History of Ultrasound in Obstetrics and Gynecology

September 7, 2006
Stuart Campbell, MD

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Stuart Campbell, MD

OBGYN.net Conference CoverageFIGO 2000 INTERNATIONAL FEDERATION of GYNECOLOGY & OBSTETRICS: Washington DC, USA

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Dr. Tom Basket: “Welcome to this the fourth in a series of luncheon historical lectures, without the luncheon I might add. I’m Tom Basket from Dalhousie University in Halifax in Canada. The topic is the History of Ultrasound in Obstetrics and Gynecology. Now without a doubt, ultrasound has probably had one of the most profound impacts on our specialty in the last half century. I think the only other thing that I would put in the same league would be the oral contraceptive pill. 

We’re very lucky today to have as our lecturer Professor Stuart Campbell who is one of the pioneers in its development. Stuart Campbell has been Professor and Head in the Department of Obstetrics and Gynaecology at St. George’s Hospital Medical School in London since 1996, and for twenty years before that he was Professor at King’s College Hospital in London. But for today’s purposes, that’s beside the point. The relevant part of his history is his early years, following graduation from the University of Glasgow in 1961, he served between 1965-1968 as a Research Registrar with Ian Donald at the Queen Mother’s Hospital in Glasgow, and that’s really where the story begins. We’re very fortunate to have someone rather like we did on Monday with Professor Edwards who was actually involved with the evolution of one of the most important aspects of the history of our specialty. Stuart.”

Professor Stuart Campbell: I have always avoided lecturing on the history of the development of ultrasound in obstetrics and gynaecology, because I was part of the history, and I have actually got to place myself in historical context, which is a difficult thing to do. However, I will try even if it means accusations of being biased and immodest! It is often difficult to know when many subjects actually begin. They sort of evolve, but ultrasound in obstetrics and gynaecology had a very definite beginning. In 1958, the classic paper by Donald, McVicar, and Brown in the Lancet, which I will elaborate on later, was the very precise beginning; no two ways about it. Nobody had applied ultrasound to obstetrical and gynaecological diagnosis before, but of course ultrasound had been used medically before that, and I am going to discuss that a little bit later. I will show you some of the early problems, and I will take you right through to the present time. In thirty minutes that’s an almost impossible task, so if I speak fast and I get my words mixed up, please forgive me. 

This is a picture of Ian Donald (1911 – 1987). He was a most charismatic man. I worked for him for several years, and he was not always easy to live with, because he would fire questions at you all the time, and if you didn’t know the answer then you really got a roasting. He was impulsive; if he was scanning a patient and her bladder was too full, then you got a terrible rollicking. His temper was quick and sometimes quite frightening, but then just as quickly it would subside. He was actually a most generous man. For example, if you did research, you got the credit. When I wrote my first paper on cephalometry, he did not ask to have his name on it, even though I was working for him. There was no “droit de Seigneur”, as you might say. So Donald was a generous and a cultured man; he played the piano, he painted, he wrote poems and made furniture. He was a workaholic; he worked so hard and he was very courageous because he had rheumatic heart disease and he needed valve replacement operations on at least three occasions, but he never wasted a second of time; for instance, he never took a lift - he always climbed the stairs, even though his chest was heaving at the top. He wouldn’t waste any time to go to the barbers; he used to cut his own hair and sometime the results weren’t all that good. So Donald was a most extraordinary man, and it was a privilege to work with him. 

