Anatomy GYN Q&A
Umbilical cord inserted at the placental margin (A) Battledore placenta (B) bipartite placenta (C) circumvallate placenta (D) multiple-pregnancy placenta (E) placenta accreta (F) placenta previa (G) succenturiate lobe
(A) Battledore placenta
Pelvic inflammatory disease (PID) occurs in women because of which of the following characteristics of the fallopian tube? (A) It is a conduit from the peritoneal space to the uterine cavity. (B) It is found in the utero-ovarian ligament. (C) It has five separate parts. (D) It is attached to the ipsilateral ovary by the mesosalpinx. (E) It is entirely extraperitoneal.
(A) It is a conduit from the peritoneal space to the uterine cavity. Fallopian tubes are a conduit from the peritoneal to the uterine cavity, which can also allow sperm or bacteria from the vagina through the uterus to the peritoneal cavity. Each tube is covered by peritoneum and consists of three layers: serosa, muscularis, and mucosa. They traverse the superior portion of the broad ligament attached by a mesentery (mesosalpinx). It has four distinct areas in its 8- to 12-cm length: the portion that runs through the uterine wall (interstitial or cornual portion), the portion immediately adjacent to the uterus (isthmic portion), the midportion of the tube (ampulla), and the distal portion containing the finger-like fimbriae that sweep the ovum into the infundibu-lum of the tube. The fimbriae are intraperitoneal. The tubal lumen becomes increasingly more complex as it approaches the ovary. In tubal reanastomoses, the greatest success is attained when isthmic-isthmic or isthmic-ampullary regions can be reapproximated. The longest of the fimbriae (the fimbriae ovarica) is attached to the ovary.
In the uterus of a normal female infant, what is the size relationship of the cervix, isthmus, and fundus? (A) The cervix is larger than the fundus. (B) The isthmus is longer than either the cervix or the fundus. (C) They are of equal size. (D) The fundus is the largest portion. (E) The cervix is smaller than either the isthmus or the fundus.
(A) The cervix is larger than the fundus. The size of the cervix and corpus changes with age and hormonal status; so does the ratio of cervix to corpus. The infant uterus is only 2.5 to 3 cm in total length, and the cervix is larger than the corpus. With aging, the size of the uterus changes, as does the ratio of cervix to corpus length. The normal adult uterus is 7 to 10 cm long.
Arcuate ligament is (A) a thick band of fibers filling the angle created by the pubic rami (B) passes from the anterior superior iliac spine to the pubic tubercle (C) triangular and extends from the lateral border of the sacrum to the ischial spine (D) attaches to the crest of the ilium and the posterior iliac spines superiorly with an inferior attachment to the ischial tuberosity (E) passes over the anterior surface of the sacrum
(A) a thick band of fibers filling the angle created by the pubic rami
Mons veneris and anterior labia majora supplied by: (A) anterior hypogastric nerve (T12) (B) posterior iliac nerve (T12-L1) (C) ilioinguinal nerve (L1) (D) genitofemoral nerve (L1-L2) (E) the pudendal nerve (S2, S3, S4) (F) terminal branch of the pudendal nerve
(A) anterior hypogastric nerve (T12)
In a female, which of the following best describes the urogenital diaphragm? (A) includes the fascial covering of the deep transverse perineal muscle (B) encloses the ischiorectal fossa (C) is synonymous with the pelvic diaphragm (D) is located in the anal triangle (E) envelops the Bartholin's gland
(A) includes the fascial covering of the deep transverse perineal muscle The urogenital diaphragm is immediately cephalad to the muscles of the external genitalia. It consists of a tough fibrous fascial membrane inferiorly covering the triangular area under the pubic arch and extending posteriorly to the ischial tuberosities. It is penetrated by the urethra and vagina in the female. Just cephalad to this fascia are the deep transverse perineal muscle and the urethral sphincter mechanism. The superior fascia of the urogenital diaphragm is attached tightly to these muscles and is just caudad to the levator ani muscle. The urogenital diaphragm supplies support for the anterior vagina, urethra, and trigone of the bladder. The area encompassing the urogenital diaphragm and the superficial and deep perineal spaces is referred to as the urogenital triangle.
Anterior vulvar cancer is most likely to spread primarily to which of the following lymph nodes? (A) inguinal (B) para-aortic (C) obturator (D) femoral (E) ovarian
(A) inguinal The lymphatic drainage of the vulva has a superficial component (draining the anterior two-thirds of the vulva) and a deep drainage system (draining the posterior one-third of the vulva). The superficial drainage is to the superficial inguinal lymph nodes, and the deep drainage is to the deep inguinal nodes, external iliac, and femoral nodes. The posterior aspects of the labia may drain to the lymphatic plexus surrounding the rectum. These anatomic relationships for lymphatic drainage are of great significance in the treatment of vulvar cancers.
