Is a McDonald's cerclage indicated as prophylaxis in a 15-week twin pregnancy with one deceased fetus and a history of multiple laparoscopic myomectomies and hysteroscopies, given a cervical length of 5 centimeters?

McDonald's Cerclage Not Indicated for This Patient

A McDonald's cerclage is not indicated as prophylaxis in this 15-week twin pregnancy with one deceased fetus at 9 weeks, despite the history of multiple laparoscopic myomectomies and hysteroscopies, given the normal cervical length of 5 cm. 1, 2

Assessment of Current Pregnancy Factors

• The patient has a normal cervical length of 5 cm, which is well above the threshold for defining a short cervix (typically <2.5 cm) 1
• One twin is deceased at 9 weeks (vanishing twin syndrome), effectively making this a singleton pregnancy from a management perspective 1
• The patient has a history of multiple laparoscopic myomectomies and hysteroscopies, but no history of spontaneous preterm birth is mentioned 2

Evidence Against Prophylactic Cerclage

• The Society for Maternal-Fetal Medicine (SMFM) explicitly recommends against cerclage placement in individuals without a history of preterm birth who have a normal cervical length 1
• Even for patients with a short cervix (10-25 mm) but no history of preterm birth, cerclage is not recommended in the absence of cervical dilation 1
• Current guidelines reserve history-indicated cerclage for patients with classic features of cervical insufficiency or unexplained second-trimester losses 1

Risk Assessment for This Patient

• The patient's cervical length of 5 cm is reassuring and indicates normal cervical competence 1
• While multiple uterine surgeries (myomectomies and hysteroscopies) may raise theoretical concerns about uterine integrity, they do not specifically indicate cervical insufficiency 2
• Transvaginal ultrasound assessment of cervical length is the reference standard for evaluating risk of preterm birth, and the patient's measurement is well within normal range 1

Alternative Management Recommendations

• Regular prenatal care with standard monitoring is appropriate 1
• If there are concerns about cervical shortening, transvaginal ultrasound surveillance of cervical length can be performed between 16-24 weeks 1
• If the cervix were to shorten significantly during pregnancy (<25 mm before 24 weeks), vaginal progesterone would be the first-line intervention rather than cerclage 1

Important Caveats

• If the patient develops signs of cervical insufficiency later in pregnancy (such as progressive cervical shortening to <10 mm or cervical dilation), management should be reassessed 2
• The loss of one twin at 9 weeks is unlikely to affect cervical competence, as this occurred early in pregnancy before significant uterine distension 1
• Unnecessary cerclage placement carries risks including uterine contractions, infection, membrane rupture, and cervical trauma 3

In conclusion, based on current evidence and guidelines, this patient with normal cervical length does not meet criteria for prophylactic McDonald's cerclage despite her surgical history 1, 2.