Give the “Little Double” A Little Bit More Time ----Discussion on Delayed-Interval Delivery of the Twin: A Case Report

Give the “Little Double” A Little Bit More Time ----Discussion on Delayed-Interval Delivery of the Twin: 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 Give the “Little Double” A Little Bit More Time ----Discussion on Delayed-Interval Delivery of the Twin: A Case Report Yanxin Zhang, Xinlu Fu, Yingyan Gu, Dan Lu This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-5468878/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Background To explore the diagnosis and clinical management of delayed-interval delivery of the twin and the near- and long-term outcomes of mother and fetus. Case presentation A 31-year-old pregnant woman was admitted to the hospital on March 23, 2022 due to “28 weeks of menopause with spontaneous vaginal discharge of tissue for 2 hours”. On March 26, 2022 a stillborn fetus was delivered. After delivering a stillborn fetus, the patient was immediately given high ligation of the umbilical cord, antibiotics to prevent infection, atosiban to inhibit contractions, magnesium sulfate to protect the fetal cerebral nerves, and hospitalized to closely monitor the condition of the mother and the other fetus, successfully delivering a baby girl vaginally at 34 + 2 weeks, and no significant complications have been observed in both mother and baby by the two-year follow-up. Conclusion Delayed-interval delivery of the twin(DIDT) is a specific complication of twin pregnancies, and proper clinical management can improve the survival of the second fetus. Delayed-interval delivery(DID) may effectively prolongs the gestational age of the delivered fetus and reduces neonatal morbidity and mortality after birth. Delayed-interval delivery twin pregnancy Maternal morbidity Neonatal morbidity Neonatal mortality Figures Figure 1 Background At any time with the strong development of assisted reproduction, twin pregnancies seem to be on the rise [ 1 ] . And the risk of miscarriage and preterm birth is significantly higher in twin pregnancies compared to singleton pregnancies [ 2 ] . Delayed-interval delivery of the twin(DIDT) gives the little twin a little more chance of survival, offering a possibility for twin pregnancies especially when the first one can not survive [ 3 ] . DID is defined as a multiple pregnancy in which, after the first foetus has been aborted or delivered prematurely,the remaining foetus remains in the womb for a few days to a few weeks to improve the survival of the undelivered fetus. It has been suggested that if the interval between vaginal deliveries exceeds 30 minutes, this may lead to asphyxia and increased morbidity in the second foetus [ 4 ] . There were some cases reported with positive pregnany outcomes, but there is no unified diagnosis and treatment protocol. A lot of details should be discussed to make the diagnosis and treatmnt protocol of DIDT. Here is our case. Case presentation A 31-year-old pregnant woman, with 2 pregnancies and 0 delivery, had hypothyroidism in the past and her thyroid function was well controlled with medication during preganancy. On September 25, 2021, two fresh embryos were transferred in our hospital, both of which survived, with dichorionic diamniotic pregnancy. On January 30, the woman underwent a fetal reduction at Nanjing Gulou Hospital due to trisomy 21 in one of the fetuses. She was admitted to the hospital on March 23 due to “28 weeks of menopause with spontaneous vaginal discharge of tissue for 2 hours”. Vaginal examination on revealed an amniotic sac protruding into the vagina, which ruptured spontaneously after admission, with grey-brown amniotic fluid flowing out of it. On March 26, a stillborn fetus was delivered with the umbilical cord was attached to the uterine cavity, no abdominal pain was evident after delivery and the placenta was not aborted after 30 minutes. After communicating with the woman and her family, the decision was made to perform a DIDT. The umbilical cord was then ligated in a high position and sterilized, and the severed end of the umbilical cord was placed in the vagina. Antibiotics were used to fight infection and atosiban and magnesium sulphate were used to inhibit uterine contractions, and the mother's systemic condition, indicators of infection, and the condition of the other fetus were closely monitored. The patient was gestated to 34+2 weeks of pregnancy and physiologically assisted delivery of a female infant on May 25, weighing 2110 g. Apgar score, 10 points at 1 minute and 10 points at 5 minutes.The placenta and membranes were delivered intact, with the two placentas fused into one, but the placental circulation was independent. One side is dark red with a thicker umbilical cord attached and the other side is atrophied with a thinner umbilical cord attached, with a clear demarcation visible in the center and no vascular traffic branches. There were two amniotic sacs separated by two layers of amniotic membrane and two layers of chorionic villi( Fig.1 ). The neonate was referred to the neonatal unit for treatment of preterm labor, no significant complications were found and was processed for discharge after 15 days of treatment with a discharge weight of 2110 g. The mother was discharged from the hospital 3 days after delivery. The neonate has been followed up to date with good physical and mental development, and the toddler currently weighs 10.1 kg, which is the normal developmental level for a child of the same age. Discussion DIDT is a specific complication of twin pregnancies and proper