In utero spinal surgery on 25 week foetus – a first in Africa

On Saturday, 13 April 2019, Prof Ermos Nicolaou, Specialist Obstetrician and Gynaecologist and Specialist in Maternal and Foetal Medicine, and his team at Mediclinic Morningside is working with a team of international experts, led by Prof Mike Belfort from the United States, to perform spinal surgery on a foetus who has Spina Bifida. This is the first time such surgery will be performed in Africa.

According to Prof Nicolaou, Academic Head: Wits Maternal and Foetal Medicine Centre and Mediclinic Morningside, “The gestational age at the time of the operation will be around 25 weeks.” Spina Bifida is an abnormality in the development of the foetal spine where part of the vertebrae that form the neural tube fails to close properly. The defect and the subsequent ‘exposure’ of the nerves that run inside the neural tube leads to damage of the nerves and neurological damage.

This kind of 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. The operation is delicate and complex and requires accurate assessment of the condition, expertise to perform this delicate operation and state of the art theatres where such surgery can be performed safely. These operations can only be performed in centres where the theatre facilities and a team of experts are available – in this case Mediclinic Morningside in Johannesburg.

Prof Belfort is leading the team of experts that, together with the South African team, will be performing the operation on the foetus with Spina Bifida. Prof Belfort and his team have been the pioneers in the field of Foetal Surgery and in particular in the repair of Spina Bifida in utero. The team of experts from South Africa that form part of the Centre for Foetal Surgery that is based at the Mediclinic Morningside will equally consist of top experts in the fields of Maternal and Foetal Medicine, Neurosurgery, Neonatology/Paediatric Neurology and Anaesthesiology.

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

Prof Nicolaou explains the particular decision making process to arrive at the point of surgery, “Parents can choose to terminate the pregnancy or to 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.”

Prof Nicolaou believes that the repair of Spina Bifida in utero may stop the inflammatory process that leads to the damage of the nerves and the potential abnormalities listed below. 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 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.

There is a caution before such surgery is performed. “One needs to mention that 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,” says Prof Nicolaou.

On Saturday, there will be two teams in theatre. Prof Belfort’s team will be the leading operating team and the South African counterparts will assist in the operation. The long-term vision is to perform this and other in-utero operations in South Africa.

The aim of this particular surgery is to have a successful operation with full recovery, minimal complications and no need to perform any further operations after the birth of the baby. The operation is performed at around 25 weeks and an immediate risk is preterm delivery of the baby. 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.

According to Prof Nicolaou, “The overall incidence of Neural Tube Defects and Spina Bifida is around 1 per 1000 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.”

“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 will lead to foetal death or severe handicap,” he continues. “Over the past fifteen years we have performed a number of in utero procedures on foetuses at Mediclinic Morningside with great success. This is now the next step in the evolution of foetal surgery in our country.”

“For this programme to be successful it is important to create the necessary awareness among the doctors and the South African public. Every foetal abnormality will need to be assessed carefully and the parents will be offered extensive counselling. Carefully selected cases will be offered the option for in-utero operation,” concludes Prof Nicolaou.