Successful Delayed Interval Delivery in Twin Pregnancies Without Cervical Cerclage: A Case Report

Successful Delayed Interval Delivery in Twin Pregnancies Without Cervical Cerclage: A Case Report | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Case Report Successful Delayed Interval Delivery in Twin Pregnancies Without Cervical Cerclage: A Case Report Yu-Bo Ou, Jing Yan, Cheng Li, Jing-Wen Wang, Zhao-Xia Zhang, Jing Zhang This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-6909752/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 6 You are reading this latest preprint version Abstract Background: Delayed interval delivery (DID) in twin pregnancies lacks standardized protocols, particularly regarding cervical cerclage. This report presents two rare cases where DID succeed without re-performing cervical cerclage, challenging conventional management strategies for cervical incompetence. Case Presentation: Case 1: A 31-year-old with dichorionic diamniotic twins experienced membrane prolapse during cerclage at 12+5 weeks, leading to first-fetus delivery. Management involved antibiotic prophylaxis, tocolysis, cervical length monitoring, and dexamethasone for fetal lung maturity (without re-cerclage). The remaining fetus was vaginally delivered at 38+6 weeks with normal development. Case 2: A 30-year-old with cerclage failure and first-fetus demise at 20+3 weeks underwent DID with antibiotics, tocolytics, and thromboprophylaxis (no cerclage). Cesarean delivery at 36 weeks yielded a healthy infant with umbilical cord entanglement. Both cases achieved prolonged gestation and favorable outcomes without cervical cerclage. Conclusions: These cases demonstrate that DID in twin pregnancies can succeed without cervical cerclage when combined with targeted infection prevention, uterine contraction inhibition, and fetal lung maturation. The findings challenge the necessity of cerclage in DID and provide clinical evidence for alternative management approaches. Delayed interval delivery Cervical Cerclage Twin Pregnancies Preterm Birth Cervical Incompetence Fetal Survival Assisted reproductive technique Figures Figure 1 Figure 2 Figure 3 Figure 4 Background Delayed interval delivery (DID) refers to a situation in a multiple pregnancy where, after the first fetus is miscarried or delivered prematurely (≤ 24 weeks), if uterine contractions gradually weaken or disappear, and there are no other contraindications to continuing the pregnancy, the undelivered fetus is retained in the uterus to continue the pregnancy for several days to weeks before delivery in order to improve its survival[ 1 , 2 ]. The rate of multiple pregnancies has risen dramatically in recent years due to the ongoing advancements in assisted reproductive technology[ 3 ]. 36% of twins is the consequence of aided conception[ 4 ]. Multiple pregnancies have a significantly increased risk of fetal and maternal complications compared with singleton pregnancies[ 5 ]. DID is increasingly used in clinical practice to improve the perinatal outcomes of premature newborns in multiple pregnancies[ 6 , 7 ]. However, there is currently no unified standard for the specific protocol for delayed delivery of twins. Here, we report two clinical cases of successful delayed delivery of twin pregnancies with good maternal and neonatal outcomes, hoping to provide valuable experience for the clinical management of DID. Case presentation Case 1 A 31-year-old female patient was admitted to the hospital with "vaginal bleeding for 3 + days and 2 + months after embryo transfer." She was 12 weeks and 5 days pregnant at this point and ultrasound revealed a dichorionic diamniotic twin pregnancy. A medium-to-high risk of Down's screening was identified, and the vulvar fluid turned pH paper blue. During the cerclage procedure, the fetal membranes completely protruded to the vaginal opening, leading to membrane rupture and the cessation of the cerclage operation. (Fig. 1 A). After communicating with the patient and family, a decision was made to implement delayed delivery. The first fetus was gently delivered, and immediate cerclage was not performed; instead, dynamic observation and monitoring of cervical length were employed, along with contraction suppression and infection prevention. Two days post-operation, vaginal ultrasound revealed a single viable fetus, with the cervical internal os exhibiting funnel-shaped changes and a closed cervical canal measuring approximately 30 mm (Fig. 1 D and 1 E). To improve blood circulation, low molecular weight heparin was administered, and dexamethasone was used to promote fetal lung maturity. At 38 weeks and 6 days, two-dimensional color Doppler ultrasound indicated a single fetus with two placentas, and placental function was rated as II+ (Fig. 1 F). Due to oligohydramnios, the bishop score for the cervix was five. A water bag was used to induce and promote cervical maturation. The infant was successfully delivered vaginally, with Apgar scores of 9 at one minute and 10 at five minutes after birth. Two