Recently, at Latifa Hospital for Women and Children, a tiny little foetus, a brave mother and a team of highly specialised doctors created history when they performed the first-ever intrauterine foetal surgery for a spinal cord defect in the Arab region.
The extremely delicate six-hour surgery was performed on a 25-week-old foetus that was diagnosed to have myelomeningocele (my-uh-lo-meh-NIN-guh-seal) a type of spina bifida (spinal cord defect). The foetus weighed only 700 grams.
As the surgery was performed at this stage and not after the baby was born (which is typically still the standard medical procedure) the foetus’ defect was corrected, giving the baby a chance for improving cognitive function, lower limb function and deformities.
Spina bifida is a neural tube defect that occurs during the first month of pregnancy when the spinal cord does not develop or close properly. In its most severe form, the defect leaves a section of the spinal cord and nerves exposed in a sac on the patient’s back.
Spina bifida can lead to many physical disabilities, including problems with walking and mobility, bowel and bladder function, wounds healing and fluid accumulating in the brain (hydrocephalus) requiring shunt surgery.
Transforming Dubai’s medical sector
DHA doctors highlighted this historic medical achievement for the Arab region at a press conference held recently at the DHA headquarters.
H.E. Humaid Al Qutami, Director-General of the Dubai Health Authority said, “The DHA dedicates this great achievement to the wise leadership of the UAE, who always direct us to implement everything that achieves security, health and safety of community members.”
He said on his behalf and on behalf of all DHA employees; he expresses his thanks and gratitude to His Highness Sheikh Khalifa bin Zayed Al Nahyan, President of the UAE; His Highness Sheikh Mohammed bin Rashid Al Maktoum, Vice President and Prime Minister of the UAE and Ruler of Dubai; His Highness Sheikh Mohamed bin Zayed Al Nahyan, Crown Prince of Abu Dhabi and Deputy Supreme Commander of the UAE Armed Forces; Their Highnesses the Members of the Supreme Council and Rulers of the Emirates.
Al Qutami thanked His Highness Sheikh Hamdan bin Mohammed bin Rashid Al Maktoum, Crown Prince of Dubai and Chairman of the Executive Council for His Highness’s continued support for the health sector in Dubai.
He also thanked His Highness Sheikh Hamdan bin Rashid Al Maktoum, Deputy Ruler of Dubai, UAE Minister of Finance and Chairman of the Dubai Health Authority for His Highness’s direction and guidance to develop and transform the medical sector in Dubai.
Al Qutami said the DHA is proud of the medical team and their achievement and that the authority tirelessly strives to provide the highest level of accessible medical care to community members.
H.E. Humaid Al Qutami and DHA doctors highlighted this historic medical achievement recently at the DHA headquarters
Dr Muna AbdulRazzaq Tahlak, Consultant in Obstetrics and Gynecology and CEO of Latifa Women and Children Hospital performed this surgery jointly with Dr Mohammad Sultan Al Olama, Consultant Neurosurgeon with Pediatric and Functional Neurosurgery Specialty at Rashid Hospital & President of the Emirates Society of Neurological Surgeons in the UAE.
A highly specialised team (20 multidisciplinary medical professionals) from Latifa Women and Children Hospital and Rashid Hospital accompanied them during the surgery. The team comprised maternal and foetal medicine experts, obstetricians, anaesthesiologists, clinical pharmacologist, NICU nurses, scrub nurses from both hospitals, nurse coordinators and a radiographer.
Dr Tahlak said, “The patient was referred to us when she was 24 weeks pregnant after her condition was diagnosed in an ultrasound. We immediately conducted a full workup which included a complete foetal evaluation including ultrasound, foetal echocardiogram and foetal MRI to understand the type and depth of the lesion and to completely evaluate the case to determine whether the patient is eligible for this kind of an intrauterine procedure.
“Upon analysis, the patient underwent comprehensive counselling to understand the situation at hand, the medical options and to prepare her for the surgery.”
The young 24-year-old Emirati patient, F.A. is a third-time mom-to-be and has two healthy children. She said she wanted to do everything possible for her baby’s well-being. “I want him to be a healthy boy and lead a healthy and happy life. As complicated and as difficult the procedure was, I never hesitated even for a second coming to Latifa Hospital and I am very thankful to the full team for everything they have done for my little boy and me.”
