Normal Uterine Anatomy and Histology in the Non-pregnant and … · 2017-04-29 · Normal Uterine...

Normal Uterine Anatomy and Histology in the Non-pregnant and Pregnant Pa7ent

EvelynLockhart,MDMedicalDirector,UNMHospitalTransfusionService

AssociateProfessor,PathologyandObstetrics/GynecologyUniversityofNewMexicoHealthScienceCenter

FWGBDUterineHemostasisColloquium4/5/2017

• None

Disclosures

Uterus

•  Nulliparous:6-8cminlength

•  MulWparous:9-10cminlength

•  Consistsofthemainbody(corpus),withasuperiorfundus

•  ConstricWonofthebodyoccurssuperiortothecervix(isthmusofuterus)

Image©2015-2017TeachMeAnatomy.info[CC-BY-NC-ND4.0]

Isthmus

Source:Chapter14.FemaleReproducWveSystem,TheBigPicture:GrossAnatomyCitaWon:MortonDA,ForemanK,AlberWneKH.TheBigPicture:GrossAnatomy;2011

Uterus: Rela7onship to Pelvic Organs

UterusRectum

Ovary

Uterine(Fallopian)tube

Bladder

Anterior

Posterior

ImagefromPelvicandRetroperitonealSpace;SobodaAtlasofHumanAnatomy,Vol.2,Paulsen,FEd.Pg157-240,Fig7.76,©2013

Rela7onship of Bladder to Uterus

ImagefromPelvicandRetroperitonealSpace;SobodaAtlasofHumanAnatomy,Vol.2,Paulsen,FEd.Pg157-240,Fig7.76,©2013

Bladder

Uterus

Uterine Peritoneal Reflec7ons

Source: MaternalAnatomy, WilliamsObstetrics,24eCitation: Cunningham F, Leveno KJ, Bloom SL, Spong CY, Dashe JS, Hoffman BL, Casey BM, Sheffield JS. WilliamsObstetrics,24e; 2013

UteruscoveredbyreflecWonofthepelvicperitoneum(liningoftheabdominalcavity)

•  ReflecWonconWnueslaterallytoformthebroadligament.

•  Broadligamenthousesthemajoruterinevesselsandthefallopiantubesattheirapices.

Uterine Size Through Lifespan

ImagefromObstetrics:NormalandProblemPregnancies.GabbeSEd.,pg1224.e16,E-FigA2-28.©2017.

Infant

Nulliparous

MulCparous

Followingmenopause,uterusshrinks,oientonulliparoussize

Uterine Fundus Levels During Pregnancy

ImagefromPelvicandRetroperitonealSpace;SobodaAtlasofHumanAnatomy,Vol.2,Paulsen,FEd.Pg157-240,Fig7.81,©2013

Uterus With Placenta and Fetus (near term)

Cervicalmucusplug

ImagefromPelvicandRetroperitonealSpace;SobodaAtlasofHumanAnatomy,Vol.2,Paulsen,FEd.Pg157-240,Fig7.80,©2013

Major Vessels of the Pelvis

Aorta

Commoniliacartery

Internaliliacartery

ImagefromObstetrics:NormalandProblemPregnancies.GabbeSEd.,pg1224.e16,E-FigA2-21.2017.

VenaCava

Uterine Arterial Supply

Image©2015-2017TeachMeAnatomy.info[CC-BY-NC-ND4.0]

DirectaorCcflow

Uterineartery:branchfrominternaliliacarteryOvarianartery:directbranchfromaortaDualarterialsupplytouterusfromanastomosesbetweenthesetwosystems

Uterine Venous Systems

Imagefrom:MaxBrödel'sPelvicAnatomy(Fig3-13),inAtlasofPelvicAnatomyandGynecologicSurgery.Baggish,MS,Ed.Pages75-92.©2016.

UterineveinsaccompanytheirrespecWvearteries.Uterineveinsemptyintointernaliliacvein.Ovarianveins:•  Right:empWesintovenacava

•  Lei:empWesintoleirenalvein

Uterine Histology

Threemajorlayers:1.   Endometrium:fibroblast

stromalcellsandendometrialglands

2.   Myometrium:smoothmusclecells,vascularplexus,andlymphaWcs

3.   Perimetrium:serosalconnecWveWssuelayer

ImagefromURL:hdp://medcell.med.yale.edu/histology/female_genital_tract_uterine_cycle.php,

lastaccessed4/1/2017

Myometrium

•  Mostlysmoothmuscle,butalsocontainscollagen,elasWnandfibronecWn.

