Giants in Obstetrics and Gynecology Series: a profile of Beryl Benacerraf, MD.

Beryl established a top postgraduate course in obstetrical and gynecological ultrasound. This course not only served to disseminate knowledge but also established a network among leaders in the field. Beryl invited renowned investigators personally by phone to lecture, which “became one of the most sought-out invitations on the speaker circuit and gave me the entrée I needed into academic meetings,” Beryl commented. As the DUA continued to grow, the file drawer moved out of the bathroom; by 1990, the team now had 4,000 square feet and eight ultrasound rooms ( Figure 9 ). In 1990, Dr Frigoletto offered Beryl a position in the Department of Obstetrics, which would have meant taking fetal imaging away from radiology. Although Beryl was confident she could do this easily, she did not want to turn her back on radiology. Beryl suggested that she and Dr Peter Doubilet, who was head of Ultrasound, set up a joint venture: the High-Risk Obstetric Ultrasound Unit of the Brigham and Women’s Hospital. As well as becoming Co-Director of the new unit, Beryl was also fast-tracked to a professorship at Brigham and became Professor of Obstetrics and Gynecology at Harvard Medical School—all while keeping her position at DUA. A change of leadership at Brigham and Women’s Hospital saw the exit of several people in leadership positions—including Dr Frigoletto, who joined Massachusetts General Hospital as Chair of Obstetrics and Gynecology. Soon after, an offer came in for Beryl to set up the ultrasound unit for obstetrics at this hospital, which she accepted in 1995. In addition to her professorship in Obstetrics and Gynecology at Harvard Medical School, Beryl became Professor of Radiology. At Massachusetts General, Beryl supported Dr Frigoletto in resurrecting the Department of Obstetrics. However, mere months after her appointment began, Massachusetts General and Brigham and Women’s announced a merger, and the fetal anomaly cases were referred to Brigham and Women’s. “I no longer had access to the fetal malformations that were my main research interest,” Beryl said. “I stayed for five years to make sure the unit was running smoothly, then decided to seek another challenge.”

During her time at Massachusetts General Hospital, Beryl became an international leader in both obstetrics and radiology. She has authored more than 300 peer-reviewed articles, and her best-selling book Ultrasound of Fetal Syndromes is now in its 2nd edition 25 ( Figure 10 ). Her appointment as Editor-in-Chief of the Journal of Ultrasound in Medicine ( JUM ) brought with it a busy international speaking schedule. During her 10 years leading JUM , Beryl took the journal from a completely paper-based to an electronic format, including the review process and all forms of communication: the Journal became stronger and more widely known. Beryl next sought a medical position at Brigham and Women’s. “I wanted to get back to the high-risk ultrasound unit I had founded years ago, so I could maintain my focus in fetal anomalies while also continuing work in private practice,” she said. “I will be forever grateful to Carol Benson and Peter Doubilet for welcoming me into the Department of Radiology and the shared ultrasound unit in 2000.” Back at Brigham and Women’s, Beryl expanded her work into gynecological imaging. As a proponent of ultrasound, she made seminal contributions in the field, particularly strengthening the value and use of 3- and 4-dimensional ultrasound in obstetrics and gynecology. Beryl co-authored the book Gynecologic Ultrasound: A Problem-Based Approach in 2014 ( Figure 11 ). 26 Her teaching covered both radiology and obstetrics and gynecology, and she co-developed the first quality assessment program for the teaching of ultrasound to residents in both disciplines. Notwithstanding the context, the focus remained on ultrasound: Beryl led the Ultrasound First initiative of the American Institute of Ultrasound in Medicine when she was President from 2015 to 2017.