placentas were observed, one atrophied and the other normal (Fig. 1 B). Pathological examination of the placenta indicated focal villous infarction with calcification (Fig. 1 C). Currently, the child is over 2 years old, with normal intelligence and growth development. Case 2 A female patient, aged 30, was admitted to the hospital due to "amenorrhea for over 4 months and increased vaginal discharge for 2 hours." All prenatal examinations revealed no notable anomalies in her dichorionic diamniotic twin pregnancy. Cervical incompetence was indicated upon admission, which showed a funnel-shaped (Fig. 2 A), so we decided to execute cervical cerclage. Six days after the cervical cerclage, a second surgery was performed because of recurrent cervical dilation. When the amniotic sac was visible again at 20 weeks and 3 days, the cerclage suture was removed, and preparations were made to allow the fetus to pass naturally. Oxytocin induction was attempted, but it failed. At 20 weeks and 6 days, an ultrasound revealed that the second fetus was still viable, but the first had ceased to grow (Fig. 2 B). Funnel-shaped dilation of the internal os and a shortening of the closed cervical canal were observed (Fig. 2 C). After discussing with the family and informing them of a previous successful case, they agreed to attempt delayed delivery, like the last case, to deliver the first fetus (Fig. 3 ). After implementing delayed delivery, antibiotic treatment was given to prevent infection, along with measures to suppress contractions and prevent thrombosis. Due to repeated positive cultures of vaginal discharge, it was decided to terminate the pregnancy at 36 weeks. Under spinal anesthesia, a live male infant was delivered via cesarean section, with a good Apgar score. At this time, the placental function was rated as I+, and the single viable fetus had the umbilical cord wrapped around its neck (Fig. 2 D). One of the two placentas observed during surgery was already calcified. Pathological analysis of the placental tissue showed areas of hemorrhagic necrosis and a small amount of inflammatory cell infiltration. Immunohistochemical results indicated scattered positivity for Cytokeratin Pan and positive staining for Desmin (Fig. 4 ). Postoperatively, the patient received treatment for infection and prevention of venous thrombosis. She fully recovered and was safely discharged. The newborn is now 1 year old and is developing well. Discussion and Conclusions These two cases demonstrate the successful experience of using the DID strategy in twin pregnancy and highlight several key measures in future clinical practice. Firstly, because multiple pregnancies face a higher risk of infection, timely use of antibiotics can effectively reduce the occurrence of maternal and infant complications[ 8 ]. Secondly, inhibiting uterine contractions is vital in the face of cervical insufficiency or early uterine contractions, which reduces the incidence of premature birth and improves the fetus' chances of survival[ 9 ]. Thirdly, interventions to promote fetal lung maturity are crucial to improving the survival rate of premature infants, as they can reduce the risk of respiratory distress syndrome after premature birth. This strategy has been widely used in clinical practice and has shown good results in multiple studies[ 10 ]. Finally, cervical cerclage is an effective means of delaying delivery and provides necessary support for pregnancy. This operation should be performed under strict monitoring to ensure the safety of mother and baby[ 11 , 12 ]. However, during the process of delayed delivery in both cases, we did not perform cerclage again, and the duration was relatively long, which is rare in our country. This suggests that cerclage is not necessarily required during delayed delivery of twin pregnancies. In summary, these cases highlight the importance of infection prevention, uterine contraction inhibition, fetal lung maturity promotion, and cervical cerclage in the DID strategy. These measures enhance the survival rate of premature infants in twin pregnancies and offer valuable insights for future clinical practice. Abbreviations DID Delayed interval delivery Declarations Ethics approval and consent to participate All procedures involving human participants were conducted in accordance with the ethical standards of the institutional review board and the 1964 Helsinki Declaration and its later amendments. Written informed consent was obtained from both patients for the publication of this case report and any accompanying images. The patients were fully informed about the purpose, procedures, and potential risks of the delayed interval delivery strategy, as well as the use of their clinical data for research purposes. The study protocol was approved by the Institutional Ethics Committee of The first People’s hospital of Changde city (No. 2025-061-01), and all personal and medical information was de-identified to ensure patient confidentiality. Competing interests No conflicts of interest. Funding The