clinical management can improve the survival rate of the second fetus. A review of the history of DIDT has found that DIDT effectively prolongs the gestational age of the delivered fetus and reduces neonatal morbidity and mortality after birth [5] . DIDT may be the best chance of achieving a viable foetus in a twin pregnancy following elective reduction.There is a lack of support for DIDT in large sample size studies. The results of this case suggest that the use of DIDT may prolong the gestational age of the second foetus. In clinical practice, the DIDT option can be implemented for those pregnant women for whom it is appropriate, after adequate communication with the pregnant women and family. Conditions for delayed labour. There is a risk of serious maternal and fetal infection during DIDT. Patients and their families should be informed of the risks and disadvantages and the decision should be carefully assessed. DIDT must be strictly indicated: 1.vaginal delivery of the first fetus; 2.intact membranes and good intrauterine condition of the delayed fetus; and absence of fetal distress, placental abruption, amniotic cavity infection or other maternal factors detrimental to the continuation of the pregnancy [5] . There are no anastomosing vessels between the placentas of double chorionic double amniotic, and the intrauterine death of one of the fetuses does not usually adversely affect the other due to vascular traffic factors [6] . Gestational age For the gestational age at which DIDT can be performed, Arabin et al. found that delayed delivery of the second child was associated with better perinatal outcomes if the first child was delivered between 20 and 29 weeks of gestational age [7] . Cheung et al. suggested that delayed deliveries should be performed at 13-31 weeks [5] . In this case, the first delivery was at 28 weeks of gestation, and the contractions gradually disappeared after delivery and the uterine opening retracted, making it possible to delayed-interval delivery(DID). Chorionicity It is contraindicated for monochorionic single-parented twins, and it is controversial whether delayed pregnancy can be performed in monochorionic twin sheep twins. It has been suggested that brain damage may occur in the other fetus after delivery of one of the monochorionic twins, but good outcomes after delayed-interval delivery of monochorionic twin sheep twins have been reported [8] , although the number of cases is of course small and the need to try them requires further discretion. Clinical treatment Emphasis on the importance of preventing infection . During DID, intrauterine infection is an important factor in determining the ability to continue to extend the gestational week. Once chorioamnionitis occurs, it can be very dangerous and the pregnancy must be terminated immediately. The first step is to tightly disinfect the vagina and cervix and then ligate the umbilical cord of the first fetus using absorbable suture as high as possible, cutting it below the ligature near the upper end of the cervical canal while the placenta of the aborted or premature foetus remains in the cavity.Then the prophylactic antibiotics should be administered to prevent infection. At the same time, before and after ligation of the umbilical cord, cultures of aerobic and anaerobic bacteria plus sensitivity tests of the vaginal and cervical canal secretions are performed and antibiotics are adjusted according to the results of the cultures in order to control the infection more effectively. Avoid vaginal examination as much as possible to minimize the chance of infection. In this case, they first used empirical broad-spectrum antibiotics, followed by timely adjustments according to the results of drug sensitization, stopping the drug after one course of antibiotic application, monitoring vital signs, indicators of infection, and intermittent application of antibiotics,which greatly reduced the risk of intrauterine infection and chorioamnionitis, as well as the risk of drug-resistant and fungal infections associated with prolonged use of antibiotics. Use of contraction-inhibiting drugs: prophylactic or on-demand An important therapeutic measure to DID is to suppress contractions. Some studies have shown that contraction suppressants are routinely used by 75% of doctors after the delivery of the first child and 25% in the presence of persistent contractions [5] . Magnesium sulfate is routinely used as a protective agent for the fetal central nervous system in patients with preterm labor before 32 weeks. Since magnesium sulfate also inhibits contractions, it may be considered the first choice if not contraindicated to reduce the incidence of distant neurologic complications, the risk of distant cerebral palsy and severe motor dysfunction in the newborn [9] . In this case, considering the persistent irregular contractions after the delivery of the first fetus, atosiban was given to suppress the contractions for one course of treatment, and magnesium sulfate was given simultaneously to protect the fetal cerebral neural development up to 48 hours.Monitor contractions closely and use contraction inhibitors intermittently until the pregnancy and fetus are stabilized. Use of cervical cerclage. The need for cervical cerclage in the management of DID remains controversia. Advantages of cervical cerclage: maintains cervical stability and provides mechanical support; reduces exposure of fetal membranes to intravaginal flora and acidic environment, reduces risk of chorioamnionitis and premature rupture of immature membranes [10] . Risks of cervical