Management of Cervical Insufficiency with Prior Second-Trimester Loss
Place history-indicated cerclage at 12-14 weeks of gestation (Option A). 1
Rationale for Early Cerclage Placement
Your patient has the classic presentation of cervical insufficiency: a prior second-trimester loss at 18 weeks with painless cervical dilation and spontaneous delivery. 1 This history alone—without needing ultrasound confirmation—qualifies her for history-indicated cerclage. 2
Key Diagnostic Features
- Cervical insufficiency is a clinical diagnosis based on history of painless cervical dilation leading to second-trimester loss, not an ultrasound finding. 2
- 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
Why 12-14 Weeks is Optimal (Option A)
- The optimal timing for history-indicated cerclage is 12-14 weeks of gestation, which allows placement after first-trimester organogenesis but before typical cervical changes occur. 1
- Waiting until 18 weeks (Option B) is too late, as cervical changes may already be underway, 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 standard. 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 American College of Obstetricians and Gynecologists specifically recommends history-indicated cerclage for patients with classic features of cervical insufficiency, rather than waiting for ultrasound changes. 1
- Serial ultrasound monitoring is NOT routinely recommended after history-indicated cerclage placement, as insufficient evidence supports clinical benefit. 1
Post-Cerclage Management
- Add vaginal progesterone 200 mg daily after cerclage placement, which reduces spontaneous preterm birth at <34 weeks (2.2% vs 18.4%) and <37 weeks (9.1% vs 29.7%). 1
- The American College of Obstetricians and Gynecologists supports vaginal progesterone supplementation after cerclage as it provides additive benefit. 1
Common Pitfalls to Avoid
- Do not conflate short cervix with cervical insufficiency—they are distinct conditions with different management approaches. 2
- Do not wait for ultrasound evidence of cervical shortening in patients with classic historical features of cervical insufficiency, as this delays appropriate intervention. 2, 1
- Do not delay cerclage placement until the gestational age of prior loss, as this misses the therapeutic window. 1