But let me go to the beginning and, of course, none of this would have happened if we hadn’t had Christian Doppler giving his theories on the Doppler Effect, Lord Rayleigh and his classic Theory of Ultrasound describing the transmission, reflection, and defraction of ultrasound, Pierre Curie describing the Piezo-electric Effect by which ultrasound is generated and Paul Langevin who described the hydrophone by which submarines could be detected by surface vessels. These were the physicists who described the basic theories on which all technical developments were based. Then we had the technical developments in medical imaging. In 1949, the A-scan with Ludwig (gallstones) at the Massachusetts Institute of Technology and J. J. Wild (breast) in Minneapolis, but I’m not going to waste time talking about A-scan. In terms of medical diagnosis, A-scan was extremely limited. It is with 2D scanning that the history of medical ultrasound imaging begins and the credit for the first 2D scanning images goes to Wild and Reid from Minneapolis, who published 2D images of breast anatomy in 1952. J.J. Wild was an English surgeon who escaped to America shortly after the Second World War and settled in Minneapolis. He gave up surgery and started doing ultrasound research with the Honeywell Corporation. Six months after his seminal paper, Howry and Bliss from Denver published their paper and 2D scanning was born. Both groups published impressive pictures of anatomy, though the patient was usually immersed in water to achieve satisfactory images. The ever-inventive J.J. Wild, however, did produce transrectal and transvaginal probes, which were rather gruesome looking, but these never became popular in these early days. In 1958, contact scanning was first described by Donald and Brown in their classic Lancet paper. They described in detail a compound scanning technique with the transducer in contact with the abdomen through a layer of olive oil and that was the real revolution in ultrasound imaging. It was this paper that transformed ultrasound into a technique that could be easily applied to all patients and all parts of the anatomy. Donald, McVicar and Brown were also the first researchers to apply ultrasound to obstetrics and gynaecology. Their equipment was the first to be commercially produced for export to other research centres. Then in 1969 there was the development of grey scale by means of the scan converter by George Kossoff and his team in Sydney, Australia. This made 
a tremendous impact on the quality and interpretation of ultrasound images. 

The development of real-time scanning occurred at much the same time and came in the form of the Vidoson from the company Siemens. In 1968 this machine was produced and officially is the first real-time scanning machine. However, it had a cumbersome probe and a flickering image and, although the equipment was popular in Germany, it had severe limitations in terms of image quality. It was the development of the Phased Array Scanner in the early 1970’s with Jan Somers in the Netherlands and the Linear Array Scanner with Nicholaas Bom, again, in the Netherlands that paved the way for the real-time revolution. In 1975 the ADR Linear Array Scanner was produced by Martin Wilcox in America, which was the first practical real-time machine in obstetrics. I cannot underestimate the impact that real-time scanning had on obstetric ultrasound. No longer was it necessary for a machine to have a large gantry suspending the probe, so machines were cheaper, lighter and smaller (and therefore could be moved to the patient); more importantly, scanning was technically easier and, therefore, the training time shorter. Technicians and radiographers , who has perhaps struggled with the larger equipment were amazed at how quickly they could achieve reproducible fetal measurements with a good quality Linear Array Scanner. Fetal movements could be followed and quantified and invasive procedures could be monitored in real-time.

Continuous wave Doppler began in the early 1970’s in Japan with Satomura, which led to the development of the fetal heart detector. Duplex Doppler equipment was produced in the early 1980’s from Angelsen in Sweden, and then colour Doppler from Namekawa from Japan who, working with Aloka, produced the first colour Doppler machine in the mid 1980’s. The first 3D scanner was produced in 1974 in Glasgow by Tom Brown, i.e. the engineer who worked with Ian Donald, but it was not computerized and without computer storage of the images it foundered very seriously and the project lost millions of pounds. But Karl Kretz, Kazunore Baba, and Thomas Nelson much about the same time in the late 1980’s started to use computerized modeling of ultrasound images, and we are now reaping the fruits of that research in beautiful 3D images, which I will discuss later on. 

So let’s show some of the pictures of the early pioneers, their equipment and images. This is a picture of J. J. Wild, the English surgeon who lives in Minneapolis. I phoned him the other day, he’s eighty-three and just as sprightly as ever. In his interview for the Wellcome Trust, he said, “Donald, at my last meeting with him, said I was 40 years ahead of my time. I corrected him and said, no, I’m 40 years ahead of your time”. So you can see he’s not exactly a modest man, but the trouble with J.J. Wild’s research is illustrated in this first 2D image of the breast. He was looking at tissue characterization, not organ structure. In other words, he felt he could tell the difference between cancer and non-cancer by their reflected echoes. Even today, tissue characterization by ultrasound is at a fairly primitive stage of development, so to be quite honest, although he is undoubtedly the pioneer of 2D scanning, the particular path he was beating I believe was going up a blind alley

