Management Recommendation for Cervical Insufficiency
Place history-indicated cerclage at 12-14 weeks of gestation (Option A: cerclage at 13 weeks). This patient has the classic presentation of cervical insufficiency—a prior second-trimester loss at 18 weeks with painless cervical dilation—and meets criteria for history-indicated cerclage rather than expectant ultrasound monitoring. 1
Rationale for Early Cerclage Placement
This patient's history is the textbook indication for history-indicated cerclage. The American College of Obstetricians and Gynecologists specifically recommends history-indicated cerclage for patients with prior second-trimester loss characterized by painless cervical dilation in the absence of labor, rupture of membranes, or placental abruption. 1, 2
Why 12-14 Weeks is Optimal Timing
- Placement at 12-14 weeks allows the procedure after first-trimester organogenesis is complete but before typical cervical changes begin. 1
- Waiting until 18 weeks (Option B) is too late—cervical changes may already be underway by the gestational age of her prior loss, making the procedure less effective and potentially requiring emergency cerclage instead. 1
- No guideline recommends delaying cerclage until the gestational age of prior loss. Early placement at 12-14 weeks is the standard of care. 1
Why Ultrasound Monitoring Alone is Inadequate (Option C)
- Ultrasound-indicated cerclage requires waiting for cervical shortening to ≤25 mm, which may occur too late to prevent pregnancy loss in patients with classic cervical insufficiency. 1
- The Society for Maternal-Fetal Medicine recommends against cerclage placement in patients WITHOUT a history of preterm birth who have sonographic short cervix (10-25 mm) in the absence of cervical dilation. 3 However, this patient DOES have a classic history, making her a different category entirely.
- Women with a history of three or more losses should receive elective cerclage, but even one prior second-trimester loss with painless cervical dilation qualifies for history-indicated cerclage. 4
Post-Cerclage Management
Vaginal Progesterone Supplementation
Consider adding vaginal progesterone 200 mg daily after cerclage placement. Limited but compelling evidence shows this reduces spontaneous preterm birth at <34 weeks (2.2% vs 18.4%) and <37 weeks (9.1% vs 29.7%) compared to cerclage alone. 1, 3
Surveillance Strategy
- Serial ultrasound monitoring is NOT routinely recommended after history-indicated cerclage placement due to insufficient evidence supporting clinical benefit. 1, 2
- However, if progressive cervical shortening occurs despite cerclage and progesterone, physical examination should be considered when cervical length reaches <11-15 mm because the prevalence of cervical dilation is very high at this threshold. 5
Common Pitfalls to Avoid
- Do not confuse this patient with someone who has an incidentally discovered short cervix without prior history—those patients do not benefit from cerclage. 3, 4
- Do not delay cerclage placement waiting for ultrasound changes—this converts an elective, planned procedure into a potentially more complicated emergency situation. 1
- Do not place cerclage if there are contraindications: active preterm labor, preterm premature rupture of membranes, intra-amniotic infection, or gestational age beyond 24 weeks. 5