Biomedical subjects
I Thaler
Publications and source records attributed to I Thaler.
Real-time spectral analysis of the fetal EEG: a new approach to monitoring sleep states and fetal condition during labor.
Adverse perinatal events affecting cerebral functions are a major cause of neonatal mortality, morbidity, and long-term neurologic deficit. Intrapartum fetal EEG, which records fetal brain electrical activity, provides a monitoring modality for evaluating the fetal CNS during labor. In this study, we describe a new approach to such monitoring that is based on real-time spectral analysis of the fetal EEG during labor. Fourteen pregnant women with uncomplicated term pregnancies who went into labor participated in the study. Two suction-cup electrodes were applied to the fetal scalp at the occipitoparietal or parietal region after rupture of membranes. Real-time spectral analysis was used to determine the frequency and amplitude of the fetal EEG signal. The spectral edge frequency (SEF) was calculated as the frequency below which 90% of the power in the power spectrum resides. The average EEG amplitude and the SEF were displayed using the density spectral array technique. Fetal heart rate and intrauterine pressure were also measured. Two fundamental EEG patterns were identified: high-voltage slow activity and low-voltage fast activity. The SEF was found to be an excellent index of cyclic EEG activity. Fetal heart rate demonstrated increased variability and an elevated baseline during low-voltage fast activity, whereas both parameters decreased during high-voltage slow activity. During episodes of variable decelerations in the fetal heart rate, a decrease in the SEF was observed, accompanied by an increased EEG voltage. The results obtained substantiate the presence of sleep cycles in the human fetus. This kind of cortical activity monitoring may enable rapid alertness to cerebral hypoxia and allow for prompt intervention, thereby decreasing the risk for birth asphyxia and subsequent brain damage.
The effect of isosorbide dinitrate on placental blood flow and maternal blood pressure in women with pregnancy induced hypertension.
The effect of isosorbide dinitrate (ISDN) on maternal and fetal circulation was assessed in 23 women with pregnancy induced hypertension (PIH). A double-blind randomized design was employed. Each woman was given a sublingual tablet of ISDN (5 mg) or placebo. Maternal blood pressure (BP) and heart rate (HR) were measured before and every 2 min after the medication or placebo, for a total of 20 min. Flow velocity waveforms in the uterine and umbilical arteries were recorded at the same time periods, using pulsed Doppler ultrasound. The ratio of peak systolic to end-diastolic flow velocity (S/D) in those vessels was calculated. After ISDN mean maternal BP fell from 103 +/- 1.8 mm Hg to 90.5 +/- 2.9 mm Hg at 14 min (P < .0001) and mean maternal HR increased from 97.3 +/- 3.8 beats/min to 115.7 +/- 3.5 beats/min at 12 min (P < .0001). The mean S/D in the umbilical artery fell from 3.07 +/- 0.33 to 2.58 +/- 0.23 at 8 min (P < .0007). The mean S/D in the uterine artery fell from 3.27 +/- 0.6 to 2.38 +/- 0.28 at 10 min (P < .0001). In seven of 12 women with an early diastolic notch in the uterine artery flow velocity waveform the notch diminished or disappeared within the first 6 min after the medication. No significant change in any of the measured parameters was observed in the placebo group. Our finding that ISDN altered maternal and fetal hemodynamics in PIH lends support to the further exploration of nitric oxide donors in the treatment and prevention of pregnancy induced hypertension.
The effect of a nitric oxide donor on Doppler flow velocity waveforms in the uterine artery during the first trimester of pregnancy.
