Dr Ismail Bhorat, Honorary Clinical Fellow at UKZN and Head of Inkosi Albert Luthuli Hospital’s Foetal Unit is the first person to graduate with a senior doctoral degree from the College of Health Sciences. A leading foetal specialist, Bhorat was part of a team of experts who conducted South Africa’s first pinhole surgery on a baby whilst still in the womb in 2012, and in 2016, performed the first successful foetal pericardiocentesis in the country.
Originally from Stanger on the KwaZulu-Natal north coast, Bhorat completed his medical and postgraduate training in Obstetrics and Gynaecology at UKZN’s Nelson R Mandela School of Medicine. He was awarded his first doctoral degree in 2015 for his study that was the first to show a link between cardiac dysfunction and adverse perinatal outcome in gestational diabetics. This research was also the first to demonstrate the role played by deteriorating cardiac function in worsening foetal growth restriction which is a warning sign before severe impairment or death occurs. In this way, timely intervention can be implemented.
A man of a number of firsts, Bhorat’s senior doctoral degree is only awarded to those who already have a PhD and are able to create new knowledge from previous research. According to his sponsor, UKZN’s Professor Colleen Aldous: ‘Senior PhDs are usually a lifetime’s work.’ Bhorat’s thesis consists of a portfolio of publications on maternal and foetal cardiac function and a synthesis of his thoughts on the interrelationship between the two. It was examined by five examiners, three of whom are leading international feto-maternal experts based in the US and UK. All the examiners praised the work and noted its novelty.
Bhorat’s current work can be hailed as an international breakthrough as it defines managing pathways for both maternal and foetal cardiac function in pre-eclampsia and in patients with other high-risk pregnancies including gestational diabetes. The thesis is titled: Clinical Significance of Maternal and Foetal Cardiac Function in High Risk Obstetrics Leading to an Integrated Model of Assessment and Proposed Fetal Risk Scoring Systems.
According to various studies conducted in South Africa as well as the South African Department of Health, pre-eclampsia is one of the five major causes of maternal mortality in the country. It is defined as a blood pressure of 140/90 mmHg or more during pregnancy as well as when proteinuria develops for the first time after 20 weeks gestation. Severe pre-eclampsia can affect a number of organs. Its side effects can cause a pregnant mother to suffer a stroke or fit. Other complications include kidney damage, fluid in the lungs and heart failure.
Early on in his career, Bhorat discovered that acute pulmonary oedema (fluid buildup in the lungs) and unexplained sudden death in the mother in severe pre-eclampsia was often due to serious cardiac arrhythmias. To test this theory, the initial study assessed the maternal cardiac function of the patient clinically by radiography, standard electrocardiograms, continuous electrocardiography and echo Doppler studies. It confirmed ventricular arrhythmias in patients with pre-eclampsia and that all patients with pulmonary oedema exhibited ventricular tachycardia. The study recommended that alpha-beta-blockade (labetalol) be incorporated around the time of childbirth to assist in the management of symptoms of hypertension in these patients.
The second part of the thesis dealt with foetal cardiac function and indicated that in patients with severe pre-eclampsia and gestational diabetes as well as other placental mediated disease conditions, the foetus was prone to myocardial dysfunction (abnormal function of the heart). An interesting finding was that the abnormal foetal heart function (myocardial dysfunction) was similar to what was happening to the heart in the mother (cardiac filling abnormalities or diastolic dysfunction). The thesis proposed that both the mother and foetus are exposed to similar toxic substances emanating from the placenta, resulting in cardiac functional abnormalities in the materno-foetal complex. Hence, the recommendation was that whilst treating the mother, foetal cardiac monitoring should also form part of the management pathway to reduce maternal and foetal morbidity and mortality.
Lastly, Bhorat and the team presented an integrated model of feto-maternal cardiac dysfunction. It proposes a holistic approach to the evaluation of the cardiac status of the materno-foetal complex in high risk obstetric conditions using combined Doppler echocardiography (maternal and fetal), electrographic monitoring and cardiac biomarkers. It is hoped that these indicators will assist in appropriate management of both the mother and child and aid in reducing the high mortality rate in KwaZulu-Natal and the country. To this end, foetal risk scoring systems were also proposed in high risk obstetric conditions in an attempt to optimise the timing of delivery to reduce perinatal morbidity and mortality.
Commenting on his latest achievement, Bhorat said: ‘I am as always eternally grateful to my family (the majority of my children are doctors or currently studying in the field) for their ongoing support as well as my co-authors and colleagues who are a constant inspiration to me. Our work has resulted in Inkosi Albert Luthuli Hospital’s Foetal Unit being one of the important foetal units in the world. This is heartening given the fact that KwaZulu-Natal has one of the highest rates of women with severe pre-eclampsia that are often diagnosed too late in their pregnancies.’
Words: MaryAnn Francis
Photograph: Abhi Indrarajan