research was supported by the following grants: General Project Guided by the Health Commission of Hunan Province No.202205025325. Project Guided by the Science and Technology Bureau of Changde City No.2024ZD142. Project Guided by Science and Technology Bureau of Changde City c. Data Availability declaration This manuscript does not report data generation or analysis Consent to Publish declaration : Not applicable Authors' contributions Yu-Bo Ou and Jing Yan contributed equally to this work. Yu-Bo Ou, as the corresponding author, was responsible for the overall design and supervision of the study, as well as drafting and revising the manuscript. Jing Yan played a pivotal role in data collection, analysis, and interpretation, and contributed significantly to the discussion and conclusion sections. Cheng Li, Jing-Wen Wang, and Zhao-Xia Zhang were involved in patient recruitment, clinical management, and data acquisition. Jing Zhang provided critical feedback on the study design, manuscript draft, and contributed to the revision process. All authors reviewed and approved the final manuscript. Acknowledgements The authors would like to express their gratitude to the patients for their willingness to participate in this case report and for providing consent to share their clinical data. We also thank the obstetrics and gynecology team at The first People’s hospital of Changde city for their collaborative efforts in the management of these cases, as well as the laboratory staff for their assistance with pathological analyses. References Bouey NJ, Saha S, Wilson-Costello DE, Rysavy MA, Walsh M, Wyckoff MH, Hibbs AM: Delayed-interval delivery in multiple gestation pregnancies: neonatal mortality, morbidity, and development . J Perinatol 2022, 42 (12):1607-1614. Maducolil MK, Loughman E, Mohan M, Venugopalan V, Lindow SW: Delayed interval delivery and survivability of the second twin with and without emergency cerclage in dichorionic diamniotic pregnancy. A systematic review . Eur J Obstet Gynecol Reprod Biol 2024, 301 :31-42. Glujovsky D, Quinteiro Retamar AM, Alvarez Sedo CR, Ciapponi A, Cornelisse S, Blake D: Cleavage-stage versus blastocyst-stage embryo transfer in assisted reproductive technology . Cochrane Database Syst Rev 2022, 5 (5):CD002118. Li Y, Chu R, Li Y, Zhang M, Ma Y: Delayed interval delivery in a quadruplet pregnancy: a case report and literature review . BMC Pregnancy Childbirth 2023, 23 (1):353. Cui H, Li H, Yin Z: Emergency cervical cerclage in delayed-interval delivery of twin pregnancies: a scoping review . BMC Pregnancy Childbirth 2024, 24 (1):323. Louchet M, Dussaux C, Luton D, Goffinet F, Bounan S, Mandelbrot L: Delayed-interval delivery of twins in 13 pregnancies . J Gynecol Obstet Hum Reprod 2020, 49 (2):101660. Yang Y, Mai Z, Chen B, He F: Delayed-interval delivery in twin pregnancies: 12 years' experience in one perinatal center . Int J Gynaecol Obstet 2023, 161 (1):329-330. Goetzl L: Maternal fever in labor: etiologies, consequences, and clinical management . Am J Obstet Gynecol 2023, 228 (5S):S1274-S1282. Gadeer RH, Alhinai A, Fung-Kee-Fung K, Werlang A: Delayed-Interval Delivery in Multiple Pregnancy: A Single-Center Experience of Five Cases . AJP Rep 2024, 14 (2):e156-e161. McGoldrick E, Stewart F, Parker R, Dalziel SR: Antenatal corticosteroids for accelerating fetal lung maturation for women at risk of preterm birth . Cochrane Database Syst Rev 2020, 12 (12):CD004454. Nan Y, Wenyuan H, Beejadhursing R, Qingling K, Wanjiang Z, Dongrui D, Suhua C, Ling F, Fuyuan Q, Xun G: Obstetric and neonatal outcomes of delayed interval delivery in cerclage: A retrospective study . Eur J Obstet Gynecol Reprod Biol 2020, 246 :45-49. Hüner B, Essers J, Schiefele L, Schütze S, Reister F, Janni W, Deniz M: Obstetric and fetal short- and long-term outcomes of delayed-interval delivery in multiple pregnancies . J Gynecol Obstet Hum Reprod 2022, 51 (10):102486. Additional Declarations No competing interests reported. Cite Share Download PDF Status: Under Review Version 1 posted Reviewers agreed at journal 15 Aug, 2025 Reviewers invited by journal 30 Jul, 2025 Editor invited by journal 24 Jun, 2025 Editor assigned by journal 22 Jun, 2025 Submission checks completed at journal 22 Jun, 2025 First submitted to journal 16 Jun, 2025 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-6909752","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Case Report","associatedPublications":[],"authors":[{"id":494628563,"identity":"88752047-4826-48e9-b13e-f6f1982e9852","order_by":0,"name":"Yu-Bo Ou","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAAz0lEQVRIiWNgGAWjYJACZgaGAwxs7M0HH3wwsLEjXgsfz7FkwxkFacnEa5GTyDGT5vlwiLGBkHJ+kMqCijtybCCGjcEBZgb2w0c34NMiOQOocsaZZ8ZsPM+KrXMM7vAx8KSl3cCnxeAGUAtv2+HENvbkjbdzDJ4xM0jwmBGphSHBQNrC4DBjA/FaOFKMpBmI0SLZA/QCxC/AQO4xSEtmI+QXfpAXQCEm3w6Myh9/bOz42Q8fw6uFgYHDAJXPhl85CLA/IKxmFIyCUTAKRjYAAKftShUcZjDNAAAAAElFTkSuQmCC","orcid":"","institution":"Jishou