Navigating the Obstacle: Hysteroscopic Management of Voluntary Termination of Pregnancy Behind a Giant Previa Isthmic Myoma

To demonstrate a minimally invasive, 2-step surgical strategy for managing a complex first-trimester voluntary termination of pregnancy obstructed by a massive 9.5 cm FIGO Type I previa isthmic myoma.

Stepwise video demonstration of a 2-step, fertility-sparing surgical technique combining interventional radiology and operative hysteroscopy.

University of Naples Federico II, Naples, Italy.

A 41-year-old woman requested a termination of pregnancy at 10 weeks of gestation; access to the viable fundal fetus was completely obstructed by a 9.5 cm previa isthmic myoma. Because of the severe distortion of the lower uterine segment, standard medical management or blind suction curettage carried a high risk of complications, such as catastrophic hemorrhage and incomplete evacuation [1-3]. Subsequently, a 2-step approach was adopted. First, uterine artery embolization using a temporary embolic agent was performed to reduce the myoma's vascularization and safely induce fetal demise without permanently compromising fertility [4]. Second, direct hysteroscopic visualization was chosen to safely navigate the myoma [5]. A miniaturized (15 Fr bipolar resectoscope; Karl Storz SE & Co. KG, Tuttlingen, Germany) was introduced via vaginoscopy to gain safe access and perform a targeted resection of the umbilical cord, fetus, and part of the gestational sac. After mechanical cervical dilation up to 9.5 Hegar, a (standard 27 Fr resectoscope; Olympus Corporation, Tokyo, Japan) was utilized to efficiently complete the resection of the remaining gestational tissue. All major tissue fragments were retrieved through the cervical canal using the resectoscopic loop under direct visualization, without the use of suction curettage. The fluid deficit was strictly limited to 1100 mL, and the estimated blood loss was minimal, with only a 0.5 g/dL postoperative hemoglobin drop.

Combining temporary uterine artery embolization with a sequential ultrasound-guided hysteroscopic approach provides a safe, reproducible, and highly effective fertility-sparing alternative for early pregnancy terminations facing severe mechanical obstructions. At the 60-day follow-up, the myoma was drastically reduced to 2.5 cm, and the endometrial cavity was completely restored, successfully avoiding demolitive surgery. VIDEO ABSTRACT.