A 32-year-old woman, gravida 1 para 0, at 19 weeks gestation comes to the emergency department due to vaginal pressure and spotting. Over the last few days, the patient has had clear vaginal discharge for which she has used sanitary napkins. Today she has had increasing pelvic pressure and has noticed blood spots on the sanitary napkins. She has had no cramping or pelvic pain; fetal movement has been normal. The patient's pregnancy was previously uncomplicated; initial prenatal laboratory testing was normal. She was scheduled to have an anatomy ultrasound later in the week. The patient has no chronic medical conditions and has had no previous surgeries. She takes a prenatal vitamin daily and acetaminophen as needed for headaches. She was treated for Chlamydia trachomatis cervicitis at age 20. She does not use tobacco, alcohol, or illicit drugs. Temperature is 36.7 C (98.1 F), blood pressure is 110/70 mm Hg, pulse is 65/min, and respirations are 18/min. Fetal heart rate is 145/min by Doppler ultrasound. Speculum examination shows amniotic membranes bulging at the vaginal introitus. There is no blood or pooling of fluid in the vaginal vault. Nitrazine paper does not turn blue on application of the vaginal discharge. The cervix is 3 cm dilated and 100% effaced on digital examination. Item 1 of 2 Which of the following is the most likely diagnosis in this patient?

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Explanation: 11ec2b69_c02b_0db5_8f63_7b65b3e325fb_MD0005_00 This patient has cervical insufficiency, a structural weakness of the cervix that predisposes to painless (ie, no uterine contractions) cervical dilation and second-trimester pregnancy loss. However, such patients can present with pelvic pressure when the gestation distends the vagina, with an increase in vaginal discharge due to loss of the mucus plug, or with light vaginal bleeding (eg, bloody show). Bulging or prolapsing amniotic membranes can also be present. The diagnosis of cervical insufficiency can be based retrospectively on >2 prior painless spontaneous second-trimester losses. It can also be based on presentation of painless advanced cervical dilation at <24 weeks gestation in the current pregnancy. Risk factors include collagen abnormalities (eg, Ehlers-Danlos syndrome), uterine anomalies (eg, septate or bicornuate uterus), obstetric trauma, and surgical trauma (eg, cold knife cone). bicornuate uterus cold knife cone (Choice A) Acute cervicitis can present with vaginal spotting; however, patients also typically have mucopurulent cervical discharge, which is not seen in this patient. There is no association between acute cervicitis and second-trimester cervical dilation. Acute cervicitis (Choice C) Preterm labor presents with cervical dilation at <37 weeks gestation. However, patients have regular, painful uterine contractions rather than constant pelvic pressure. (Choice D) Amniotic fluid is basic (ie, turns nitrazine paper blue); the lack of change in the color of the nitrazine paper in this patient excludes premature rupture of membranes. (Choice E) A threatened abortion presents at <20 weeks gestation with vaginal bleeding, a closed cervix, and a normal fetal heartbeat on ultrasound. threatened abortion Educational objective: Cervical insufficiency refers to a structural weakness of the cervix. Diagnosis can be made retrospectively based on a history of >2 spontaneous painless second-trimester losses or on presentation of painless advanced cervical dilation at <24 weeks in the current pregnancy. References: Overview of cervical insufficiency: diagnosis, etiologies, and risk factors. (http://www.ncbi.nlm.nih.gov/pubmed/27015229) ACOG Practice Bulletin No. 142: cerclage for the management of cervical insufficiency. (http://www.ncbi.nlm.nih.gov/pubmed/24451674)

A 32-Year-Old Woman, Gravida 1 Para 0, at 19 Weeks