What is the most recommended intervention for a 13-week pregnant patient with a history of cervical insufficiency, having experienced a painless fetal passage at 22 weeks in her first pregnancy?

Cervical Cerclage

For this patient with a history of painless fetal passage at 22 weeks (classic cervical insufficiency), cervical cerclage is the most recommended intervention and should be placed at 12-14 weeks of gestation. 1, 2

Rationale for Cerclage in This Case

This patient's history is pathognomonic for cervical insufficiency:

• Painless mid-trimester fetal loss at 22 weeks represents the classic presentation of cervical insufficiency—painless cervical dilation leading to fetal expulsion without labor or membrane rupture. 3, 2
• With one prior second-trimester loss due to cervical insufficiency, this patient qualifies for history-indicated cerclage, which should be placed electively at 12-14 weeks of gestation. 1, 2
• The American College of Obstetricians and Gynecologists recommends history-indicated cerclage for patients with classic historical features of cervical insufficiency, including prior second-trimester loss with painless cervical dilation. 3

Why Not the Other Options

Aspirin (Option A)

• Aspirin is indicated for pre-eclampsia prevention, not cervical insufficiency prevention. 2
• This patient has no indication for aspirin based on the clinical scenario presented. 2

Folic Acid (Option B)

• While folic acid is standard prenatal supplementation for neural tube defect prevention, it does not address this patient's specific risk of recurrent cervical insufficiency. 2
• Folic acid will not prevent recurrent mid-trimester loss from cervical insufficiency. 2

Regular Antenatal Visits Only (Option D)

• Expectant management alone carries an unacceptably high risk of recurrence in patients with proven cervical insufficiency. 4
• Without intervention, this patient faces substantial risk of losing this pregnancy at a similar gestational age. 4

Optimal Management Algorithm

Primary intervention:

• Place history-indicated cerclage at 12-14 weeks of gestation (the patient is currently at 13 weeks, making this the ideal timing). 1, 2

Adjunctive therapy:

• Consider adding vaginal progesterone 200 mg daily after cerclage placement, as one study demonstrated reduction in spontaneous preterm birth at <34 weeks from 18.4% to 2.2% when progesterone was added to cerclage. 1, 2

Monitoring:

• Serial cervical length assessments are not routinely recommended after cerclage placement due to insufficient evidence of clinical benefit. 3

Critical Distinction: History-Indicated vs. Ultrasound-Indicated Cerclage

This case requires history-indicated cerclage (prophylactic cerclage based on obstetric history), not ultrasound-indicated cerclage:

• History-indicated cerclage is reserved for patients with classic features of cervical insufficiency, which this patient clearly demonstrates. 3
• The threshold for history-indicated cerclage is typically three or more losses, but patients with even one classic mid-trimester loss due to painless cervical dilation qualify for this intervention. 3, 2
• Ultrasound-indicated cerclage would be the approach if this patient had 1-2 prior losses and developed cervical shortening ≤25 mm on surveillance ultrasound. 1

Common Pitfall to Avoid

Do not wait for cervical shortening on ultrasound before acting in this patient. 1 Her history alone justifies immediate cerclage placement at the current gestational age of 13 weeks, which falls within the optimal 12-14 week window. 1, 2