Hernias occur more commonly in men than in women beneath the thickened lower margin of a fascial aponeurosis extending from the pubic tubercle to the anterior superior iliac spine. This thickened fascia is called which of the following? (A) inguinal ligament (B) Cooper's ligament (C) linea alba (D) posterior rectus sheath (E) round ligament
(A) inguinal ligament From the pubic tubercle to the anterior superior iliac spine, the thickened lower margin of the fascial aponeurosis forms the inguinal ligament. This aponeurosis of the external oblique muscle fuses with its counterpart from the opposite side and with the underlying internal oblique fascia. Cooper's ligament is a thickening of fascia along the pubic bone. The linea alba is in the midline and the round ligament attaches to the uterus.
A woman has a radical hysterectomy and pelvic lymphadenectomy for Stage I carcinoma of the cervix. After surgery she complains that she cannot adduct her left leg and there is an absence of sensation on the medial aspect of her left thigh. What is the most likely explanation? (A) injury to the obturator nerve (B) femoral nerve injury (C) hematoma in the pouch of Douglas (D) injury to the uterosacral nerve (E) injury to the pudendal nerve
(A) injury to the obturator nerve The injury is to the obturator nerve, which has both a sensory component on the medial thigh and a motor component to adduct the leg. At the time of the lymphadenectomy, the obturator nerve is often exposed. Just below it in the obturator space are many venous plexuses. If bleeding becomes active in this area, efforts to control it could damage the obturator nerve. This same type of nerve injury can also happen in pregnancy secondary to its compression by the fetus against the pelvic floor. Problems in the other areas would not produce this set of symptoms.
During a hysterectomy, vaginal bleeding may be a significant complication even after removal of the uterus. Such bleeding would most likely originate from which of the following arteries? (A) internal pudendal (B) superior hemorrhoidal (C) inferior mesenteric (D) superior vesical (E) ovarian
(A) internal pudendal The arterial supply of the vagina comes from the cervicovaginal branch of the uterine artery internal pudendal, inferior vesical, and middle hemorrhoidal arteries. If the uterus is removed, neither the uterine nor ovarian arteries could be the source. Venous drainage of the vagina is accomplished through an extensive plexus rather than through well-defined channels. The same is true of the surrounding venous drainage of the bladder. The lymphatic drainage is such that the superior portion of the vagina (along with the cervix) drains into the external iliac nodes, the middle portion into the internal iliac nodes, and the lower third mainly into the superficial inguinal nodes and internal iliac nodes (like the vulva). The vagina is richly supplied with blood and lymphatics.
Formed by the superior and inferior pubic rami and covered by a central membrane through which a nerve, artery, and vein pass (A) obturator foramen (B) greater sciatic foramen (C) lesser sciatic foramen (D) sacrospinous ligament (E) pudendal (Alcock's) canal (F) sacral foramina
(A) obturator foramen
Which artery provides the main blood supply to the vulva? (A) pudendal (B) inferior hemorrhoidal (C) ilioinguinal (D) femoral (E) inferior hypogastric
(A) pudendal The major blood supply to the vulva is from the internal pudendal or its branches, the inferior hemorrhoidal and perineal. Some is provided by the external pudendal artery, which is from the femoral. There is good collateral circulation to the vulva, and either the hypogastric or pudendal artery can be occluded on either side without compromise to the vulva. The pelvic circulation provides communication so that right- and left-sided vessels may provide accessory flow to the contralateral side.
The uterus and adnexa have some relatively fixed anatomic characteristics that can be noted on pelvic examination or laparoscopic observation. Which of the following characteristics would you most likely find in a normal patient? (A) retroflexion of the uterus (B) ovaries caudad to the cervix (C) round ligaments attached to the uterus posterior to the insertion of the fallopian tubes (D) immobility of the uterus (E) cervix not palpable on rectal examination
(A) retroflexion of the uterus The cervix protrudes into the fornix of the vagina, and the ovaries are intraperitoneal; therefore, they are found cephalad to the cervix. The round ligaments are attached to the uterus anterior to the attachment of the fallopian tubes. Retroflexion implies a sharp angle between the cervix and the fundus of the uterus, which is bent posteriorly. This is a less common position of the uterus, which can also, more commonly, be midposition or anteflexed. These are all normal positions of the uterus. It is important to recognize which way the uterine body is flexed so that you do not perforate the lower uterine segment while sounding the uterus or dilating the cervix. The uterus is normally mobile and if it is not, adhesions or tumor may be present. The cervix is normally palpated anterior to the rectum on rectal examination.
