Dr Stuart Campbell, Emeritus Professor of Obstetrics and Gynecology at King’s College London in the United Kingdom, revolutionized obstetrics and gynecology through his seminal contributions in ultrasound imaging. Dr Campbell’s vision, talent, and inspired leadership are at the heart of these important advances in women’s health.
Dr Campbell introduced the use of fetal biometry to date pregnancy, initiated longitudinal studies of fetal growth, made the first prenatal diagnosis of anencephaly with ultrasound, and pioneered the use of uterine artery Doppler velocimetry to predict adverse pregnancy outcome. In gynecology, he has played a key role in the development of screening for ovarian cancer by combining imaging and biomarkers. He remains actively engaged in the use of imaging to optimize reproductive outcome in patients undergoing in vitro fertilization (IVF).
The department under Dr Campbell’s direction at King’s College trained a generation of leaders, and his power of convocation made possible the founding of the International Society of Ultrasound in Obstetrics and Gynecology (ISUOG). He is the founding Editor in Chief of Ultrasound in Obstetrics and Gynecology and recipient of the Ian Donald Gold Medal for excellence in ultrasound research in our discipline.
Dr Campbell is herein recognized as a “Giant in Obstetrics and Gynecology” for his many groundbreaking contributions to obstetrics and gynecology that have improved the lives of women and their families and for the lasting impact he has had on our discipline.
Early life, medicine, and obstetrics and gynecology
Stuart was born in Glasgow, Scotland, in 1936. His father, a businessman, served as a soldier after the Great Depression, and his mother, a nurse and “matron” (a hands-on director of nursing), instilled her medical interests in Stuart and his older brother, David ( Figure 1 ). When Stuart was three years old, the family moved to Inveraray on Scotland’s western coast for safety during World War II, and he grew up in the small port town as a self-professed “country boy.”
The family eventually returned inland to care for Stuart’s grandparents, settling in Paisley, a large town outside of Glasgow known for its production of textiles woven in the paisley pattern. Stuart commuted by train to attend the University of Glasgow Medical School. His field of study was influenced not only by his mother but also his brother, who had become a physician and passed down his medical textbooks to Stuart.
When I asked Stuart why he decided to go into medicine, he acknowledged that he did not receive the “call” to medicine at the start. When asked by an interviewer at the medical school why he wished to be a doctor, Stuart quipped, “I didn’t hear the voice in the night, if that’s what you mean,” much to the interviewer’s amusement. Yet, when Stuart began his clinical rotations, he found excitement in the delivery room, distinguished himself in obstetrics and gynecology during his final examinations, and then decided to pursue the field. After graduating in 1961, Stuart took a position as a junior physician with Dr Ian Donald at the Queen Mother’s Hospital in Glasgow. Stuart noted that he became serious about medicine when he “suddenly realized that people depended on me.”
Use of biparietal diameter to date pregnancy
Stuart spent the early part of his career with Dr Donald, a British obstetrician and Regius Chair of Midwifery at the University of Glasgow, who built the first ultrasound machine in collaboration with engineer Thomas Brown. Dr Donald introduced Stuart to the basic principles of ultrasound and the application of this tool to clinical medicine, such as diagnosing the hydatidiform mole.
During this time, Stuart became aware of the need to develop a standardized method to measure the biparietal diameter (known then as fetal cephalometry). The ultrasonographic technique in use, which applied the one-dimensional amplitude mode (A-mode) to measure this fetal parameter, had limitations: it was often difficult to locate the fetal head in early pregnancy, and measurements were not reproducible. “I thought that by requiring the landmark of a midline echo the measurement of the biparietal diameter would become more reproducible and accurate,” he said.
The issue of standardizing the plane to measure the biparietal diameter kept him awake at night. “I puzzled over how to angle the ultrasound transducer to capture the optimal axial plane of the fetal head and how to balance the echoes correctly to get a midline echo,” he recalled. “I eventually worked it out and developed a precise technique of measuring the biparietal diameter of the fetal head by combining the amplitude mode and bright mode methods” ( Figure 2 ). To determine the orientation of the fetal head, Stuart first used the brightness mode (B-mode) to visualize the midline echo of the fetal brain on a two-dimensional display. He then performed A-mode scans to measure the distance between the two parietal bones (A-mode was required because the placement of calipers on the B-mode image was imprecise). The 1968 groundbreaking study described this combined approach, a method quickly adopted as the standard practice in obstetric ultrasound examination for the next decade , ( Figure 3 ).
The biparietal diameter became, and still is, the most commonly used fetal biometric parameter to assess gestational age worldwide. In another landmark study in 1969, Stuart reported that early measurement of the biparietal diameter gave an equivalent (or better) estimate of gestational age in pregnancies with an unknown date or a date/size discrepancy compared to those with a certain date. In a later study based on a large technician-based routine ultrasound program, he found that biparietal diameter measurements performed between 12 and 18 weeks of gestation were significantly more accurate in gestational-age predictions (89.4%) than those based on optimal menstrual history (84.7%) or crown-rump length measurement (84.6%) (all P <.001). The study concluded that a single ultrasound scan of the biparietal diameter performed before 18 weeks of gestation was the single-best dating parameter, thus justifying a routine scan in all pregnancies. Moreover, Stuart’s finding established scanning at 16 to 18 weeks of gestation as the optimal time for studying fetal morphology, which became standard practice in his department.
