Anatomical basis for the uterine vascular control: implications in training, knowledge, and outcomes

The efficiency of uterine vascular control depends on the precise management of its arterial pedicles and anastomotic network. Although all specialists know the uterine and ovarian arteries, only a few are familiar with the anatomy of the inferior supply system and the connections of the pelvic vessels. For this reason, specific proven inefficient hemostatic procedures are still used worldwide. The pelvic arterial system is extensively interconnected with the aortic, internal iliac, external iliac, and femoral anastomotic components. Most uterine vascular control methods act on the blood supply to the uterus and ovary but rarely on the anastomotic network of the internal pudendal artery. Therefore, the effectiveness of vascular control procedures depends on the topographic area in which they are performed. In addition, the procedure's effectiveness depends on the skill and experience of the operator, among other factors. From a practical point of view, the uterine arterial supply is divided into 2 sectors, sector S1, which involves the uterine body, supplied by the uterine and ovarian arteries, and sector S2, which includes the uterine segment, the cervix, and the upper part of the vagina, provided by pelvis subperitoneal pedicles arising from the internal pudendal artery. As both sectors receive different arterial pedicles, the hemostatic procedures for one or the other are also different. The urgent nature of obstetrical hemorrhage, correct application of a specific technique, surgeon experience, time to provide accurate informed consent in a person under a life-threatening condition, lack of precise or possible harmful consequences of the proposed method, lack of randomized controlled trials or multiple phase II trials, epidemiologic data, qualitative data, and reports from the field from clinicians using an intervention multiple other aspects could be impossible to randomize all patients to obtain more precise information. Apart from actual effectiveness, there are no reliable morbidity data, as most complications are rarely published for various reasons. However, a simple and current presentation of pelvic and uterine blood supply and its anastomotic system allows readers to understand the value of different hemostatic procedures.