During an operation, a midline incision was made at an anatomic location 2 cm below the umbilicus. Which of the following lists (in order) the layers of the anterior abdominal wall as they would be incised or separated? (A) skin, subcutaneous fat, superficial fascia (Camper's), deep fascia (Scarpa's), fascial muscle cover (anterior rectus sheath), rectus muscle, a deep fascial muscle cover (posterior rectus sheath), preperitoneal fat, and peritoneum (B) skin, subcutaneous fat, superficial fascia (Scarpa's), deep fascia (Camper's), fascial muscle covering (anterior abdominal sheath), transverse abdominal muscle, a deep fascial muscle cover (posterior rectus sheath), preperitoneal fat, and peritoneum (C) skin, subcutaneous fat, superficial fascia (Camper's), deep fascia (Scarpa's), fascial muscle cover (anterior rectus sheath), rectus muscle, a deep fascial muscle cover (posterior rectus sheath), peritoneum, and preperitoneal fat (D) skin, subcutaneous fat, superficial fascia (Scarpa's), deep fascia (Camper's), fascial muscle cover (anterior rectus sheath), rectus muscle, a deep fascial muscle cover (posterior rectus sheath), preperitoneal fat, and peritoneum (E) skin, subcutaneous fat, superficial fascia (Camper's), deep fascia (Scarpa's), fascial muscle cover (anterior rectus sheath), transverse abdominal muscle, a deep fascial muscle covering (posterior rectus sheath), preperitoneal fat, and peritoneum
(A) skin, subcutaneous fat, superficial fascia (Camper's), deep fascia (Scarpa's), fascial muscle cover (anterior rectus sheath), rectus muscle, a deep fascial muscle cover (posterior rectus sheath), preperitoneal fat, and peritoneum Layers at the midline of the abdominal wall, 2 cm below the umbilicus that would be incised or separated are skin, subcutaneous fat, superficial fascia (Camper's), deep fascia (Scarpa's), and the fascial muscle coverings (anterior rectus sheath). The rectus muscles would be separated and the deep fascial layer (posterior rectus sheath), preperitoneal fat, and peritoneum would be incised. The posterior rectus sheath is only present cephalad to the arcuate line. Camper's is the most superficial fascia and transversus abdominal muscle would not be found in the midline
During normal delivery, an infant must pass through the maternal true pelvis. Which of the following most accurately describes the characteristics of the true pelvis? (A) It has an oval outlet. (B) It has three defining planes: an inlet, a midplane, and an outlet. (C) It has an inlet made up of a double triangle. (D) It is completely formed by two fused bones. (E) It lies between the wings of the paired ileum.
(B) It has three defining planes: an inlet, a midplane, and an outlet. The true pelvis has three planes: inlet, mid-plane, and outlet. It is made up of the paired ileum, ischium, and pubic bones, and the single sacrum and coccyx. The true pelvis is cau-dad to the false pelvis, which lies between the paired ileum wings. Its inlet is usually gynecoid.
A woman who is 32 weeks pregnant comes in complaining of lumps in her breasts. These lumps are multiple in number and on inspection are within the areola. By palpation they seem to be small, superficial, uniform in size, nontender, and soft. What is the most likely diagnosis? (A) Mondor's disease (B) Montgomery's follicles (C) inflammatory breast carcinoma (D) fibrocystic breast changes (E) lactiferous ducts
(B) Montgomery's follicles These multiple, small, elevated nodules, beneath which lie the sebaceous glands, are called Montgomery's follicles. The glands are responsible for lubrication of the areola. They may hypertrophy markedly in pregnancy. The small openings of the lactiferous ducts are situated on the nipple.
The levator ani is the major component of the pelvic diaphragm, which is commonly compromised during pregnancy and delivery with resulting prolapse of uterus, bladder/urethra, and /or rectum. This is especially true if obstetric lacerations are not repaired keeping the normal anatomical relationships in mind. Which of the following is the best description of the levator ani? (A) a superficial muscular sling of the pelvis (B) a tripartite muscle of the pelvic floor penetrated by the urethra, vagina, and rectum (C) is made up of the bulbocavernosus, the ischiocavernosus, and the superficial transverse perineal muscle (D) a muscle that abducts the thighs (E) is part of the deep transverse perineal muscle
(B) a tripartite muscle of the pelvic floor penetrated by the urethra, vagina, and rectum The levator ani muscle has three portions: iliococcygeous, pubococcygeus, and puborec-talis.
Divided into two lobes (A) Battledore placenta (B) bipartite placenta (C) circumvallate placenta (D) multiple-pregnancy placenta (E) placenta accreta (F) placenta previa (G) succenturiate lobe
(B) bipartite placenta
How do nabothian cysts occur? (A) Wolffian duct remnants (B) blockage of crypts in the uterine cervix (C) squamous cell debris that causes cervical irritation (D) carcinoma (E) paramesonephric remnants
(B) blockage of crypts in the uterine cervix Nabothian cysts are also called retention cysts because they are full of mucus from the blocked crypts. They are benign and need no specific therapy. Their appearance is characteristic both grossly and through the colpo-scope. Seldom is there any need for biopsy. Wolffian duct remnants cause cystic structures along the broad ligament under the fallopian tube (paraovarian cysts) or on the lateral aspect of the vagina (Gartner's duct cysts). The parmesonephron becomes the female reproductive system.