Dr Tahlak said, “A multidisciplinary team was present for the surgery. This kind of surgery requires extreme precision and is a very delicate surgery. It requires opening the uterus but not the way it is done for C-Section. In this particular case, the incision was done from the back of the uterus because her placenta was anterior. A minor incision was performed delicately – it had to be done in layers without opening the membrane that has the amniotic fluid and the foetus inside. We meticulously eventually opened the membrane. We then used certain tools to extend the incision as the baby had a 6 cm lesion in the spinal cord that needed to the fixed. We then gently positioned the baby in a way that the lesion was facing the incision so that Dr Mohammad Sultan Al Olama, the Neurosurgeon, could correct the spinal cord defect. All through this time, the baby and the mother were being monitored with regular foetal heart rate monitoring.”
Dr Al Olama said: “I first gave the foetus anaesthesia. Then, under the microscope, I started to repair the defect. There was an extra sac that I removed and then preserved the spinal cord and the nerves. Then I covered it delicately using micro instruments with layers of different membranes sealed and then covered that by the skin so that amniotic fluid does not touch the foetus’ spinal cord and this step is essential to prevent leakage of spinal fluid. I used 6.0 sutures to close this delicate defect. These sutures are considered one of the finest sutures used in surgery. It took me less than 50 minutes to correct the defect and achieve the normal anatomical form for the foetus.”
Dr Tahlak said, “Once Dr Al Olama finished his part, I gently filled up the uterus with a special solution with antibiotics and saline. I filled the fluid according to the amount of amniotic fluid lost during this procedure. We then closed the uterus again and tightly sealed it to prevent any leak of amniotic fluid. This procedure is also crucial as the uterus will expand in size as the foetus grows”.
Dr Tahlak added, “The procedure was a success. Both mother and foetus recovered in the Intensive Care Unit (ICU) in the immediate post-operative period.
“Currently, the patient is well and stable and out of ICU care. The future follow-up plan is to closely monitor the mother in our clinic until the day of the C-section. Post-delivery, the child will be followed-up by a multidisciplinary team led by Dr Al Olama.”
Dr Tahlak highlighted that since 2018, DHA has actively been involved with training and preparation for this kind of surgery and a DHA team underwent training in the U.S. in November 2018 under Dr Samer K. ElBabaa, Pediatric Neurosurgeon and Dr Cole Douglas Greves, Maternal and Fetal Medicine Specialist, who are pioneers in this kind of delicate surgery.
He further added: “Moreover, Dr Samer and Dr Cole even travelled to Dubai and were present in the surgery room with us as we carried out this historic surgery for the first time in the Arab region.
“This is a true example of advancement in medicine. We are now able to stop the pathology of the disease halfway. Previously we had to wait until the baby is born and then do the surgery. So, this is really a huge breakthrough in medicine, and we are extremely proud to be one of the few centres in the world to perform this kind of complex surgery.”
Dr Al Olama mentioned that there are only 12 countries in the world performing this type of surgery.
He said: “This is an extremely delicate but important procedure since we can correct existing deformity, prevent further deformity and help the baby grow and develop organs inside the womb without any complications so that the baby can be as healthy as possible when the baby is born. With the intrauterine foetal procedure, we can eliminate chiary malformation, which is a condition in which brain tissue extends into your spinal canal and this causes several complications. While this can be totally eliminated, other complications can be reduced largely offering the baby a high chance to walk and be independent.
“Traditionally, the defect is repaired during first days after birth, but studies have shown that repairing the defect between 22-25 weeks of gestation when the foetus is still in his mother’s tummy, will increase the chance for the child to walk and to avoid shunt surgeries for hydrocephalus and many other complications. When the procedure is done after the baby is born, usually the baby does not have a chance to walk as the damage is too late to rectify.”
Dr Al Olama added, “Immediately after the baby is born, we will thoroughly assess the baby neurologically.”
He added, “There are very few foetal surgery centres in the world and to have such a kind of advanced surgery in Dubai makes us very grateful and proud.”
Dr. Tahlak added, “His Highness Sheikh Mohammed bin Rashid Al Maktoum, Vice President and Prime Minister of the UAE and Ruler of Dubai said that despite the COVID-19 pandemic challenge, nothing is impossible to hinder us to advance. Over the last few months, UAE successfully launched its Mars-bound Hope Probe, marking the Arab world’s first interplanetary mission. In terms of medicine, we achieved this historic surgery, we feel a deep sense of gratitude and pride as we pledge to continue providing our patients with excellence in healthcare.