In a 14‑week pregnant woman with one prior cesarean delivery, a remote pregnancy loss at 28 weeks due to fetal distress and abruptio placentae, 8 years of secondary infertility, and a complete abortion at 17 weeks two months ago, is cervical cerclage indicated?

Cervical Cerclage Is NOT Indicated at 14 Weeks in This Patient

Based on current ACOG guidelines, this patient does not meet criteria for history-indicated cerclage and should instead undergo serial transvaginal ultrasound cervical length surveillance starting now, with ultrasound-indicated cerclage placement only if the cervix shortens to ≤25 mm before 24 weeks. 1

Why History-Indicated Cerclage Is Not Appropriate

History-indicated cerclage at 12-14 weeks should be reserved exclusively for patients with three or more second-trimester pregnancy losses or extreme premature deliveries without other identifiable causes. 1 This patient does not meet these criteria because:

• Her loss at 28 weeks (7 months) was due to placental abruption with fetal distress—a clear identifiable cause that is not cervical insufficiency 2
• Her recent loss at 17 weeks was a complete abortion, not classic cervical insufficiency 1
• ACOG explicitly states that history-indicated cerclage should be reserved for unexplained second-trimester loss in the absence of placental abruption 3

The Correct Management Algorithm

Step 1: Initiate Cervical Length Surveillance Now

• Begin transvaginal ultrasound cervical length measurements at 14-16 weeks (which is now for this patient) 1
• Continue surveillance every 1-2 weeks through 24 weeks of gestation 1
• Transvaginal ultrasound is the reference standard, superior to clinical examination alone 1

Step 2: Intervention Thresholds Based on Objective Findings

If cervical length remains >25 mm: No cerclage is needed—approximately 69% of high-risk women maintain adequate cervical length and avoid cerclage 1

If cervical length measures ≤25 mm before 24 weeks: Offer ultrasound-indicated cerclage placement 1

If cervical length is <10 mm: Cerclage shows particular benefit, with decreased preterm birth at <35 weeks (39.5% vs 58.0%) 1

Step 3: Consider Progesterone Supplementation

• Initiate vaginal progesterone 200 mg daily per standard preterm birth prevention protocols, as ACOG recommends managing subsequent pregnancies after PPROM using the same protocol as prior spontaneous preterm birth 4, 3
• If cerclage is ultimately placed, continue vaginal progesterone as adjunctive therapy—one study showed reduced spontaneous preterm birth at <34 weeks (2.2% vs 18.4%) 1

Critical Pitfalls to Avoid

Do not place cerclage at arbitrary gestational ages without objective cervical assessment. 1 Placing prophylactic cerclage based solely on this patient's history could actually cause harm:

• Cerclage placement after previous PPROM was associated with increased odds of preterm birth (OR 14.0; 95% CI 3.97-49.35) 4
• Clinical cervical dilation assessment alone is insufficient—transvaginal ultrasound provides superior risk stratification 1

Do not use 17-alpha hydroxyprogesterone caproate (17-OHPC) for short cervix treatment—ACOG recommends against it with GRADE 1B strength 1

Do not place cervical pessary due to conflicting trial data and recent safety signals, including increased perinatal mortality 1

Additional Management Considerations

Prior Cesarean Delivery Implications

• This patient's prior cesarean at 28 weeks does not contraindicate cerclage if objectively indicated 1
• However, be aware that cesarean delivery increases risks in subsequent pregnancies including placental abruption (OR 1.7) and uterine rupture 5

Recurrence Risk Counseling

• Nearly 50% of subsequent pregnancies after previable/periviable PPROM result in recurrent preterm birth, with 30% delivering at <34 weeks 4
• Patient education on daily self-monitoring for vaginal discharge, bleeding, contractions, and pelvic pressure is essential 4

Activity Recommendations

• Routine daily activities are permitted and light upper-body resistance exercise may be performed 1
• Moderate-to-vigorous physical activity should be avoided 1
• Bed rest is explicitly not recommended as it offers no benefit and may be harmful 1