Abnormalities of the reproductive tract

1. FEMALE GENITAL
TRACT ANOMALIES

2. The human female reproductive system (or
female genital system) contains two main parts:
the uterus, which hosts the developing fetus,
produces vaginal and uterine secretions, and
passes the male's sperm through to the fallopian
tubes; and the ovaries, which produce the
female's egg cells. These parts are internal; the
vagina meets the external organs at the vulva,
which includes the labia, clitoris and urethra. The
vagina is attached to the uterus through the
cervix, while the uterus is attached to the ovaries
via the Fallopian tubes. At certain intervals, the
ovaries release an ovum, which passes through
the Fallopian tube into the uterus.
Anatomy of Female internal
reproductive organs

4. The internal reproductive organs include:
Vagina: The vagina is a canal that joins the cervix (the
lower part of uterus) to the outside of the body. It also is
known as the birth canal.
Uterus (womb): The uterus is a hollow, pear-shaped organ
that is the home to a developing fetus. The uterus is
divided into two parts: the cervix, which is the lower part
that opens into the vagina, and the main body of the
uterus, called the corpus. The corpus can easily expand to
hold a developing baby. A channel through the cervix
allows sperm to enter and menstrual blood to exit.
Ovaries: The ovaries are small, oval-shaped glands that
are located on either side of the uterus. The ovaries
produce eggs and hormones.

6. Fallopian tubes: These are narrow tubes that
are attached to the upper part of the uterus
and serve as tunnels for the ova (egg cells)
to travel from the ovaries to the uterus.
Conception, the fertilization of an egg by a
sperm, normally occurs in the fallopian
tubes. The fertilized egg then moves to the
uterus, where it implants into the lining of the
uterine wall.
Cervix: The Cervix (the lower part of the uterus
that protrudes into the vaginal canal) has an
orifice that allows passage of menstrual flow
form the uterus and passage of sperm into the
uterus.

7.  Developmental anomalies incurred during
embryogenesis.
 May be acquired during adulthood,
sometimes during pregnancy.

8.  Failure of fusion of the two müllerian ducts
leads to separate uterine horns
 Failure of cavitation between them results
in some degree of persistent uterine
septum
 Uncommonly, there is cervical and vaginal
duplication associated with a septate uterus

9.  Vagina forms between the urogenital sinus and
the müllerian tubercle by a dissolution of the
cell cord between the two structures.
 Dissolution starts at the hymen and moves
upward toward the cervix. Failure of this process
is associated with persistence of the cell cord.
 Vaginal agenesis is the result of either failed
caudal migration of the fused müllerian duct or
incomplete cell cord resorption. The latter may
result in complete vaginal obstruction, or, if less
severe, partial persistence and a vaginal septum

11. 1. Defective canalization of the vagina results
in a transverse septum, or in the most
extreme form, vaginal agenesis.
2. Unilateral maturation of the müllerian duct
with incomplete or absent development of
the opposite duct results in defects
associated with upper urinary tract
abnormalities.
3. The most common abnormality is absent or
faulty midline fusion of the müllerian
ducts.

14. Atresia
 Complete atresia of the vulva includes atresia of the
introitus and lower third of the vagina.
 In most cases, however, atresia is incomplete and results
from adhesions or scars following injury or infection
 The defect may present a considerable obstacle to vaginal
delivery, deep perineal tears may result.
Labial Fusion
 Most commonly due to congenital adrenal hyperplasia.
Imperforate hymen
 is persistence of the fusion between the sinovaginal bulbs
at the vestibule
 Associated with primary amenorrhea and hematocolpos
and is not encountered often during pregnancy.