cerclage: invasive procedures that increase the risk of maternal infection, chorioamnionitis and premature rupture of membranes [11] . In this case,considering that she had no history of cervical insufficiency, and the cervical os was naturally closed without amniotic sac protrusion after delivery of the first fetus, and a gestational age of 28 weeks, the patient did not undergo cervical cerclage. Promotion of fetal lung maturation Most recommend the use of glucocorticoids at 24-34 weeks of gestation for those at risk of preterm labour, with the best benefit for delivery within 48 hours to 7 days after use, to help improve neonatal outcome. Some recommend glucocorticoids for fetal lung maturation from 24 weeks, with a repeat course at around 28 weeks' gestation. Glucocorticoids may be reused for more than 2 weeks after the previous lung maturation treatment, up to a maximum of two lung maturation treatments [12] . In this case, during the course of the disease, the patient completed two treatments to promote fetal lung maturation. Inpatient or outpatient follow-up; Maternal and fetal monitoring. As most DID failures occur within a week of delivery of the first fetus, hospitalisation for observation for at least 7 days is generally recommended and outpatient treatment may be considered once the condition has stabilised. Long-term hospitalization is not recommended [13] . When DID occurs, monitoring of the mother and retained fetus should be intensified. In this DIDT case, the patient was anxious and the fetus was precious, so she refused to be discharged from hospital. The woman underwent weekly ultrasound examinations, the fetus was in good condition. Tests for inflammatory markers and coagulation were performed every two days, with no significant inflammatory response and coagulation abnormality, and several cultures of cervical secretions were performed with no bacteria. Pregnancy outcomes Common intrapartum and postpartum complications are chorioamnionitis, placental abruption and postpartum haemorrhage [5] . No maternal deaths have been reported so far. Pablo et al. followed up two newborns who underwet DID born after 28 weeks for 2 years, and both children showed no significant sequelae and had satisfactory cognitive and neurologic development [14] . The number of cases in this group is small and requires long term follow up. Despite the improvement in neonatal salvage, complications related to gestational age in preterm infants are still difficult to avoid, so our technique needs to be used in appropriate cases. Fortunately, this pregnant woman did not experience premature rupture of membranes, intrauterine infection, placental abruption. And we had been following this child for more than two years, and she had the same intellectual and motor skills as her peers, and was able to live and study normally as her peers. Conclusion DIDT is rare, and there is a lack of statistical analysis of large samples globally,and there is no consensus on this. DIDT is an attempt to obtain a viable foetus in twin pregnancies, but there is still a risk that a child with severe morbidity and disability will be left behind.Therefore, it is important to come up with an individualised plan that is appropriate to the patient's situation, and after the couple has discussed and made a decision, the obstetrician will do everything possible to help the patient. Abbreviations DIDT: Delayed-interval delivery of the twin DID: Delayed-interval delivery Declarations Acknowledgements Not Applicable Author information Authors and Affiliations Northern Jiangsu People's Hospital Affiliated to Yangzhou University, Yangzhou, 225001, China Yanxin Zhang, Xinlu Fu, Yingyan Gu, Dan Lu Corresponding author Correspondence to Dan Lu. Authors’ contributions All authors contributed to the conceptualization and design of the study.Yanxin Zhang and Xinlu Fu collected and analyzed the case, and designed, planned, wrote the manuscript. Yingyan Gu collected the clinical data and revised the manuscript. Dan Lu made useful critique of this manuscript and revised the manuscript. All authors read and approved the fnal manuscript. Ethics approval and consent to participate Ethics approval and consent to participate were authorized by the ethical committee of Northern Jiangsu People's Hospital.(2022ky343). Consent for publication Written informed consent was obtained from the patient for publication of this case report. Competing interests The authors report no confict of interests. Funding YangZhou Municipal Science and Technology Bureau, YZ2017075 Availability of data and material Not Applicable Code availability Not Applicable References ACOG Practice Bulletin No. 144: Multifetal gestations: twin, triplet, and higher-order multifetal pregnancies[J]. Obstet Gynecol, 2014, 123(5): 1118-1132. http://doi.org/10.1097/01.AOG.0000446856.51061.3e Gardner M O, Goldenberg R L, Cliver S P, et al. The origin and outcome of preterm twin pregnancies[J]. Obstet Gynecol, 1995, 85(4): 553-7.http://doi.org/10.1016/0029-7844(94)00455-m Feys S, Jacquemyn Y. Delayed-interval delivery can save the second twin: evidence from a systematic review[J]. Facts Views Vis Obgyn, 2016, 8(4): 223-231 Hjortø S, Nickelsen C, Petersen J, et al. The effect of chorionicity and twin-to-twin delivery time interval on short-term outcome of the second twin[J]. J Matern Fetal Neonatal Med, 2014, 27(1): 42-7. http://doi.org/10.3109/14767058.2013.799657 Cheung K W, Seto M T Y, Wang W, et al. Effect of delayed interval delivery of remaining fetus(es) in multiple pregnancies on survival: a systematic review and