In a 28-year-old gravida 3, para 0+2 woman at 12 weeks gestation with a history of two painless second‑trimester losses due to cervical insufficiency and a closed cervix on exam, what is the most appropriate management?

McDonald Cerclage (History-Indicated)

This patient meets criteria for history-indicated cerclage placement at 12-14 weeks of gestation based on her classic presentation of cervical insufficiency with two prior painless second-trimester losses associated with cervical dilatation. 1, 2

Clinical Reasoning

This patient's history is pathognomonic for cervical insufficiency:

• Two prior second-trimester losses at 18 and 20 weeks 1
• Painless cervical dilatation without contractions 1, 2
• Minimal bleeding without labor 1
• No alternative explanations (uterine anomalies, infection, or surgery) 1

History-indicated cerclage should be placed at 12-14 weeks for patients with classic features of cervical insufficiency, particularly those with multiple prior second-trimester losses or extreme premature deliveries without other identifiable causes. 1, 2

Why Other Options Are Inappropriate

Vaginal Progesterone (Option A)

• Vaginal progesterone is reserved for patients with 1-2 prior losses who develop short cervix (≤20-25 mm) on surveillance ultrasound 2
• This patient has TWO prior losses with classic cervical insufficiency features, making her a candidate for cerclage rather than progesterone alone 1, 2
• Progesterone may be added AFTER cerclage placement as adjunctive therapy, reducing spontaneous preterm birth at <34 weeks from 18.4% to 2.2% 1, 2

Bed Rest and Activity Restriction (Option B)

• Bed rest is explicitly NOT recommended and should be avoided in cervical insufficiency management 3
• Women with cervical insufficiency should maintain activities of daily living and potentially complete light upper-body resistance exercise, but avoid moderate-to-vigorous physical activity 3
• These activity recommendations apply both before and after cerclage placement 3

High-Risk Follow-Up Alone (Option C)

• Serial cervical length monitoring is appropriate for patients with 1-2 prior losses who do NOT have classic cervical insufficiency features 2, 4
• This patient's history is too compelling for expectant management—approximately 69% of high-risk women maintain normal cervical length, but this patient has already demonstrated cervical failure twice 2
• Delaying intervention until cervical shortening occurs misses the opportunity for optimal prophylactic intervention 1, 2

Post-Cerclage Management

After cerclage placement at 12-14 weeks:

• Add vaginal progesterone 200 mg daily, which significantly reduces spontaneous preterm birth at <34 weeks (2.2% vs 18.4%) and <37 weeks (9.1% vs 29.7%) 1, 2
• Serial ultrasound monitoring after cerclage is NOT routinely recommended due to insufficient evidence of clinical benefit 1, 2
• Advise the patient to maintain activities of daily living but avoid moderate-to-vigorous physical activity 3
• Instruct immediate reporting of contractions, pelvic pressure, vaginal bleeding, or fluid leakage 2
• Monitor for infection signs including fever, uterine tenderness, or purulent discharge 2

Critical Pitfalls to Avoid

• Do not delay cerclage placement waiting for cervical shortening on ultrasound—this patient's history alone justifies intervention 1, 2
• Do not prescribe bed rest, which is contraindicated and potentially harmful 3
• Do not use 17-alpha hydroxyprogesterone caproate (17-OHPC) for cervical insufficiency management 2
• Do not place cervical pessary due to conflicting data and safety signals including increased perinatal mortality 2