University","correspondingAuthor":true,"prefix":"","firstName":"Yu-Bo","middleName":"","lastName":"Ou","suffix":""},{"id":494628564,"identity":"815cc2d4-c74c-42cc-8f36-47d741cbcada","order_by":1,"name":"Jing Yan","email":"","orcid":"","institution":"Changde Hospital, Central South University (The first People’s hospital of Changde city)","correspondingAuthor":false,"prefix":"","firstName":"Jing","middleName":"","lastName":"Yan","suffix":""},{"id":494628565,"identity":"91219c68-7c62-4d63-89f0-721d86f8bc2a","order_by":2,"name":"Cheng Li","email":"","orcid":"","institution":"Changde Hospital, Central South University (The first People’s hospital of Changde city)","correspondingAuthor":false,"prefix":"","firstName":"Cheng","middleName":"","lastName":"Li","suffix":""},{"id":494628566,"identity":"57c64764-ed3d-4c97-a54a-b7bf5ce52fc3","order_by":3,"name":"Jing-Wen Wang","email":"","orcid":"","institution":"Changde Hospital, Central South University (The first People’s hospital of Changde city)","correspondingAuthor":false,"prefix":"","firstName":"Jing-Wen","middleName":"","lastName":"Wang","suffix":""},{"id":494628567,"identity":"c9a552dd-3efa-4971-912b-0be773c0148a","order_by":4,"name":"Zhao-Xia Zhang","email":"","orcid":"","institution":"Changde Hospital, Central South University (The first People’s hospital of Changde city)","correspondingAuthor":false,"prefix":"","firstName":"Zhao-Xia","middleName":"","lastName":"Zhang","suffix":""},{"id":494628568,"identity":"9024cc93-6184-4fda-bf36-264640b13cbd","order_by":5,"name":"Jing Zhang","email":"","orcid":"","institution":"Jishou University","correspondingAuthor":false,"prefix":"","firstName":"Jing","middleName":"","lastName":"Zhang","suffix":""}],"badges":[],"createdAt":"2025-06-17 03:08:24","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-6909752/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-6909752/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":88419789,"identity":"e0c6af19-c13d-4d75-863b-f475ffcad94d","added_by":"auto","created_at":"2025-08-06 09:22:29","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":435905,"visible":true,"origin":"","legend":"\u003cp\u003e(A) The amniotic sac was clearly visible via the vaginal opening at the time of admission. (B) Two placental structures from the fetuses observed during delivery. (C) Pathological examination of the placenta. Localized villous infarction and calcification can be observed (HE staining, x200). (D) Transvaginal ultrasonography showed the pregnant woman was pregnant with a single live fetus and placental function grade 0. (E) Transvaginal ultrasonography showed funnel-like change and closed cervical canal was about 30 mm long. (F) Two-dimensional color ultrasound showed one live-birth and two placentas.\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-6909752/v1/8fdf07787ac69a7ff36b0132.png"},{"id":88419792,"identity":"76d69a23-b784-4e8e-b1d5-bd33c7ac1daf","added_by":"auto","created_at":"2025-08-06 09:22:29","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":268549,"visible":true,"origin":"","legend":"\u003cp\u003eColor Doppler ultrasound examination. (A) The funnel shape of the cervical os (B) Dichorionic and diamniotic fetus B is alive, while fetus A has stopped developing (C) The internal cervical os is dilated like a funnel and the length of the closed cervical canal is shortened (D) Intrauterine pregnancy with single live-birth at 36 weeks and 6 days, with the umbilical cord wrapped around the neck.\u003c/p\u003e","description":"","filename":"2.png","url":"https://assets-eu.researchsquare.com/files/rs-6909752/v1/944d008167c8f13c32bc08c4.png"},{"id":88421490,"identity":"265ccc64-9597-4dbd-85ef-4767ec192975","added_by":"auto","created_at":"2025-08-06 09:30:29","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":260427,"visible":true,"origin":"","legend":"\u003cp\u003eClamp surgery (A) In the process of clamping. (B) One month after the clamp.\u003c/p\u003e","description":"","filename":"3.png","url":"https://assets-eu.researchsquare.com/files/rs-6909752/v1/f18bb56b133d2c04bbb0e601.png"},{"id":88419794,"identity":"ebcfb1a0-b3a5-4bd6-aa41-98097e32a6a2","added_by":"auto","created_at":"2025-08-06 09:22:29","extension":"png","order_by":4,"title":"Figure 4","display":"","copyAsset":false,"role":"figure","size":557783,"visible":true,"origin":"","legend":"\u003cp\u003e(A) Placenta and Endometrium Tissue. Placental tissue size 4.4*1.9*1.5cm, grayish white and grayish brown, solid, medium texture. Fetal membrane tissue size 10.1*9.8*0.5cm, grayish brown. Endometrial tissue size 1.6*0.9*0.3cm, with grayish white and grayish brown cross section, solid texture, and medium texture. (B) Placental tissue, hemorrhagic infarction, focal calcification. (C) Placental tissue, a small amount of inflammatory cell infiltration. (D) Endometrium, with a small amount of smooth muscle tissue under the microscope (HE staining, x40).\u003c/p\u003e","description":"","filename":"4.png","url":"https://assets-eu.researchsquare.com/files/rs-6909752/v1/77955549d084e2c9e4fbdb36.png"},{"id":88425534,"identity":"8caa7108-60f1-4352-9369-8ae3aa682ae0","added_by":"auto","created_at":"2025-08-06 09:54:29","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":2726107,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-6909752/v1/a8d22216-b446-4f0e-bc69-211597bbf6e6.