This next image is of Douglas Howry, a very able physicist who worked in Denver, Colorado, and here is a typical machine that he created. He believed that optimal imaging was by water delay scanning and here you can see a man immersed in a water chamber. You will notice the rather inelegant toilet seat that he’s sitting on, and that’s a thing that you’ve got to realize that these were people cobbling together bits of equipment. They did not have massive funding, and they usually published in relatively obscure journals. Howry was actually beginning to produce good images; here is a picture of a gall bladder and with his compound B technique, he began to get very nice circumferential views of structures, such as the adult neck and here you can see the thyroid in front. At the time that Ian Donald was just beginning, Douglas Howry in Denver, Colorado was getting impressive 2D images, by using the technique of immersing a patient in a bath of degassed water. This would not have been suitable for pregnancy scanning. 

Now we come to Ian Donald, this charismatic figure I was telling you about. Here is a picture of him at his famous Diasonograph, which was the first commercial machine to be produced. This is the Queen Mother’s Hospital, which he persuaded the government to build for him. He was such a dominating personality; he just persuaded the government to build a hospital just for him! It couldn’t happen now, but this was built in 1965. 

This is a picture of Tom Brown, the brilliant engineer, and you can see the rather primitive equipment that they cobbled together at the beginning. He has hitched the pulley and the transducer to the bed table, so, very simple equipment to begin with. This is a slide of Donald’s famous paper in 1958, and what a paper it was. I mean nowadays we would probably stretch this to about five publications, certainly I would! It began with the physics of ultrasound scanning techniques, safety experiments, ultrasound imaging of pregnancy, ultrasound images of gynecology, and a really detailed description of the strengths and weaknesses of this new technique. It was a seminal work. Here are some of the images he obtained in the early years; a fetal head, polyhydramnios, malignant ascites, hydatidiform mole, which he described in 1962, and here is an early pregnancy seen through a full bladder. He was the one to develop the full bladder technique to visualize early pregnancy. Now it’s interesting, because Donald never quite grasped the importance of transvaginal sonography, which was really propagated in Vienna by Alfred Kratochwil.

On the next two slides, I summarise the main schools in the 1960’s during the early development of ultrasound diagnosis. These schools were in Glasgow, Denver, Sydney, Vienna, Copenhagen, Lund and Tokyo. I have highlighted the engineers in yellow, because they were the key factor in these days, for each centre needed a top class engineer, for they were developing new models all the time. Furthermore, although commercial ultrasound companies were appearing, they had a limited ability to maintain the machines that they produced. So the progress of development in each of these centres was very much reliant on the quality of the engineer. 

Ian Donald, of course, had Tom Brown and his clinical researchers were John McVicar, who did studies on hydatidiform mole, James Willocks, who did early studies on cephalometry, Usama Abdullah who did studies on placentography and safety, myself (and I will indulge myself by discussing my contribution later), Hugh Robinson, who pioneered early studies on the first trimester embryo and Joachim Hackeloer, who was visiting Glasgow from Germany and did early studies on follicular development. The leader of the rival group in Denver was Joe Holmes, backed up by Douglas Howry, the famous early pioneer of 2D scanning. His clinical researchers were Horace Thompson, who did first studies on measuring the chest circumference, Ken Gottesfeld, who produced the first paper on placental location, much to Ian Donald’s frustration, and Stewart Taylor. The clinical leader of the Australian group was Bill Garrett and supporting him was George Kossoff, the pioneer of grey scaling, who unfortunately decided that water delay scanning was still the best method of obtaining obstetric images and rejected the concept of contact scanning. In Vienna we had Alfred Kratochwil backed up by his engineer Paul Kretz, perhaps one of the most inventive of all ultrasound engineers. Kretz built equipment for Kratochwil suitable for transvaginal scanning and Kratochwil was the lonely advocate for this approach until the development of the real-time transvaginal scanners in the 1980’s made this the optimal method for gynaecological scanning. Kretz founded the company Kretztechnik, which pioneered many innovative ideas including 3D scanning. In Copenhagen, the leader of obstetrical and gynaecological research was Jens Bang backed up by a brilliant engineer called Hans Henrik Holm, who developed the Smith Kline instruments. In Lund, the major figure was Edler, who started off the clinical science of echocardiography. He had the support of a brilliant engineer called Hellmuth Hertz. Working in this department was Bertil Sunden, who was the first person to buy one of Ian Donald’s Diasonographs and did some very interesting early work on obstetric and gynaecological imaging with this equipment. Finally in Tokyo we had Hisaya Takeuchi and an engineer called Uchida, who may actually have been the first to do clinical A-scan studies. So these were the groups in the 1960’s. 