Solving the problem of assigning gestational age was one of the most important contributions to obstetrics by Stuart during the 20th century. Gestational age established along with fetal size had important benefits: a decrease in inductions of inaccurately diagnosed postterm gestations, the prevention of iatrogenic prematurity, and an accurate interpretation of biomarkers in maternal blood and amniotic fluid. Furthermore, this new, solid dimension of visualization improved the clinical management of pregnancy by freeing practitioners and patients from reliance on the first day of the last menstrual period as a parameter for gestational dating.
Stuart is the first obstetrician to advocate for routine scanning of all pregnancies to date gestational age. He insisted that fetal biometric parameters be obtained in a precise plane defined by anatomic landmarks: first, the biparietal diameter, followed by abdominal circumference, and then virtually all biometric parameters. His initiative has influenced clinical research and the practice of medicine.
Serial biometry to assess fetal growth: another first
Pediatricians have studied infant growth for decades. However, investigation of fetal growth was impossible given the dearth of safe imaging techniques to assess changes in fetal size throughout gestation. Stuart originated the scientific genre of fetal growth studies by describing changes in biparietal diameter that occur with advancing gestational age in the same fetus, generating the first estimates of fetal growth (velocity). , ,
The longitudinal study of fetal growth generally began around 16 weeks of gestation, and Stuart obtained serial measurements every two to three weeks. His method allowed reporting of the first fetal growth velocity graphs. Stuart identified two distinct patterns of growth deceleration: (1) fetuses that were small from an early age and whose growth gradually fell below the reference range (ie, the “low profile growth pattern” associated with congenital abnormalities) and (2) fetuses of normal size whose growth declined later in pregnancy (ie, the “late flattening pattern” associated with fetal growth restriction) ( Figure 4 ).
From Glasgow to London
In 1968, Stuart applied for a position at the Institute of Obstetrics and Gynaecology at Queen Charlotte’s Maternity Hospital in London. No Scottish-born junior physician had ever been given a position there, and sure enough, Stuart received a letter politely declining his application. A few days later, however, he received a call from Dr Jack Dewhurst, who had just begun his tenure at the hospital and had made diversity of staff a priority. Speaking in a quiet voice, he told Stuart that he had read his curriculum vitae and then invited him to interview for the position. After Stuart met with Dr Dewhurst and Dr Richard Beard the next day, he received the job offer.
In 1973, Dr Juiry (Yuri) Wladimiroff joined Stuart’s team as his first research fellow at Queen Charlotte’s. “He worked with me on fetal urine production rates in the assessment of fetal wellbeing,” Stuart recalled. “After a year, he returned to Rotterdam to Erasmus University and ultimately became a leader in our field pioneering Doppler studies of the fetal circulation, particularly in the internal carotid artery. Yuri served on the Society’s first Executive Committee and is a Gold Medal winner.”
Fetal abdominal circumference to assess fetal weight and growth
Stuart was determined to develop a more accurate way of measuring fetal body size. A paper published by this Journal in 1965 reported on the use of fetal chest circumference measurements in assessing fetal growth. However, given the conical shape of the fetal thorax, the results were not easily reproducible. Consequently, Stuart looked to the more cylindrically shaped fetal abdomen, focusing on the liver as the organ most affected by fetal growth restriction. He identified the plane where the umbilical vein meets the portal vein as an easily identifiable landmark to measure the abdominal circumference, thus increasing accuracy and reliability.
In 1975, Stuart reported a nomogram of fetal abdominal circumference vs birthweight in fetuses delivered within 48 hours of abdominal circumference measurement. That study showed the accuracy of predictions varied with the size of the fetus: at a predicted weight of 1 kg, 95% of birthweights fell within 160 g, whereas at 2 kg, 3 kg, and 4 kg, the corresponding values were 290 g, 450 g, and 590 g, respectively. He recommended abdominal circumference as the optimal parameter in screening for the small-for-gestational-age fetus, provided an early dating scan had been performed. Stuart would have been amused to know at that time that abdominal circumference would be the key parameter in predicting fetal macrosomia right into the next century. Two years later, he described the ratio of head circumference to abdominal circumference, observing that this ratio was abnormal in cases of asymmetric fetal growth restriction.
By 1980, with the advent of real-time ultrasound, Stuart’s group in London began to measure fetal limb bones and described yet another significant parameter—fetal femur length to assess gestational age in the second trimester, a factor that would also become a method to screen for fetal skeletal dysplasias.
The first prenatal diagnosis of a congenital anomaly with ultrasound: anencephaly
During his time in Glasgow, Stuart made good use of the Diasonograph, the large ultrasound scanning machine designed by Dr Donald and engineer Thomas Brown. Consequently, Stuart arranged to have one procured for Queen Charlotte’s Maternity Hospital, which allowed the team there to take a lead in the early diagnosis of fetal abnormalities by ultrasound, and established Queen Charlotte’s Maternity Hospital as being at the “cutting edge” in 1972 ( Figure 5 ).