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Successful Delayed Interval Delivery in Twin Pregnancies Without Cervical Cerclage: A Case Report","fulltext":[{"header":"Background","content":"\u003cp\u003eDelayed interval delivery (DID) refers to a situation in a multiple pregnancy where, after the first fetus is miscarried or delivered prematurely (\u0026le;\u0026thinsp;24 weeks), if uterine contractions gradually weaken or disappear, and there are no other contraindications to continuing the pregnancy, the undelivered fetus is retained in the uterus to continue the pregnancy for several days to weeks before delivery in order to improve its survival[\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. The rate of multiple pregnancies has risen dramatically in recent years due to the ongoing advancements in assisted reproductive technology[\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. 36% of twins is the consequence of aided conception[\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. Multiple pregnancies have a significantly increased risk of fetal and maternal complications compared with singleton pregnancies[\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. DID is increasingly used in clinical practice to improve the perinatal outcomes of premature newborns in multiple pregnancies[\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. However, there is currently no unified standard for the specific protocol for delayed delivery of twins. Here, we report two clinical cases of successful delayed delivery of twin pregnancies with good maternal and neonatal outcomes, hoping to provide valuable experience for the clinical management of DID.\u003c/p\u003e"},{"header":"Case presentation","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e\u003ch2\u003eCase 1\u003c/h2\u003e\u003cp\u003eA 31-year-old female patient was admitted to the hospital with \"vaginal bleeding for 3\u0026thinsp;+\u0026thinsp;days and 2\u0026thinsp;+\u0026thinsp;months after embryo transfer.\" She was 12 weeks and 5 days pregnant at this point and ultrasound revealed a dichorionic diamniotic twin pregnancy. A medium-to-high risk of Down's screening was identified, and the vulvar fluid turned pH paper blue. During the cerclage procedure, the fetal membranes completely protruded to the vaginal opening, leading to membrane rupture and the cessation of the cerclage operation. (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003eA). After communicating with the patient and family, a decision was made to implement delayed delivery. The first fetus was gently delivered, and immediate cerclage was not performed; instead, dynamic observation and monitoring of cervical length were employed, along with contraction suppression and infection prevention. Two days post-operation, vaginal ultrasound revealed a single viable fetus, with the cervical internal os exhibiting funnel-shaped changes and a closed cervical canal measuring approximately 30 mm (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003eD and \u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003eE). To improve blood circulation, low molecular weight heparin was administered, and dexamethasone was used to promote fetal lung maturity. At 38 weeks and 6 days, two-dimensional color Doppler ultrasound indicated a single fetus with two placentas, and placental function was rated as II+ (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003eF). Due to oligohydramnios, the bishop score for the cervix was five. A water bag was used to induce and promote cervical maturation. The infant was successfully delivered vaginally, with Apgar scores of 9 at one minute and 10 at five minutes after birth. Two placentas were observed, one atrophied and the other normal (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003eB). Pathological examination of the placenta indicated focal villous infarction with calcification (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003eC). Currently, the child is over 2 years old, with normal intelligence and growth development.\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003c/div\u003e\n\u003ch3\u003eCase 2\u003c/h3\u003e\n\u003cp\u003eA female patient, aged 30, was admitted to the hospital due to \"amenorrhea for over 4 months and increased vaginal discharge for 2 hours.