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

OBJECTIVE: To demonstrate a minimally invasive, two-step surgical strategy for managing a complex first-trimester voluntary termination of pregnancy (TOP) obstructed by a massive 9.5 cm FIGO type 1 previa isthmic myoma. SETTING: University of Naples "Federico II" (Italy). PARTICIPANTS: A 41-year-old woman requesting a TOP at 10 weeks of gestation, where access to the viable fundal fetus was completely obstructed by a 9.5 cm previa isthmic myoma. INTERVENTIONS: Due to 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. Subsequently a two-step approach was adopted. First, Uterine Artery Embolization (UAE) - using a temporary agent - was performed to reduce the myoma's vascularization and safely induce fetal demise without permanently compromising fertility. Second, direct hysteroscopic visualization was chosen to safely navigate the myoma. A miniaturized 15 Fr bipolar resectoscope was introduced via vaginoscopy to gain safe access and perform a targeted resection of the umbilical cord, the fetus, and part of the gestational sac. Following mechanical cervical dilation up to 9.5 Hegar, a standard 27 Fr resectoscope 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 post-operative hemoglobin drop. CONCLUSION: Combining temporary UAE 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 drastically reduced to 2.5 cm and the endometrial cavity was completely restored, successfully avoiding demolitive surgery.