What is the best next step in management for a patient with recurrent mid-trimester pregnancy loss?

From the Guidelines

The best next step in management for this patient is to follow guidelines for management of pregnant persons with a previous spontaneous preterm birth, as recommended by the Society for Maternal-Fetal Medicine 1. This patient has a history of two second-trimester pregnancy losses at 21 weeks with precipitous, nonpainful deliveries preceded by light vaginal spotting, which strongly suggests a history of previable or periviable preterm prelabor rupture of membranes (PPROM). According to the most recent evidence, in subsequent pregnancies after a history of previable or periviable PPROM, history-indicated cerclage should be reserved for individuals with classic historical features of cervical insufficiency or an unexplained second-trimester loss in the absence of placental abruption 1. However, the patient's history of two second-trimester losses with painless cervical dilation is not classic for cervical insufficiency, but rather for PPROM. The evidence suggests that nearly 50% of immediate subsequent pregnancies resulted in recurrent preterm birth, with 30% at <34 weeks of gestation, 23% at <28 weeks of gestation, and 17% at <24 weeks of gestation 1. Additionally, cerclage placement for management of subsequent pregnancies after a previous previable PPROM was associated with increased odds of preterm birth in a retrospective cohort study 1. Therefore, the best next step in management for this patient is to follow guidelines for management of pregnant persons with a previous spontaneous preterm birth, which may include close monitoring of cervical length and fetal well-being, rather than immediate cerclage placement. The patient should be monitored with serial cervical length measurements via transvaginal ultrasound every 2-3 weeks, and other interventions such as vaginal progesterone may be considered based on shared decision-making and individual risk factors. It is essential to weigh the potential benefits and risks of each intervention and to consider the patient's individual circumstances and preferences when making management decisions. In this case, the most recent and highest quality evidence suggests that a conservative approach, with close monitoring and consideration of other interventions, may be the best course of action 1.

From the Research

Patient Management

The patient is a 27-year-old woman, gravida 3 para 2, at 14 weeks gestation with a history of two previous pregnancies ending in losses at 21 weeks gestation. The patient's history suggests a possible diagnosis of cervical insufficiency.

Cervical Cerclage

• Cervical cerclage has been used in the management of cervical insufficiency for several decades, yet the indications are uncertain and benefits marginal 2.
• The diagnosis of cervical insufficiency is traditionally based on a history of recurrent second trimester miscarriages, or very preterm delivery whereby the cervix is unable to retain the pregnancy until term 2.
• There is evidence supporting cervical cerclage in the following limited circumstances: a history of 3 or more spontaneous preterm births or second trimester losses; a high-risk patient with a singleton pregnancy who has a short cervix in the second trimester 3.
• Systematic review evidence offers transabdominal cerclage (TAC) as a more effective procedure to transvaginal cerclage (TVC) in reducing preterm birth and maximizing neonatal survival 4.

Next Steps in Management

• Given the patient's history of two previous second trimester losses, cervical cerclage may be considered as a treatment option to prevent preterm birth and miscarriage.
• However, the patient's history does not meet the criteria of 3 or more spontaneous preterm births or second trimester losses, which is one of the limited circumstances where cervical cerclage is supported by evidence 3.
• Ultrasound measurement of the cervical length may be considered to assess the risk of preterm birth and guide the decision for cervical cerclage 5.
• The patient should be closely monitored and managed by a healthcare provider to prevent preterm birth and ensure the best possible outcome for the pregnancy.