MRCOG Part 1 - Anatomy Chapters to Study

1. Pelvis and Abdomen - Surgical Anatomy (Core Modules 5-7, 14-16)

• Bony pelvis: types (gynaecoid, android, anthropoid, platypelloid), diameters (obstetric conjugate, diagonal conjugate, transverse), pelvic inlet/outlet
• Pelvic walls and floor: levator ani (pubococcygeus, iliococcygeus, puborectalis), coccygeus - motor supply from S3/S4 (nerve to levator ani) and pudendal nerve - classic exam topic
• Pelvic fascia: endopelvic fascia, arcus tendineus
• Perineum: urogenital triangle and anal triangle, perineal body, ischiorectal fossa, pudendal canal (Alcock's canal)
• Abdominal wall layers: skin, Camper's fascia, Scarpa's fascia, external oblique, internal oblique, transversus abdominis, transversalis fascia, peritoneum
• Rectus sheath: arcuate line and its significance
• Inguinal canal: boundaries, contents (round ligament in females), Hesselbach's triangle

2. Female Reproductive Organs - Gynaecological Anatomy (Core Module 13)

• Uterus: body, isthmus, cervix; ligaments (broad, round, uterosacral, cardinal/Mackenrodt's); blood supply (uterine artery from internal iliac - direct branch); lymph drainage (iliac and para-aortic nodes)
• Uterine artery relationship to ureter: ureter passes under uterine artery ("water under the bridge") - extremely high-yield
• Fallopian tubes: four parts (interstitial, isthmic, ampullary, infundibulum), blood supply, relation to ovary
• Ovaries: position, ligaments (ovarian ligament, suspensory ligament of ovary), blood supply from ovarian artery (branch of aorta at L2), venous drainage (left ovarian vein to left renal vein; right to IVC)
• Vagina: relations anteriorly (bladder/urethra), posteriorly (pouch of Douglas, rectum), blood supply, supports
• Vulva: labia majora/minora, clitoris, vestibule, Bartholin's glands, blood supply (pudendal artery), innervation (pudendal nerve, ilioinguinal nerve)

3. Obstetric Anatomy (Core Module 10)

• Pelvic dimensions in labour: pelvic inlet, mid-cavity, outlet diameters
• Symphysis pubis: type of joint (fibrocartilaginous, secondary cartilaginous - classic SBA)
• Changes during late pregnancy and labour: ligamentous laxity, uterine lower segment formation
• Mechanism of childbirth: engagement, descent, flexion, internal rotation, extension, restitution, external rotation

4. Fetal Skull Anatomy (Core Module 10-11)

• Vault bones: frontal (x2), parietal (x2), temporal (x2), occipital
• Sutures: sagittal, coronal, lambdoid, frontal (metopic)
• Fontanelles: anterior (bregma - diamond shaped, closes 18 months) and posterior (lambda - triangular, closes 6-8 weeks)
• Diameters of fetal skull: suboccipitobregmatic (9.5 cm - presenting diameter in vertex), suboccipitofrontal, occipitofrontal, mentovertical, submentobregmatic
• Structural changes in the newborn (Core Module 12): ductus arteriosus closure (mediated by oxygen and prostaglandins), foramen ovale, ductus venosus

5. Urinary Tract Anatomy (Core Module 18)

• Ureters: course from renal pelvis to bladder; three anatomical narrowings; relation to uterine artery in the pelvis; at the pelvic brim crossing iliac vessels
• Bladder: detrusor muscle, trigone, internal urethral sphincter (smooth, involuntary), external sphincter (striated, voluntary)
• Urethra: female (4 cm), sphincter mechanisms
• Pelvic floor supports of the bladder: pubourethral ligaments, pubovesical fascia

6. Vascular and Lymphatic Anatomy (Core Modules 5-7, 14-16)

• Internal iliac artery and branches: anterior division (uterine, vaginal, obturator, inferior vesical, internal pudendal, inferior gluteal) and posterior division (iliolumbar, lateral sacral, superior gluteal)
• Ovarian vessels: origin and drainage as above
• Lymph node drainage:
  • Vulva/lower vagina → superficial inguinal nodes
  • Upper vagina/cervix → iliac nodes (internal, external, common)
  • Uterine body → iliac and para-aortic
  • Ovaries → para-aortic (L2 level)
  • Critical for staging of gynaecological cancers