15. Developmental abnormalities of the normal single vagina
include:
 Vaginal agenesis
 Vaginal atresia
 Double vagina
 Longitudinal vaginal septum
 Transverse vaginal septum

16. Vaginal
Atresia
Longitudinal
vaginal
septum

17.  Complete mullerian agenesis – pregnancy is
impossible because uterus and vagina is absent
 About one third of women with vaginal atresia have
associated urological abnormalities
 Complete vaginal atresia – precludes pregnancy by
vaginal intercourse unless corrected operatively
 Incomplete septum – manifestation of faulty
development, or the result of scarring from injury or
inflammation
 In most cases of partial atresia, because of
pregnancy-induced tissue softening, obstruction
during labor is gradually overcome.interferes with
descent

18.  Complete longitudinal vaginal septum
usually does not cause dystocia because half
of the vagina through which the fetus
descends dilates satisfactorily.
 Incomplete septum, however, occasionally
interferes with descent.
 Upper vagina is separated from the rest of
the canal by a transverse septum with a
small opening and some are associated with
in utero exposure to DES

19. Atresia.
 The entire cervix may fail to develop.
 This may be combined with incomplete development of the
upper vagina or lower uterus
Double cervix.
 Each distinct cervix results from separate müllerian duct
maturation.
 Both septate and true double cervices are frequently
associated with a longitudinal vaginal septum.
 Many septate cervices are erroneously classified as double.
Single hemicervix.
 This arises from unilateral müllerian maturation.
Septate cervix.
 This consists of a single muscular ring partitioned by a
septum.
 The septum may be confined to the cervix, or more often, it
may be the downward continuation of a uterine septum or the
upward extension of a vaginal septum.

20. Uncorrected complete cervical atresia is
incompatible with natural conception.
In 2001 reported six successful pregnancies in
four women with cervical atresia after
creation of a uterovaginal anastomosis.

21. DIAGNOSIS
 Discovered by routine pelvic examination.
 Frequently they are discovered at cesarean delivery
or first discovered at laparoscopy
 Sonographic screening for uterine anomalies, while
specific, is not sensitive
 Sonohysterography can be used to differentiate
septate and bicornuate uteri
 Hysteroscopy and hysterosalpingography (HSG) are
of value in ascertaining the configuration of the
uterine cavity
 MRI may be necessary to delineate müllerian duct
anomalies and their extent. Accuracy of up to 100
percent in evaluation of müllerian duct anomalies

22. Urological Defects
 Asymmetrical reproductive tract
abnormalities are frequently associated with
urinary tract anomalies. When unilateral
uterine atresia is present or when one side of
a double vagina terminates blindly, an
ipsilateral urological anomaly is common
Auditory Defects
 Up to a third of women with müllerian
defects will have auditory defects
 Typically these are sensorineural hearing
deficits in the high-frequency range.

23. Uterine Anomalies in Wilms Tumor Survivors
 This rare malignancy appears to be
associated with an increased incidence of
congenital urinary and reproductive tract
anomalies
 This might partially explain the increased
rate of infertility reported in female
survivors.

24.  Defects that result from development of only
one müllerian duct, or from lack of fusion,
often give rise to a hemiuterus that fails to
dilate and hypertrophy appropriately
 This may result in miscarriage, ectopic
pregnancy, rudimentary horn pregnancy,
preterm delivery, fetal growth restriction,
abnormal fetal lie, uterine dysfunction, or
uterine rupture.

26.  Women with a unicornuate uterus have an
increased incidence of infertility,
endometriosis, and dysmenorrhea.
 Implantation in the normal-sized hemiuterus
is associated with increased incidence of:
 spontaneous abortion
 preterm delivery
 intrauterine fetal demise

29.  This anomaly is distinguished from bicornuate
and septate uteri by the presence of complete
nonfusion of the cervix and hemiuterine cavity
 Except for ectopic and rudimentary horn
pregnancies, problems associated with uterine
didelphys are similar but less frequent than
those seen with unicornuate uterus
 Complications may include
- preterm delivery (20%)
- fetal growth restriction (10%)
- breech presentation (43%)
- cesarean delivery rate (82%)

31.  Marked increase in miscarriages that is likely
due to the abundant muscle tissue in the
septum
 Pregnancy losses in the first 20 weeks were
reported from the case studies
 70 percent for bicornuate
 88 percent for septate uteri
 There also is an increased incidence of
preterm delivery, abnormal fetal lie, and
cesarean delivery.

