What is the recommended management for a 10‑week pregnant woman with a prior painless cervical dilation and second‑trimester loss at 18 weeks?

Management of Subsequent Pregnancy After Prior Painless Second-Trimester Loss

Serial transvaginal ultrasound monitoring of cervical length starting at 14-16 weeks is the recommended approach, with ultrasound-indicated cerclage placement only if the cervix shortens to ≤25 mm before 24 weeks of gestation. 1

Why Serial Ultrasound Is the Preferred Strategy

This patient has one prior second-trimester loss at 18 weeks with painless delivery, which is suggestive of cervical insufficiency but does not meet the threshold for prophylactic (history-indicated) cerclage. 1, 2

History-Indicated Cerclage Is NOT Appropriate Here

• History-indicated cerclage at 12-14 weeks should be reserved for patients with three or more second-trimester pregnancy losses or extreme premature deliveries without other identifiable causes. 1, 2
• With only one prior loss, this patient does not meet criteria for prophylactic cerclage at an arbitrary gestational age (such as 13 or 15 weeks). 1
• The American College of Obstetricians and Gynecologists explicitly recommends against placing cerclage at predetermined gestational ages without objective cervical assessment. 1

The Correct Management Algorithm

Step 1: Initiate Serial Ultrasound Surveillance

• Begin transvaginal ultrasound assessment of cervical length at 14-16 weeks of gestation. 1
• Continue monitoring through 24 weeks of gestation. 2
• Transvaginal ultrasound is the reference standard for cervical assessment, superior to clinical examination alone. 1

Step 2: Intervention Thresholds Based on Cervical Length

If cervical length remains >25 mm:

• Continue expectant management with serial monitoring. 1
• Approximately 69% of high-risk women maintain cervical length >25 mm and do not require cerclage. 1

If cervical length measures ≤25 mm before 24 weeks:

• Offer ultrasound-indicated cerclage placement. 1
• This approach is supported by compelling data showing benefit in patients with short cervix and previous preterm birth. 2

If cervical length is <10 mm:

• Cerclage shows particular benefit, with decreased preterm birth at <35 weeks (39.5% vs 58.0%). 1, 2

Step 3: Consider Adjunctive Progesterone Therapy

• For cervical length ≤20 mm: prescribe vaginal progesterone 200 mg daily (GRADE 1A recommendation). 1
• For cervical length 21-25 mm: consider vaginal progesterone through shared decision-making (GRADE 1B recommendation). 1
• If cerclage is placed, add vaginal progesterone 200 mg daily, which reduces spontaneous preterm birth at <34 weeks (2.2% vs 18.4%). 1, 2

Critical Pitfalls to Avoid

• Do not place cerclage at 13 or 15 weeks without objective evidence of cervical shortening. 1
• Clinical cervical dilation assessment alone is insufficient—transvaginal ultrasound provides superior risk stratification. 1
• Do not use 17-alpha hydroxyprogesterone caproate for short cervix treatment (GRADE 1B recommendation against). 1
• Do not place cervical pessary due to conflicting trial data and recent safety signals. 1

Why Reassurance Alone Is Inadequate

Simple reassurance (Option A) is inappropriate because this patient has a documented history of painless second-trimester loss, placing her at increased risk for recurrence. 3, 4 The risk of recurrence is high in such cases, and active surveillance with objective cervical assessment is warranted. 3

Answer to the Question

The correct answer is D: Serial ultrasound for progress (cervical length monitoring). This approach allows for objective, evidence-based decision-making about cerclage placement if and when cervical shortening occurs, rather than performing prophylactic cerclage at an arbitrary gestational age. 1, 2