Professor Ermos Nicolaou

RMB Solutionist Thinking
Ermos Nicolaou

Bruce Whitfield: Today's guest is Professor Ermos Nicolaou. He is the Academic Head at Wits Maternal and Foetal Medicine Centre. He’s an unusual Solutionist Thinker or maybe not so unusual… He is a problem solver. And, he is a problem solver of problems that occur before we're even born and what Professor Ermos Nicolaou has done is broken huge barriers in the care and treatment of unborn babies.

In April this year, he collaborated with a team of international experts to perform spinal surgery on an unborn foetus with Spina Bifida. It’s the first time on the African continent that this type of surgery had been attempted.

“The feeling of enabling a child to actually have a reasonable life, almost normal life. That for me is priceless. That's exactly what we have been doing with our lives. And that's exactly what the aim was of this surgery.”

I’m Bruce Whitfield and you're listening to RMB Solutionist Thinking.

Bruce Whitfield: Is the little baby born yet, Ermos?

Professor Ermos Nicolaou: No, the baby is now 7 weeks after surgery, he’s about 33 weeks. I saw the mom and baby yesterday and they're both doing. Well, obviously the baby's still inside the mom's tummy and hopefully we'll be able to go to full term sometime beginning of July, expected date of delivery.

Bruce Whitfield: What is Spina Bifida? Why is it such a threat to a foetus and to giving that child a normal life?

Professor Ermos Nicolaou: Yes, well. Spina Bifida is an abnormality that obviously happens in utero when the baby is developing. It happens quite early actually and the earliest, we can see Spina Bifida is probably from about 12, 13 weeks. Spina Bifida is a Latin name, means basically an opening of the spine that allows exposure of the baby's little nerves to the amoebic fluid that causes actually, damage to those nerves and whatever is below the Spina Bifida, usually the legs, the bladder, things like that, then become affected. There are various degrees of severity, but by and large Spina Bifida is a bad condition to have.

Bruce Whitfield: What are the sort of, birth issues? I mean, when a child is born with Spina Bifida are they likely then to be confined to a wheelchair for the rest of their lives? I mean, what are the consequences of being born with Spina Bifida?

Professor Ermos Nicolaou: Yes, the commonest problem, of course is being wheelchair-bound. They're unable to use their legs. So at least they're only partly able to use their legs. There’s stool incontinence, urinary incontinence, issues with impotence and infertility. But of course, the spine is connected to the rest of the body and to the brain as well. So, there are problems with the brain as well water accumulation in the brain, something called Hydro Cephalus… water head, there's a need sometimes to put a drain inside the baby's brain to drain the excess fluid. So, it's a complex situation never mind the psychological aspects in the psychological stress from both parents and the child with such a problem.

Bruce Whitfield: And, I suppose 10 years ago when the diagnosis was available and you could do a scan and you would pick up a problem, you would then offer the parents the option saying, you are welcome to carry this pregnancy to term but here's the consequence of doing so and in many cases parents may have chosen to abort the foetus and, say rather than bring this child into the world when the consequences would be so devastating. Suddenly that prognosis changes dramatically because if you can fix the problem in the womb, the child has got a far better chance of having a normal life.

Professor Ermos Nicolaou: Yeah, absolutely. Until now it was, we make the diagnosis and we sit and, discuss the problem with the parent and say okay. These are the two options termination of the pregnancy or you are cutting with the pregnancy as is and the neurosurgeons will then have a look and try and repair the problem after birth. The problem of course is some of this damage can become irreversible and the longer the exposure, the longer, the opening if you wish, into them amoebic fluid causes more severe damage and obviously most severe handicap. So, this alternative that we now have to go in and try and repair the problem 25, 26 weeks will make a difference in terms of the severity of the condition.

Bruce Whitfield: I mean, it's complicated enough carrying out an operation on a new born baby or on a two-year-old baby. I mean, this is a tiny little body and, you can use anaesthetics and all of those sorts of things. It's done all the time, but the added complexicity of going through the stomach wall of the mother and then into her into her womb and then, operating on the child is beyond my comprehension. Take me, in simple terms, if you can through that process.

Professor Ermos Nicolaou: Look, first of all, you need to get the parents to obviously, think about its extensive counselling is important. They need to understand what it means to have a child with Spina Bifida. What are the options available and they need time sometimes to digest the news. In our case, we had made the diagnosis at around 21 weeks. So, there was plenty of time to think about it and make a decision because we wouldn't really operate on the baby before 25, 26 weeks. The reason for that is if things go wrong and we need to bail out, the baby is not happy with what we're doing and sometimes we need to deliver at least the baby may have a good chance to survive after delivery. Before that, you know, it wouldn’t stand a chance of survival.