Our objectives were to study the effect of a nitric oxide donor on uterine blood flow velocity waveforms and maternal heart rate and blood pressure during the first trimester of pregnancy. Eleven women were examined at 8-12 weeks' gestation, prior to elective termination of pregnancy. Each woman was randomly given a sublingual tablet containing 5 mg of isosorbide dinitrate or placebo, on two consecutive days. Measurements of maternal blood pressure, heart rate and Doppler flow velocity waveforms of the ascending branch of the main uterine artery were obtained before, and every 2 min (for 20 min) after taking the drug or placebo. Following administration of isosorbide dinitrate, the mean arterial blood pressure fell from a control value of 82.5 +/- 5.6 mmHg to a nadir of 73 +/- 4.1 mmHg at 16 min (p < 0.0001). The mean maternal heart rate increased from a control value of 80.9 +/- 2.8 beats/min to a peak of 90.4 +/- 4.6 beats/min at 10 min (p < 0.001). The mean resistance index in the uterine artery fell from a control value of 0.80 +/- 0.02 to a nadir of 0.73 +/- 0.03 at 10 min (p < 0.0001). Analysis of covariance was employed to compensate for the effect of heart rate on the resistance index. The drug had a significant effect on the resistance index in the uterine artery, independent of maternal heart rate. These results suggest that drugs such as isosorbide dinitrate may have a potential benefit under such conditions where the production of nitric oxide (i.e. endothelium-derived relaxing factor) is decreased.
Fetal heart rate patterns in pregnancies complicated by maternal diabetes.
OBJECTIVE: To compare the fetal heart rate (FHR) pattern between fetuses of well controlled diabetic and non diabetic mothers using a computerized analysis of FHR. STUDY DESIGN: Weekly fetal surveillance was performed in 99 fetuses of mothers with diabetes class A, 21 fetuses of mothers with diabetes class B-R, and 55 fetuses of non-diabetic women, starting at 30 weeks' gestation. All diabetic patients were well controlled. Fetal surveillance included a computerized analysis of the FHR, umbilical and uterine Doppler velocimetry, and a biophysical profile. Changes of FHR variation, frequency of FHR accelerations, and umbilical and uterine Doppler velocimetry were calculated using a regression analysis for each patient. The average slopes and the intercept at 30, 34, and 38 weeks' gestation of these variables were compared among the three groups. RESULTS: The slope of FHR variation and the frequency of accelerations had a lower rate of increase during the third trimester in fetuses of mothers with diabetes class A (0.84 +/- 0.25 ms/week and 0.06 +/- 0.02/20 min/week, respectively) compared with fetuses of non-diabetic mothers (1.34 +/- 0.55 ms/week and 0.5 +/- 0.1/20 min/week, respectively). In fetuses of mothers with diabetes class B-R, FHR variation did not change with gestation (-0.011 +/- 0.2 ms/week) with a small increase in the frequency of accelerations (0.02 +/- 0.004/20 min/week). While no differences were observed at 30 weeks' gestation, FHR variation and the frequency of accelerations were significantly reduced at 34 weeks' gestation in fetuses of mothers with diabetes class B-R compared with fetuses of non-diabetic mothers (P < 0.01). At 38 weeks' gestation, fetuses of mothers with diabetes class B-R and diabetes class A had both significantly reduced FHR variation as well as frequency of accelerations compared with fetuses of non-diabetic mothers (P < 0.01). The rate of decrease of the umbilical and uterine artery S/D ratios were similar among the three groups. CONCLUSIONS: The FHR pattern appears to be different in fetuses of well controlled diabetic mothers when related to fetuses of non-diabetic mothers. Disease specific standards should be considered for interpretation of FHR patterns in diabetic pregnancies.
The effect of isosorbide dinitrate on uterine artery and umbilical artery flow velocity waveforms at mid-pregnancy.
OBJECTIVE: To study the effect of isosorbide dinitrate, a nitric oxide donor, on the maternal cardiovascular system and on uterine and umbilical artery blood flow velocities in mid-pregnancy. METHODS: Eighteen women with low-risk pregnancy at 17-24 weeks' gestation were given a single 5-mg dose of sublingual isosorbide dinitrate, a nitrovasodilator. Blood flow velocity waveforms in the ascending uterine artery and in the umbilical artery were measured by an image-directed, pulsed color Doppler ultrasound scan before and after the medication was administered. Maternal blood pressure (BP) and heart rate were also obtained. RESULTS: The mean arterial BP decreased from 86 mmHg (95% confidence interval [CI] 72-99) to a nadir of 73 mmHg at 6 minutes (95% CI 61-85, P < .04). Mean maternal heart rate increased from 85 beats per minute (95% CI 80-90) to 96 beats per minute at 6 minutes (95% CI 87-105, P < .01). Mean systolic-diastolic flow velocity ratio (S/D) in the umbilical artery rapidly declined from 4.18 (95% CI 3.80-4.56), reaching a nadir of 3.12 at 6 minutes (95% CI 2.65-3.84, P < .001). The S/D in the uterine artery decreased from 4.83 (95% CI 3.99-5.56) to a nadir of 4.02 at 10 minutes (95% CI 3.41-4.63, P < .001). CONCLUSION: Isosorbide dinitrate, a donor of nitric acid, lowers mean maternal BP and reduces the Doppler impedance in the umbilical and uterine arteries. This drug could prove to be beneficial when endothelial cell dysfunction leads to insufficient synthesis and release of endothelium-derived relaxing factor, resulting in generalized vasoconstriction and increased resistance to flow in the uteroplacental circulation.