\" All prenatal examinations revealed no notable anomalies in her dichorionic diamniotic twin pregnancy. Cervical incompetence was indicated upon admission, which showed a funnel-shaped (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003eA), so we decided to execute cervical cerclage. Six days after the cervical cerclage, a second surgery was performed because of recurrent cervical dilation. When the amniotic sac was visible again at 20 weeks and 3 days, the cerclage suture was removed, and preparations were made to allow the fetus to pass naturally. Oxytocin induction was attempted, but it failed. At 20 weeks and 6 days, an ultrasound revealed that the second fetus was still viable, but the first had ceased to grow (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003eB). Funnel-shaped dilation of the internal os and a shortening of the closed cervical canal were observed (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003eC). After discussing with the family and informing them of a previous successful case, they agreed to attempt delayed delivery, like the last case, to deliver the first fetus (Fig.\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003e). After implementing delayed delivery, antibiotic treatment was given to prevent infection, along with measures to suppress contractions and prevent thrombosis. Due to repeated positive cultures of vaginal discharge, it was decided to terminate the pregnancy at 36 weeks. Under spinal anesthesia, a live male infant was delivered via cesarean section, with a good Apgar score. At this time, the placental function was rated as I+, and the single viable fetus had the umbilical cord wrapped around its neck (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003eD). One of the two placentas observed during surgery was already calcified. Pathological analysis of the placental tissue showed areas of hemorrhagic necrosis and a small amount of inflammatory cell infiltration. Immunohistochemical results indicated scattered positivity for Cytokeratin Pan and positive staining for Desmin (Fig.\u0026nbsp;\u003cspan refid=\"Fig4\" class=\"InternalRef\"\u003e4\u003c/span\u003e). Postoperatively, the patient received treatment for infection and prevention of venous thrombosis. She fully recovered and was safely discharged. The newborn is now 1 year old and is developing well.\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003cp\u003e\u003c/p\u003e"},{"header":"Discussion and Conclusions","content":"\u003cp\u003eThese two cases demonstrate the successful experience of using the DID strategy in twin pregnancy and highlight several key measures in future clinical practice. Firstly, because multiple pregnancies face a higher risk of infection, timely use of antibiotics can effectively reduce the occurrence of maternal and infant complications[\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. Secondly, inhibiting uterine contractions is vital in the face of cervical insufficiency or early uterine contractions, which reduces the incidence of premature birth and improves the fetus' chances of survival[\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. Thirdly, interventions to promote fetal lung maturity are crucial to improving the survival rate of premature infants, as they can reduce the risk of respiratory distress syndrome after premature birth. This strategy has been widely used in clinical practice and has shown good results in multiple studies[\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]. Finally, cervical cerclage is an effective means of delaying delivery and provides necessary support for pregnancy. This operation should be performed under strict monitoring to ensure the safety of mother and baby[\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e, \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]. However, during the process of delayed delivery in both cases, we did not perform cerclage again, and the duration was relatively long, which is rare in our country. This suggests that cerclage is not necessarily required during delayed delivery of twin pregnancies. In summary, these cases highlight the importance of infection prevention, uterine contraction inhibition, fetal lung maturity promotion, and cervical cerclage in the DID strategy. These measures enhance the survival rate of premature infants in twin pregnancies and offer valuable insights for future clinical practice.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cdiv class=\"DefinitionList\"\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eDID\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eDelayed interval delivery\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003c/div\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll procedures involving human participants were conducted in accordance with the ethical standards of the institutional review board and the 1964 Helsinki Declaration and its later amendments. Written informed consent was obtained from both patients for the publication of this case report and any accompanying images. The patients were fully informed about the purpose, procedures, and potential risks of the delayed interval delivery strategy, as well as the use of their clinical data for research purposes. The study protocol was approved by the Institutional Ethics Committee of The first People’s hospital of Changde city\u0026nbsp;(No. 2025-061-01), and all personal and medical information was de-identified to ensure patient confidentiality.