Analysis of the implementation value of abdominal B-ultrasound combined with cervical cerclage in the prevention and treatment of late recurrent spontaneous abortion (2025)

• Research
• Open access
• Published: 31 December 2024

• Lili Shi1,
• Lei Dong1,
• Yuanying Cui2,
• Dan Bu1 &
• …
• Bo Hu1

BMC Pregnancy and Childbirth volume24, Articlenumber:889 (2024) Cite this article

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Abstract

Objective

To study the implementation value of abdominal B-ultrasound combined with cervical cerclage in the prevention and treatment of recurrent late abortion.

Methods

From October 2020 to December 2023, 196 pregnant patients who had a history of late abortions at our institution were chosen. They were divided into groups based on the treatments used. In the observational team, 98 instances received abdominal B-ultrasound along with cervical cerclage, while 98 instances in the controlling team underwent traditional conservative treatment. Vaginal flora, inflammatory factor levels, labor outcomes, uterine artery parameters, and adverse effects were observed in both groups of pregnant women.

Results

Comparing the detection of vaginal flora between the two groups, the difference was not statistically significant (P > 0.05); the detection values of WBC, neutrophil percentage and neutrophil absolute value in the observation group were lower than those in the control group (P < 0.05). The recurrent late abortion rate (4.08%) and premature delivery rate (16.33%) were lower than those of the control group, and the full-term delivery rate (79.59%) and total fetal survival rate (93.88%) were higher than those of the control group, and the difference was statistically significant (P < 0.05). The resistance index (RI) and pulsatility index (PI) of pregnant women with abortion were higher than those of live birth pregnant women. The RI and PI of group A (pregnant women with recurrent late abortion) at 7, 12, 24 and 32 weeks of gestation were also higher than those of group B (pregnant women without recurrent late abortion), and the difference was statistically significant (P < 0.05). At 7 weeks of gestation, there was no statistical difference between the observation and control groups in terms of RI and PI (P > 0.05)0.12 By 32 weeks of gestation, the RI and PI were lower in the observation group than in the control group (P < 0.05)0.13 In the observation group, the RI and PI were lower than in the control group (P < 0.05). The incidence of gestational hypertension, gestational diabetes mellitus, and eclampsia were significantly lower in the observation group compared to the control group (P < 0.05).

Conclusion

Abdominal ultrasound combined with cervical cerclage reduces the risk of miscarriage by improving the hemodynamic status of the uterus and placenta, and also optimizes the pregnancy environment by reducing the inflammatory response in the uterine cavity, which has important clinical applications in the prevention and treatment of late recurrent spontaneous abortion.

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Introduction

Recurrent spontaneous abortion (RSA) is generally defined as three or more consecutive spontaneous abortions occurring after 12 weeks of gestation and before 28 weeks of gestation, with a prevalence of about 0.5–3% [1,2,3]. It is clinically believed that the causes of recurrent spontaneous abortion may lie in reproductive tract infection, chromosomal abnormalities, maternal endocrine abnormalities, cervical insufficiency, and immune dysfunction and so on, among which cervical insufficiency is the most common. When cervical insufficiency occurs, the cervix relaxes and the fetus will loss of support, which will lead to the occurrence of premature delivery or miscarriage. Therefore, cervical insufficiency will further increase the risk of recurrent late miscarriage, and it is necessary to pay attention to physical examination and monitoring during pregnancy [4]. How to prevent recurrent late miscarriage is a key research topic in obstetrics and gynecology. Conservative treatment and surgical treatment are carried out according to the actual situations of pregnant women. Pregnant women with recurrent spontaneous abortion before pregnancy have increased uterine artery resistance. Abdominal ultrasonography can be used to understand the changes of uterine artery parameters in pregnant women, so as to predict the pregnancy outcomes [5]. Cervical cerclage is suitable for groups with placenta previa and cervical insufficiency and so on. This study retrospectively analyzed the application effects of abdominal B-ultrasound and cervical cerclage, and explored the role of uterine artery parameters in the occurrence of the disease. The text is elaborated as follows.

Data and methods

Data

The research samples were 196 pregnant women with a history of late abortion received by our hospital. The sample inclusion starts in October 2020 and ends in December 2023. They were divided into groups of 98 instances each based on the various treatment modalities.