Shortly after Beryl was born in New York, her family followed her father’s research career to Paris; thus, her earliest years were spent in France. As a single child, she bore the pressure of expectation from parents with exacting standards: her father, Dr Baruj Benacerraf ( Figure 2 ), was already a respected immunologist, and he would go on to become the 1980 Nobel Laureate in Physiology or Medicine. Beryl was seven years old when the family moved back to New York City where she was introduced to the sights, sounds, and language of her new country. Their home was a “French oasis,” and Beryl recalls her mother working hard to pass on her European upbringing, amid the rush of the very American city. The family spoke French at home and maintained European cultural traditions, such as a formal dinner every evening. Her parents soon became involved in the city’s cultural side, to which Beryl’s extracurricular activities contributed: “My parents gave frequent dinner parties in New York which were heavily involved with classical music. Whenever there were guests at home, I was expected to perform on the flute.” An array of interesting people would be seated at the dinner table. From a very young age, Beryl spent time with distinguished people, from gifted musicians to eminent scientists; among the guests were Drs Francis Crick, Leo Szilard, David Baltimore, André Cournand, Lewis Thomas, and Gerald Edelman. “My mother always made sure that I knew the importance of my different background, and that I never be tempted to minimize it,” she said. As a French-speaking child, Beryl was placed in the Brearley School, a girls’ school in New York. English as a second language was not Beryl’s only challenge: she spoke with a stutter and, unbeknownst to anyone at the time, she could not read in her native language, let alone her second one. Her inability to read was attributed to the change in language, and Beryl was enrolled in remedial reading classes. Reading remained “laborious and unpleasant,” and although she achieved good grades in mathematics, she found the other subjects difficult.

Despite feeling “blacklisted,” Beryl became more committed. Her dedication to fetal imaging continued in the form of sheer grind—she did not take a vacation for eight years when running her practice. “Alone in my office, I was changing the face of prenatal care, based on my observations and using the large volume of patients I was seeing daily,” she said. During this time, her partnership with Dr Frigoletto strengthened further; they worked together to publish their observations, and he became a valued mentor ( Figure 8 ). In the eight years following Beryl’s establishment of her private ultrasound practice in 1982, her practice became an extension of the Department of Obstetrics and Gynecology at Brigham and Women’s Hospital, and her office, the training ground for residents and Fellows. Together, Beryl and Dr Frigoletto performed invasive procedures, such as intrauterine blood transfusions for Rh-negative mothers with red-blood-cell incompatibilities, under local anesthesia. They also performed midtrimester and early amniocenteses, fetal thoracenteses, and chorionic villous sampling.

Beryl noticed patterns across, as well as within, images. Most notably, she saw an association between the thickening of the nuchal fold of the fetus and trisomy 21, or Down syndrome, in the second trimester. When she first observed the nuchal fold, she thought it was a cystic hygroma—a cyst found in babies with Turner Syndrome; however, the karyotype showed trisomy 21. A second patient presented similarly, and the karyotype also showed trisomy 21. Then, nearly three weeks later, a 28-year-old patient without risk factors presented a nuchal fold—Beryl told her that it may be a risk factor for trisomy 21 and recommended an amniocentesis, which proved that the fetus had trisomy 21. The papers were published in the American Journal of Obstetrics and Gynecology . 1 – 3 , 5 ( Figure 7 ). The first paper was initially criticized, as Beryl recounted: “I was almost booed off the stage at several national meetings and papers emerged discrediting my research and me. I was devastated but that much more determined to prevail because I knew I was right.”

Beryl graduated high school and was granted early acceptance to Barnard College, where she excelled academically and in other interests ( Figure 3 ). In 1971, she graduated cum laude . After spending a year working with Nobel Laureate Dr Rita Levi-Montalcini in Italy, Beryl attended Harvard Medical School and graduated in 1976 (Alpha Omega Alpha) with the intention of becoming a surgeon. Surgery was Beryl’s first choice—a path that would have suited her ambidexterity and her love of problem-solving. She applied for surgical internships at the Massachusetts General Hospital and the Brigham and Women’s Hospital. Beryl’s application to Brigham was successful, and life as an intern was “grueling”—she was on call every other night. Given the cultural climate of the 1970s, she worked even harder to compete in a strongly patriarchal environment: “I felt as though I had to prove myself over and over just to be accepted in the group of men.” Beryl decided that surgery was not the right fit, and when she remembered a professor who had observed a special talent in her, she decided to change direction.

