Cervical Cerclage is NOT Indicated in This Case
Based on current evidence, prophylactic cervical cerclage is not indicated for this patient at 14 weeks gestation. Her obstetric history does not meet the established criteria for either history-indicated or ultrasound-indicated cerclage.
Why Cerclage is Not Indicated
History Does Not Meet Criteria for History-Indicated Cerclage
- History-indicated cerclage requires a history of spontaneous preterm birth (sPTB) due to cervical insufficiency, typically defined as painless cervical dilation in the second trimester 1
- This patient's prior pregnancy losses do not fit the classic pattern:
- Her first delivery at 7 months (28 weeks) was via cesarean for fetal distress and placental abruption—these are acute obstetric emergencies, not cervical insufficiency 2
- Placental abruption is an acute placental separation event that necessitates immediate delivery and is unrelated to cervical competence 2
- Her recent loss at 17 weeks was a complete abortion, which could represent various etiologies but occurred only once and does not establish a pattern of recurrent second-trimester losses due to cervical insufficiency 1
No Evidence for Ultrasound-Indicated Cerclage at This Time
- Ultrasound-indicated cerclage is considered when transvaginal cervical length is ≤25 mm before 24 weeks in women with prior sPTB 1
- This patient should receive 17-alpha-hydroxyprogesterone caproate (17P) 250 mg intramuscularly weekly starting at 16-20 weeks until 36 weeks given her history of prior preterm delivery, regardless of the indication 1
- Serial transvaginal ultrasound cervical length screening should be performed every 2 weeks from 16-23 6/7 weeks in patients with prior sPTB receiving 17P 1
- If cervical length shortens to <25 mm on serial monitoring, cerclage may be considered at that time, particularly if the cervix measures <15 mm 1, 3
Recommended Management Algorithm
Immediate Actions (14 Weeks)
- Initiate 17P 250 mg intramuscularly weekly starting now (between 16-20 weeks is optimal timing) and continue until 36 weeks 1
- Begin serial transvaginal cervical length measurements every 2 weeks starting at 16 weeks through 23 6/7 weeks 1
- Provide folic acid supplementation and nutritional counseling 1
Ongoing Surveillance Protocol
- If cervical length remains >25 mm: Continue 17P and routine obstetric care 1
- If cervical length measures 15-25 mm: Consider cerclage placement with shared decision-making; continue 17P regardless of cerclage decision 1, 3
- If cervical length <15 mm: Strongly consider cerclage placement as this represents significant shortening; physical exam should be performed to assess for cervical dilation, as 30-70% may already have dilation ≥1 cm at this length 3
Critical Monitoring Points
- Weekly outpatient visits once cervical shortening is detected to assess for signs of preterm labor or infection 4
- Patient should monitor daily for vaginal bleeding, discharge changes, contractions, or pelvic pressure 4
- If cerclage is placed, continue vaginal progesterone 400 mg daily in addition to 17P, as this combination reduces preterm birth <34 weeks (2.2% vs 18.4%) 3
Common Pitfalls to Avoid
- Do not place prophylactic cerclage based solely on one prior preterm delivery when that delivery was indicated for acute complications (abruption/fetal distress) rather than cervical insufficiency 1
- Do not confuse a complete abortion at 17 weeks with recurrent second-trimester losses due to cervical insufficiency—a single event does not establish the pattern required for history-indicated cerclage 1
- Do not skip 17P administration in favor of waiting for cervical length assessment—17P should be started regardless and is the first-line intervention for prior sPTB 1
- Avoid placing cerclage after 24 weeks unless it meets criteria for emergency cerclage with visible membranes and cervical dilation 3