The human pelvis is a complex structure that permits upright posture and being capable with childbirth despite the relatively large fetal head. Which option includes all of the bones that make up the pelivs? (A) trochanter, hip socket, ischium, sacrum, and pubis (B) ilium, ischium, pubis, sacrum, and coccyx (C) ilium, ischium, and pubis (D) sacrum, ischium, ilium, and pubis (E) trochanter, sacrum, coccyx, ilium, and pubis
(B) ilium, ischium, pubis, sacrum, and coccyx The pelvis surrounds the birth passage, provides attachment for muscles and fascia, and includes the ilium, ischium, pubis, sacrum, and coccyx. The ilium, ischium, and pubic bone compose the innominate bone.
The plane from the sacral promontory to the inner posterior surface of the pubic symphysis is an important dimension of the pelvis for normal delivery. What is the name of this plane? (A) true conjugate (B) obstetric conjugate (C) diagonal conjugate (D) bi-ischial diameter (E) oblique diameter
(B) obstetric conjugate The obstetric conjugate is the shortest line from the inside of the symphysis to the most prominent point on the front two segments of the sacrum. It defines what is often the smallest diameter of the pelvic inlet. It should be estimated during clinical examination (pelvimetry) and considered whenever evaluating a pelvis for possible cephalopelvic disproportion, especially during abnormalities of labor. It differs from the true conjugate, which is measured from the top of the symphysis, and also from the diagonal conjugate, which is measured clinically from the bottom of the symphysis to the sacral promontory. The biischial diameter is on the pelvic outlet.
A patient, following a pelvic lymphadenectomy for cervical cancer, complains of some numbness in the medial thigh. On examination, she is found to have full range of motion of her leg, but weakness to adduction. (A) electrolyte imbalance (B) obturator nerve injury (C) pudendal nerve injury (D) femoral nerve injury (E) disruption of peripheral (skin) nerves (F) ilioinguinal nerve injury (G) spinal cord injury (H) sciatic nerve injury (I) diabetes
(B) obturator nerve injury Iatrogenic injury to the obturator nerve can cause sensory defects over the medial thigh. As it supplies the medial muscles of the thigh, injury may cause a decrease in ability to adduct. Fortunately, the injury is often transitory or easily compensated.
Ilioinguinal ligament is (A) a thick band of fibers filling the angle created by the pubic rami (B) passes from the anterior superior iliac spine to the pubic tubercle (C) triangular and extends from the lateral border of the sacrum to the ischial spine (D) attaches to the crest of the ilium and the posterior iliac spines superiorly with an inferior attachment to the ischial tuberosity (E) passes over the anterior surface of the sacrum
(B) passes from the anterior superior iliac spine to the pubic tubercle
Gluteal area is supplied by (A) anterior hypogastric nerve (T12) (B) posterior iliac nerve (T12-L1) (C) ilioinguinal nerve (L1) (D) genitofemoral nerve (L1-L2) (E) the pudendal nerve (S2, S3, S4) (F) terminal branch of the pudendal nerve
(B) posterior iliac nerve (T12-L1)
The clitoris is a major sensory sexual organ. Where does it get its major nerve supply from? (A) lumbar spinal nerve (B) pudendal nerve (C) femoral nerve (D) ilioinguinal nerve (E) anterior gluteal nerve
(B) pudendal nerve The clitoris consists of two crura, a short body, and the glans clitoris with overlying skin called the prepuce. It is attached to the pubic bone by a suspensory ligament. Within the shaft are corpora cavernosa consisting of erectile tissue (loose in structure) that engorges with blood, causing erection and enlargement (two times usual size) during sexual excitement. The clitoris and prepuce are the primary areas of erotic stimulation in most women. The prepuce has the most innervation, which usually comes from a terminal branch of the pudendal nerve in most women. Some women, however, have alternate innervations and, in a few, innervation is sparse.
A patient develops a neurologic disease that destroys components of S2, S3, S4 bilaterally. What clinical manifestation would you expect the patient to have as a result? (A) inability to abduct her thigh (B) rectal incontinence (C) painless menses (D) labor without pain (E) inability to extend her knees
(B) rectal incontinence The S2, S3, S4 innervation, if damaged at the level of the spinal cord, is most likely to produce incontinence of bladder or bowel. The patient may also have decreased vulvar sensation. Uterine pain with labor or menses is mediated by the sympathetic and parasympathetic system. Movement of the leg is mediated by L2-L4.
