A 24-year-old woman lost her previous two pregnancies at approximately 20 weeks' gestation, without having noted any contractions. She is currently at 15 weeks' gestation and denies having uterine contractions. Her cervix is undilated and uneffaced. Which of the following is the most appropriate management of this patient?
- bed rest
- terbutaline
- hydroxyprogesterone
- DES
- a cervical cerclage
Answer(s): E
Explanation:
The patient described in the question has a classic history of an incompetent cervix: expulsion of a fetus without labor. It is believed to be caused by previous cervical trauma, DES exposure, or, most commonly, a congenital defect in cervical stroma. In the absence of preterm labor, there is no indication for terbutaline or other tocolytic agents. DES is contraindicated in pregnancy, but was used in the past to treat repeated pregnancy loss. Hydroxyprogesterone is a progestational compound that is being used by some hospitals for patients in premature labor, but its use is controversial. Bed rest is occasionally encouraged by some practitioners for patients with a history of premature deliveries. The probability of a successful pregnancy after a cervical cerclage increases from 20% to approximately 80%. It is crucial to eliminate the possibility of preterm labor before placing a cerclage.