•  Outerlongitudinalmuscularlayer•  Innercircularsubmucosallayer•  ThickmiddlelayerrichwithvesselsandrandominterdigitaWngfibers

•  Moresmoothmuscleinbody,lessinloweruterinesegmentandcervix

Imagesfrom:FemaleReproducWveSystem,inStevens&Lowe'sHumanHistology.LoweJS,AndersonPG.Pages337-362.©2015.FIGURE17.10

Non-pregnant

8mo.pregnant

Myometrial Growth During Pregnancy

•  Estradioldrivesmyometrialhypertrophyandhyperplasia

• MyometrialcellshavedramaWcincreaseinnumberofgapjuncWons(topermitforcoordinateduterinecontracWons)

• Uterineweightincrease:~75gà~1300g

•  Followingdelivery:•  Lossof85%ofweightin3weeks,mostlyduetointracellularvolumecontracWonandcollagendegradaWon.

Myometrium

•  JuncWonalZone(JZ):lowsignalonT2-weightedMRIidenWfyingjuncWonbetweenbasalendometriumandmyometrium.

•  JZlessprominentinpre-menarcheandpost-menopause;poorlyseeninpregnancybutreappearsweekstomonthspost-delivery.

•  Moreconcentricmyocytearrangement(outerismorelongitudinal)

Novellas,etal.AJR.2011;196:1206–1213

JuncWonalZone:shortarrowsFullmyometrium:longarrows

Myometrialsmoothmusclecompressbloodvesselswhencontracted.

Source: MaternalAnatomy, WilliamsObstetrics,24eCitation: Cunningham F, Leveno KJ, Bloom SL, Spong CY, Dashe JS, Hoffman BL, Casey BM, Sheffield JS. WilliamsObstetrics,24e; 2013

Uterine Corpus Endometrial Histology Twolayers:1.   Basalis

•  IrregularjuncWonwithmyometrium,interdigitatedwithsmoothmuscleandendometrialstroma

•  “Reservecelllayer”oftheendometrium

•  Fewchangeswithmenstrualcycle

2.   FuncConalis•  Containsdistalendometrialglands•  Significantchangeswithmenstrualcycle

ImagefromURL:hdp://medcell.med.yale.edu/histology/female_genital_tract_uterine_cycle.php,

lastaccessed4/1/2017

Source:Chapter9.FemaleReproducWveSystem,EndocrinePhysiology,4eCitaWon:MolinaPE.EndocrinePhysiology,4e;2013

Prolifera7ve Endometrium

ImagefromURL:hdps://librepathology.org/wiki/ProliferaWve_phase_endometrium,lastaccessed4/1/2017

Stromalcells:small,scantcytoplasm•  LateproliferaWve:increased

intra-andextracellularcollagen

Glands:small,straight

Secretory Endometrium

ImagefromURL:hdps://librepathology.org/wiki/Secretory_phase_endometriumlastaccessed4/1/2017

Glands:Coiled,serratedStromalcells:“PredecidualizaWon”—smallsheetsofpolygonalcellswithdisWnctcellsbordersduetoincreasedpericellularmatrixIncreasedstromaledema

Decidualized Endometrium

ImagefromURL:hdp://library.med.utah.edu/WebPath/PLACHTML/PLAC094.htmlLastaccessed4/1/2017

•  Decidua:specializedendometrialstromaofpregnancy

•  SecretesproductsinvolvedwithparacrineandautocrineregulaWonoffeto-maternalinterface.

•  DecidualcellsarecapableofphagocytosisandplayroleincollagenscaffoldbreakdownatimplantaWonsite.

Source: The Female Reproductive System, Junqueira's Basic Histology, 14e Citation: Mescher AL. Junqueira's Basic Histology, 14e; 2016

Microvascular Supply of Endometrium

Uterineandovarianarteriesgiverisetoarcuatearteries.Arcuatearteriesbranchintoradial,straightandspiralarteries,whichsupplyendometrium.

Uterine Microvasculature During Menses

Imagefrom:FemaleReproducCveSystem;TextbookofHistology.Gartner,LEd.Pages529-558.e3.©2017.Figure20–11

Withlossofendometriallayer,fluidwithintheuterinecavitycanentertheuterinevenoussystem.Uterineintrinsicveinsdonotcontainvalves;1lossofendometriallayeralsocausesvenousbloodloss.

Uterinecavity

1.Chap59:ManagementofpelviccongesWonsyndromeandperinealvaricosiWes.WhiteJV,SchwartzLB,RyjewskiC.InHandbookofVenousandLymphaWcDisorders,4thEd.GloviczkiP,Ed.2017CRCPressp685-687

Ques7ons?