meta-analysis[J]. Am J Obstet Gynecol, 2020, 222(4): 306-319.e18.http://doi.org/10.1016/j.ajog.2019.07.046 Blickstein I, Perlman S. Single fetal death in twin gestations[J]. J Perinat Med, 2013, 41(1): 65-9. http://doi.org/10.1515/jpm-2012-0019 Arabin B, Van Eyck J. Delayed-interval delivery in twin and triplet pregnancies: 17 years of experience in 1 perinatal center[J]. Am J Obstet Gynecol, 2009, 200(2): 154.e1-8. http://doi.org/10.1016/j.ajog.2008.08.046 Baltus T, Martin M L. Successful delayed-interval delivery in monochorionic diamniotic twin pregnancy: A case report[J]. Case Rep Womens Health, 2019, 21: e00093.http://doi.org/10.1016/j.crwh.2018.e00093 Committee Opinion No 652: Magnesium Sulfate Use in Obstetrics[J]. Obstet Gynecol, 2016, 127(1): e52-e53. http://doi.org/10.1097/aog.0000000000001267 Reinhard J, Reichenbach L, Ernst T, et al. Delayed interval delivery in twin and triplet pregnancies: 6 years of experience in one perinatal center[J]. J Perinat Med, 2012, 40(5): 551-5. http://doi.org/10.1515/jpm-2011-0267 Benito Vielba M, De Bonrostro Torralba C, Pallares Arnal V, et al. Delayed-interval delivery in twin pregnancies: report of three cases and literature review[J]. J Matern Fetal Neonatal Med, 2019, 32(2): 351-355. http://doi.org/10.1080/14767058.2017.1378336 Louchet M, Dussaux C, Luton D, et al. Delayed-interval delivery of twins in 13 pregnancies[J]. J Gynecol Obstet Hum Reprod, 2020, 49(2): 101660. http://doi.org/10.1016/j.jogoh.2019.101660 Porreco R P, Sabin E D, Heyborne K D, et al. Delayed-interval delivery in multifetal pregnancy[J]. Am J Obstet Gynecol, 1998, 178(1 Pt 1): 20-3. http://doi.org/10.1016/s0002-9378(98)70620-9 Padilla-Iserte P, Vila-Vives J M, Ferri B, et al. Delayed interval delivery of the second twin: obstetric management, neonatal outcomes, and 2-year follow-up[J]. J Obstet Gynaecol India, 2014, 64(5): 344-8.http://doi.org/10.1007/s13224-014-0544-1 Additional Declarations No competing interests reported. Cite Share Download PDF Status: Posted Version 1 posted 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. We do this by developing innovative software and high quality services for the global research community. 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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-5468878","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Case Report","associatedPublications":[],"authors":[{"id":379260083,"identity":"57dee03c-fcaa-4d8b-9bd9-3ffad045a135","order_by":0,"name":"Yanxin Zhang","email":"","orcid":"","institution":"Northern Jiangsu People's Hospital Affiliated to Yangzhou University","correspondingAuthor":false,"prefix":"","firstName":"Yanxin","middleName":"","lastName":"Zhang","suffix":""},{"id":379260084,"identity":"639b1a0d-c04a-472e-b9f6-d0f0dbcd6cad","order_by":1,"name":"Xinlu Fu","email":"","orcid":"","institution":"Northern Jiangsu People's Hospital Affiliated to Yangzhou University","correspondingAuthor":false,"prefix":"","firstName":"Xinlu","middleName":"","lastName":"Fu","suffix":""},{"id":379260085,"identity":"47f71b94-535f-4322-87c0-98dd734e1b2d","order_by":2,"name":"Yingyan Gu","email":"","orcid":"","institution":"Northern Jiangsu People's Hospital Affiliated to Yangzhou University","correspondingAuthor":false,"prefix":"","firstName":"Yingyan","middleName":"","lastName":"Gu","suffix":""},{"id":379260086,"identity":"77892a26-f6e3-437e-b6d1-0036104d0ec0","order_by":3,"name":"Dan Lu","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAAxklEQVRIiWNgGAWjYBACPgYGAyCykeNnb2x88IEYLWxgLQVpxpI9h5sNZxCv5cPhRIMb6W3SHERpkUje+LnA4HCC5MyHDdIMDHZyug0EtaQVS88wSM/jl05sMC5gSDY2O0BQS46BNI+BdbHk7MSG5BkMBxK3EaHF+DePAXPihpsHGw7zEKnFDGiLc+KGG4yNzcRp4XlWZs1jAArkxGbGGQZE+IWfPXnzbZ4/oKg8/vzHhwo7OYJa0IABacpHwSgYBaNgFOAAAHRPPtLpBvG1AAAAAElFTkSuQmCC","orcid":"","institution":"Northern Jiangsu People's Hospital Affiliated to Yangzhou University","correspondingAuthor":true,"prefix":"","firstName":"Dan","middleName":"","lastName":"Lu","suffix":""}],"badges":[],"createdAt":"2024-11-17 08:23:07","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-5468878/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-5468878/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":71878324,"identity":"515c2e2a-ac2c-4bd8-9c6d-751d35fa4d3a","added_by":"auto","created_at":"2024-12-19 11:10:39","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":241127,"visible":true,"origin":"","legend":"\u003cp\u003ePlacenta\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-5468878/v1/bf86847a977d3bed1e3b47fd.png"},{"id":72529064,"identity":"6e5b5b3c-b3be-4f09-9957-771b6771bfdd","added_by":"auto","created_at":"2024-12-28 18:16:25","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":649840,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-5468878/v1/cb03b5ad-3072-48b9-9aca-7a36c62abafc.