Under the influence of relaxin and the pressure of pregnancy the junction between the two pubic bones may become unstable near the time of delivery. This will result in a waddling gait in the woman to minimize discomfort. What is this junction called? (A) sacroiliac joint (B) symphysis (C) sacrococcygeal joint (D) piriformis (E) intervertebral joint
(B) symphysis The joint between the two pubic bones is the pubic symphysis. It is not a stable joint. Joints between the bones of the pelvis, such as the sacroiliac and sacrococcygeal, are called synarthroses. They have limited motion but do become more mobile and even separate a bit during pregnancy. The relaxation is attributed to the hormone relaxin. The piriformis is a muscle.
During delivery of a first twin, a very tight nuchal cord is reduced from the baby's neck by clamping and dividing it. After this, the second twin (as yet unborn) develops severe fetal distress. Of the following, what is the most likely mechanism for the distress in the second twin? (A) a twin-to-twin transfusion before birth (B) the second twin may no longer be connected to its placenta (C) placenta previa in the second twin (D) amniotic fluid embolism (E) uterine rupture
(B) the second twin may no longer be connected to its placenta In this case placenta previa can be ruled out because the first twin has already been delivered through the cervix. If there had been a severe twin-twin transfusion, it would be unlikely to manifest itself at this time in the pregnancy. An amniotic fluid embolism does not affect the fetus but rather the mother. Uterine rupture with no other signs and occurring at that precise time would be unlikely. That leaves us with a cord accident. Using our knowledge of the placenta, we know that there may be one placenta or two, but we know that both babies have their own umbilical cord. The cord wrapped around the neck of the first twin might belong to the second twin!
The shape of the escutcheon may change with masculinization. The presence of a male escutcheon in a female is one of the clinical signs of hirsutism or increased testosterone. What is the usual shape of the escutcheon in the normal female? (A) diamond shaped (B) triangular (C) oval (D) circular (E) heart shaped
(B) triangular The escutcheon, or configuration of the pubic hair on the mons veneris and lower abdomen, is generally an inverted triangle in the female. It is considered a secondary sex characteristic. The male pattern (a diamond shape extending upward toward the umbilicus) may exist in 25% of women. Sometimes a male-pattern escutcheon in the female may be associated with increased levels of androgens.
When performing a hysterectomy, the surgeon should be aware that at its closest position to the cervix, the ureter is normally separated from the cervix by which of the following distances? (A) 0.5 mm (B) 1.2 mm (C) 12 mm (D) 3 cm (E) 5 cm
(C) 12 mm A surgeon has a little more than a 1-cm space between the cervix and the ureter when performing a hysterectomy. Just lateral to the cervix is a high-risk area for injury to the ureter during gynecologic surgery. The importance of dissecting away the bladder, staying close to the cervix, and not placing clamps too far laterally or inserting wide sutures is apparent. At times, it is necessary to dissect enough to allow visualization of both ureters prior to ligation of the uterine arteries.
A small central chorionic plate surrounded by a thick whitish ring, associated with increased rates of perinatal bleeding and fetal death (A) Battledore placenta (B) bipartite placenta (C) circumvallate placenta (D) multiple-pregnancy placenta (E) placenta accreta (F) placenta previa (G) succenturiate lobe
(C) circumvallate placenta
Anterior and medial labia majora supplied by (A) anterior hypogastric nerve (T12) (B) posterior iliac nerve (T12-L1) (C) ilioinguinal nerve (L1) (D) genitofemoral nerve (L1-L2) (E) the pudendal nerve (S2, S3, S4) (F) terminal branch of the pudendal nerve
(C) ilioinguinal nerve (L1)
The internal pudendal vessels and pudendal nerve exit the pelvis but then reenter through this structure (A) obturator foramen (B) greater sciatic foramen (C) lesser sciatic foramen (D) sacrospinous ligament (E) pudendal (Alcock's) canal (F) sacral foramina
(C) lesser sciatic foramen
What is the uterine corpus mainly composed of? (A) fibrous tissue (B) estrogen receptors (C) smooth muscle (D) elastic tissue (E) endometrium
(C) smooth muscle The uterus has a body (corpus) composed mainly of smooth muscle, and a cervix composed mainly of connective and elastic tissues that are joined by a transitional portion (isthmus). It is an estrogen-dependent organ measuring about 7.5 cm long x 5 cm wide, with a 4-cm anterior-to-posterior diameter. After puberty, the uterus weighs about 50 g in the nullipara and 70 g in the multipara. It lies between the bladder anteriorly and the pouch of Douglas in front of the rectum posteriorly, with the cervical portion extending from the intraperitoneal area into the vagina. The opening at the distal tip of the cervix is called the external os. It is connected by the cervical canal to the internal os, which is located just below the endometrial cavity. This cavity is lined by an epithelium, the endometrium.