Inclusion criteria: (1) Those with a history of late miscarriage; (2) Those with a singleton pregnancy; (3) Short cervix: the length of the cervical canal and the width of the endocervical os are less than 2.5 centimeters and more than 1.5 centimeters, respectively, on abdominal ultrasound; (4) Those who were conscious and in good mental condition.

Exclusion criteria: (1) Those with severe endocrine diseases; (2) Those with reproductive tract abnormalities, reproductive system tumors or other gynecological diseases; (3) Those with pregnancy complications; (4) Those with genetic medical history and fetal chromosomal abnormalities; (5) Those who had received hormone therapy before pregnancy; (6) Those who had a history of uterine cavity surgery.

Controlling team: The age range was specifically 26 to 38 years old, with an average of (31.74 ± 3.44). The average gestational age was (16.00 ± 0.37) weeks, with a range of 14 to 17 weeks. The gestational weeks of previous miscarriages ranged from 14 weeks to 26 weeks, with an average of (20.44 ± 2.17) weeks. Number of miscarriages: 58 cases in 2 times, 32 cases in 3 times, 8 cases in 4 times.

Observation group: the minimum age was 25 years old, the maximum age was 40 years old, and the average age was (31.85 ± 3.51) years old. The average gestational age was (16.05 ± 0.45) weeks, with a range of 14 to 18 weeks. The gestational weeks of previous miscarriages ranged from 15 weeks to 27 weeks, with an average of ( 20.53 ± 2.24 ) weeks. Number of miscarriages: 55 cases in 2 times, 33 cases in 3 times, 10 cases in 4 times.

The information data obtained by the two groups were balanced (P > 0.05) .

Methods

Control group: conservative treatment. Vitamin E Capsules (Zhejiang Pharmaceutical Co., Ltd. Xinchang Pharmaceutical Factory, national drug approval number H20003539) 1 capsule at a time, 2–3 times a day; Progesterone Capsules (Zhejiang Xianju Pharmaceutical Co., Ltd., SFDA approval number: H20041902) 100mg / time, twice a day. The dosage and frequency of medication were adjusted according to the actual situations of pregnant women, and pregnant women were advised to stay in bed more. For those with threatened miscarriage, cervical cerclage was used for treatment.

Observation group: Abdominal B-ultrasound combined with cervical cerclage. Corresponding examinations were carried out before the operation to ensure that there were no surgical contraindications, and the length of the cervical canal and the width of the internal cervical os were checked by abdominal ultrasound. Because transvaginal ultrasound is difficult for some pregnant women to accept for psychological reasons and may increase the risk of infection, and because transvaginal ultrasound may not be suitable for pregnant women with vaginal bleeding or cervical inflammation, abdominal ultrasound is a better choice. Specific operation: patients need to hold urine appropriately to make the bladder full and lie on the examination bed on their backs; apply coupling agent on the abdomen, place the ultrasound probe above the pubic symphysis, and carry out multi-angle sweeping, the cervical canal will be presented as a linear or tubular structure on ultrasound images, and measurements will be made according to the characteristics of its morphology, alignment, and length. Combined with the actual situations of pregnant women, elective surgery was performed. Progesterone injection (Zhejiang Xianju Pharmaceutical Co., Ltd., national drug approval number H33020828) was intramuscularly inflooded 20–30mg/d 3–5 days before the operation to protect the fetus. And 30min before the operation, 0.1mg of phenobarbital sodium injection (Fujian Mindong Lijiexun Pharmaceutical Co., Ltd., national drug approval number H20057384) was inflooded, and magnesium sulfate was intravenously dripped (Hangzhou Minsheng Pharmaceutical Co., Ltd., national drug approval number H33021961) to suppress uterine contractions; routine disinfection treatment was carried out on the vulva and vagina of pregnant women, the gauze was put into the liquid containing 20 mL of potassium permanganate (10%) and 20 mL of hydrogen peroxide (3%). The condition of the cervix should be observed 48h after the operation to determine whether there were tissue necrosis or infection and other situations. Knotting too tightly will affect the local blood supply of cervical tissue, causing cervical ischemia and necrosis, ultimately leading to suture failure [6]. And 48h after the operation, the vulva and vagina of the pregnant women were disinfected again, and the sutured cervix and secretions were observed to judge whether there was ischemia and necrosis of the cervix. After the operation, the pregnant women were told to stay in bed for 3 days, and antibiotics were given for anti-infection treatment at the same time. The pregnant women can be discharged from the hospital when no signs of miscarriage were found. Pregnant women were reminded to follow up regularly before surgery and be hospitalized in advance. If there were signs of labor and uterine contractions after cervical cerclage, when the treatment failed, the sutures should be removed in time to prevent cervical tears. Generally, sutures should be removed at 37–38 weeks of gestation or before delivery, or one week before previous miscarriages.