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Give the “Little Double” A Little Bit More Time ----Discussion on Delayed-Interval Delivery of the Twin: A Case Report","fulltext":[{"header":"Background","content":"\u003cp\u003eAt any time with the strong development of assisted reproduction, twin pregnancies seem to be on the rise\u003csup\u003e[\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]\u003c/sup\u003e. And the risk of miscarriage and preterm birth is significantly higher in twin pregnancies compared to singleton pregnancies\u003csup\u003e[\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]\u003c/sup\u003e. Delayed-interval delivery of the twin(DIDT) gives the little twin a little more chance of survival, offering a possibility for twin pregnancies especially when the first one can not survive\u003csup\u003e[\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eDID is defined as a multiple pregnancy in which, after the first foetus has been aborted or delivered prematurely,the remaining foetus remains in the womb for a few days to a few weeks to improve the survival of the undelivered fetus. It has been suggested that if the interval between vaginal deliveries exceeds 30 minutes, this may lead to asphyxia and increased morbidity in the second foetus\u003csup\u003e[\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]\u003c/sup\u003e. There were some cases reported with positive pregnany outcomes, but there is no unified diagnosis and treatment protocol. A lot of details should be discussed to make the diagnosis and treatmnt protocol of DIDT. Here is our case.\u003c/p\u003e"},{"header":"Case presentation","content":"\u003cp\u003eA 31-year-old pregnant woman, with 2 pregnancies and 0 delivery, had hypothyroidism in the past and her thyroid function was well controlled with medication during preganancy. On September 25, 2021, two fresh embryos were transferred in our hospital, both of which survived, with dichorionic diamniotic pregnancy. On January 30, the woman underwent a fetal reduction at Nanjing Gulou Hospital due to trisomy 21 in one of the fetuses. She was admitted to the hospital on March 23 due to \u0026ldquo;28 weeks of menopause with spontaneous vaginal discharge of tissue for 2 hours\u0026rdquo;. Vaginal examination on revealed an amniotic sac protruding into the vagina, which ruptured spontaneously after admission, with grey-brown amniotic fluid flowing out of it. On March 26, a stillborn fetus was delivered with the umbilical cord was attached to the uterine cavity, no abdominal pain was evident after delivery and the placenta was not aborted after 30 minutes. After communicating with the woman and her family, the decision was made to perform a DIDT. The umbilical cord was then ligated in a high position and sterilized, and the severed end of the umbilical cord was placed in the vagina. Antibiotics were used to fight infection and atosiban and magnesium sulphate were used to inhibit uterine contractions, and the mother\u0026apos;s systemic condition, indicators of infection, and the condition of the other fetus were closely monitored. The patient was gestated to 34+2 weeks of pregnancy and physiologically assisted delivery of a female infant on May 25, weighing 2110 g. Apgar score, 10 points at 1 minute and 10 points at 5 minutes.The placenta and membranes were delivered intact, with the two placentas fused into one, but the placental circulation was independent. One side is dark red with a thicker umbilical cord attached and the other side is atrophied with a thinner umbilical cord attached, with a clear demarcation visible in the center and no vascular traffic branches. There were two amniotic sacs separated by two layers of amniotic membrane and two layers of chorionic villi(\u003cstrong\u003eFig.1\u003c/strong\u003e). The neonate was referred to the neonatal unit for treatment of preterm labor, no significant complications were found and was processed for discharge after 15 days of treatment with a discharge weight of 2110 g. The mother was discharged from the hospital 3 days after delivery. The neonate has been followed up to date with good physical and mental development, and the toddler currently weighs 10.1 kg, which is the normal developmental level for a child of the same age.\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eDIDT is a specific complication of twin pregnancies and proper clinical management can improve the survival rate of the second fetus. A review of the history of DIDT has found that DIDT effectively prolongs the gestational age of the delivered fetus and reduces neonatal morbidity and mortality after birth\u003csup\u003e[5]\u003c/sup\u003e. DIDT may be the best chance of achieving a viable foetus in a twin pregnancy following elective reduction.There is a lack of support for DIDT in large sample size studies. The results of this case suggest that the use of DIDT may prolong the gestational age of the second foetus. In clinical practice, the DIDT option can be implemented for those pregnant women for whom it is appropriate, after adequate communication with the pregnant women and family.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConditions for delayed labour.\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThere is a risk of serious maternal and fetal infection during DIDT. Patients and their families should be informed of the risks and disadvantages and the decision should be carefully assessed. DIDT must be strictly indicated: 1.vaginal delivery of the first fetus; 2.intact membranes and good intrauterine condition of the delayed fetus; and absence of fetal distress, placental abruption, amniotic cavity infection or other maternal factors detrimental to the continuation of the pregnancy\u003csup\u003e[5]\u003c/sup\u003e. There are no anastomosing vessels between the placentas of double chorionic double amniotic, and the intrauterine death of one of the fetuses does not usually adversely affect the other due to vascular traffic factors\u003csup\u003e[6]\u003c/sup\u003e.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eGestational age\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eFor the gestational age at which DIDT can be performed, Arabin et al. found that delayed delivery of the second child was associated with better perinatal outcomes if the first child was delivered between 20 and 29 weeks of gestational age\u003csup\u003e[7]\u003c/sup\u003e. Cheung et al. suggested that delayed deliveries should be performed at 13-31 weeks\u003csup\u003e[5]\u003c/sup\u003e.