What is the best course of action for a 10-week pregnant female with a history of mid-trimester abortion (miscarriage) at 18 weeks due to cervical insufficiency?

Recommendation for Management of Cervical Insufficiency in Second Pregnancy

Insert history-indicated cervical cerclage at 12-14 weeks of gestation (Option A at 13 weeks is correct). This patient has the classic presentation of cervical insufficiency—painless cervical dilation with spontaneous expulsion at 18 weeks—and meets criteria for prophylactic cerclage placement rather than expectant monitoring. 1, 2

Rationale for Early Cerclage Placement

Your patient's history is the textbook definition of cervical insufficiency that warrants history-indicated cerclage. The American College of Obstetricians and Gynecologists specifically identifies prior second-trimester loss at 18 weeks with painless cervical dilation as the classic presentation requiring history-indicated cerclage. 1 This differs from ultrasound-indicated or examination-indicated cerclage, which require waiting for objective cervical changes. 1

Optimal Timing: 12-14 Weeks

• Place the cerclage at 12-14 weeks of gestation, which allows completion of first-trimester organogenesis while intervening before typical cervical changes occur. 1
• Option A (13 weeks) is the correct answer. 1
• Option B (18 weeks) is incorrect and dangerous—waiting until 18 weeks (the gestational age of prior loss) is too late, as cervical changes may already be underway, making the procedure less effective and potentially requiring emergency cerclage. 1
• No guideline recommends delaying cerclage until the gestational age of prior loss. 1

Why Serial Ultrasound Monitoring Alone is Inadequate

Option C (serial ultrasound assessment) is the wrong approach for this patient. While ultrasound-indicated cerclage is appropriate for some patients, it requires waiting for cervical shortening to ≤25 mm, which may occur too late to prevent pregnancy loss in patients with classic cervical insufficiency. 1

• Ultrasound-indicated cerclage is reserved for patients with 1-2 prior second-trimester losses who do NOT have the classic painless dilation presentation. 3
• The American College of Obstetricians and Gynecologists specifically recommends history-indicated cerclage rather than waiting for ultrasound changes in patients with your patient's classic presentation. 1
• Serial ultrasound monitoring is NOT routinely recommended after history-indicated cerclage placement, as insufficient evidence supports clinical benefit. 1, 2

Additional Management Considerations

Adjunctive Progesterone Therapy

• Consider adding vaginal progesterone 200 mg daily after cerclage placement. One study demonstrated dramatic reductions in spontaneous preterm birth at <34 weeks (2.2% vs 18.4%) and <37 weeks (9.1% vs 29.7%) when progesterone was added post-cerclage. 1, 3

What NOT to Do

• Do not use 17-alpha hydroxyprogesterone caproate (17-OHPC) for cervical insufficiency management. 3
• Do not place a cervical pessary due to conflicting trial data and recent safety signals including increased perinatal mortality. 3

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

This case requires understanding the three types of cerclage indications:

1. History-indicated (prophylactic): For classic cervical insufficiency presentation—your patient qualifies. Place at 12-14 weeks. 1, 2
2. Ultrasound-indicated: For patients with prior preterm birth AND short cervix (≤25 mm) on ultrasound—not appropriate here as first-line. 2, 3
3. Examination-indicated (emergency): For cervical dilation detected on exam before 24 weeks—not applicable as your patient is only 10 weeks. 3

The key pitfall to avoid is treating this patient with the ultrasound-indicated approach when she clearly meets criteria for history-indicated cerclage. 1