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Rarely used procedure results in twins born 24 days apart

When Lindalva DaSilva’s unborn twins were in danger, doctors performed a rare and risky procedure — delivering one twin while giving the other more time to keep growing

Lindalva DaSilva with her twins, Ronaldo and Alexandre Antunes, in the neonatal intensive care unit at Tufts Medical Center in Boston.

Jessica Rinaldi/Globe Staff

Lindalva DaSilva with her twins, Ronaldo and Alexandre Antunes, in the neonatal intensive care unit at Tufts Medical Center in Boston.

Lindalva DaSilva, 35, had always wanted to be a mother, so she was thrilled when an ultrasound revealed she was pregnant with twins. But when she went into labor on Feb. 27 — nearly four months before her due date — DaSilva was frightened.

At Tufts Medical Center, doctors injected her with magnesium sulfate in an attempt to calm her contractions — babies born at 24 weeks often don’t survive. But after four days, it was clear they could not hold off the birth any longer.

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Before bringing DaSilva to the delivery room, Dr. Sabrina Craigo mentioned a rarely used strategy that might improve the odds for one of the babies. If conditions were right, they could deliver one twin, and then try to keep the second twin inside his mother — hopefully for days or even weeks.

There were potential dangers to DaSilva, including the risk of infection. But the benefits of giving the second twin more time to develop were great. The conditions turned out to be perfect. DaSilva gave birth to Alexandre R.P. Antunes at 11 a.m. and then her labor slowed. Doctors gave antibiotics to DaSilva and moved her back to her room. As Alexandre fought for his life on a ventilator, doctors hoped to spare his twin brother the same struggle.

In one of the most successful delayed twin deliveries Boston doctors can recall, Ronaldo F. P. Antunes was born 24 days later. Fortunately, Alexandre survived his early birth. As of last week, both twins continued to recover in the hospital’s neonatal intensive care unit.

“One twin was born in winter, and one was born in spring,’’ said DaSilva with tears in her eyes, as Alexandre rested on her chest. The boys’ father, Ronaldo Antunes, 40, held Ronaldo. The couple, both from Brazil, met at Muqueca, a popular Brazilian restaurant in Cambridge.

Delayed twin deliveries are so rare they are not closely counted. In the journal Obstetrics & Gynecology, two large medical centers in Virginia and Tennessee reported just 14 cases over 12 years, out of 96,922 deliveries.

‘The only time it makes sense to do it is if the prognosis is poor for the second baby if it’s born.’

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“The only time it makes sense to do it is if the prognosis is poor for the second baby if it’s born,’’ said Dr. Steven Ralston, director of Maternal-Fetal Medicine at Beth Israel Deaconess Medical Center.

The strategy is only considered with fraternal twins, who have their own amniotic sacs and don’t share a placenta. And the mother’s contractions have to abate after the first baby is born.

“When you have a situation where one baby is born and labor stops, you are given this window of opportunity,’’ Ralston said. “But it’s a rare window. Most times, labor does not stop.’’

When it does, the benefits to the second-born twin can be significant. An analysis of 200 twin pregnancies found that one-year survival rates for second-born twins whose births were delayed was 56 percent. That compared to 24 percent for twins who were delivered at about the same time as their very premature sibling.

However, another study found that eight of 24 mothers with delayed twin deliveries had postpartum infections requiring antibiotic therapy, and other doctors have reported cases of serious sepsis.

That’s partly why Dr. Jeffrey Ecker, a specialist in maternal fetal medicine at Massachusetts General Hospital, has never performed a delayed twin delivery in his 18 years of practice. “It’s a big deal to do, and has to be undertaken with great caution,’’ he said. “I’ve never had the appropriate circumstance and I’d be very leery about the risks to the mother.’’

In some cases, doctors stitch the mother’s cervix closed to help keep the baby inside, which carries a risk that contractions could tear the tissue, he said. Craigo, chief of Maternal-Fetal Medicine at Tufts, said she is reluctant to take that step, and that it was not necessary in DaSilva’s case.

Craigo said she has done fewer than 10 delayed twin births over the last two decades, but never with both as much time between deliveries as with DaSilva, and when both babies survived.

Even before she went into premature labor, DaSilva and Antunes traveled a bumpy road to parenthood. The couple met at the restaurant where she is a waitress and he was a regular weekend customer. They began dating seriously five years ago.

While DaSilva eagerly anticipated becoming a mother, Antunes, a catering driver for Harvard University, has a daughter and a son from previous relationships, and did not want more children. They broke up for six months, but then last May, Antunes came around. DaSilva got pregnant almost immediately.

“Let’s talk,’’ Antunes said one night. “This is it. Only one.’’

A week later, DaSilva returned to their Somerville apartment after the first ultrasound. “Guess what?’’ she said. “Are you ready?’’

“It’s two?!’’ Antunes responded, starting to cry.

“It was so heavy in my chest,’’ he said during an interview. “She was so happy.’’

When her water broke on Feb. 26, DaSilva’s obstetrician at Cambridge Health Alliance sent her by ambulance to Tufts. In addition to labor-slowing drugs, doctors gave her steroids to speed the growth of her babies’ lungs. After Alexandre was born, doctors were nervous about keeping the second twin inside his mother and at first ordered DaSilva on bed rest.

“I was afraid, to be honest,’’ DaSilva said. “But they were optimistic.’’

DaSilva rode in a wheelchair to visit Alexandre in the ICU. “We weren’t sure he was going to make it,’’ said Dr. Jonathan Davis, chief of Newborn Medicine.

After a few days, DaSilva was allowed to walk, but she still could not leave the hospital. They worried that Alexandre’s precarious hold on life would put DaSilva under so much stress that it could send her into labor. “We gave her the information but we tried to stay positive,’’ Davis said.

On March 26, DaSilva began having contractions again. Ronaldo was born at 28 weeks, 1 day.

Doctors at Tufts said only time will tell whether the twins experience significant developmental delays, and if Alexandre has more problems than his younger brother. Right now, he is only a pound lighter than his 6-pound, 13-ounce later-born twin. And both brothers are breathing normally and are starting to drink from a bottle and breast-feed.

One day last month, the twins wore identical blue and white striped outfits in the ICU. But DaSilva said she won’t dress them alike routinely. She wants them to develop their own personalities — which they seem to be doing already. While Ronaldo is mellow with a soft cry, Alexandre wails when he’s hungry and is feisty, perhaps because he had to be to survive.

Dr. Geoffrey Binney Jr., associate chief of Newborn Medicine at Tufts, said he hopes the twins will be ready go go home about the time of their original due date, June 18.

“They are doing great,’’ he said.

Related:

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Babymoon on the horizon?

Liz Kowalczyk can be reached at kowalczyk@globe.com.
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