A 32-year-old woman, gravida 3 para 2, at 12 weeks gestation comes to the office to initiate prenatal care. The patient has had some fatigue and breast tenderness but no vaginal bleeding or abdominal pain. The patient's prior pregnancies ended with painless spontaneous vaginal deliveries at 20 and 21 weeks gestation. She has no chronic medical conditions and takes no daily medications. Four years ago, she underwent a cold knife cone procedure for high-grade cervical intraepithelial neoplasia. All her subsequent Pap and human papillomavirus results have been normal. Blood pressure is 110/60 mm Hg. BMI is 24 kg/m². Pelvic examination reveals a 12-week-sized uterus with a closed cervix and no adnexal masses or tenderness. Speculum examination shows a nonfriable cervix with no visible lesions. Transvaginal ultrasound shows an 12-week intrauterine gestation; the fetus has a normal heart rate. The patient asks about preventing another preterm delivery. Which of the following is the best management option for this patient?

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Explanation: 11ec2b69_c02a_7173_8f63_8f87d24f98a8_MD0005_00 This patient has cervical insufficiency, a structural weakness of the cervix that predisposes to second-trimester pregnancy loss. Cervical insufficiency can be diagnosed based on a history of >2 painless, second-trimester losses or the presentation of painless, advanced cervical dilation in the second trimester of the current pregnancy. Risk factors include collagen abnormalities (eg, Ehlers-Danlos syndrome), uterine anomalies (eg, septate or bicornuate uterus), prior obstetric trauma, and cervical conization (eg, cold knife cone). Treatment of cervical insufficiency is with cerclage placement, a procedure in which a suture is placed to reinforce the cervix. A cerclage is typically placed at 12-14 weeks gestation and removed at term, allowing for vaginal delivery. bicornuate uterus cerclage (Choice A) Neither bed rest nor pelvic rest has been shown to decrease the risk of preterm delivery or improve neonatal outcomes. Conversely, bed rest increases the maternal risk for venous thromboembolism. (Choice C) Fetal fibronectin testing is indicated to determine the risk of preterm delivery in patients with preterm contractions. It does not predict the recurrence of preterm delivery in asymptomatic patients. (Choice D) Low-dose aspirin is indicated to decrease the recurrence risk of preeclampsia. It does not prevent the recurrence of preterm birth from cervical insufficiency. (Choice E) Patients with no history of preterm delivery who are incidentally diagnosed with a short cervix by ultrasound are managed with serial ultrasound cervical length measurements and vaginal progesterone supplementation. Educational objective: Cervical insufficiency typically presents as painless cervical dilation that results in second-trimester pregnancy losses. Risk factors include collagen abnormalities, cervical conization, uterine anomalies, and prior obstetric trauma. Management of cervical insufficiency is typically via cerclage. References: ACOG Practice Bulletin No. 142: cerclage for the management of cervical insufficiency. (http://www.ncbi.nlm.nih.gov/pubmed/24451674) Cervical cerclage. (http://www.ncbi.nlm.nih.gov/pubmed/24979354)

A 32-Year-Old Woman, Gravida 3 Para 2, at 12 Weeks