I will now show you some slides of these early days. This is James Willocks demonstrating his A-scan method of fetal head measurement. This technique had problems, because it was impossible to be certain that the echoes were derived from the parietal eminences and so inaccuracies inevitably occurred. The following year I developed the combined A and B-scan technique, which is illustrated in the next slide. This technique demanded that the midline echo was demonstrated on B-scan before the A-scan measurements were taken. With hindsight, nowadays, I think I should have just taken the measurements on the Polaroid, but in general, the A-scan measurements were more precise. Because the Diasonograph had a strong gantry (also rather heavy!) in those days, it was easy to line up the fetal head in the precise plane for an accurate measurement. The following slide shows the sort of pictures that were being obtained from Denver in those days. You can see that there are no midline structures in the Denver picture and there is a very thick outline to the head, so I had a tremendous advantage in having a machine that could do the business.

This is a picture of Bertil Sunden, who as I explained before used one of Ian Donald’s original Diasonographs and was the first to recognize a fetal abnormality by ultrasound. This was a case of anencephaly in the third trimester, associated with polyhydramnios. Sunden produced some excellent papers, both on obstetric scanning and in assessing gynaecological tumours. 

This is an picture of Alfred Kratochwil, who introduced transvaginal scanning in the late 1960’s. He was the first person to recognize, for instance, an ovarian follicle transvaginally. 

I will now show a few more slides from my own collection. When I had completed growth charts of the biparietal diameter, I went down to London to Queen Charlotte’s Hospital and with the Diasonograph I started a programme of diagnosing early fetal abnormalities with this brilliant machine. On the left you will see a picture of the first early diagnosis of anencephaly (at 18 weeks), which I described in 1972 and the other slide shows a picture of the early diagnosis of a spina bifida which I diagnosed in 1975. So the early diagnosis of fetal abnormalities was now a reality. After I left Glasgow, Hugh Robinson, who is shown in the next slide, took my place and concentrated his efforts on first trimester diagnosis. Hugh was the first to chart the growth of the crown-rump length in the first trimester and did some seminal work on the early fetal heart rate. Hugh did these studies abdominally with the full bladder technique and, although we can say first trimester began in the early 1970’s, the major development occurred in the 1980’s when the real-time transvaginal probe became available.

The next slide shows this extraordinary man, George Kossoff, who worked away in the Commonwealth Acoustic Laboratories in Sydney, Australia in the 1970’s. George had visited Howry in the old days and still believed that water delay scanning was the way to do it, and he built this huge tank on top of which the patient lay. Here he is with David Robinson and Bill Garrett, who was the obstetrician who worked with him, and they built this tank, which held 50 gallons of water. I understand that one day the water leaked out and spilled on the floor and they thought at first that the patient had ruptured her membranes. I guess a 50 gallon leak would suggest polyhydramnios. The next slide shows the typical image they got in the early 1970’s and although they were impressive, the outlines were rather thick and did not concern me too much. However, suddenly like a bombshell in the mid-1970’s they produced beautiful grey scale images like this. This was because Kossoff had invented the scan converter, which allowed the demonstration of small back-scattered echoes to give the appearance of tissue texture. In other words, grey scale. To show you the impact of this, the next slide shows a typical abdomen circumference, which I was measuring at this time, and the one on the right is their picture of an abdominal circumference. You can see how beautiful the gray tones are of the Garrett/Kossoff image. So the scan converter was the breakthrough in showing subtle small-reflected echoes. Here is another comparative slide showing my picture of a fetal chest and heart on the left, but the Garrett/Kossoff image is so much better and you can even see calcification in the placenta. I remember going to a lecture by George Kossoff in the Royal Marsden in London and I just couldn’t believe the quality of these images. Eventually, of course, the scan converter was incorporated into all our contact scanning machines, and the water delay scanner fell out of existence. 

