In a first for Africa, baby receives spinal surgery while in utero
“Wits University’s Professor Ermos Nicolaou, Specialist Obstetrician and Gynaecologist, and Specialist in Maternal and Foetal Medicine, in collaboration with a team of international experts, led by Prof Michal Belfort from the United States, performed spinal surgery on an unborn foetus with spina bifida at around 25weeks”.
Foetal surgery in South Africa has taken a step into the future, as a team of experts worked together to help repair a spinal defect in an unborn baby.
Spina bifida is a birth defect that affects the neural tube. Usually, the neural tube forms early on in the development of a foetus, and closes by the 28th day after conception – but for children with this condition, the neural tube fails to develop or close properly. This abnormality causes significant defects in the spinal cord and vertebrae.
Until now, parents whose babies were diagnosed with spina bifida during the pregnancy could either choose to terminate the pregnancy or to have the baby at term and undergo a series of operations after delivery to repair the defect on the spine, the brain and the feet. Often the damage to the nerves is irreversible and these children are wheelchair bound. Urinary and faecal incontinence and impotence in males are common problems associated with spina bifida.
In-utero surgery provides the parents with an additional option where a repair can be performed before the baby is born. The advantage of this approach is the repair of the defect before the damage is severe and irreversible.
Antenatal in-utervo surgery to correct spina bifida-related defects involves intricate surgery. This kind of operation requires considerable expertise and involves a team of experienced clinicians ranging from Maternal and Foetal Medicine to experts in Neurosurgery, Anaesthesiology, Neonatology and Specialized Neonatal ICU care. The operation also requires state-of-the-art surgical theatre facilities.
The Centre for Foetal Surgery at the Mediclinic Morningside is home to a range of such experts, and forms part of the Wits Maternal and Foetal Medicine Centre.
For the operation we were joined by Professor Michael Belfort and his team from the Texas Childrens Hospital, Baylor College of Medicine, United States, who have been pioneers in the field of foetal surgery and in particular, the repair of spina bifida in utero.
Prof Michael Belfort is the Chairman and Professor of the Department of Obstetrics and Gynecology Baylor College of Medicine.
One big advantage with the antenatal repair of spina bifida in utero is that we may be able to stop the inflammatory process that typically leads to damage of the nerves and a range of potential abnormalities. The repair in utero, if successful, may actually be the only surgery that is needed. The neurodevelopmental handicap may be less severe and the overall prognosis may improve dramatically. As the operation is performed through tiny instruments through the uterine wall and not by 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.
The aim of this particular surgery is to achieve a successful operation with full recovery, minimal complications and no need to perform further operations on the baby after the birth.
One needs to be aware of the risks that are associated with antenatal surgery such as the immediate risk of preterm delivery of the baby. After the immediate postoperative period, close monitoring of both the mother and foetus until delivery is 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 specifically is around 1 per 1500 pregnancies. We have around a million live births in South Africa every year, so we are looking at around 650 new cases of neural tube defects every year. Our vision is to expand our foetal surgery services to correct other severe foetal abnormalities as well.
Specialists and surgeons will be able to offer surgery to correct defects in the heart, lungs, abdomen, kidneys and bladder. These procedures should only be performed if the foetal abnormality is so severe that it may lead to foetal death or severe handicap.
For this program to be successful it is important to create the necessary awareness among doctors and the South African public. Every foetal abnormality will need to be assessed carefully and the parents should be offered extensive counselling. Carefully selected cases will be offered the option for in-utero operation.
Over the past fifteen years we have performed a number of in utero procedures on foetuses at the Mediclinic Morningside and at the Chris Hani Baragwanath Academic Hospital with great success.
This is the next step in the evolution of foetal surgery in our country.
Prof Ermos Nicolaou
Wits Maternal and Foetal Medicine Unit
Chris Hani Baragwanath Hospital and Morningside Mediclinic