HELLP syndrome associated with factor V R506Q mutation.
The pathogenesis of HELLP (haemolysis, elevated liver enzyme and low platelet count) syndrome, a severe presentation of pre-eclampsia, is still an enigma. Activated protein C resistance resulting from a mutation in coagulation factor V has recently emerged as the leading cause of thrombosis in pregnancy. We report on two patients with HELLP syndrome who were found to be heterozygous for factor V R506Q mutation, leading to activated protein C resistance. These findings suggest that the pathogenesis of HELLP syndrome is associated with a thrombotic process, and point to the potential benefit of anti-thrombotic therapy in this condition.
Interpretation of nonstress tests by an artificial neural network.
OBJECTIVE: Our purpose was to evaluate an artificial neural network in the interpretation of nonstress tests. STUDY DESIGN: A nonlinear artificial neural network trained by backpropagation was taught to interpret records of nonstress tests by two learning sets. The first set contained nonstress tests that were similarly interpreted by three human experts; the second set contained a subset of nonstress tests that led to interobserver disagreement. Both "raw" fetal heart rate and uterine contraction data and 17 quantified variables obtained by automated computer analysis were introduced to the input layer. After training, the network was tested by presenting it with input patterns to which it had not been exposed. The performance of the system was examined in relation to the human expert. RESULTS: After training the neural network with the first set, a sensitivity of 88.9% and a false-positive rate of 4.3% were obtained at testing. When the learning and test set contained records that led to interobserver disagreement, a sensitivity of 86.7% and a false-positive rate of 19.7% were obtained. Sixty percent of fetal heart rate records interpreted as abnormal by the neural network were interpreted likewise by the human experts. CONCLUSIONS: The results obtained are encouraging in that the neural network could discriminate between normal and abnormal nonstress tests. Further evaluation of this new technique is mandatory to evaluate its efficacy and reliability in interpreting fetal heart rate records.
Estradiol- and progesterone-related increases in the renin-aldosterone system: studies during ovarian stimulation and early pregnancy.
To investigate the degree to which endogenous increases in estradiol (E2) and progesterone (P4) are associated with changes in the renin system, we studied eight patients undergoing ovarian stimulation for in vitro fertilization (FSH/human menopausal gonadotropin or clomiphene citrate for 5-11 days, followed by hCG). Three conceived and were followed for up to 62 days after hCG treatment. The others were followed until the end of the luteal phase. During the follicular phase, E2 increased 10-fold, PRA increased 2-fold, and absolute levels of E2 and P4 were positively correlated (r = 0.63; P < 0.05). After ovulation, which was induced by hCG, E2 fell by 50% (day 7), but there was a 50-fold increase in P4 and a further 5-fold increase in PRA. By day 14, E2 increased again in the women who conceived, to levels even higher than those in the follicular phase, and both P4 and PRA increased 2- to 3-fold between days 7 and 14. In contrast, E2, P4, and PRA returned toward baseline levels in the nonpregnant women. On day 21, E2, P4, and PRA remained very high in the pregnant women [E2, 2297 +/- 255 pg/mL (8430 pmol/L); P4, 103 +/- 22 pg/mL (328 pmol/L); PRA, 33 +/- 8 ng/mL.h (9.17 ng/L.s)]. During the luteal phase and early pregnancy, there was a positive relationship between PRA and P4 (r = 0.68; P < 0.05). There was also a positive relationship between PRA and E2 (r = 0.54; P < 0.05); compared to the follicular phase level, PRA was 4-fold higher in the luteal phase at any E2 level. Like renin, urinary aldosterone excretion (UA) increased 5-fold during the luteal phase (day 7) and by a further 3-fold between days 7 and 21 in the pregnant women, reaching very high levels [135 +/- 28 micrograms/day (375 nmol/day); n = 3]. PRA and UA positively correlated (r = 0.59; P < 0.08). Plasma angiotensinogen increased from 2146 +/- 283 ng angiotensin-I/mL (n = 8) to 3682 +/- 607 (n = 8) on day 7 and to 5353 +/- 799 (n = 3) on day 21. Urinary sodium excretion did not fall, and urinary potassium did not increase in coordination with the changes in renin and aldosterone. There was no hypokalemia. These results demonstrate marked increases in plasma renin and UA in coordination with increases in plasma E2 and P4 during ovarian stimulation and early pregnancy, and coordinated falls during luteolysis.(ABSTRACT TRUNCATED AT 400 WORDS)
The value of Doppler ultrasonography in prolonged pregnancies.