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNo conflicts of interest.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe research was supported by the following grants: General Project Guided by the Health Commission of Hunan Province No.202205025325. Project Guided by the Science and Technology Bureau of Changde City No.2024ZD142. Project Guided by Science and Technology Bureau of Changde City c.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData Availability declaration\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis manuscript does not report data generation or analysis\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent to Publish declaration\u003c/strong\u003e:\u003c/p\u003e\n\u003cp\u003eNot applicable\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors' contributions\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eYu-Bo Ou and Jing Yan contributed equally to this work. Yu-Bo Ou, as the corresponding author, was responsible for the overall design and supervision of the study, as well as drafting and revising the manuscript. Jing Yan played a pivotal role in data collection, analysis, and interpretation, and contributed significantly to the discussion and conclusion sections. Cheng Li, Jing-Wen Wang, and Zhao-Xia Zhang were involved in patient recruitment, clinical management, and data acquisition. Jing Zhang provided critical feedback on the study design, manuscript draft, and contributed to the revision process. All authors reviewed and approved the final manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors would like to express their gratitude to the patients for their willingness to participate in this case report and for providing consent to share their clinical data. \u0026nbsp;We also thank the obstetrics and gynecology team at The first People’s hospital of Changde city for their collaborative efforts in the management of these cases, as well as the laboratory staff for their assistance with pathological analyses.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n \u003cli\u003eBouey NJ, Saha S, Wilson-Costello DE, Rysavy MA, Walsh M, Wyckoff MH, Hibbs AM: \u003cstrong\u003eDelayed-interval delivery in multiple gestation pregnancies: neonatal mortality, morbidity, and development\u003c/strong\u003e. \u003cem\u003eJ Perinatol\u0026nbsp;\u003c/em\u003e2022, \u003cstrong\u003e42\u003c/strong\u003e(12):1607-1614.\u003c/li\u003e\n \u003cli\u003eMaducolil MK, Loughman E, Mohan M, Venugopalan V, Lindow SW: \u003cstrong\u003eDelayed interval delivery and survivability of the second twin with and without emergency cerclage in dichorionic diamniotic pregnancy. A systematic review\u003c/strong\u003e. \u003cem\u003eEur J Obstet Gynecol Reprod Biol\u0026nbsp;\u003c/em\u003e2024, \u003cstrong\u003e301\u003c/strong\u003e:31-42.\u003c/li\u003e\n \u003cli\u003eGlujovsky D, Quinteiro Retamar AM, Alvarez Sedo CR, Ciapponi A, Cornelisse S, Blake D: \u003cstrong\u003eCleavage-stage versus blastocyst-stage embryo transfer in assisted reproductive technology\u003c/strong\u003e. \u003cem\u003eCochrane Database Syst Rev\u0026nbsp;\u003c/em\u003e2022, \u003cstrong\u003e5\u003c/strong\u003e(5):CD002118.\u003c/li\u003e\n \u003cli\u003eLi Y, Chu R, Li Y, Zhang M, Ma Y: \u003cstrong\u003eDelayed interval delivery in a quadruplet pregnancy: a case report and literature review\u003c/strong\u003e. \u003cem\u003eBMC Pregnancy Childbirth\u0026nbsp;\u003c/em\u003e2023, \u003cstrong\u003e23\u003c/strong\u003e(1):353.\u003c/li\u003e\n \u003cli\u003eCui H, Li H, Yin Z: \u003cstrong\u003eEmergency cervical cerclage in delayed-interval delivery of twin pregnancies: a scoping review\u003c/strong\u003e. \u003cem\u003eBMC Pregnancy Childbirth\u0026nbsp;\u003c/em\u003e2024, \u003cstrong\u003e24\u003c/strong\u003e(1):323.\u003c/li\u003e\n \u003cli\u003eLouchet M, Dussaux C, Luton D, Goffinet F, Bounan S, Mandelbrot L: \u003cstrong\u003eDelayed-interval delivery of twins in 13 pregnancies\u003c/strong\u003e. \u003cem\u003eJ Gynecol Obstet Hum Reprod\u0026nbsp;\u003c/em\u003e2020, \u003cstrong\u003e49\u003c/strong\u003e(2):101660.\u003c/li\u003e\n \u003cli\u003eYang Y, Mai Z, Chen B, He F: \u003cstrong\u003eDelayed-interval delivery in twin pregnancies: 12\u003c/strong\u003e\u003cstrong\u003e\u0026thinsp;years\u0026apos; experience in one perinatal center\u003c/strong\u003e. \u003cem\u003eInt J Gynaecol Obstet\u0026nbsp;\u003c/em\u003e2023, \u003cstrong\u003e161\u003c/strong\u003e(1):329-330.\u003c/li\u003e\n \u003cli\u003eGoetzl L: \u003cstrong\u003eMaternal fever in labor: etiologies, consequences, and clinical management\u003c/strong\u003e. \u003cem\u003eAm J Obstet Gynecol\u0026nbsp;\u003c/em\u003e2023, \u003cstrong\u003e228\u003c/strong\u003e(5S):S1274-S1282.\u003c/li\u003e\n \u003cli\u003eGadeer RH, Alhinai A, Fung-Kee-Fung K, Werlang A: \u003cstrong\u003eDelayed-Interval Delivery in Multiple Pregnancy: A Single-Center Experience of Five Cases\u003c/strong\u003e. \u003cem\u003eAJP Rep\u0026nbsp;\u003c/em\u003e2024, \u003cstrong\u003e14\u003c/strong\u003e(2):e156-e161.