Fetal attraction

British professor has spent decades diagnosing and treating babies in the womb.

By JUDY SIEGEL-ITZKOVICH
womb 88.224 (photo credit: wikipedia)
womb 88.224
(photo credit: wikipedia)
In some ways, Prof. Kypros Nicolaides is more suited to Israel than to England, the adopted home of the Cyprus-born, world-renowned "father of fetal medicine." Israel and Judaism, with their child-oriented ideology - there are more in-vitro fertilization centers per capita here than anywhere in the world - are attuned to his decades of work to save distressed fetuses. And Israelis - with their informality and tendency to tell their life stories to complete strangers - would likely understand his controversial methods of calming frightened patients. Israelis' desire for the "perfect baby" also suits Nicolaides, who discovered that nuchal translucency in a fetus is a marker for Down Syndrome. This leaves open the option for an early abortion. Ultrasound measures the almost-clear (translucent) space in the tissue at the back of a baby's neck. Babies with abnormalities tend to accumulate more fluid there during the first trimester. The BBC even produced a two-part documentary called Life Before Birth that starred Nicolaides. The 55-year-old head of the Research Center for Fetal Medicine at King's College Hospital in London - on his third visit to Israel to attend a conference of the Israel Ultrasound Society - says in an interview with The Jerusalem Post that he first decided to be a doctor when he was two. Although obviously brilliant, "perhaps I remember what my parents told me later about what I had said about wanting to be a doctor," he concedes. But he had a strong role model - his father, Dr. Herodotos Nicolaides, a family practitioner who travelled by donkey to outlying Cypriot villages as a general practitioner, surgeon and obstetrician. Kypros spent some of childhood going with him. If a patient had a fever in this pre-antibiotics era, Herodotos would stay over a few nights - sleeping on the floor or on a bed next to the sick person. Although Herodotos was a leader of the nationalist movement of Greek Cypriots fighting for independence and in 1955 was imprisoned by the British for four years due to his involvement, the London professor describes his father as "an admirer of British democracy." AT 17, after completing his studies at the English school in Cyprus, his father send him to King's College to study medicine. In 1978, his fellow students went abroad on the pretense of studying an "elective" (when they were in fact going on vacation). Kypros preferred to spend the time at Kings College, and it changed his life. "During those weeks, I was introduced to the first ultrasound machine on campus. It was a monster of a device, taking up nearly a whole room. For me, this opened up a whole new philosophy." The sight through the primitive machine of a tiny fetus moving in its mother's uterus fascinated him so much that he began to wonder about the child's legal and philosophical rights, not just the medical situation. Ultrasound scans for pregnant women "caught on quickly. At first, there were questions about whether it might be harmful, as people were very concerned about health risks from X-rays. Today, there are questions about the safety of everything. Fetuses should be scanned with ultrasound only when it is necessary. Now there is routine 3-D ultrasound, and doctors have become photographers. I think there is some benefit of parents 'bonding' to a fetus before birth, but the availability of ultrasound in US shopping malls is wrong; it's just a way to make money." Nicolaides used the ultrasound machine to make one of his major discoveries - that if a section of the fetal neck is overly thick, it may indicate Down syndrome. He found that between 65 percent and 85% of fetuses suffering from the genetic defect have thickness in this portion of the head. Combined with a blood test of the mother for alpha-feto proteins and other markers, the scan can make an invasive amniocentesis of the placental fluid or chorionic villae sampling in the uterus unnecessary. "It was 1991, and I was examining a woman with a negative RH factor who had lost several fetuses and was trying desperately to deliver a healthy baby. When she was 41 and at higher risk for a Down baby, she conceived again." Nicolaides did a scan of the fetus and found what he thought was liquid in its neck. He later noticed two similar cases and wondered if there was a connection between Down and such nuchal translucency, and he also noted the absence of the nasal bone in Down syndrome fetuses. "I told the hospital I had to do a clinical study and examine 20,000 pregnant women. They wanted