Evaluation indicators and judgment criteria

1. (1)

   Collect vaginal secretions from two groups of pregnant women before delivery, conduct bacterial culture, and observe the vaginal flora.

2. (2)

   5 mL of fasting venous blood was taken from the two groups of pregnant women before delivery. A fully automatic blood cell analyzer was used to measure white blood cell count (WBC), neutrophil percentage, and neutrophil absolute value.

3. (3)

   The delivery outcomes of the two groups were observed. The outcomes of pregnant women between the two groups were compared, that is, whether pregnant women had recurrent late miscarriage or premature delivery. At the same time, the fetal outcomes of the two groups were compared to calculate the overall fetal survival rate, that is, the sum of the number of preterm surviving cases and the number of full-term surviving cases.

4. (4)

   Uterine artery parameters (resistance index (RI), pulsatility index (PI) were observed in pregnant women with miscarriages and live births. Pregnant women were categorized into Group A (occurrence) and Group B (non-occurrence) according to whether recurrent late miscarriage occurred or not. The results of abdominal ultrasound examinations of pregnant women in the two groups at 7, 12, 24 and 32 weeks of gestation were recorded by reviewing and analyzing the available medical records, laboratory findings and imaging data, respectively. The process of data collection, processing and analysis followed scientific research methods and strict quality control standards to ensure the reliability and validity of the findings. Most late recurrent spontaneous abortions occur after 20 weeks of gestation, so monitoring uterine artery parameters (RI, PI) at 24 and 32 weeks captures hemodynamic changes and assesses the risk of miscarriage. Normal uterine arterial RI and PI gradually decrease with the progression of pregnancy, but high resistance or abnormal pulsations may persist in high-risk pregnancies. This monitoring allows observation of parameter trends and provides timing for clinical intervention. Meanwhile, this time-point examination ensures that the results of this study are comparable with other studies and verifies its validity and reliability.

5. (5)

   Comparison of the levels of uterine artery parameters between the observation and control groups at different trimesters of pregnancy.

6. (6)

   Comparison of the incidence of adverse reactions during treatment between the two groups.

Statistical processing

Statistical analysis was performed using SPSS 25.0: measurement data were expressed as mean ± standard deviation (‾x ± s), and t-test was used for comparison between groups; count data were expressed as number of cases and percentage [n (%)], and the difference in the distribution of groups was tested using the X² test. p < 0.05 was taken as the difference was statistically significant.

Results

Vaginal flora

There was little difference in vaginal flora between the two groups (P > 0.05). See Table1.

Blood routine indicators

The WBC, neutrophil percentage and neutrophil absolute value detection values in the observation group were significantly lower than those in the control group (P < 0.05). See Table2.

Delivery outcomes

With a P < 0.05, the observational team’s rates of full-term delivery and overall fetal survival were both greater than those of the controlling team, while their percentage of recurrent late miscarriage and premature birth were both lower. See Fig.1; Table3.

Pie chart of comparison of the delivery outcomes of each group. Group A: recurrent late miscarriage occurred; Group B: no recurrent late miscarriage occurred

Uterine artery parameters

The comparison of RI and PI between live birth pregnant women and abortion pregnant women showed that data of the former were all lower (P < 0.05). See Table4; Fig.2 .

Violin plot of uterine artery parameters in two groups. Note **** represents P < 0.0001. Group A: recurrent late miscarriage occurred; Group B: no recurrent late miscarriage occurred

Resistance index at different gestational stages

The RI of different pregnancy cycles in group B was lower than that in group A (P < 0.05). See Table5; Fig.3 .