34. Arcuate Uterus
 This malformation is only a mild deviation
from the normally developed uterus.

35.  Women with nonobstructive defects such as
uterine didelphys and unicornuate uterus
usually do not need surgical correction. Although
abnormal fetal presentation is common,
external cephalic version is less likely to be
successful
 CERCLAGE
 Transabdominal cerclage may offer the best
prognosis for women with partial cervical atresia
or hypoplasia
 Transvaginal cerclage has been used
successfully in DES-exposed women with cervical
hypoplasia

36. METROPLASTY
 Women with septate or bicornuate anomalies
and poor reproductive outcomes may benefit
from uterine surgery
 Repair of a bicornuate uterus is by
transabdominal metroplasty involving septal
resection and fundal recombination
 Repair of a septate uterus is usually by
hysteroscopic septal resection

37.  Development of rare vaginal clear cell
adenocarcinoma.
 Increased risk of developing
 cervical intraepithelial neoplasia
 small-cell cervical carcinoma
 vaginal adenosis,
 non-neoplastic structural abnormalities

38. Structural Abnormalities:
 transverse septa,
 circumferential ridges involving the vagina
and cervix
 cervical collars
 smaller uterine cavities
 shortened upper uterine segments
 T-shaped and irregular
 oviduct abnormalities

39. Reproductive Performance
 Women exposed to DES in utero in general have
impaired conception rates possibly associated
with cervical hypoplasia and atresia
 Their incidences of miscarriage, ectopic
pregnancy, and preterm delivery are also
increased, especially in women with structural
abnormalities
Transgenerational Anomalies
 Genital tract anomalies have been described in
the offspring of women exposed to DES when
they were a fetus

40. Vulvar Abnormalities
 Edema
 Inflammatory Lesions
 Bartholin Gland Lesions
 Cysts of the Bartholin glands are usually sterile and need no
treatment during pregnancy.
 If the cysts are large enough to cause difficulty at delivery,
then needle aspiration as a temporary measure is sufficient.
 Abscess is present, broad-spectrum antimicrobials are given
and drainage is established.
 Urethral and Bladder Lesions
 Condyloma Acuminata
 Venereal warts can be so extensive that vaginal delivery
may be prohibited.
 Female Genital Mutilation

41.  Acquired vaginal abnormalities are uncommon
 Even after major trauma, long-term sexual and
reproductive function is usually normal
 Vaginal stenosis may develop as a result of
mucositis from graft-versus-host reaction
following organ transplantation
Partial Atresia
 Incomplete atresia may result from infection or
trauma that leads to extensive scarring
 During labor, this is usually overcome by
pressure from the presenting part, but
occasionally incisions or even cesarean delivery
are necessary.

42. Genital Tract Fistulas
 VESICOVAGINAL FISTULA following a
McDonald cerclage done at 20 weeks
 VESICOUTERINE FISTULA that developed
following vaginal delivery after prior
cesarean delivery
 Rarely, the anterior cervical lip is
compressed against the symphysis pubis with
development of A VESICOCERVICAL FISTULA

43.  Cicatricial cervical stenosis is uncommon, but it
may follow cervical trauma such as conization.
 Overall, both surgical and laser conization or
loop excision for cervical intraepithelial
neoplasia increase preterm delivery
o Conglutinated cervix may undergo almost
complete effacement without dilation, with the
presenting part separated from the vagina by
only a thin layer of cervical tissue. Dilatation
usually promptly follows pressure with a
fingertip, although manual dilatation or cruciate
incisions may be required. Finally, extensive
cervical carcinoma may impair vaginal delivery

44. Uterine Abnormalities
Anteflexion
 Exaggerated degrees of anteflexion frequently
observed in early pregnancy are without significance.
 Marked anteflexion of the enlarging pregnant uterus
usually is associated with diastasis recti and a
pendulous abdomen. The abnormal uterine position
sometimes prevents proper transmission of
contractions; this is overcome by repositioning with
an abdominal binder.
Retroflexion
 The growing normally retroflexed uterus remains
incarcerated in the hollow of the sacrum.
 Symptoms include abdominal discomfort and inability
to void normally.

45. Uterine Prolapse
The cervix, and occasionally a portion of
the body of the uterus, may protrude to a
variable extent from the vulva during early
pregnancy.
If the uterus persists in its prolapsed
position, symptoms of incarceration may
develop from 10 to 14 weeks.
To prevent this, the uterus is replaced early
in pregnancy and held in position with a
suitable pessary.