7. Nerve Supply to the Pelvis (Core Modules 5-7)

• Lumbosacral plexus: L1 (ilioinguinal, iliohypogastric), L1/L2 (genitofemoral), L2-L4 (femoral, obturator), L4-S3 (sciatic)
• Pudendal nerve (S2-S4): course through greater sciatic foramen, around ischial spine, through lesser sciatic foramen into pudendal canal - clinically vital for pudendal blocks
• Autonomic supply: hypogastric plexus (sympathetic, T10-L2), pelvic splanchnic nerves (parasympathetic, S2-S4)
• Levator ani motor supply: direct branches from S3/S4 (not pudendal) - frequent exam trap

8. Hypothalamus, Pituitary, and Endocrine Gland Anatomy (Core Module 14-16)

• Pituitary gland: sits in the sella turcica (sphenoid bone) covered by diaphragma sellae; optic chiasm lies just above (bitemporal hemianopia with macroadenoma)
• Hypothalamus: position in floor of third ventricle
• Adrenal glands: position, zones, blood supply
• Thyroid and parathyroid: position and blood supply

9. Breast Anatomy (Core Module 8)

• Structure: 15-20 lobes each drained by a lactiferous duct; lactating breast has approximately 15-20 lobules per breast - tested directly
• Blood supply: internal thoracic (mammary), lateral thoracic, intercostal arteries
• Lymph drainage: 75% to axillary nodes (anterior/pectoral, central, posterior, lateral, apical/infraclavicular); also internal mammary and supraclavicular nodes
• Axillary lymph node levels: Level I (lateral to pectoralis minor), Level II (behind), Level III (medial) - surgical relevance for breast cancer

10. Anatomical Changes Relevant to Tumours and Imaging (Core Modules 17-18)

• Cervical cancer: ureteric obstruction (obstructs ureter as it passes through the parametrium) - classic SBA
• Anatomical interpretation of imaging: X-ray, USS, and MRI of pelvis and fetus
• Fetal and maternal imaging: normal appearances on USS including fetal anatomy survey

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MRCOG Part 1 - Physiology Chapters to Study

1. Reproductive Physiology - Female (Core Modules 10, 13, 14-16)

Menstrual Cycle and Ovarian Physiology

• HPO axis: GnRH (pulsatile from hypothalamus), LH and FSH from anterior pituitary, feedback loops
• Folliculogenesis: primordial → primary → secondary → Graafian follicle; granulosa cell vs theca cell roles
• Ovarian cycle phases: follicular phase, ovulation (LH surge mechanism - positive feedback of estrogen, classic exam trap), luteal phase
• Corpus luteum: formation, progesterone secretion, regression (luteolysis), rescue by hCG in pregnancy
• Ovarian hormones: estradiol (17β-estradiol) and progesterone - chemistry, synthesis, transport, receptor action
• Endometrial cycle: proliferative phase (estrogen-driven), secretory phase (progesterone-driven), menstruation

Puberty and Menarche

• Thelarche, pubarche, menarche sequence; GnRH pulse frequency change; adrenarche
• Age of puberty onset; hormonal changes; bone age

Menopause

• Ovarian failure, loss of negative feedback → raised FSH/LH, low estradiol
• Physiological effects: vasomotor symptoms, bone loss (osteoporosis mechanism), cardiovascular risk
• Hormone replacement therapy: types, risk/benefit principles

Spermatogenesis and Sperm Function

• Stages: spermatogonia → spermatocytes → spermatids → spermatozoa
• Role of FSH (Sertoli cells) and LH (Leydig cells/testosterone)
• Capacitation, acrosome reaction, fertilisation

Fertilisation and Implantation

• Events in the ampulla; zona reaction; sex determination
• Implantation window (days 6-10 post-fertilisation); endometrial receptivity

2. Physiology of Pregnancy (Core Modules 8, 9, 10)

Cardiovascular Changes

• Cardiac output rises 40-50% (increased stroke volume + heart rate); peaks at 28-32 weeks
• Systemic vascular resistance falls (progesterone, NO, prostacyclin)
• Blood pressure: falls in first/second trimester, returns toward normal in third
• Supine hypotension syndrome (aortocaval compression)
• Heart: displaced upward and laterally; physiological murmurs; ECG changes (left axis deviation)

