What is the best management approach for a 13-week pregnant woman with a history of mid-trimester abortion due to cervical insufficiency?

Management of Cervical Insufficiency in Second Pregnancy

This patient requires history-indicated cervical cerclage (Option C) placed at 12-14 weeks of gestation, as her history of painless mid-trimester cervical dilation with spontaneous fetal expulsion at 18 weeks is the classic presentation of cervical insufficiency. 1, 2

Rationale for Cervical Cerclage

History-indicated cerclage is specifically reserved for patients with classic features of cervical insufficiency or unexplained second-trimester loss, which this patient clearly demonstrates 1. Her presentation—painless cervical dilation at 18 weeks followed by spontaneous expulsion—is the textbook definition of cervical insufficiency 3.

Evidence Supporting Cerclage in This Case:

• Women with a history of three or more second-trimester losses should receive elective cerclage at 12-14 weeks, though this patient has only one loss, her presentation is so characteristic that she qualifies for history-indicated cerclage 2
• The classic history of painless second-trimester loss after cervical dilation is the strongest indication for prophylactic cerclage 2, 3
• Emergency cerclage has shown benefit even with advanced cervical dilation, with studies showing median pregnancy prolongation of 3.3 weeks and survival rates of 57% (8/14 babies) when placed at mean 23 weeks gestation 4

Why Other Options Are Insufficient:

Folic Acid (Option A):

• Standard prenatal supplementation but does not address the underlying cervical insufficiency 2
• Does not prevent recurrent mid-trimester loss from cervical incompetence 1

Aspirin (Option B):

• Indicated for pre-eclampsia prevention, not cervical insufficiency 1
• No role in preventing mechanical cervical failure 1

Antenatal Follow-up Alone (Option D):

• Serial cervical length monitoring is reserved for patients with 1-2 prior losses or less classic presentations 2
• This patient's history is too compelling to rely on expectant management 1, 3
• Waiting for cervical shortening before intervention increases risk of recurrence 3

Optimal Management Algorithm:

1. Place history-indicated cerclage at 12-14 weeks of current pregnancy (now at 13 weeks, timing is appropriate) 2
2. Screen for and treat any infections before cerclage placement: obtain urinalysis with culture and vaginal cultures for bacterial vaginosis 2
3. Consider vaginal progesterone supplementation after cerclage placement, as one study showed reduced spontaneous preterm birth at <34 weeks (2.2% vs 18.4%) when added to ultrasound-indicated cerclage 5
4. Routine cervical length monitoring after cerclage is not recommended due to insufficient evidence of benefit 5

Critical Pitfall to Avoid:

Do not delay cerclage placement waiting for cervical shortening on ultrasound—this patient's history alone justifies prophylactic intervention 1, 2. The risk of recurrence with expectant management is unacceptably high given her classic presentation 3.