47. *There are many different degrees of prolapse.
Incomplete prolapse occurs when the uterus
drops only partway into the vagina.
Complete prolapse occurs when the uterus and
cervix protrude out of the vagina and the vagina
becomes inverted.
Along with uterine prolapse there may be
relaxation of the front and back portions of the
vagina. This can cause a part of the bladder or
rectum to protrude into the vagina.
*Uterine prolapse is the "dropping" of the uterus
from its normal position at the top of the vagina. It
drops to a lower part of the vagina and may even
drop outside the vagina. This is caused by a
relaxation of the ligaments that support the uterus
within the abdominal walls.

48. Cystocele and Rectocele
Attenuation of fascial support between
the vagina and the bladder can lead to
prolapse of the bladder into the vagina,
or cystocele.
Attenuation of fascia between the
vagina and the rectum results in a
rectocele.
During labor, either a cystocele or a
rectocele can block normal fetal
descent unless they are emptied and
pushed out of the way.

49. Enterocele
 In rare instances, an enterocele of
considerable size may complicate pregnancy.
 If symptomatic, the protrusion should be
replaced and the woman kept in a recumbent
position.
 If the mass interferes with delivery, it should
be pushed up or held out of the way.

50. Leiomyoma
 Also known as myomas and somewhat called
fibroids
 Common benign smooth muscle tumors.
 Incidence during pregnancy is probably about
2 percent
 Symptoms from leiomyomas depend
principally on their location.

51.  TYPES OF MYOMA
A.SUBMUCOUS
 beneath the endometrial or decidual lining of the uterine
cavity
B. SUBSEROUS
 immediately beneath the uterine serosa
 becomes parasitic and derives its blood supply through
the highly vascularized omentum.
C.INTRAMURAL
 confined within the myometrium
 it may develop a significant subserous or submucosal
component, or both.
 Submucous and subserous myomas may be
pedunculated and can undergo torsion with
necrosis

52. Myomas during pregnancy or the puerperium
occasionally undergo red or carneous
degeneration that is caused by hemorrhagic
infarction.
It is not clear whether they diminish fertility,
other than by possibly causing early
miscarriage.
It concluded that only submucous myomas
had a significant negative impact on
fertility.

55. Effects of Myoma in Pregnancy
 excessive preterm labor
 placental abruption
 fetal malpresentation
 obstructed labor
 cesarean delivery
 postpartum hemorrhage
*** Two factors most important in determining
morbidity are myoma size and location.
Proximity to the placental implantation site is
important.

56. Management of Myomas during Pregnancy
 After the diagnosis is confirmed, expectant
management is recommended.
 Resection of myomas during pregnancy is
generally contraindicated
 Resection of intramural myomas during
pregnancy or at the time of delivery usually
stimulates profuse bleeding.
 Intramural myomectomy is especially
hazardous for subsequent pregnancy

57. ENDOMETRIOSIS
 Almost never symptomatic during pregnancy, occasionally
endometriosis is problematic.
 More commonly, symptoms subsequently develop from
endometrial implants at the time of cesarean delivery or
episiotomy
ADENOMYOSIS
 found in older women
 Its acquisition may be at least partially related to
disruption of the endometrial-myometrial border during sharp
curettage for abortion
 associated with uterine rupture, ectopic pregnancy,
uterine atony, and placenta previa
 Successful pregnancy may follow treatment of
adenomyosis with gonadotropin-releasing hormone agonists or
MR-guided focused ultrasound surgery

58.  Most common ovarian tumors are cystic.
 Ovarian tumors unique to pregnancy are also
found by ultrasound or at cesarean delivery.
 In addition to corpus luteal cysts, these
include luteomas, which may be virilizing.
 Ovarian hyperstimulation syndrome,
although usually caused by ovulation-
induction therapy, may be spontaneous
 Second to malignancy, the most serious
complications of ovarian cysts during
pregnancy are torsion or hemorrhage.

59.  Resection of all cysts is recommended in:
>10cm
Suspected rupture or torsion
Capable of obstructing labor
 Cysts 5cm or less – left alone, most
undergo resolution