Violin plot of the resistance index of different gestational periods in each group. Note **** represents P < 0.0001

Pulsatility index at different gestational stages

At four points from 7 weeks to 32 weeks of pregnancy, team A’s PI was higher than team B’s (P < 0.05). See Table6; Fig.4 .

Violin plot of comparison of the pulsatility index of different gestational periods in each group. Note **** represents P < 0.0001

Levels of uterine arterial parameters in both groups at different trimesters

At 7 weeks of gestation there was no statistically significant difference between the two groups in terms of RI and PI (P > 0.05)0.12 By 32 weeks, the RI and PI of the observation group were lower than those of the control group (P < 0.05). See Tables7 and 8.

Comparison of the incidence of adverse reactions between the two groups

The incidence of gestational hypertension, gestational diabetes mellitus, and eclampsia were significantly lower in the observation group compared to the control group (P < 0.05). See Table9.

Discussion

In recent years, with the relaxation of the multiple-child policy and the increase in the number of women of advanced maternal age, the rate of miscarriage and recurrent spontaneous abortion has climbed [7, 8]. As a serious adverse pregnancy outcome, the causes of recurrent miscarriage are complex, involving endocrine abnormalities (e.g., thyroid function, glucose-lipid metabolism, insulin problems [9, 10]), reproductive organ pathology (e.g., uterine developmental abnormality, leiomyosarcoma [11, 12]), uterine contraction (affected by hormones, infection, bleeding [13, 14]), infectious factors (including viral and bacterial [15, 16]), immune imbalance, pregnancy complications, and cervical insufficiency. Recurrent miscarriage not only jeopardizes the physical and mental health of pregnant women, but also affects the harmony of the family, so prevention and treatment are crucial [17]. Pregnant women are advised to consult a doctor in a timely manner to identify the cause of the disease through professional examination and take targeted measures. Cervical insufficiency is particularly critical, and prevention and treatment strategies should be tailored to the cause of the disease in order to improve the prognosis.

The data of this study show that the proportion of vaginal flora imbalance among pregnant women is less, and there is little difference between the two groups, which suggests that there will be no obvious clinical symptoms and have a great impact on pregnancy outcome. Cervical insufficiency refers to cervical damage and cervical relaxation caused by congenital abnormal development and acquired damage (miscarriage, excessive number of deliveries, dystocia, etc.). Abdominal ultrasonography can rule out the presence of cervical insufficiency in pregnant women. When abdominal ultrasonography before 24 weeks of gestation shows that the length of the cervical canal is < 2.5cm, and cervical dilatation is found by abdominal ultrasonography or speculum examination at 16 to 23 weeks of gestation, it indicates that there is a high possibility of cervical insufficiency. In addition, abdominal ultrasonography has the advantages such as simple operation, good repeatability, and objective results, which can clarify the cervical condition of pregnant women. In this study, the observation group first underwent abdominal ultrasound examination, and all pregnant women were diagnosed with cervical insufficiency, so they chose to undergo cervical cerclage for treatment. While the 14th to 18th week of pregnancy is the golden period for cervical cerclage, which is helpful for prolonging the pregnancy time, because the fetus has developed to a certain extent during this period, and the cervix has been dilated, which provides convenience for the smooth operation. At the same time, during this period, the risk of surgery is relatively low, the recovery period is also relatively short, and it has relatively little impact on the body of pregnant women [18]. Cervical cerclage is commonly used clinically for cervical insufficiency to prevent early pregnancy loss and premature delivery, and it can prevent the occurrence of miscarriage to a certain extent when used in high-risk pregnant women. Cervical cerclage repairs the shape of the internal os of the cervix, which can promote the recovery of cervical function, prolong the duration of pregnancy to term, and further improve the survival rate of the fetus.

Since surgical treatment during pregnancy may cause the occurrence of bleeding, miscarriage, premature delivery and other situations, after the etiology was confirmed by transabdominal ultrasound, tocolysis treatment should be performed 3 to 5 days before surgery. Cervical cerclage can improve the local microenvironment of the uterus and correct cervical insufficiency. Through the analysis of this study, it can be known that the hormone levels and serum inflammatory factor levels of the observation group were lower than those of the control group. Cervical insufficiency is an important factor affecting recurrent late miscarriage in pregnant women. Uterine stress responses can cause cervical disorder, and excessive uterine stress responses can affect the local state of the uterine cavity, thereby inducing miscarriage [19] .