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eIn this case, the first delivery was at 28 weeks of gestation, and the contractions gradually disappeared after delivery and the uterine opening retracted, making it possible to delayed-interval delivery(DID).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eChorionicity\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eIt is contraindicated for monochorionic single-parented twins, and it is controversial whether delayed pregnancy can be performed in monochorionic twin sheep twins. It has been suggested that brain damage may occur in the other fetus after delivery of one of the monochorionic twins, but good outcomes after delayed-interval delivery of monochorionic twin sheep twins have been reported\u003csup\u003e[8]\u003c/sup\u003e, although the number of cases is of course small and the need to try them requires further discretion.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eClinical treatment\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEmphasis on the importance of preventing infection\u003c/strong\u003e.\u003c/p\u003e\n\u003cp\u003eDuring DID, intrauterine infection is an important factor in determining the ability to continue to extend the gestational week. Once chorioamnionitis occurs, it can be very dangerous and the pregnancy must be terminated immediately.\u003c/p\u003e\n\u003cp\u003eThe first step is to tightly disinfect the vagina and cervix and then ligate the umbilical cord of the first fetus using absorbable suture as high as possible, cutting it below the ligature near the upper end of the cervical canal while the placenta of the aborted or premature foetus remains in the cavity.Then the prophylactic antibiotics should be administered to prevent infection. At the same time, before and after ligation of the umbilical cord, cultures of aerobic and anaerobic bacteria plus sensitivity tests of the vaginal and cervical canal secretions are performed and antibiotics are adjusted according to the results of the cultures in order to control the infection more effectively. Avoid vaginal examination as much as possible to minimize the chance of infection.\u003c/p\u003e\n\u003cp\u003eIn this case, they first used empirical broad-spectrum antibiotics, followed by timely adjustments according to the results of drug sensitization, stopping the drug after one course of antibiotic application, monitoring vital signs, indicators of infection, and intermittent application of antibiotics,which greatly reduced the risk of intrauterine infection and chorioamnionitis, as well as the risk of drug-resistant and fungal infections associated with prolonged use of antibiotics.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eUse of contraction-inhibiting drugs: prophylactic or on-demand\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAn important therapeutic measure to DID is to suppress contractions. Some studies have shown that contraction suppressants are routinely used by 75% of doctors after the delivery of the first child and 25% in the presence of persistent contractions\u003csup\u003e[5]\u003c/sup\u003e.\u003c/p\u003e\n\u003cp\u003eMagnesium sulfate is routinely used as a protective agent for the fetal central nervous system in patients with preterm labor before 32 weeks. Since magnesium sulfate also inhibits contractions, it may be considered the first choice if not contraindicated to reduce the incidence of distant neurologic complications, the risk of distant cerebral palsy and severe motor dysfunction in the newborn\u003csup\u003e[9]\u003c/sup\u003e.\u003c/p\u003e\n\u003cp\u003eIn this case, considering the persistent irregular contractions after the delivery of the first fetus, atosiban was given to suppress the contractions for one course of treatment, and magnesium sulfate was given simultaneously to protect the fetal cerebral neural development up to 48 hours.Monitor contractions closely and use contraction inhibitors intermittently until the pregnancy and fetus are stabilized.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eUse of cervical cerclage.\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe need for cervical cerclage in the management of DID remains controversia. Advantages of cervical cerclage: maintains cervical stability and provides mechanical support; reduces exposure of fetal membranes to intravaginal flora and acidic environment, reduces risk of chorioamnionitis and premature rupture of immature membranes\u003csup\u003e[10]\u003c/sup\u003e. Risks of cervical cerclage: invasive procedures that increase the risk of maternal infection, chorioamnionitis and premature rupture of membranes\u003csup\u003e[11]\u003c/sup\u003e.\u003c/p\u003e\n\u003cp\u003eIn this case,considering that she had no history of cervical insufficiency, and the cervical os was naturally closed without amniotic sac protrusion after delivery of the first fetus, and a gestational age of 28 weeks, the patient did not undergo cervical cerclage.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003ePromotion of fetal lung maturation\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eMost recommend the use of glucocorticoids at 24-34 weeks of gestation for those at risk of preterm labour, with the best benefit for delivery within 48 hours to 7 days after use, to help improve neonatal outcome. Some recommend glucocorticoids for fetal lung maturation from 24 weeks, with a repeat course at around 28 weeks' gestation. Glucocorticoids may be reused for more than 2 weeks after the previous lung maturation treatment, up to a maximum of two lung maturation treatments\u003csup\u003e[12]\u003c/sup\u003e.