Prenatal diagnosis of congenital abnormalities had not been a particular focus of Stuart’s research until he encountered a patient whose 17-week scan did not show the landmarks of the biparietal diameter. “I was certain it was a case of anencephaly,” he recalled. “I measured the patient for two successive weeks to confirm this diagnosis.” His acumen afforded the first early diagnosis of a congenital abnormality, and Stuart published this case report in The Lancet ( Figures 6 and 7 ).
He subsequently emphasized the value of screening women who had previously delivered a child with neural tube defects, thus predicting the possibility of screening all women for anencephaly in early pregnancy. This contribution was the basis for what is now an essential component of prenatal care—screening for congenital anomalies during pregnancy. That initial case report led to a series of studies evaluating diagnostic methods for neural tube defects. Stuart collaborated with Dr Mary Seller of the Pediatric Research Unit at Guy’s Hospital, now Professor of Developmental Genetics at King’s College London, to compare the reliability of ultrasound examination and the estimation of alpha-fetoprotein (AFP) levels in both amniotic fluid and maternal serum in diagnosing neural tube defects and spina bifida in particular. The ultrasound examination included not only fetal head assessment for anencephaly but also a detailed fetal spine examination, followed by a series of transverse scans to demonstrate the circular appearance of a spinal cord. Stuart and Dr Seller reported on three representative cases in The Lancet that revealed the important role of ultrasound examination in the prenatal assessment of spina bifida, including the first successful early diagnosis of spina bifida by ultrasound ( Figure 8 ).
Concurrently, the team also compared AFP levels in maternal serum between two groups of women: those whose fetus had severe neural tube defects (some taken from the prospective study) and a control group. They found increased concentrations of AFP in maternal serum samples collected in the cases with neural tube defects; however, this finding was not significantly different from the higher levels seen in the control group. Assessing levels of AFP in amniotic fluid provided a more clearly defined difference and was more reliable in diagnosing neural tube defects. However, by 1977, Stuart reported on 329 high-risk pregnancies examined at 16–20 weeks of gestation in which ultrasound identified 25 of 28 neural tube defects; 10 of 13 cases of spina bifida were detected, with low sacral lesions presenting as false negatives. He also found that examining AFP concentrations could not describe the location and precise nature of the neural tube defect, whereas ultrasound examination usually enabled this diagnosis, including associated ventriculomegaly.
Fetoscopy, fetal blood sampling, and the Harris Birthright Research Centre for Fetal Medicine
In 1976, Stuart was appointed Professor and Head of Obstetrics and Gynaecology at King’s College Hospital Medical School in London ( Figure 9 ). “I was lucky to have as my lecturer then-Associate Professor Dr Charles Rodeck, who was carrying out studies on human placental lactogen,” Stuart reminisced. “Yet, he agreed to learn the technique of ultrasound-guided fetoscopy – an endoscopic procedure to visualize the fetus and vessels on the placental surface.”
Stuart believed that this procedure, pioneered by Dr John Hobbins at Yale University, might well have great potential in prenatal diagnosis. He again acquired a Diasonograph, and soon thereafter, Dr Rodeck performed fetoscopy in cases of spina bifida diagnosed in the second trimester. King’s College in London quickly became a referral center for cases of suspected fetal anomalies. In 1978, he and Stuart published a paper in The Lancet on the use of fetoscopy for the early prenatal diagnosis of neural tube defects. A breakthrough occurred when Dr Rodeck obtained pure fetal blood from the cord insertion by ultrasound-guided fetoscopy. “I was his first assistant during the procedure,” Stuart said, “and I remember Charles’ excitement as he immediately recognized that direct access to the fetal circulation could begin a new era in prenatal diagnosis.”
Together, they realized the need to establish an institute devoted to fetal medicine based on ultrasound and this new fetoscopic technique. With the help of Dr Michael Brudenell, a supportive National Health Service Consultant at King’s, they invited Sir Philip Harris, a renowned English businessman, and his team to visit King’s College in 1982. They showed a video of a live fetoscopy, during which one of the observers fainted, hitting his head hard on the way down to the floor. Stuart recalled his whispered comment to Dr Rodeck: “I think that’s our grant, gone.” A few days later, however, they heard from Sir Philip Harris, who was excited about the project and wanted to invest. The Harris Birthright Research Centre for Fetal Medicine was thus established and continues to operate today. At King’s, the academic Department of Obstetrics and Gynecology was located on the ninth floor of the Ruskin Wing in two parallel corridors, and the Harris Birthright Centre was assigned to one of the corridors, with Dr Rodeck taking a lead role.
Of historical interest, the Princess of Wales, Diana Spencer, who was an expectant mother at that time, was present to open the Harris Birthright Centre ( Figure 10 ). Stuart served as the sonographer to the British royal family for several years, scanning both Princess Anne and Princess Diana during their pregnancies. He often visited Buckingham Palace with his mobile ultrasound machine.