The number of WBC and neutrophils in the blood of women in the second trimester of normal pregnancy will increase with the increase of gestational age. In the present study, the percentage and absolute values of leukocytes and neutrophils in the observation group were lower than those in the control group, indicating that abdominal ultrasound combined with cervical cerclage has significant advantages in reducing the inflammatory response and increasing the success rate of fetal preservation. Leukocytes and neutrophils are important markers of the body’s inflammatory response. The decrease in their levels suggests that abdominal ultrasound combined with cervical cerclage is effective in reducing the inflammatory response in pregnant women. This may be related to the ability of this treatment to reduce cervical damage and reduce the risk of infection, thereby reducing the release of inflammatory factors and the accumulation of inflammatory cells. Cervical cerclage is effective in preventing recurrent miscarriages by increasing the tension of the cervical canal and stopping the dilatation of the cervical canal caused by the enlargement of the fetus and its appendages in the middle and late stages of pregnancy. The combined use of abdominal ultrasound provides a more accurate assessment of cervical morphology and function, which provides a reliable basis for surgical operation. The combination of the two can significantly improve the success rate of fetal preservation and reduce the occurrence of recurrent miscarriage. Reducing the inflammatory response not only helps to reduce complications in pregnant women, such as intrauterine infection and premature rupture of membranes, but also improves the intrauterine environment of the fetus and increases the survival rate and health of the fetus. In this study, the full-term delivery rate and total fetal survival rate of the observation group were significantly higher than those of the control group, further confirming the positive effect of abdominal ultrasound combined with cervical cerclage in improving the prognosis of mothers and infants. Abdominal ultrasound, as a noninvasive and reproducible means of imaging, can monitor the condition of the fetus and uterus in real time and provide an important basis for clinical decision-making. Cervical cerclage, on the other hand, reduces the risk of cervical dilatation by strengthening the support of the cervix, thus preventing the occurrence of late miscarriage. The combined application of the two provides new ideas and methods for the prevention and treatment of late recurrent spontaneous abortion. However, the high fetal mortality rate in the control group was much higher than that of spontaneous abortion or preterm labor in general, probably due to the possible lack of effective monitoring and therapeutic interventions during pregnancy in the control group. Abdominal ultrasound and cervical cerclage, which are effective means of preventing late recurrent spontaneous abortion, were not used in the control group. This may have led to the failure to detect and manage some potential pregnancy complications or abnormalities in time, thus increasing the risk of fetal death.

Uterine artery blood flow ensures that nutrients can be properly transported in the uterus, and when abnormal blood flow occurs, it is often indicative of a poor development of the embryo in the uterus. Therefore, abnormal uterine artery perfusion is considered a risk factor for recurrent miscarriage. Ultrasonography, as the most commonly used adjunctive tool in obstetrics and gynecology, is not only effective in evaluating uterine artery blood flow, but also in predicting the outcome of a pregnancy. PI and RI values are the most commonly used clinical parameters for detecting uterine artery blood flow. Blood flow in uterine arteries is closely related to the state of utero-fetal-placental circulation. In normal pregnancies, as the pregnancy progresses, the proteases secreted by the embryo and the chorionic villi after implantation invade the uterine metamorphosis and spiral arteries, the blood vessels become thicker, and the walls of the spiral arteries are damaged, so the blood flow rate increases, and the uterus receives a low-impedance, high-velocity perfusion, leading to a gradual decrease in the PI and RI values.A study by Ndubuisi VA [20] showed that the detection of blood flow-related parameters in the early stages of pregnancy by Doppler ultrasound could be helpful in early warning. Detection of flow related parameters at early stages of pregnancy helps in early warning of adverse pregnancies, and uterine arterial flow abnormalities in pregnant women with a history of recurrent miscarriages were associated with higher PI and RI values compared to normal pregnancies. The present study also revealed that the RI and PI were lower in live births than in miscarriages (P < 0.05), suggesting that the hemodynamic status of the uterine arteries is closely related to pregnancy outcome. Further analysis showed that in the middle and late stages of pregnancy (12 to 32 weeks), the RI and PI of the observation group were significantly lower than those of the control group, which may be attributed to the fact that cervical cerclage improves the blood supply to the uterus and the placenta, reduces vascular resistance, and thus facilitates the growth and development of the fetus. In addition, after grouping the pregnant women according to whether or not recurrent late miscarriages occurred, the RI of group B, in which no miscarriages occurred, was lower than that of group A in all gestational weeks, and the PI of group A was higher than that of group B throughout the entire gestation period (P < 0.05), which further confirmed the strong association between uterine artery hemodynamic parameters and recurrent late miscarriages. Therefore, pregnant women with high risk factors for late recurrent spontaneous abortion should be monitored with abdominal ultrasound as early as possible to assess cervical morphology and uterine artery hemodynamic status. Once cervical insufficiency or hemodynamic abnormalities are detected, timely interventions such as cervical cerclage should be performed.