Haematological Changes

• Plasma volume increases 40-50% (greater than red cell mass increase 20-30%) → physiological anaemia of pregnancy - classic SBA
• White cell count rises; platelet count may fall slightly
• Hypercoagulable state: raised fibrinogen, factors VII, VIII, X, XII; reduced protein S; raised D-dimer
• ESR rises; CRP unreliable marker

Respiratory Changes

• Tidal volume increases 40% (progesterone acts on respiratory centre)
• Respiratory rate unchanged
• Minute ventilation rises → respiratory alkalosis (low PaCO2 ~30 mmHg, compensated by renal bicarbonate excretion)
• FRC decreases (elevated diaphragm)
• Oxygen consumption increases 20%; PaO2 slightly higher than non-pregnant

Renal Changes

• GFR and renal plasma flow increase 50% → lower serum creatinine and urea (normal values in pregnancy are lower)
• Glycosuria in pregnancy is physiological (tubular maximum exceeded)
• Ureteric dilatation (progesterone effect + mechanical)
• Increased renin-angiotensin-aldosterone activity (Na retention)

Gastrointestinal Changes

• Reduced lower oesophageal sphincter tone → heartburn/reflux (aspiration risk in anaesthesia)
• Reduced gastric motility; nausea (hCG levels correlate)
• Constipation (progesterone effect)

Metabolic and Endocrine Changes

• Insulin resistance increases progressively (placental hormones: hPL, cortisol, progesterone, glucagon)
• Basal metabolic rate rises 15-20%
• Weight gain distribution: fetus, placenta, amniotic fluid, uterus, breasts, blood volume, fat
• Thyroid: total T3/T4 rise (increased TBG), free T3/T4 normal; hCG has weak TSH-like activity → transient first trimester hyperthyroidism

3. Placental Physiology (Core Module 9)

• Structure: cytotrophoblast and syncytiotrophoblast; intervillous space; Nitabuch's layer
• Placental transfer mechanisms: simple diffusion (O2, CO2, lipid-soluble substances), facilitated diffusion (glucose), active transport (amino acids, Ca, Fe), pinocytosis (IgG)
• Fetal-placental oxygen transfer: Bohr effect, double Bohr effect; fetal haemoglobin (HbF) has higher O2 affinity
• Placental hormones:
  • hCG: glycoprotein, α/β subunits, peaks at 8-10 weeks, rescues corpus luteum, basis of pregnancy test
  • Human placental lactogen (hPL): insulin antagonist, promotes lipolysis and gluconeogenesis, fetal nutrition
  • Progesterone: produced by corpus luteum until 8-10 weeks (luteo-placental shift), then placenta
  • Oestrogens (mainly oestriol): requires fetal adrenal precursors (DHEAS) - reflects feto-placental unit
• Uteroplacental blood flow: low-resistance circuit; factors that reduce it (vasoconstrictors, cocaine, adrenaline)
• Gestational trophoblastic disease: molar pregnancies - physiology of hCG excess

4. Fetal Physiology (Core Modules 9, 10, 11)

Fetal Circulation

• Shunts (must know all three):
  • Foramen ovale: right atrium → left atrium (bypasses lungs)
  • Ductus arteriosus: pulmonary artery → aorta (bypasses lungs); closure mediated by oxygen and prostaglandins - repeated SBA
  • Ductus venosus: umbilical vein → IVC (bypasses liver)
• Umbilical vein carries oxygenated blood (unique); umbilical arteries carry deoxygenated blood
• Fetal PaO2 is low (~30 mmHg) - compensated by HbF, high cardiac output, Bohr effect

Fetal Haematology

• HbF (α2γ2): higher O2 affinity than HbA due to poor binding of 2,3-DPG
• Haemopoiesis: yolk sac (early) → liver/spleen → bone marrow (final)
• Fetal blood volume, haematocrit

Fetal Monitoring and Assessment

• Cardiotocography (CTG): baseline FHR, variability, accelerations, decelerations - physiology behind each
• Fetal blood sampling (FBS): biochemical basis of acid-base balance; normal cord pH ≥ 7.25; acidosis definition
• Fetal breathing movements, tone, movements, liquor (biophysical profile)

Structural Changes in the Newborn (Core Module 12)

• Closure of foramen ovale (functional within hours; anatomical over months - due to reversal of pressure gradient)
• Ductus arteriosus: functional closure within 24-48 hours (oxygen + prostaglandin withdrawal); anatomical closure by 2-3 weeks
• Ductus venosus: closes shortly after birth (becomes ligamentum venosum)
• First breath physiology: lung fluid clearance, surfactant role, establishment of FRC