\u003c/p\u003e\n\u003cp\u003eIn this case, during the course of the disease, the patient completed two treatments to promote fetal lung maturation.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eInpatient or outpatient follow-up; Maternal and fetal monitoring.\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAs most DID failures occur within a week of delivery of the first fetus, hospitalisation for observation for at least 7 days is generally recommended and outpatient treatment may be considered once the condition has stabilised. Long-term hospitalization is not recommended\u003csup\u003e[13]\u003c/sup\u003e. When DID occurs, monitoring of the mother and retained fetus should be intensified.\u003c/p\u003e\n\u003cp\u003eIn this DIDT case, the patient was anxious and the fetus was precious, so she refused to be discharged from hospital. The woman underwent weekly ultrasound examinations, the fetus was in good condition. Tests for inflammatory markers and coagulation were performed every two days, with no significant inflammatory response and coagulation abnormality, and several cultures of cervical secretions were performed with no bacteria.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003ePregnancy outcomes\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eCommon intrapartum and postpartum complications are chorioamnionitis, placental abruption and postpartum haemorrhage\u003csup\u003e[5]\u003c/sup\u003e. No maternal deaths have been reported so far.\u003c/p\u003e\n\u003cp\u003ePablo et al. followed up two newborns who underwet DID born after 28 weeks for 2 years, and both children showed no significant sequelae and had satisfactory cognitive and neurologic development\u003csup\u003e[14]\u003c/sup\u003e. The number of cases in this group is small and requires long term follow up. Despite the improvement in neonatal salvage, complications related to gestational age in preterm infants are still difficult to avoid, so our technique needs to be used in appropriate cases.\u003c/p\u003e\n\u003cp\u003eFortunately, this pregnant woman did not experience premature rupture of membranes, intrauterine infection, placental abruption. And we had been following this child for more than two years, and she had the same intellectual and motor skills as her peers, and was able to live and study normally as her peers.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eDIDT is rare, and there is a lack of statistical analysis of large samples globally,and there is no consensus on this. DIDT is an attempt to obtain a viable foetus in twin pregnancies, but there is still a risk that a child with severe morbidity and disability will be left behind.Therefore, it is important to come up with an individualised plan that is appropriate to the patient\u0026apos;s situation, and after the couple has discussed and made a decision, the obstetrician will do everything possible to help the patient.\u0026nbsp;\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cp\u003eDIDT: Delayed-interval delivery of the twin\u003c/p\u003e\n\u003cp\u003eDID: Delayed-interval delivery\u0026nbsp;\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eAcknowledgements\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot Applicable\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthor information\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors and Affiliations\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNorthern Jiangsu People\u0026apos;s Hospital Affiliated to Yangzhou University, Yangzhou, 225001, China\u003c/p\u003e\n\u003cp\u003eYanxin Zhang, Xinlu Fu, Yingyan Gu, Dan Lu\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCorresponding author\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eCorrespondence to Dan Lu.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors\u0026rsquo; contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll authors contributed to the conceptualization and design of the study.Yanxin Zhang and Xinlu Fu collected and analyzed the case, and designed, planned, wrote the manuscript. Yingyan Gu collected the clinical data and revised the manuscript. Dan Lu made useful critique of this manuscript and revised the manuscript. All authors read and approved the fnal manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eEthics approval and consent to participate were authorized by the ethical committee of Northern Jiangsu People\u0026apos;s Hospital.(2022ky343).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWritten informed consent was obtained from the patient for publication of this case report.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors report no confict of interests.