During delivery, which of the following muscles is most likely to be obviously torn? (A) ischiocavernosus muscle (B) bulbocavernosus muscle (C) superficial transverse perineal muscle (D) levator ani muscle (E) coccygeus
(C) superficial transverse perineal muscle The superficial transverse perineal muscle is most likely to have an obvious tear. The bul- bocavernosus and ischiocavernosus are lateral. The levators and coccygeus are deep in the pelvis and not seen, though they may suffer tears
Sacrospinous ligament: (A) a thick band of fibers filling the angle created by the pubic rami (B) passes from the anterior superior iliac spine to the pubic tubercle (C) triangular and extends from the lateral border of the sacrum to the ischial spine (D) attaches to the crest of the ilium and the posterior iliac spines superiorly with an inferior attachment to the ischial tuberosity (E) passes over the anterior surface of the sacrum
(C) triangular and extends from the lateral border of the sacrum to the ischial spine
The anatomy of the spinal cord and dural space is important when giving regional spinal anesthesia. At what approximate spinal level do the dural space and the spinal cord, respectively, end? (A) T10, T8 (B) L2, T10 (C) L5, T12 (D) S2, L2 (E) S5, S2
(D) S2, L2 The spinal cord ends within the dura at about L2. The dural space ends at about S2. The filum terminal and cauda equina extend within the dura for some distance after the spinal cord ends. Caudal anesthesia intercepts the spinal nerves after they emerge from the dural space. When giving spinal anesthesia, one should recognize that one usually enters the subarachnoid space at or below the termination of the spinal cord. The cauda equina extends for some distance within the dura. This relationship allows for effective anesthesia and analgesia with minimal risk of injury to the spinal cord.
Sacrotuberous ligament is: (A) a thick band of fibers filling the angle created by the pubic rami (B) passes from the anterior superior iliac spine to the pubic tubercle (C) triangular and extends from the lateral border of the sacrum to the ischial spine (D) attaches to the crest of the ilium and the posterior iliac spines superiorly with an inferior attachment to the ischial tuberosity (E) passes over the anterior surface of the sacrum
(D) attaches to the crest of the ilium and the posterior iliac spines superiorly with an inferior attachment to the ischial tuberosity
During the performance of a pelvic examination, the area of the Bartholin's ducts should be inspected. Where do the Bartholin's glands' ducts open? (A) into the midline of the posterior fourchette (B) bilaterally, beneath the urethra (C) bilaterally, on the inner surface of the labia majora (D) bilaterally, into the posterior vaginal vestibule (E) bilaterally, approximately 1 cm lateral to the clitoris
(D) bilaterally, into the posterior vaginal vestibule The vestibule is an area enclosed by the labia minora. Bartholin's glands, sometimes called the major vestibular glands, open into the posterior vestibule. These glands are prone to infection with resulting occlusion of the ducts and the formation of grossly enlarged tender cysts.
A 56-year-old woman comes to your office for a yearly examination. During physical examination, you notice that her left breast has a 2-cm area of retraction in the upper-outer quadrant that can be seen by simple inspection. What is the most likely diagnosis? (A) Mondor's disease (B) benign fibroadenoma (C) fibrocystic change (D) breast cancer (E) intraductal polyp
(D) breast cancer The deep surface of the breast lies on the fascia covering the chest muscles. The fascia of the chest is condensed into many bands (Cooper's ligaments) that support the breast in its normal position on the chest wall. It is the distortion of these ligaments caused by infiltrative tumors that results in the "dimpling" appearance of the breast associated with malignancy. At age 56, the most likely cause of this is cancer. Fibroadenomas are usually found in younger women, and neither fibrocystic change nor fibroadenomas usually cause significant dimpling (see Figure 1-4). Mondor's disease is a residual of venous thrombophlebitis of the breast; it is rare. An intraductal polyp may cause a nipple discharge, but is unlikely to result in dimpling especially at a distance from the areola.
A patient presents approximately 10 years post-menopausal with complaints of pressure vaginally and the sensation that something is falling out. When told she has a fallen uterus, she wonders if it is due to the damage from her round ligaments since she had a great deal of round ligament pain during her pregnancies. Which of the following ligaments provide the most support to the uterus in terms of preventing prolapse? (A) broad ligaments (B) round ligaments (C) utero-ovarian ligaments (D) cardinal ligaments (E) arcuate ligament
(D) cardinal ligaments The cardinal ligaments are also called the transverse cervical ligaments, or Mackenrodt's ligaments, and are considered part of the uterosacral ligament complex. These ligaments serve as the major support for the apex of the vagina and are severed at the time of hysterectomy. Once divided at hysterectomy, vaginal vault prolapse becomes more likely. The broad ligaments are mainly peritoneum and the round ligaments mainly muscle. Neither provides much support. The arcuate ligament is not attached to the uterus.