The treatment plan should be individualized with full consideration of the specific conditions of the pregnant woman, such as gestational week, cervical length, and fetal status. For pregnant women with cervical insufficiency, cervical cerclage is an effective treatment, but the timing, modality and postoperative management of the procedure still need to be adjusted according to the specific situation. For pregnant women who receive treatment, long-term follow-up and monitoring should be conducted to assess the treatment effect and pregnancy outcome. Attention should also be paid to observing possible complications and adverse reactions for timely management and adjustment of the treatment program.

Conclusion

In summary, abdominal ultrasound combined with cervical cerclage demonstrates an important clinical application value in the prevention and treatment of late recurrent spontaneous abortion. It can not only reduce the risk of miscarriage by improving the hemodynamic status of the uterus and placenta, but also optimize the pregnancy environment by reducing the inflammatory response in the uterine cavity. Despite the results achieved in this study, further in-depth studies are needed to clarify the specific mechanism of action of abdominal ultrasound combined with cervical cerclage. Future studies could focus on the dynamic changes in uterine artery hemodynamic parameters at different gestational weeks and the specific relationship between these changes and pregnancy outcomes. Other possible interventions, such as immunotherapy and hormonal therapy, can also be explored to further improve the prevention and treatment of late recurrent spontaneous abortion.

Data availability

All data generated or analysed during this study are included in this article. Further enquiries can be directed to the corresponding author.

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Acknowledgements

We would like to acknowledge the hard and dedicated work of all the staff that implemented the intervention and evaluation components of the study.

Funding

No external funding received to conduct this study.

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Authors and Affiliations

1. Ultrasound Department, Ganzhou Maternal and Child Health Hospital, No. 25, Nankang Road, Zhanggong District, Ganzhou City, Jiangxi Province, 341000, China

   Lili Shi,Lei Dong,Dan Bu&Bo Hu

2. Ganzhou Maternal and Child Health Hospital Premature Birth Prevention and Treatment Center, Ganzhou City, Jiangxi Province, 341000, China

   Yuanying Cui

Authors

1. Lili Shi

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2. Lei Dong

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3. Yuanying Cui

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4. Dan Bu

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Contributions

SLL and HB conceived the idea and conceptualised the study. SLL, CYY and DL collected the data. DL, BD and CYY analysed the data. SLL and HB drafted the manuscript, then DL, BD and CYY reviewed the manuscript. All authors read and approved the final draft.

Corresponding author

Correspondence to Bo Hu.

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Ethics approval and consent to participate

This study was conducted with approval from the Ethics Committee of Ganzhou Maternal and Child Health Hospital. This study was conducted in accordance with the declaration of Helsinki. Written informed consent was obtained from all participants.

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The authors declare no competing interests.

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Shi, L., Dong, L., Cui, Y. et al. Analysis of the implementation value of abdominal B-ultrasound combined with cervical cerclage in the prevention and treatment of late recurrent spontaneous abortion. BMC Pregnancy Childbirth 24, 889 (2024). https://doi.org/10.1186/s12884-024-06912-2

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• Received: 19 May 2024

• Accepted: 18 October 2024

• Published: 31 December 2024

• DOI: https://doi.org/10.1186/s12884-024-06912-2

Keywords

• Recurrent late abortion
• Abdominal ultrasound
• Cervical cerclage