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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?