So, once this is done and the parents are happy to go ahead then obviously, the long process of planning starts. In our case, we collaborate with a Texas Children's Hospital with Professor Mike Belfort, whose an ex-South African. We have been collaborating for a number of years on various levels, but the idea was to bring actually our foetal surgery program at Wits and at the Morningside Clinic to the next level. So, what we're looking for a suitable candidate and when I say suitable candidate, we see lots of abnormalities but not every abnormality is amenable to surgery and to repair. This particular baby was just right for what we were looking for. In other words, the spine was normal, just open and therefore the task was to try and close that defect at the at the back and try and optimize outcome.

Now, the surgery itself. It's complex. And it took I think overall about six and a half hours to get through the whole process obviously wasn't all operating on the baby. There's a little preparation before you get to the baby. But essentially what we did we open the timing of the mom like we would do in a normal society Nation, but we didn't open the uterus, the uterus, the womb remains closed and we then insert scopes, little telescopes but three millimetres in diameter to… look obviously, all these things are done after we have already assessed the baby or an ultrasound. We have assessed the extent of the damage we know exactly how big it is. So, and we have made some preparations but, on the day, we put our scopes in we went to exactly where we knew there was a problem and with the help of a neurosurgeon, so just to stop here for a second.

We had two teams, Bruce. We had a team from Texas. It had a South African team, experts, who had a neurosurgeon from South Africa and in Euro signal from the state's the Maternal Foetal Medicine specialist, Mike Belfort from Texas and myself and, we had the anaesthetists and then ornithologist on standby, just in case. So, we then identified the problem, we cleared the area because there are new skins a little membranes covering the Spina Bifida, we clear the area and they would put a special membrane a special patch that is very sort of body friendly, it's a collagen kind of patch to cover the defect and then slowly bit by bit, we close the skin above the Spina Bifida to achieve a water-tight enclosure.

Bruce Whitfield: I mean, you say it… I've had I've had mechanics more stressed about doing work on a car engine of mine than you sound about the process of opening up a woman who is well on her way, she’s six months pregnant, you’re opening her up you then going through the into the womb your piercing the amniotic sac. And anybody who's ever been present within amniocentesis knows the stress of just a needle going through a mom's tummy and into the into the amniotic fluid just to draw for little bit of fluid to make sure that there isn't any defect there. But, you doing the surgery you're not communicating with people who are watching on screens 10,000 miles away, there are lots of dynamics here, there are lots of dynamics at play and yet you there to lives in your hands at that particular moment in time with a whole bunch of influences and stresses that an ordinary surgeon doesn't have to deal with it any moment.

Professor Ermos Nicolaou: Yeah, that's true. I must correct you here, Mike Belford actually was with us. Okay, and I'm imagining the video screens… Okay, obviously, you know the patient and her husband had plenty of time to get used to the idea. They did lots of research, you know, thank goodness for Google nowadays. They had the opportunity to speak to parents in Texas where the went through the same experience. They looked at video clips. They so little kids running around at the age of two and three, so they're familiarize themselves and although it was stressful, very stressful for all of us the knew it was the right thing to do certainly, you know provided you follow certain rules and you know, you plan it beforehand and you know, what is the next step, you know, it's a precise kind of process, you know, this is step one, you will secure the membranes because you say by putting a needle into the amniotic sac. You may cause damage you may separate the membranes. You may cause miscarriage or bleeding. So that's the one to stick to secure those membranes so that they don't separate special stitches you put there.

Bruce Whitfield: How about how life-changing is this for you as a professional somebody who's worked as an obstetrician, somebody who's worked all your career as a gynaecologist. This is such a new level of intervention in foetal abnormality and trying to rectify that foetal abnormality to give the child the best possible chance at having a comfortable a comfortable life, but that's it.

Professor Ermos Nicolaou: Isn't it? The feeling of enabling a child to actually have a reasonable life, almost normal life, that's for me is priceless. That's exactly what we have been doing with our lives. And that's exactly what the aim was of this surgery, but by creating this kind of excitement in this new techniques, obviously, we establish more collaborations with the overseas centres. We want to work with the other senses overseas. We create awareness of people in South Africa colleagues of ours want to know what's going on because that's collaboration is very important. We need you young doctors to say, hold on a second. I would like to do that and come and sit with us and learn with us because we need to leave a legacy behind us as well. But one day someone else will carry on doing this and that's all of the above actually

Bruce Whitfield: so when we look at it and at the possible applications, this is to deal with Spina Bifida, but there are a plethora of things, anybody who's ever been through a pregnancy understands just the stress of the excitement and all of these things but you're always second-guessing whether or not there's a problem the opportunity to fix problems in the womb is it's got to be far bigger than just Spina Bifida their multiplicity of applications. I'm sure