Real-time scanning began in 1969 with the development of the Vidoson by Siemens, and the great practitioner of this equipment was Dr. Manfred Hansmann in Bonn. Manfred Hansmann used this machine to do intraperitoneal transfusions under direct ultrasound control and I think he was the first person to do that. You can see it had a large water bag in which the transducer was placed, so it was a very large probe that you placed on the abdomen and angling this to get fetal planes was difficult. Furthermore, because the beam was swept mechanically with a parabolic mirror, it was a very flickery picture, and I was personally unimpressed with the quality of the images. Actually, I remember in the early 1970’s being asked to go to Singapore to train the doctors there in ultrasound scanning. When I arrived there, I found I had to use the Vidoson and was a bit shattered because I found it difficult to obtain planes of the biparietal diameter and abdominal circumference, which I was used to getting. However, Manfred Hansmann did brilliant work with this machine. As I said, he pioneered invasive needling procedures under real-time control with this equipment, but when the ADR came into existence in 1975, then everyone was able to get beautiful real-time images with a small manoeuvrable probe, so ultrasound guided invasive procedures quickly became the norm. This is a typical ADR picture in 1975. You can see that the image looks a bit stripey, because at this time they had not learnt to interpolate scanning lines, but really the quality was actually quite good. I remember I first saw the ADR when I was in Canada visiting Fred Winsberg, and I was totally bowled over by the images he was obtaining. I picked up the phone in his laboratory and phoned up the Chief Executive of my hospital and said, ‘I’m buying this machine, and I expect you to pay for it.’ You could do things like that in those days. 

How about routine ultrasound scanning in pregnancy? I would like to claim that I was the first person who drew the attention of people that routine ultrasound was a desirable thing. This is a statement I made in 1969 in the British Journal of Obstetrics and Gynaecology (called then Journal of Obstetrics and Gynaecology of the British Commonwealth ): “It may be that a routine ultrasonic measurement of the biparietal diameter in the second trimester in all antenatal patients, would reduce the number of inductions of labour and that more attention could be paid to cases of true post maturity. Certainly in those maternity hospitals, where ultrasonic equipment is available, routine assessment of the fetal biparietal diameter would be practically feasible, as the method is safe, causes no discomfort to the patient and rarely takes more than 10 minutes”. It is strange to think that it could take up to 10 minutes to measure a biparietal diameter in those days, when now we would expect to do all fetal biometry in the same period of time. Anyway, this is one prediction which has come to pass, because it has been demonstrated that routine second trimester biometry will reduce the number of unnecessary inductions of labour, as is demonstrated in the meta-analysis of 8 trials of routine versus selective ultrasound in pregnancy, where one of the significant advantages of routine ultrasound is reduction in the numbers of inductions for post-term pregnancies. However, Persson and Grennert from the Malmo group were the first researchers to publish a study on routine ultrasound in pregnancy. You can see that they started in 1974 and published in 1978. The first national programme for routine ultrasound scanning was in the Federal Republic of Germany and I think there is no doubt they were influenced by the persuasive powers of Manfred Hansmann; they recommended two routine scans for all women. The Royal College of Obstetricians and Gynaecologists in Britain belatedly in 1984 recommended that women in the United Kingdom should be offered a routine scan between 16 and 18 weeks’ gestation, but in the same year, the NIH in the U.S.A. did not support routine scanning. They did produce a list of seventeen indications for an antenatal scan, which could allow for liberal interpretation, but still basically in the United States you do not believe in routine scanning, which I have to say with current knowledge on the benefits of routine scanning is difficult to understand. I am putting this in very diplomatic language.

The schools in the 1970’s and 1980’s did not require a physicist to support their work; they all had the availability of the very latest equipment produced by commercial companies, such as Acuson, ATL, Aloka, Toshiba, etc. In the next two slides, I outline some of the key researchers and schools of the 1970’s and 80’s. All of these researchers and centres made singular contributions to the development of the ultrasound scanning techniques and the various applications to which ultrasound is put today. 