A career move was soon in the cards: Beryl had completed her training and was ready to join the faculty. However, the Chair of Radiology at Harvard and Beryl’s father, who was the Head of the Dana Farber Institute, had a tense relationship. “It became apparent that, for me to stay in Boston, I would have to open my own private practice down the street from the University,” she said. “I wanted to stay in academic medicine, but I would have to make my own way without the backing of a mentor, department, or hospital.” In 1982, with a one-year-old and a one-month-old baby, Beryl set up her private practice: Diagnostic Ultrasound Associates, PC (DUA). It was established in the start-up spirit: Beryl had some capital to buy two ultrasound machines and hire two employees, and DUA started as a 700-square-foot location with two ultrasound rooms, a small waiting area, and a back office. There was so little space that the file drawer was kept in the bathroom. When the Head of Ultrasound at Brigham-Women’s Hospital moved away, the hospital was left without a fetal imaging expert. Although Beryl felt she had been excluded from the mainstream academic environment in Radiology, she had an excellent relationship with Dr Fredric Frigoletto, who was Chief of Obstetrics at Brigham and Women’s Hospital. The hospital’s obstetricians came to depend on DUA for fetal imaging, especially for high-risk cases, as Beryl’s results were more informative than those of others.

Ultrasound was a revelation for Beryl. “I entered a whole new world of wonder! I was in the land of pictures and patterns,” she said. “All of a sudden, I was a star beyond anything I have ever dreamed.” It was the technology being used at the time—the late 1970s—and although the images were low-resolution and difficult for most to decipher, Beryl could spot an abnormality easily. “It would leap off the image like a beacon! I found it amazing.” Throughout her career, Beryl has regularly reviewed images from 100 patient examinations a day, and she can correctly identify the anomaly. She attributes her talent to a broad peripheral vision, which enables her to see the whole picture and, therefore, to spot patterns more readily. I, too, believe Beryl has a gift that propelled her to the top of the field. Capitalizing on this natural talent, Beryl played to her strengths. “I could not have been a lawyer due to all the reading required, and certainly would not have excelled as a professor of literature,” she said. “I focused my life’s work on imaging and radiology.” Beryl completed a Residency in Radiology at Massachusetts General Hospital and then pursued a Fellowship in Ultrasound and Computerized Tomography at Brigham and Women’s Hospital. Beryl married Dr Peter Libby, who is now Mallinckrodt Professor of Medicine at Harvard Medical School and Chief of Cardiovascular Medicine at Brigham and Women’s Hospital, and a top physician-scientist with worldwide recognition ( Figure 4 ). Peter and Beryl wanted to begin their family, and knowing the impact motherhood could have on Beryl’s professional career, they devoted time to plan this step. Beryl told me that she considered that a Fellowship in Ultrasound would be an ideal time and, soon thereafter, Beryl became pregnant. Consequently, she found the subject matter—prenatal diagnosis of congenital anomalies—challenging, as she had not only to identify the anomalies but also to counsel the patients about the short- and long-term implications of her findings.

Beryl told me that she would sometimes struggle to finish assignments by the deadlines and that she found an approach to alleviate some of the stress. She would request assignments earlier and earlier, and she worked on them as soon as possible to give herself the best chance of success. “This feeling of immediate pressure whenever a task is assigned to me still haunts me today,” she commented. “To lessen this apprehension, I still often complete the requested tasks on the day they are first ‘assigned,’ lest I get behind and more work comes in.” Although it started as a coping mechanism, this approach has since earned Beryl a reputation for submitting papers, book chapters, and other work before the deadline—an unusual trait in academia. “This habit keeps me organized and prevents me from taking on more tasks than what I know I can do,” she commented. “Nothing ever piles up and I am never behind in my work, although I work very hard to achieve this peace of mind.” At the time, though, the reason for Beryl’s challenges with language was unclear. “Little did I know then that I was suffering from dyslexia,” she said. Today, we understand dyslexia as a reading disability that affects the language processing areas of the brain, and those found to have dyslexia are supported with tools and approaches to make reading easier. Beryl did not have this support.