Professor Ermos Nicolaou: yeah, absolutely. That was the beginning of hopefully of many more exciting things to come we have been actually doing already procedures in utero. We have done many things from blood transfusions in sight the room where babies for example get blood transfusions through the umbilical cord to save them from developing severe. Anaemia, like in recess for example disease to putting little capillaries into their kidneys their bladders their chests to allow their lungs for example to expand so when the baby is born is able to breathe so we have been doing these things for a number of years now with good success, but this is a level up, this is now proper surgery where you actually would operate it on the baby like you would do with the babies born with a difference is that you do it much earlier and try and prevent irreversible damage.

Bruce Whitfield: There is also the decision to make as to whether to take the risk of doing it in utero or to allow the child to develop to his full close to term as possible allow the child to be born and then put the child through the trauma of surgery at that particular point and I'm from a parent's point of view. I wonder which is more traumatic.

Professor Ermos Nicolaou: Look we I said principal would never perform any surgery on a baby inside the womb just for the sake of it. So unbalanced. He has to be an abnormality that would cause severe handicap or death. So basically, there's only one way forward either to consider termination or allow the pregnancy to continue to full term but knowing that they will be irreversible damage or try and repair the problem before the baby's born and actually have a better outcome. So, these are really essentially the three questions that any prospective couple will have to answer isn't it.

Bruce Whitfield: and it comes down to economics all. So, is to what parents are able to afford what the Medical Aid will pay for you? Nobody wants to be faced with the choice of aborting a foetus that is seldom the intention of any couple trying to have a child but faced with an extraordinary crippling cost versus the possibility of rectifying an abnormality. It does ultimately come down to economics.

Professor Ermos Nicolaou: Yes, you're absolutely right. We're very fortunate in our country that people are willing to hear people are willing to go to the next step in this particular case. The medical aid that we asked if they will be prepared to pay for the expenses of the operation. They actually said yes by all means, send us what exactly you want to do, obviously we need to look at it and discuss it among ourselves, but we'll be more than happy to support these and a couple of weeks later. We had actually the go ahead and they said by all means the future if you want to do another case like this, let us know.

Bruce Whitfield: I'm is it because it's in an experimental stage and they want to see what can and can't be done before really committing to a long-term future of funding the sort of surgery because it's a bottomless pit of need, potentially?

Professor Ermos Nicolaou: It's not so much experimental anymore. This particular case with it, was a modification of a technique that has been used in the past. I think they have done about 60 cases worldwide with various modifications over the years initially they were delivering the baby like the would do the, you know, after the normal delivery or a caesarean section that would deliver the baby do the repair and then put the paper back inside the womb, close the womb and hope that yeah, so exactly although the results were pretty good in terms of the spinal repair or any other surgery that was performed. The risks were too high, and patients went on to going to premature labour or miscarry.

So, this new technique where we now do everything through little Scopes is a relatively new technique and initially, we were the team in Texas, we're closing the skin without actually using any cover. But there were problems with that they do pay wasn't as good as water-tight and these new techniques now where we use this particular membrane is it's a relatively new technique looks like it works pretty well judging from our own case where we are now seven weeks post-operative period installed going strongly. I think, we're looking good.

Bruce Whitfield: As a medical professional, I mean, this is a new toy box for you. If you like your new tool in Your Arsenal of again, trying to improve the lives not only of the parents and reduce the stress and reduce the trauma, but again providing that sense of hope that sense of optimism that assume a medical diagnosis isn't a death sentence or a sentence to be spent in a wheelchair or incontinent all of your life, whatever the case might be. The advances in medical science are fundamentally changing people's life outcomes.

Professor Ermos Nicolaou: Absolutely and we need to keep up with the rest of the world. We as a country, we have an obligation to, you know, our patients, to society to actually provide them the best possible service and if this is happening elsewhere the world. There's no reason why South Africa should be left behind, you know. Collaborations and centres of excellence around the world are there and we just need to reach out to them and they're more than happy to help us and, we help them because there are stuff that we do that there are solar want to learn from us.

The remarkable story of the operation carried out by Professor Ermos Nicolaou, who’s the Academic Head of the Wits Maternal and Foetal Medicine Centre, using the best of global best practice and carrying out an operation in South Africa.

The baby, still in its mother's womb and still growing strong stands a far better chance at leading an uncomplicated life will come, life is complicated enough, isn't it? But you don't need to be compromised in the complicated life that the child is going to lead and one day they have a great story to tell and maybe it can even motivate them to go and become medical Solutionists as well.

Professor, thank you so much for joining us on RMB Solutionist Thinking.