In the following slides I will go through some of the seminal papers on the various applications of ultrasound in obstetrics and gynaecology, which have shaped the way in which ultrasound is practiced today.

Fetal Biometry:



I will begin with my 1971 paper on biparietal diameter growth charts, which were very detailed and not only had cross sectional data, but velocity graphs according to weeks’ gestation and biparietal diameter size as well. I had earlier in 1969 produced the first BPD growth curve, but the 1971 paper, I think, had a seminal influence on the construction of growth charts. After this, there was a large number of such charts from all parts of the world, but the next seminal paper must be Hugh Robinson’s crown-rump length graph in 1973, which set the stage for first trimester biometry. In 1975, the Campbell and Wilkin paper on measurement of abdominal circumference was an important milestone because this remains the most important parameter in the assessment of fetal weight and nutrition. I place Steve Warsof’s 1977 paper on fetal weight prediction next on the list, for this was the first to use multiparameter equations for the prediction of fetal weight. Finally, I would place Hadlock’s series of papers on fetal biometry and weight estimation produced between 1981-1984 on my list of seminal papers, because these are the most frequently used graphs worldwide, even today.

Fetal Anomalies:



Again I begin with one of my papers in 1972, which was the early diagnosis of anencephaly followed by termination of pregnancy. This was in effect the beginning of early prenatal diagnosis by ultrasound and I followed this up a few years later with the early diagnosis of spina bifida. However, the second paper I would put on my list is Hobbin’s classic paper in the American Journal of Obstetrics and Gynecology in 1979, which described the prenatal diagnosis of a variety of congenital abnormalities including skeletal anomalies. The seminal paper on echocardiography was produced by Lindsey Allan in 1980. This was a really important development and her paper was an absolute classic, where she described the systematic planes of the heart to make the diagnosis of fetal abnormalities. It really was the beginning of fetal echocardiography. Finally, I would put on my list of seminal papers, Nicolaides paper on the intracranial signs (lemon and banana) for spina bifida. This is a classic paper because it introduced the concept of screening for a major abnormality with a very simple screening technique, so it actually had a tremendous influence on our ability to diagnose spina bifida. 

Fetal Chromosome Abnormalities:



The seminal paper on identification of fetuses at high risk of chromosome abnormalities in the second trimester, by looking for anatomical markers, was Benacerraf’s 1987 paper in the New England Journal of Medicine. It was she who focused the world’s attention on nuchal fold thickness, short femur, renal pelvic dilatation and other markers, which soon became an important part of the routine second trimester scan. I include in this section Timor-Tritsch’s important 1988 paper in the American Journal of Obstetrics and Gynaecology on sonoembryology, because the majority of defects in the first trimester are associated with chromosome abnormalities and he, more than anyone, focused attention on early prenatal diagnosis. The breakthrough in terms of using a fetal marker to screen for Down’s syndrome came with Nicolaides’s seminal paper in 1992 in the British Medical Journal, where he used the measurement of fetal nuchal translucency between 11 and 14 weeks to screen for Down’s syndrome. The establishment for likelihood ratios for a particular nuchal translucency measurement meant that for the first time ultrasound could be demonstrated to be superior to biochemical methods in screening for karyotype abnormalities. Now I know that nuchal translucency screening is not popular in the United States yet, but surely you will have to fall in line with the rest of the world, because this is now becoming the standard test for screening for Down’s syndrome in the first trimester, although in the future nuchal translucency will probably be combined with biochemistry, such as PAPP A and free hCG. At the present time, with combined nuchal translucency and biochemistry, we can now detect about 90% of Down’s babies with a 5% invasive testing rate so this is quite clearly the way to go. 

