Abstract
RATIONALE: Large uterine fibroids in specific locations (e.g., lower uterus) pose significant controversy regarding removal during cesarean section (C-section) due to surgical difficulty, bleeding risk, and maternal/fetal safety concerns. This case addresses the challenge of a huge fibroid completely blocking the birth canal, preventing standard C-section. PATIENT CONCERNS: A 35-year-old woman at 35 + 1 weeks presented with poorly controlled hypertension for 9 weeks, diagnosed as chronic hypertension with superimposed preeclampsia and a large uterine fibroid. DIAGNOSES: Chronic hypertension accompanied by preeclampsia, pregnancy with uterine fibroids. INTERVENTIONS: After failed medical management (antihypertensives and antispasmodics) and onset of labor, an innovative "reverse-sequence cesarean myomectomy" (RCM) was performed with patient consent. This involved removing the giant lower uterine segment fibroid before delivering the fetus via C-section, utilizing a tourniquet. OUTCOMES: The RCM procedure was successful. The fibroid was removed, the baby delivered, and the C-section completed with only 400 mL blood loss. Both mother and infant had good outcomes, avoiding fetal removal difficulty and massive hemorrhage. Pathology confirmed leiomyoma. The approach utilized post-myomectomy uterine contraction for hemostasis and prevented the need for secondary surgery. LESSONS: This case demonstrates that RCM is a safe, feasible, and innovative strategy for extreme cases where huge, strategically located fibroids (e.g., lower uterus) completely obstruct the birth canal. Its core advantages are: (1) solving the "unable to remove fetus" dilemma; (2) reducing bleeding risk via reverse timing (tumor first) and tourniquet; (3) avoiding a second surgery. RCM provides a valuable new option for managing these complex, high-risk pregnancies.