In a 14‑week pregnant woman (G2P1) with 8 years of secondary infertility, a prior complete second‑trimester loss at 17 weeks two months ago, and one previous low‑segment cesarean delivery, and no other medical or family history, is cervical cerclage indicated?

Cervical Cerclage is NOT Indicated in This Case

This patient does not meet criteria for history-indicated cerclage because she has only ONE prior second-trimester loss, and current guidelines require either three or more losses OR classic features of painless cervical dilation. 1, 2, 3

Why History-Indicated Cerclage Does Not Apply

• History-indicated cerclage at 12-14 weeks is reserved for patients with three or more second-trimester pregnancy losses or extreme premature deliveries without other identifiable causes. 2, 3

• The American College of Obstetricians and Gynecologists recommends history-indicated cerclage only for individuals with classic historical features of cervical insufficiency—specifically, prior second-trimester loss with painless cervical dilation in the absence of labor, rupture of membranes, or placental abruption. 3

• This patient has only ONE prior loss at 17 weeks (described as "complete abortion"), with no documentation of painless cervical dilation, making her ineligible for prophylactic cerclage at this time. 3, 4

The Appropriate Management Strategy

Serial transvaginal ultrasound monitoring of cervical length starting at 14-16 weeks is the recommended approach for this patient. 2

Surveillance Protocol

• Begin transvaginal ultrasound assessment of cervical length at 14-16 weeks and continue monitoring through 24 weeks of gestation. 2

• Transvaginal ultrasound is the reference standard for cervical assessment, superior to clinical examination alone. 2

Intervention Thresholds Based on Cervical Length

If cervical length shortens to ≤25 mm before 24 weeks:

• Offer ultrasound-indicated cerclage placement when cervical length measures ≤25 mm before 24 weeks. 2

• If cervical length is <10 mm specifically, cerclage shows particular benefit, with decreased preterm birth at <35 weeks (39.5% vs 58.0%). 2, 3

If cervical length is 10-25 mm:

• Do NOT place cerclage routinely for cervical length 10-25 mm without cervical dilation. 2

• Instead, prescribe vaginal progesterone 200 mg daily if cervical length is ≤20 mm before 24 weeks. 2

• Consider vaginal progesterone through shared decision-making if cervical length is 21-25 mm. 2

Physical Examination Considerations

• When ultrasound shows cervical length <11-15 mm, perform physical examination, as 30-70% will have cervical dilation of ≥1 cm, making them candidates for examination-indicated cerclage. 2

• Examination-indicated cerclage is appropriate when cervical dilation is detected on physical examination before 24 weeks, particularly with cervical length <11-15 mm on ultrasound. 2

Critical Pitfalls to Avoid

• Do not place cerclage at arbitrary gestational ages (like 14 weeks) without objective cervical assessment. 2

• Approximately 69% of high-risk women maintain cervical length >25 mm and do not require cerclage, making surveillance the appropriate first step. 2

• Clinical cervical dilation assessment alone is insufficient—transvaginal ultrasound provides superior risk stratification. 2

• After prior previable preterm prelabor rupture of membranes (PPROM), history-indicated cerclage should be reserved only for those with classic historical features of cervical insufficiency, as one study showed cerclage placement after prior previable PPROM was associated with increased odds of preterm birth. 3

Additional Management Recommendations

• Permit routine daily activities and light upper-body resistance exercise, but avoid moderate-to-vigorous physical activity. 2

• Bed rest is explicitly NOT recommended for patients with cervical insufficiency and should be avoided as it offers no benefit and may be harmful. 2

• Do NOT use 17-alpha hydroxyprogesterone caproate for short cervix treatment. 2

• Do NOT place cervical pessary due to conflicting trial data and recent safety signals, including increased perinatal mortality. 2

If Cerclage Is Eventually Placed

• 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, 2, 3

• Serial ultrasound monitoring is NOT routinely recommended after history-indicated cerclage placement, as insufficient evidence supports clinical benefit. 1, 3

• Advise the patient to promptly report signs of preterm labor (uterine contractions, pelvic pressure, vaginal bleeding, fluid leakage) or infection indicators (fever, uterine tenderness, purulent discharge). 2