Invasive Procedures:



Ultrasound guided procedures were developed even before the advent of real-time scanning. The classic early paper by Bang and Northved in 1972 from Copenhagan described the use of a specially developed transducer with a central hole for the needle in order to reduce the risks of amniocentesis. Hobbins and Mahoney first described the use of ultrasound guided fetoscopy in 1974. Hobbins used this technique not just to examine fetal anatomy, but also obtain red blood cells from the surface of the placenta for the prenatal diagnosis of thalassaemia. Then in 1979, Charles Rodeck and myself described pure blood sampling from the cord insertion; it was the first time pure blood had ever been achieved and this paved the way for biochemical studies on the fetus. Then in 1983, Daffos in Paris first described a technique to obtain pure fetal blood without the use of the fetoscope by directing the tip of the needle under ultrasound control directly into the cord insertion. Daffos actually had a sonographer identifying the cord insertion, while he inserted the needle, but Nicolaides described the two-handed technique of cordocentesis, where the operator performed both scanning and needle insertion. Finally, of course the procedure of chorion villus sampling would not have become so wide spread and indeed the most important method of determining the fetal karyotype, were it not for the classic paper by Hahnemann in 1984, where he described the transabdominal technique, which has pretty well confined the transcervical method to the dustbin of history. 

Ultrasound Guided Therapeutic Procedures:



Although Hansmann, I believe, ultrasound guided intraperitoneal transfusion, I have put on my list of seminal papers the 1976 paper by Hobbins, as this was hugely influential in persuading people to abandon the old Xray method pioneered by Lilley. Charles Rodeck in 1981 first described fetoscopic intravascular transfusion, which overcame problems associated with absorption of fetal cells from the fetal peritoneal cavity. Nicolaides and Berkowitz separately described intravascular transfusion by cordocentesis very shortly after that. 

Golbus, in San Francisco, and Berkowitz in New York were the first to describe the insertion of a vesico-amniotic amniotic shunt to relieve bladder obstruction due to posterior urethral valves. Although shunting procedures have subsequently been performed for this and many other indications, there is little proof that these are life saving procedures. I have also included Ville’s 1995 paper, where he described laser surgery to the placenta. Although I have jumped to the 1990’s, which is unfair, I just wanted to point out that although the fetoscope was abandoned following the development of cordocentesis, it is gradually being rediscovered and this is a very important application for the fetoscope.

Doppler Ultrasound:



We must begin with the first Doppler ultrasound paper on continuous wave assessment of umbilical artery flow, which was published in 1977 in the British Medical Journal by Fitzgerald and Drumm from Dublin. This really was a seminal paper from a city with no big ultrasound tradition In 1980, Sturla Eik-Nes, who was working in Mlmo, showed that fetal aortic velocimetry could be carried out using a duplex scanner, i.e. an imaging transducer linked to a pulsed Doppler transducer. With the same system, I first described in 1983 in the Lancet, the assessment of the utero-placental circulation and that high resistance waveforms were obtained in pre-eclampsia. Subsequently these studies were done with colour Doppler and in many centres this has become an important screening technique to predict women at risk of pre-eclampsia. With the use of colour Doppler, Wladimiroff pioneered the study of the middle cerebral artery in 1987 and the use of the middle cerebral to umbilical artery PI ratio to demonstrate centralisation of the fetal circulation. In 1991 Kiserud completed the Doppler story by describing waveforms in the ductus venosus, which is now recognised as a key examination to predict right heart failure in the hypoxic fetus and the most important indicator of imminent fetal demise. 

Fetal Activity:



The first fetal activity to be studied was fetal micturition by Campbell and Wladimiroff in 1973 and they subsequently demonstrated that in IUGR fetuses, fetal urinary production was reduced. With the advent of real-time scanning, detailed studies of fetal activity were produced. The group of Patrick in London, Ontario, was one of the first to document the incidence of fetal breathing movements over a 24 hour period. More detailed studies of fetal behaviour were given a stimulus by the 1981 paper of Birnholz on fetal eye movements. Perhaps the most seminal paper produced on this subject was in 1980 when Manning and Platt described the biophysical score, which for 20 years has remained the most important method of assessing fetal wellbeing, certainly in the United States.