One hundred forty-two gravid women at term were followed prospectively by a non-stress test, estimation of amniotic fluid volume and Doppler velocimetry of the umbilical and uterine arteries. Adverse perinatal outcome was detected in 12 women (8.5%). Abnormal antepartum tests were detected in 26 women (17%). Seven women had an abnormally elevated resistance index (RI) in the umbilical artery; but only two had an abnormal outcome. Seven women had an abnormally elevated RI in the uterine artery, but only two had abnormal outcome. Three out of 11 women with oligohydramnion had abnormal perinatal outcome. Only one out of seven women with an abnormal non-stress test had abnormal perinatal outcome. In six women, more than one antepartum test was abnormal. The various surveillance methods demonstrated a low sensitivity (the highest was obtained by estimating amniotic fluid volume: 25%) and a low positive predictive value (the highest obtained by measuring the resistance index in either the umbilical or the uterine arteries: 28.6%). By considering any abnormal test as a positive test result for a given patient, a substantial improvement in sensitivity (66.7%) and positive predictive value (33.3%) are obtained. Doppler velocimetry adds very little in itself to the follow-up of patients with post-term gestations. However, when combined with additional antepartum tests, it may increase our ability to predict the compromised fetus in this condition.
Assessment of ovarian and uterine blood flow by transvaginal color Doppler in ovarian-stimulated women: correlation with the number of follicles and steroid hormone levels.
OBJECTIVE: To study the changes that occur in vascular resistance to flow in the utero-ovarian circulation and their correlation with the number of follicles and steroid hormone levels in patients undergoing ovarian stimulation with gonadotropin. DESIGN: In a prospective study, the impedance to flow in the intraovarian and uterine vessels was measured by means of transvaginal color flow Doppler imaging throughout the cycle. SETTING: University-based IVF program. PATIENTS: Eleven infertile patients undergoing ovarian stimulation with gonadotropin in preparation for IVF and ET. MAIN OUTCOME MEASURES: Intraovarian, uterine, and arcuate artery blood flow velocity waveforms, follicular growth, and serum E2 and P concentrations throughout the cycle. RESULTS: Pulsatility index (PI) of the intraovarian blood vessels and uterine artery decreased gradually during the follicular and luteal phase. The PI of the arcuate artery did not change significantly. The PI of the intraovarian blood vessels correlated with the number of follicles (> 15 mm; day of hCG). Serum E2 concentrations but not P demonstrated negative linear correlation with the PI of the intraovarian vessels and uterine artery. CONCLUSIONS: Induced cycles are associated with decreased impedance to blood flow in the utero-ovarian circulation. Intraovarian PI correlates negatively at each stage of the cycle with the eventual number of preovulatory follicles. Little or no changes are observed when the response to ovarian stimulation is poor.
Uterine artery flow velocity waveforms and color flow imaging in women with perimenopausal and postmenopausal bleeding. Correlation to endometrial histopathology.