5. Physiology of Parturition and Labour (Core Module 8)

• Onset of labour: progesterone withdrawal theory; CRH from placenta (biological clock); oxytocin receptor upregulation; prostaglandins (PGE2, PGF2α)
• Myometrial contractility: role of oxytocin (MLCK pathway), prostaglandins, gap junction formation, connexin-43
• Fetal endocrine maturation: cortisol surge → surfactant production; adrenal maturation
• Cervical ripening: prostaglandins, relaxin, matrix metalloproteinases; Bishop score physiological basis
• Third stage physiology: myometrial contraction → shearing of placenta; uterotonic drugs mechanism
• Tocolysis principles: β2-agonists (relax myometrium), magnesium sulphate, calcium channel blockers (nifedipine), oxytocin antagonists (atosiban)

6. Physiology of the Puerperium and Lactation (Core Module 9)

• Uterine involution: from 1 kg at delivery to 60-80 g at 6 weeks; myometrial autolysis and ischaemia
• Lactation physiology:
  • Prolactin (anterior pituitary): stimulates milk production; suppressed by dopamine; rises with suckling
  • Oxytocin (posterior pituitary): milk let-down reflex; conditioned reflex
  • Colostrum: immunoglobulins (especially IgA), protein-rich, produced first 2-3 days
  • Lactational amenorrhoea: GnRH suppression by high prolactin; ~98% contraceptive effect if exclusive breastfeeding in first 6 months + amenorrhoea
• Breast changes in pregnancy: ductal/lobular proliferation under oestrogen/progesterone; Montgomery's tubercles
• Postpartum endocrine changes: oestrogen and progesterone fall; FSH/LH recovery

7. General Physiology - Systems Relevant to O&G

Renal Physiology (Guyton, Ch. 26-31)

• GFR, tubular reabsorption/secretion; renin-angiotensin-aldosterone system
• Acid-base balance: metabolic acidosis in labour (lactic acid from uterine muscle); respiratory alkalosis of pregnancy
• Electrolyte regulation: Na, K, Ca, Mg (important for pre-eclampsia management)

Cardiovascular Physiology (Guyton, Ch. 9-22)

• Cardiac output = heart rate × stroke volume; Starling's law
• Blood pressure regulation; baroreceptor reflex
• Changes in shock (haemorrhagic shock - obstetric haemorrhage)
• Coagulation cascade (relevant to DIC in obstetrics)

Respiratory Physiology (Guyton, Ch. 37-42)

• Lung volumes (TV, IRV, ERV, FRC, RV) - FRC falls in pregnancy
• Oxygen-haemoglobin dissociation curve: left shift (HbF, alkalosis, low temperature, low 2,3-DPG) vs right shift (Bohr effect - acidosis, high CO2, fever)
• Control of ventilation: central and peripheral chemoreceptors; progesterone lowers CO2 set-point

Endocrine Physiology (Guyton, Ch. 75-80)

• Thyroid: T3/T4 synthesis, TBG changes in pregnancy, hypothyroidism vs hyperthyroidism
• Adrenal: cortisol (HPA axis), aldosterone, DHEAS (precursor to fetal oestrogens)
• Pituitary: anterior (GH, prolactin, TSH, ACTH, FSH, LH) and posterior (ADH/vasopressin, oxytocin)
• Calcium metabolism: PTH, vitamin D (1,25-dihydroxycholecalciferol), calcitonin; hypercalcaemia/hypocalcaemia
• Insulin and glucose: insulin resistance mechanism in pregnancy; gestational diabetes physiology
• Prolactin: control by dopamine (PIF); conditions of hyperprolactinaemia

Autonomic Nervous System

• Sympathetic vs parasympathetic effects on pelvic organs; relevant to epidural anaesthesia physiology

8. Continence and Micturition Physiology (Core Module 18)

• Detrusor: smooth muscle; parasympathetic (S2-S4) causes contraction; sympathetic (T11-L2, β3) causes relaxation
• Internal sphincter: smooth muscle, sympathetic (α1) keeps closed
• External sphincter: striated, voluntary (pudendal nerve, S2-S4)
• Filling phase vs voiding phase: storage reflex vs micturition reflex
• Mechanisms of stress incontinence (poor urethral support) vs urge incontinence (detrusor overactivity)
• Effects of pregnancy, oestrogen deficiency, and childbirth on continence

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