\u003c/li\u003e\n \u003cli\u003eMcGoldrick E, Stewart F, Parker R, Dalziel SR: \u003cstrong\u003eAntenatal corticosteroids for accelerating fetal lung maturation for women at risk of preterm birth\u003c/strong\u003e. \u003cem\u003eCochrane Database Syst Rev\u0026nbsp;\u003c/em\u003e2020, \u003cstrong\u003e12\u003c/strong\u003e(12):CD004454.\u003c/li\u003e\n \u003cli\u003eNan Y, Wenyuan H, Beejadhursing R, Qingling K, Wanjiang Z, Dongrui D, Suhua C, Ling F, Fuyuan Q, Xun G: \u003cstrong\u003eObstetric and neonatal outcomes of delayed interval delivery in cerclage: A retrospective study\u003c/strong\u003e. \u003cem\u003eEur J Obstet Gynecol Reprod Biol\u0026nbsp;\u003c/em\u003e2020, \u003cstrong\u003e246\u003c/strong\u003e:45-49.\u003c/li\u003e\n \u003cli\u003eH\u0026uuml;ner B, Essers J, Schiefele L, Sch\u0026uuml;tze S, Reister F, Janni W, Deniz M: \u003cstrong\u003eObstetric and fetal short- and long-term outcomes of delayed-interval delivery in multiple pregnancies\u003c/strong\u003e. \u003cem\u003eJ Gynecol Obstet Hum Reprod\u0026nbsp;\u003c/em\u003e2022, \u003cstrong\u003e51\u003c/strong\u003e(10):102486.\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-pregnancy-and-childbirth","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"prch","sideBox":"Learn more about [BMC Pregnancy and Childbirth](http://bmcpregnancychildbirth.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/prch/default.aspx","title":"BMC Pregnancy and Childbirth","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Delayed interval delivery, Cervical Cerclage, Twin Pregnancies, Preterm Birth, Cervical Incompetence, Fetal Survival, Assisted reproductive technique","lastPublishedDoi":"10.21203/rs.3.rs-6909752/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-6909752/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground: \u003c/strong\u003eDelayed interval delivery (DID) in twin pregnancies lacks standardized protocols, particularly regarding cervical cerclage. This report presents two rare cases where DID succeed without re-performing cervical cerclage, challenging conventional management strategies for cervical incompetence.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCase Presentation:\u003c/strong\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCase 1:\u003c/strong\u003e A 31-year-old with dichorionic diamniotic twins experienced membrane prolapse during cerclage at 12+5 weeks, leading to first-fetus delivery. Management involved antibiotic prophylaxis, tocolysis, cervical length monitoring, and dexamethasone for fetal lung maturity (without re-cerclage). The remaining fetus was vaginally delivered at 38+6 weeks with normal development.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCase 2:\u003c/strong\u003e A 30-year-old with cerclage failure and first-fetus demise at 20+3 weeks underwent DID with antibiotics, tocolytics, and thromboprophylaxis (no cerclage). Cesarean delivery at 36 weeks yielded a healthy infant with umbilical cord entanglement. Both cases achieved prolonged gestation and favorable outcomes without cervical cerclage. \u003cstrong\u003eConclusions:\u003c/strong\u003e These cases demonstrate that DID in twin pregnancies can succeed without cervical cerclage when combined with targeted infection prevention, uterine contraction inhibition, and fetal lung maturation. The findings challenge the necessity of cerclage in DID and provide clinical evidence for alternative management approaches.\u003c/p\u003e","manuscriptTitle":"Successful Delayed Interval Delivery in Twin Pregnancies Without Cervical Cerclage: A Case Report","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-08-06 09:22:24","doi":"10.21203/rs.3.rs-6909752/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"reviewerAgreed","content":"133590089660882814798539716288193529218","date":"2025-08-15T10:43:01+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-07-31T03:59:30+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2025-06-24T17:32:09+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-06-23T01:26:21+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-06-23T01:25:38+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Pregnancy and Childbirth","date":"2025-06-17T02:57:04+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-pregnancy-and-childbirth","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"prch","sideBox":"Learn more about [BMC Pregnancy and Childbirth](http://bmcpregnancychildbirth.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/prch/default.aspx","title":"BMC Pregnancy and Childbirth","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"540b24a3-4f50-466d-b3ff-0cf85e56eda6","owner":[],"postedDate":"August 6th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2025-08-06T09:22:24+00:00","versionOfRecord":[],"versionCreatedAt":"2025-08-06 09:22:24","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-6909752","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-6909752","identity":"rs-6909752","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}