to fire me, but by the end of the year we had done 20,000 scans. Now nuchal translucency is used routinely around the world." With all the tests together, he says, one can know with 98% accuracy if a fetus has Down syndrome or not. WITH THE growing Muslim population in London, and the ultra-Orthodox (haredi) Jews as well, Nicolaides is well aware that 10% to 15% of his patients refuse to have ultrasound screening, and 10% of those whose fetuses are found to have Down decline an abortion. Nicolaides, who identifies himself as a nominal Christian, says he informs parents of the options and "completely support their decision." Not only does he have strong ties with Israeli fetal medicine and fertility specialists, but he also hopes to "add a little brick in the wall" of future peace between Israel and the Palestinians. Long an admirer of Shimon Peres, he met with him during his visit, as well as with Palestinian Authority president Mahmoud Abbas. He invited them to appear jointly in June 2009 at an international conference he is organizing. He and his 75 staffers are also doing clinical trials for Diagnostic Technologies, an Israeli startup in Yokneam that has developed the world's first kit for early identification of high-risk pregnancies. The local developers created a simple blood test that identifies which pregnant women have a higher risk of pre-eclampsia, a toxemia of pregnancy that occurs in 3% of them and significantly increases the risk of the baby's and mother's death. Pre-eclampsia is characterized by sudden hypertension and high levels of protein in the urine that can cause secondary damage to the kidneys, liver, eyes, the clotting system and most severely in the brain. The test can be carried out after the seventh week of pregnancy and predicts the development of pre-eclampsia six months later. Until the kit was put on the market, there were no other methods of identifying women at risk before the clinical symptoms arose; by then, lives are in danger. "Women can come to a clinic for a 12-week checkup for this and other tests, and her doctor can rationalize and manage her care" based on that assessment; the test is available at Zer labs in Israel and has been presented for approval to the US Food and Drug Administration. Early on in his career, he promoted the taking of blood samples from the fetus via placental cord insertion, and used it to investigate many aspects of fetal physiology and pathophysiology. In 1986, the described the "lemon" and "banana" shapes that can be seen by ultrasound in fetuses with spina bifida, a congenital central nervous system defect that causes disability. HE AND HIS lab work on improving fetal surgery and preventing premature births. Nicolaides also developed a laser treatment for twin-to-twin transfusion syndrome, in which one fetus gets more blood from the placenta than the other. "This occurs in one in 1,000 pregnancies. You give local anesthesia and insert an endoscope to identify the blood vessels. Then you use a laser to cut and close the vessels to separate the blood supply. In most cases, the weaker fetus is saved." Just as Kypros was influenced by his own father to go into medicine, his two children - 13-year-old Herodotos and 10-year-old Despina, have both told him they want to be physicians. They live in Cyprus with his estranged wife, and he communicates with them regularly by cellphone from wherever he is. A physician on a regular National Health Service salary, Nicolaides founded the Fetal Medicine Foundation in central London, which functions as a private clinic but devotes its earnings to training physicians around the world and do research in his field. In his meeting with Peres, he discussed scholarships for Israeli and Palestinian doctors who will come for post-graduate training to London. While widely praised for his research, innovation and patient care, he has also gotten into trouble for his unorthodox methods of calming down patients before informing them of bad news, such as that their fetus will die before birth or be hopelessly disabled. Britain's General Medical Council reportedly criticized his bedside manner after it heard that he absentmindedly left his hand on patients' abdomens, teased them, made odd jokes or laughed at their underwear. His hospital has also held internal inquiries. But Nicolaides insists that "cultural differences" and the desire to make patients relax are to blame. "When a patient's muscles are relaxed, she is more able to take the blow of bad news. Yes, I almost got into real trouble a few times," he says at the end of the interview. "But I won't change. Didn't Shakespeare use comedy in his tragic plays? My motives - to help my patients - are clear."