ↓ gastric acidity
▪ Lung compliance
- Altered pancreatic secretion
▪ Maximum breathing capacity
- ↑ progesterone → ↓ smooth muscle tone → ↓
▪ Forced and timed vital capacity
motility
Renal changes - Impaired gallbladder contraction by inhibiting
cholecystokinin mediated smooth muscle
- Increased blood flow → dilatation of the renal stimulation → ↑ risk of gallstones
calyces, pelvis, ureters → ↑ GFR → ↑ urine
- Associated symptoms during pregnancy
output → ↑ urinary frequency o Nausea and vomiting: prolonged gastric
- Hydronephrosis emptying time
o Increased size of kidneys o Constipation and bloating: prolonged
Renal system intestinal transit time
o ↑ chance of hemorrhoids due to
- ↑ Kidney size: 1 to 1.5 cm increased venous pressure
o Returns to normal upon delivery o GERD: due to ↑ gastric pressure and ↓
- Renal function closure of LES
o ↑ GFR and renal plasma flow by 50% →
↑ urinary frequency and nocturia Endocrine changes
o Effects of progesterone Pituitary gland and hormones
▪ Glucosuria
▪ Proteinuria - ↑ in size up to 135% due to:
▪ Excretion of Na and K o ↑ cell proliferation
▪ ↑ progesterone → vasodilation o ↑ blood flow to support ↑ hormone
of afferent arterioles → ↑ blood production
flow to the glomerulus → ↑ GFR - Involutes by 6 months postpartum
→ ↑ urination, excretion of - Enlargement may compress optic chiasma and
glucose, albumin and protein reduce visual fields
o Progesterone on the ureter - Hormones secreted:
▪ ↓ ureteral motility → stagnant o Growth hormone (maternal)
urine → bacterial colonization → ▪ Serum levels rise slowly at 10
↑ risk for UTI weeks and plateaus after 28
o Urinary bladder weeks
▪ Reduced bladder capacity due ▪ Regulates metabolism of
to the uterine compression→ glucose and lipids
urinary incontinence o Placental growth hormone
- Changes in urine components ▪ Secreted by
o Serum creatinine: decreased due to ↑ syncytiotrophoblasts
creatinine clearance; an increase of ▪ Detectable as early as 6 weeks
>0.9mg/dL signals pathology AOG
o Glucosuria: normal due to ↑ GFR ▪ Placenta becomes the major
o Proteinuria: ↑ excretion rate up to source by 20 weeks AOG
250mg/d ▪ ↑ insulin-like growth factor 1 for
▪ Threshold: >300mg/d or UPCR fetal growth
> 0.3g/g → may lead to o Prolactin
preeclampsia ▪ Ensure lactation
o Hematuria: maybe due to contamination ▪ Initiates DNA synthesis and
or UTI mitosis of glandular epithelial
▪ Common after delivery due to cells and presecretory alveolar
trauma to urethra and bladder cells of the breast
 o Oxytocin o Increased in preparation for stress of
▪ Aid in uterine contraction pregnancy, delivery, and lactation
- Aldosterone
Thyroid gland and hormones o Protects against natriuretic effect of
- Hyperplasia (12 cm → 15 cm) and ↑ vascularity progesterone
- ↑ BMR o ↑ as early as 15 weeks AOG
- ↑ production of thyroid hormones o Promotes sodium retention
- Pregnancy is a mild hyperthyroid state Neuromuscular changes
- Hormones secreted
o Thyrotrophin-releasing hormone (TRH) CNS
▪ does not rise during pregnancy
- Transient pregnancy-related memory decline
but crosses the placenta and
limited to 3rd trimester
stimulates fetal pituitary to
- ↓ intraocular pressure due to greater vitreous
secrete TSH
outflow
o Thyrotropin
- Brownish opacities on posterior surface of
▪ Unchanged
cornea
▪ Stimulate maternal FT4
- Difficulty falling asleep, frequent awakening,
secretion
reduced sleep efficiency after 12 weeks AOG
▪ Does not cross the placenta
o T3 and T4 Musculoskeletal
▪ ↑ total T3 and T4 levels
• Due to stimulation by - Progressive lordosis
hCG to thyroid - Increased mobility of sacroiliac, sacrococcygeal,
• Increase in thyroid- and pubic joints
binding globulin - Joint laxity and discomfort
▪ Unchanged free T3 and T4

Parathyroid gland and hormones

- There is increased demand for calcium during

the 2nd and 3rd trimesters → ↑ in parathyroid
hormones (PTH)
- PTH
o Raises extracellular Ca concentrations
and lowers phosphate levels
o Decline in Mg2+ or Ca2+ levels →
stimulate PTH release
o Declines during the 1st trimester and
rises progressively
- Calcitonin
o Opposes actions of PTH and Vitamin D
o Protects maternal skeleton during time
of calcium stress
o Inhibits osteoclast activity and maintain
maternal bone health by regulating bone
resorption
o ↑ during pregnancy

Adrenal hormones

- ACTH
o Produced by the pituitary gland to
stimulate production of cortisol and
glucocorticoids
- Cortisol