Teaching has been an increasingly important part of Beryl’s career: she has become the female role model and mentor she never had. “Surprisingly, none of my role models were women,” she said. “I felt I was blazing new roads and, that while others might follow, I was alone in my quest for opportunities.” Beryl has trained many young physicians in ultrasound and imaging who, she hopes, will eventually continue her work. She is especially proud of her co-workers at DUA—Drs Bryann Bromley, Thomas Shipp, and Yvette Groszmann. Dr Bromley, now Professor of Obstetrics and Gynecology at Harvard Medical School, has held several important offices in professional societies, including the Ultrasound Accreditation Commission at the American Institute of Medicine and the Perinatal Quality Foundation. Dr Shipp has also been a strong advocate of ultrasound teaching as President of the American Registry of Diagnostic Medical Sonographers, an organization that tests and credentials all sonographers in the United States and beyond. Both Drs Bromley and Shipp are Maternal-Fetal Medicine (MFM) specialists who have dedicated their activities outside of clinical practice to improving the quality of ultrasound nationally and internationally. Dr Groszmann, as the newest member of the team at DUA, has a special interest in gynecology rather than obstetrics. She is currently developing new techniques of imaging the infertile patient, endometriosis, and pelvic masses. Throughout the years when Beryl trained the MFM Fellows in Ultrasound for Dr Frigoletto, she also provided guidance for the papers these young trainees wrote during their Fellowships (often their MFM thesis paper). These Fellows included Drs Vanessa Barss, 1 , 27 Daniel Saltzman, 13 Christine Penso, 28 Michael Greene, 15 , 29 Laura Riley, 30 Catherine Zelop, 31 William Barth, 32 and others. Beryl’s dedication to ultrasound seems strongly connected to her gift for deciphering images that are obscure to so many, which itself, she believes, is linked to her dyslexia. “I think entirely visually, using patterns, flowcharts, and pictures in my mind,” she said. “Even outside of imaging, I realize that, when thinking through a problem, I do not think linearly or verbally as someone would who is speaking or reading. I see the entire problem as a big image that fills in with information, or sometimes as a flowchart flashing before me.” A selection of Beryl’s informative images with diagnostic value are displayed in Figures 12 – 18 . Beryl’s generosity, loyalty, humility, dedication, and remarkable talent make her unforgettable, professionally and personally ( Figure 19 ). The field owes Dr Beryl Benacerraf a debt of gratitude, and we are proud to honor her as a “Giant in Obstetrics and Gynecology.”

Beryl herself had a high-risk pregnancy: she had been exposed, in utero , to diethylstilbestrol (DES) because her mother had vaginal bleeding—DES was the standard treatment to prevent miscarriage at the time in Boston. DES exposure is known to predispose to Müllerian duct abnormalities—and Beryl was diagnosed to have a hypoplastic cervix, for which she was treated with cerclage. Despite that treatment, she had contractions during much of her pregnancy, which were treated with the beta adrenergic agent of choice at the time, terbutaline. During Beryl’s pregnancy, her father, Dr Baruj Benacerraf, was awarded the Nobel Prize in Physiology or Medicine, and the whole family prepared for a trip to Stockholm. Beryl’s obstetrician urged her take this “unique opportunity” and go with her parents ( Figure 5 ). In the past, premature labor was remedied with alcohol to inhibit uterine contractions. Baruj was aware of this, and he treated Beryl with the most exclusive champagne available in Stockholm during the trip. Beryl recalled that “ultimately, my son, Oliver, delivered at term, does not seem to be the worse for wear.” Beryl stayed on for a second year as an ultrasound Fellow at Brigham—enough time to have another baby. “I checked my ovaries with ultrasound frequently until I located a developing follicle (egg),” she recalled. And so came her daughter Brigitte, born on Oliver’s first birthday ( Figure 6 ). Her own pregnancies stimulated an interest in the physiology of pregnancy—fetal anatomy, biometry, pathology, and genetics. In particular, she studied fetal hearing by looking at eye movement in response to sound, which resulted in a publication in Science . 7