The part of the pelvis lying above the linea ter-minalis has little effect on a woman's ability to deliver a baby vaginally. What is the name of this portion of the pelvis? (A) true pelvis (B) midplane (C) outlet (D) false pelvis (E) sacrum
(D) false pelvis The false pelvis or pelvis major lies above the linea terminalis. It seldom affects obstetric management, and measurements of the iliac crest flare do not usually aid in determining the size of the true pelvis. An important measurable indicator of the size of the true pelvis is the inter-spinous diameter.
A 36-year-old patient who underwent a total abdominal hysterectomy for uterine fibroids complains of weakness of her left leg and numbness of her left anterior medial thigh. (A) electrolyte imbalance (B) obturator nerve injury (C) pudendal nerve injury (D) femoral nerve injury (E) disruption of peripheral (skin) nerves (F) ilioinguinal nerve injury (G) spinal cord injury (H) sciatic nerve injury (I) diabetes
(D) femoral nerve injury The femoral nerve rises from L2 to L4 and supplies motor fibers to the quadriceps and sensation to the anterior and medial thigh. The nerve may be compressed by abdominal retractor blades that have impinged on the psoas muscle where the nerve perforates. The nerve can also undergo stretch injury from hip flexion or abduction during vaginal procedures. Either of these can result in pain or numbness or paresthesias over the anterior and medial thigh, as well as weakness of the quadriceps, causing inability to raise the knee and therefore affecting gait.
Deep labial structures supplied by (A) anterior hypogastric nerve (T12) (B) posterior iliac nerve (T12-L1) (C) ilioinguinal nerve (L1) (D) genitofemoral nerve (L1-L2) (E) the pudendal nerve (S2, S3, S4) (F) terminal branch of the pudendal nerve
(D) genitofemoral nerve (L1-L2)
A healthy 5 ft 6 in. tall, adult female is most likely to have a pelvic inlet that would be classified as which of the following Caldwell-Moloy types? (A) android (B) platypelloid (C) anthropoid (D) gynecoid (E) triangular
(D) gynecoid Pelvises in most U.S. women are gynecoid, but they may be of a mixed type (for instance, having a gynecoid forepelvis and an anthropoid posterior pelvis). The obstetrician has to judge the capacity of the pelvis on the basis of its total configuration, including midplane and outlet capacities, and always in relation to the size and position of the fetus.
May be distinct entities or fused (A) Battledore placenta (B) bipartite placenta (C) circumvallate placenta (D) multiple-pregnancy placenta (E) placenta accreta (F) placenta previa (G) succenturiate lobe
(D) multiple-pregnancy placenta
When performing surgery, the position of important structures should be well known to avoid injury. What is the ureter's relationship to the arteries in its course through the pelvis? (A) anterior to the internal iliac and uterine arteries (B) posterior to the iliac artery and anterior to the uterine artery (C) anterior to the uterine artery and posterior to the iliac artery (D) posterior to the uterine artery and medial to the iliac artery (E) posterior to the uterine artery and posterior to the hypogastric artery
(D) posterior to the uterine artery and medial to the iliac artery One can remember the ureter's distal course posterior to the uterine artery by recalling that "water runs under the bridge." Do not confuse the uterine artery-ureteral relationship with the iliac artery-ureteral relationship. In the pelvis, the ureter is always anterior and medial to the iliac arteries. The position of the ureter in relation to the uterine artery makes it particularly vulnerable at the time of hysterectomy.
During a physical examination myrtiform caruncles may be noted. What are they? (A) circumferential nodules in the areola of the breast (B) healing Bartholin's cysts (C) remnants of the Wolffian duct (D) remnants of the hymen (E) remnants of the Müllerian duct
(D) remnants of the hymen The hymen is a membrane that may cover all or part of the vaginal opening just above the vestibule. It may vary from being only small integumental remnants (known as myrtiform caruncles) to being perforated with one or many openings of various sizes, to being completely closed (imperforate hymen) and require surgical intervention to allow menstruum to drain. The presence of myrtiform caruncles is not pathognomonic of prior vaginal penetration (e.g., intercourse or childbirth). They are of no pathologic significance.