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eYangZhou Municipal Science and Technology Bureau, YZ2017075\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and material\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot Applicable\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCode availability\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot Applicable\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eACOG Practice Bulletin No. 144: Multifetal gestations: twin, triplet, and higher-order multifetal pregnancies[J]. Obstet Gynecol, 2014, 123(5): 1118-1132. http://doi.org/10.1097/01.AOG.0000446856.51061.3e\u003c/li\u003e\n\u003cli\u003eGardner M O, Goldenberg R L, Cliver S P, et al. The origin and outcome of preterm twin pregnancies[J]. Obstet Gynecol, 1995, 85(4): 553-7.http://doi.org/10.1016/0029-7844(94)00455-m\u003c/li\u003e\n\u003cli\u003eFeys S, Jacquemyn Y. Delayed-interval delivery can save the second twin: evidence from a systematic review[J]. Facts Views Vis Obgyn, 2016, 8(4): 223-231\u003c/li\u003e\n\u003cli\u003eHjort\u0026oslash; S, Nickelsen C, Petersen J, et al. The effect of chorionicity and twin-to-twin delivery time interval on short-term outcome of the second twin[J]. J Matern Fetal Neonatal Med, 2014, 27(1): 42-7. http://doi.org/10.3109/14767058.2013.799657\u003c/li\u003e\n\u003cli\u003eCheung K W, Seto M T Y, Wang W, et al. Effect of delayed interval delivery of remaining fetus(es) in multiple pregnancies on survival: a systematic review and meta-analysis[J]. Am J Obstet Gynecol, 2020, 222(4): 306-319.e18.http://doi.org/10.1016/j.ajog.2019.07.046\u003c/li\u003e\n\u003cli\u003eBlickstein I, Perlman S. Single fetal death in twin gestations[J]. J Perinat Med, 2013, 41(1): 65-9. http://doi.org/10.1515/jpm-2012-0019\u003c/li\u003e\n\u003cli\u003eArabin B, Van Eyck J. Delayed-interval delivery in twin and triplet pregnancies: 17 years of experience in 1 perinatal center[J]. Am J Obstet Gynecol, 2009, 200(2): 154.e1-8. http://doi.org/10.1016/j.ajog.2008.08.046\u003c/li\u003e\n\u003cli\u003eBaltus T, Martin M L. Successful delayed-interval delivery in monochorionic diamniotic twin pregnancy: A case report[J]. Case Rep Womens Health, 2019, 21: e00093.http://doi.org/10.1016/j.crwh.2018.e00093\u003c/li\u003e\n\u003cli\u003eCommittee Opinion No 652: Magnesium Sulfate Use in Obstetrics[J]. Obstet Gynecol, 2016, 127(1): e52-e53. http://doi.org/10.1097/aog.0000000000001267\u003c/li\u003e\n\u003cli\u003eReinhard J, Reichenbach L, Ernst T, et al. Delayed interval delivery in twin and triplet pregnancies: 6 years of experience in one perinatal center[J]. J Perinat Med, 2012, 40(5): 551-5. http://doi.org/10.1515/jpm-2011-0267\u003c/li\u003e\n\u003cli\u003eBenito Vielba M, De Bonrostro Torralba C, Pallares Arnal V, et al. Delayed-interval delivery in twin pregnancies: report of three cases and literature review[J]. J Matern Fetal Neonatal Med, 2019, 32(2): 351-355. http://doi.org/10.1080/14767058.2017.1378336\u003c/li\u003e\n\u003cli\u003eLouchet M, Dussaux C, Luton D, et al. Delayed-interval delivery of twins in 13 pregnancies[J]. J Gynecol Obstet Hum Reprod, 2020, 49(2): 101660. http://doi.org/10.1016/j.jogoh.2019.101660\u003c/li\u003e\n\u003cli\u003ePorreco R P, Sabin E D, Heyborne K D, et al. Delayed-interval delivery in multifetal pregnancy[J]. Am J Obstet Gynecol, 1998, 178(1 Pt 1): 20-3. http://doi.org/10.1016/s0002-9378(98)70620-9\u003c/li\u003e\n\u003cli\u003ePadilla-Iserte P, Vila-Vives J M, Ferri B, et al. Delayed interval delivery of the second twin: obstetric management, neonatal outcomes, and 2-year follow-up[J]. J Obstet Gynaecol India, 2014, 64(5): 344-8.http://doi.org/10.1007/s13224-014-0544-1\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"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":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Delayed-interval delivery, twin pregnancy, Maternal morbidity, Neonatal morbidity, Neonatal mortality","lastPublishedDoi":"10.21203/rs.3.rs-5468878/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-5468878/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003eTo explore the diagnosis and clinical management of delayed-interval delivery of the twin and the near- and long-term outcomes of mother and fetus.\u003c/p\u003e\u003ch2\u003eCase presentation\u003c/h2\u003e \u003cp\u003eA 31-year-old pregnant woman was admitted to the hospital on March 23, 2022 due to \u0026ldquo;28 weeks of menopause with spontaneous vaginal discharge of tissue for 2 hours\u0026rdquo;. On March 26, 2022 a stillborn fetus was delivered. After delivering a stillborn fetus, the patient was immediately given high ligation of the umbilical cord, antibiotics to prevent infection, atosiban to inhibit contractions, magnesium sulfate to protect the fetal cerebral nerves, and hospitalized to closely monitor the condition of the mother and the other fetus, successfully delivering a baby girl vaginally at 34\u0026thinsp;+\u0026thinsp;2 weeks, and no significant complications have been observed in both mother and baby by the two-year follow-up.\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e \u003cp\u003eDelayed-interval delivery of the twin(DIDT) is a specific complication of twin pregnancies, and proper clinical management can improve the survival of the second fetus. Delayed-interval delivery(DID) may effectively prolongs the gestational age of the delivered fetus and reduces neonatal morbidity and mortality after birth.\u003c/p\u003e","manuscriptTitle":"Give the “Little Double” A Little Bit More Time ----Discussion on Delayed-Interval Delivery of the Twin: A Case Report","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-12-19 11:10:35","doi":"10.21203/rs.3.rs-5468878/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"b1ad68d9-2e55-4f58-ac21-7db7c8814316","owner":[],"postedDate":"December 19th, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2024-12-28T18:08:19+00:00","versionOfRecord":[],"versionCreatedAt":"2024-12-19 11:10:35","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-5468878","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-5468878","identity":"rs-5468878","version":["v1"]},"buildId":"qtupq5eGEP_6zYnWcrvyt","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}