A 27-year-old woman, gravida 3 para 2, at 14 weeks gestation comes to the office for an initial prenatal visit. The patient has had no vaginal bleeding, pelvic pain, or abnormal vaginal discharge. Her first 2 pregnancies ended at 22 weeks gestation; both deliveries occurred after light vaginal spotting followed by a precipitous, nonpainful vaginal delivery. The patient has no chronic medical conditions or prior surgeries. Her only medication is a prenatal vitamin. She does not use tobacco, alcohol, or illicit drugs. Vital signs are normal. BMI is 22 kg/m². Fetal heart tones are 160/min. Ultrasound reveals a single intrauterine fetus measuring 14 weeks gestation, a cervical length of 2.9 cm (normal: 2.5), and no adnexal masses. Which of the following is the best next step in management of this patient?

Question

A 27-year-old woman, gravida 3 para 2, at 14 weeks gestation comes to the office for an initial prenatal visit. The patient has had no vaginal bleeding, pelvic pain, or abnormal vaginal discharge. Her first 2 pregnancies ended at 22 weeks gestation; both deliveries occurred after light vaginal spotting followed by a precipitous, nonpainful vaginal delivery. The patient has no chronic medical conditions or prior surgeries. Her only medication is a prenatal vitamin. She does not use tobacco, alcohol, or illicit drugs. Vital signs are normal. BMI is 22 kg/m². Fetal heart tones are 160/min. Ultrasound reveals a single intrauterine fetus measuring 14 weeks gestation, a cervical length of 2.9 cm (normal: >2.5), and no adnexal masses. Which of the following is the best next step in management of this patient?

Quizplus · Accepted Answer

Explanation: 11ec25c8_da40_cee8_bc81_11df432c0201_MD0003_00 This patient has cervical insufficiency, a structural weakness of the cervix that predisposes to second-trimester pregnancy loss. It is diagnosed by any 1 of the following criteria: Painless cervical dilation in the current pregnancy (ie, examination-based) OR A second-trimester cervical length of ≤2.5 cm plus a prior preterm delivery (ie, ultrasound-based) OR ≥2 prior consecutive, painless, second-trimester losses (ie, history-based), which typically present with mild symptoms (eg, vaginal discharge, light spotting) followed by precipitous delivery Because of the high risk of recurrence, patients with history-based cervical insufficiency are treated with prophylactic cerclage, a procedure in which a suture is placed to reinforce and add tensile strength to the cervix. Prophylactic cerclage is performed in the first trimester (ie, 12-14 weeks gestation) in patients with a history of cervical insufficiency before it can recur in the second trimester (Choice E). The suture is removed at term to allow vaginal delivery. suture (Choice A) Amniocentesis is typically performed for fetal karyotype analysis in patients with suspected fetal aneuploidy (eg, abnormal first-trimester integrated screening test). It is not used in the management of cervical insufficiency because it increases the risk of preterm labor and preterm premature rupture of membranes. Amniocentesis (Choice C) Fetal fibronectin (fFN), an extracellular matrix protein located between the maternal decidua and fetal chorion, is secreted whenever this interface is disrupted (ie, labor). Therefore, in patients with preterm contractions between 22 and 35 weeks gestation, fFN testing helps distinguish between preterm and false labor. However, fFN testing is not used in patients who are asymptomatic or at <22 weeks gestation, such as this patient, because of a high rate of false-positive results. (Choice D) Pessaries were once recommended to decrease tension on the cervix from the growing uterus; however, they do not improve obstetric outcomes (ie, no decrease in preterm delivery rates) and therefore are no longer used for management of cervical insufficiency. Pessaries Educational objective: Cervical insufficiency, a structural weakness of the cervix, causes painless cervical dilation, resulting in second-trimester pregnancy loss. Patients with a history of cervical insufficiency are managed with a prophylactic cerclage performed in the first trimester to decrease the risk of recurrence. 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 27-Year-Old Woman, Gravida 3 Para 2, at 14 Weeks