Divides and demarcates the greater and lesser sciatic foramen (A) obturator foramen (B) greater sciatic foramen (C) lesser sciatic foramen (D) sacrospinous ligament (E) pudendal (Alcock's) canal (F) sacral foramina
(D) sacrospinous ligament
The inguinal canal in an adult female was opened surgically. Which of the following structures would normally be found? (A) a cyst of the canal of Nuck (B) Gartner's duct cyst (C) Cooper's ligament (D) the round ligament and the ilioinguinal nerve (E) the pyramidalis muscle
(D) the round ligament and the ilioinguinal nerve The superficial inguinal ring is just cephalad to the pubic tubercle and just lateral to it, the deep inguinal ring passes through the transversalis fascia. The connection of these rings forms the inguinal canal. The round ligament, the ilioinguinal nerve, and the processus vaginalis pass out of the abdomen through this canal (as does the spermatic cord in the male). Gartner's ducts are found in the lateral walls of the vagina. One would not normally find a cyst of the processus vaginalis (cyst of the canal of Nuck).
Urinary incontinence is a major problem for some women. Which of the following characteristics of the female urethra helps prevent incontinence? (A) its 15- to 20-cm length (B) its junction with the bladder at the level of the midtrigone (C) its true anatomic sphincter (D) its upper two-thirds integration with the anterior vaginal wall (E) its intrinsic resting tone
(E) its intrinsic resting tone The urethra has a higher intrinsic resting pressure than the bladder in normal women, thus helping to maintain continence. It is a hollow, multilayered tube, 2.5 to 5 cm long in the female, as opposed to being about 20 cm long in the male. It connects the bladder with the outside world. The proximal portion begins at the junction of the bladder base at the lowest portion of the trigone. It contains a functional sphincter mechanism but not a true anatomic sphincter. The distal two-thirds of the urethra is just anterior to the anterior vaginal wall.
Placenta abnormally adherent to the myometrium (A) Battledore placenta (B) bipartite placenta (C) circumvallate placenta (D) multiple-pregnancy placenta (E) placenta accreta (F) placenta previa (G) succenturiate lobe
(E) placenta accreta
A sheath of fascia on the lateral wall of the ischiorectal fossa containing vessels and nerve(A) obturator foramen (B) greater sciatic foramen (C) lesser sciatic foramen (D) sacrospinous ligament (E) pudendal (Alcock's) canal (F) sacral foramina
(E) pudendal (Alcock's) canal
Which of the following is the best description of the pelvic diaphragm? (A) made up mainly by the coccygeus (B) covered on one side by fascia and on the other by peritoneum (C) a muscle innervated by L2, L3, and L4 (D) an extension of the sacrococcygeal ligament (E) synonymous with the pelvic floor
(E) synonymous with the pelvic floor The pelvic diaphragm (also called the pelvic floor) is made up of the levator ani muscle and the coccygeus. It is connected to the pelvic side-wall by its attachment to the obturator internus muscle at the arcus tendineus. The pelvic diaphragm provides support and closure for the intraperitoneal cavity caudally just as the thoracic diaphragm provides closure in the cephalad direction. It is covered by fascia on both sides and innervated from S2, S3, S4. The potential spaces through which the vagina, urethra, and rectum pass are the possible sites of pelvic prolapse
Main innervation of the labia by (A) anterior hypogastric nerve (T12) (B) posterior iliac nerve (T12-L1) (C) ilioinguinal nerve (L1) (D) genitofemoral nerve (L1-L2) (E) the pudendal nerve (S2, S3, S4) (F) terminal branch of the pudendal nerve
(E) the pudendal nerve (S2, S3, S4)
A 56-year-old white woman who had paravaginal suspension and Burch procedure 2 days ago complains of pain over the right mons pubis, right labia, and right medial thigh. (A) electrolyte imbalance (B) obturator nerve injury (C) pudendal nerve injury (D) femoral nerve injury (E) disruption of peripheral (skin) nerves (F) ilioinguinal nerve injury (G) spinal cord injury (H) sciatic nerve injury (I) diabetes
(F) ilioinguinal nerve injury The ilioinguinal nerve passes medially to the inguinal ligament and supplies the mons pubis, labia, and medial thigh. Entrapment of the nerve during surgical procedures for incontinence may result in pain over these areas. The pain may occur immediately or within a few days.
Placenta covers the cervical os (A) Battledore placenta (B) bipartite placenta (C) circumvallate placenta (D) multiple-pregnancy placenta (E) placenta accreta (F) placenta previa (G) succenturiate lobe
(F) placenta previa
Clitoris is supplied by (A) anterior hypogastric nerve (T12) (B) posterior iliac nerve (T12-L1) (C) ilioinguinal nerve (L1) (D) genitofemoral nerve (L1-L2) (E) the pudendal nerve (S2, S3, S4) (F) terminal branch of the pudendal nerve
(F) terminal branch of the pudendal nerve
An accessory cotyledon that is possible not to remove with the placenta at birth and cause post-partum atony and hemorrhage (A) Battledore placenta (B) bipartite placenta (C) circumvallate placenta (D) multiple-pregnancy placenta (E) placenta accreta (F) placenta previa (G) succenturiate lobe
(G) succenturiate lobe