Gynaecological Scanning: 



Even before the advent of transvaginal sonography, which has now become the standard method of evaluating the pelvis to diagnose gynaecological conditions Kadar et al in 1981 had produced their seminal paper on the early diagnosis of ectopic pregnancy, describing the discriminatory zone of hCG, above which an intrauterine gestation sac should be visible. Cacciatore’s classic paper in 1984 established that transvaginal sonography was the most accurate method of diagnosing ectopic pregnancy. Campbell et al in 1989 were the first to publish on a large scale 5 year screening project for ovarian cancer. Subsequent to this DePriest et al in Denver published similar encouraging reports on screening for ovarian cancer by transvaginal sonography. Morphological scoring systems to improve the diagnosis of ovarian cancer in masses detected by ultrasound was carried out by several workers, but the paper of Sassone and Timor-Tritsch in 1991 remains the classic. Finally, Bourne and Kurjak both published papers advocating the use of colour Doppler in refining the prediction of ovarian cancer in ovarian masses. Granberg was the pioneer in using the measurement of endometrial thickness to predict endometrial cancer and the use of a 5 mm limit is used widely to exclude this disease.


Reproductive medicine:



Even before the advent of transvaginal sonography, Hackeloer working in Glasgow, described the growth of the ovarian follicle and correlated growth rates with oestrodial values. The 1984 paper by Susan Lenz in the Lancet was a seminal work, because for the first time it was demonstrated that eggs could be obtained from ovarian follicles directly under ultrasound control. Susan Lenz described a transvesical approach and I have to say it made a profound impression on me. I remember reading the paper and I said to my Lecturer, John Parsons, “Fantastic, this is the way we are going to obtain eggs from now on - throw away the laparoscope!”, so I think we probably had the first truly outpatient system for IVF anywhere in the world. Then Dellenbach in 1988 described transvaginal egg collection by guiding a needle along a transvaginal probe and this has become the standard method for egg collection. The use of Doppler in reproductive medicine was pioneered by Steer when he correlated impedance in the uterine arteries to successful implantation and Bourne for his studies on peri-follicular blood flow and oocyte maturity. Finally we must give credit to Deichert in Germany for his seminal paper in 1990, where he described evaluation of the Fallopian tubes with a positive contrast agent (HyCoSy). This I believe will turn out to be the standard method of tubal evaluation, especially as now we can look at the tubes by this method in three-dimensions. Talking about 3D scanning, this must be the big development of the new century. If this lecture is given in ten years’ time, then researchers like Eberard Merz in Germany, Bernard Benoit in France and Davor Jurkovic in London will undoubtedly be featured strongly. This is a 3D picture I took of a 12 week fetus just three days ago. This is not just a pretty picture. The fine detail you can see of the spinal column is a huge advance on what we can do with 2D scanning. I believe that three dimensional scanning will transform sonoembryology.

A final point about education. Although each of us in our units ran training courses for people wanting to learn new techniques, it was Asim Kurjak with the Ian Donald School in Dubrovnik, who was the first person to set up a large international school for teaching and training in ultrasound. It was he, who during one of these meetings in Dubrovnik proposed that we should have an International Society of Ultrasound in Obstetrics and Gynecology and I was delegated to set up such a society and run the first World Congress in London, which was held in 1991. I also have to acknowledge the huge contribution to training of Kypros Nicolaides, who runs several international courses each year through his Fetal Medicine Foundation. But to return to the International Society of Ultrasound in Obstetrics and Gynecology; it runs annual world congresses each year in different parts of the world. It has an Executive Committee, a Board of Directors, a Secretariat, a Scientific Committee, and a Education Committee. It is totally committed to education in ultrasound and it publishes a monthly journal, which now has an impact rating even higher than the Green Journal, which is very exciting indeed. I believe the International Society and the White Journal, as it is called, are setting standards and making ultrasound in obstetrics and gynaecology a well respected subspecialty. 

Finally, I end up with a slide of the Ian Donald Gold Medal, because the International Society gives annually this medal to people who have contributed enormously to the development of ultrasound. I have mentioned many of them today and some of the people I have mentioned today will receive it in the future, but showing this slide is a fitting way to end a lecture on the history of ultrasound in obstetrics and gynaecology, for it is to Ian Donald that we must pay homage as the ultimate pioneer of this subspecialty. Thank you all very much indeed.”

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