Doctors in JHB perform a medical first in Africa

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In a first for the continent, an expert team of doctors in Joburg has successfully performed spinal surgery on a foetus who has spina bifida, an abnormality in the development of the spine. Specialist obstetrician and gynaecologist and specialist in maternal and foetal medicine, Professor Ermos Nicolaou, and his team at Mediclinic Morningside worked with a team of international experts, led by Professor Mike Belfort from the US, to perform the spinal surgery on the 25-week-old foetus on Saturday. Spina bifida is an abnormality in the foetal spine where part of the vertebrae that form the neural tube fail to close properly. The defect and the subsequent “exposure” of the nerves that run inside the neural tube lead to damage of the nerves and neurological damage. The delicate and complex operation requires considerable expertise and involves a team of experienced clinicians ranging from maternal and foetal medicine to neurosurgery, anaesthesiologists, neonatologists and specialised neonatal ICU care. Belfort and his team have been pioneers in the field of foetal surgery and in particular in the repair of spina bifida in utero.

As was the case of this particular patient, identifying the problem during the pregnancy empowered the prospective parents to inform themselves about the condition and enabled them to make an informed decision about the way forward.

Nicolaou said parents could choose to terminate the pregnancy or have the baby and have a number of surgeries after delivery to repair the defect on the spine, the brain and the feet, and take measures to improve the problem of incontinence.

“The in-utero surgery will provide them with an additional option where a repair can be performed before the baby is born,” he said.

Nicolaou believes that the repair of spina bifida in utero may stop the inflammatory process that leads to the damage of the nerves and potential abnormalities.

As the operation is performed with tiny instruments through the uterine wall and by not cutting the uterus open, the recovery period is a lot faster and the patient may go on to have a normal vaginal delivery if she wishes. “This is a very delicate surgery and the success varies.

In utero laparoscopic repair can also have complications such as foetal death or premature labour. Careful evaluation and selection of these cases is very important,” Nicolaou said.

After the immediate post-operative period, close monitoring of both the mother and foetus until delivery will be mandatory. Once the baby is born, the neurosurgeon who was a member of the operating team will assess the baby and decide if further corrective procedures will be required.

“The overall incidence of neural tube defects and spina bifida is around 1 in 1 000 pregnancies. We have around 1 million live births in South Africa every year, so we are looking at around 1000 new cases of neural tube defects every year in our country.

“Our plan is to expand our foetal surgery service to other abnormalities as well,” Nicolaou said.

“A few examples of what the team would be able to offer are operations on the heart, lungs, abdomen, kidneys and bladder. “One has to be very clear that operations on foetuses will only be considered if the foetal abnormality is so severe that it will lead to foetal death or severe handicap,” Nicolaou said.

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