We performed Doppler studies of the uterine artery in 85 women with postmenopausal and perimenopausal bleeding. Sixty-six women had non-malignant changes and 19 women had malignant changes on histologic examination of the endometrium. Uterine fibroids were detected in 30 women. When malignant changes were detected in the endometrium, uterine artery resistance index was always below 0.83. The mean uterine artery resistance index was significantly lower in the group of women with pathologic changes of the endometrium (RI = 0.77 +/- 0.03) compared to the group with non pathologic changes (RI = 0.85 +/- 0.08 p < 0.01), excluding the women with uterine fibroids. The lowest mean resistance index in the uterine artery was observed in the group of women with uterine fibroids (RI = 0.60 +/- 0.09 p < 0.001). In five of six patients with endometrial carcinoma blood vessels were detected around the myometrium by using color flow imaging. Their RI was always less than 0.5. In five patients, blood vessels were detected in uterine fibroids but their RI was always more than 0.5. All six women with endometrial carcinoma but only seven of 13 women with endometrial hyperplasia, had endometrial thickness greater than 5 mm. Doppler velocimetry of the uterine artery carries a high sensitivity (100%) in detecting pathological changes of the endometrium in patients presenting with postmenopausal or perimenopausal bleeding. The presence of high resistance in this vessel, may allow a more conservative approach in this group of patients.
Transvaginal embryo aspiration--a safe method for selective reduction in multiple pregnancies.
OBJECTIVE: To evaluate pregnancy outcome after transvaginal selective embryo aspiration and to compare the results with those reported previously with other techniques for selective abortion. DESIGN: Retrospective case series. SETTING: University-based in vitro fertilization (IVF) program. PATIENTS: Nineteen women with multiple pregnancy who conceived after ovulation induction or IVF/gamete intrafallopian transfer. INTERVENTION: Transvaginal ultrasound-guided aspiration of the embryo(s) was performed at 7 to 8 weeks of gestation. MAIN OUTCOME MEASURES: Early and late complications related to the procedure, outcome of pregnancy, and birth weight. RESULTS: In 18 cases, the initial number of embryos (3 to 7) was reduced to two. In 1 case, the number of embryos was reduced from 4 to 3. None of the remaining fetuses vanished after the procedure. One patient delivered at 25 weeks and all other patients delivered healthy, viable infants (a pregnancy loss rate of 5.3%). CONCLUSIONS: Transvaginal embryo aspiration in early gestation appears to be a simple and relatively safe procedure for selective termination in patients with high-order multiple pregnancy. The cumulative loss rate of selective termination procedures previously reported by others is three times higher than the loss encountered in our series. This earlier procedure may be more acceptable to patients from emotional and religious points of view.
Renal artery flow velocity waveforms in normal and hypertensive pregnant women.
Pregnancy is associated with marked changes in renal functions. Hypertensive disorders in pregnancy are frequently accompanied by deteriorated renal functions and by pathological lesions in the glomeruli. Using a pulsed Doppler ultrasound, we measured the resistance to flow in the renal artery in normal and hypertensive pregnant patients. We performed 176 pulsed Doppler ultrasound measurements of the renal arteries at various stages of gestation in 60 low risk pregnant patients. Another 111 Doppler measurements of the same vessels were obtained from 80 hypertensive pregnant patients throughout the third trimester. Twenty-six patients had preeclampsia, 35 patients had pregnancy-induced hypertension, and 19 patients had chronic hypertension. The resistance to flow in the renal arteries (expressed by the resistance index, RI) did not change significantly during pregnancy. The renal artery RI was not significantly different between the hypertensive group (RI = 0.61 +/- 0.06) and the low risk group (RI = 0.605 +/- 0.04). The RI values were also similar in all hypertensive patient categories: preeclampsia (RI = 0.62 +/- 0.07), pregnancy-induced hypertension (RI = 0.60 +/- 0.06), and chronic hypertension (RI = 0.61 +/- 0.05). The renal artery RI did not correlate with the severity of the hypertensive disease or with the status of renal functions. The outcome of pregnancy was worse in patients with abnormally elevated resistance index in the renal arteries. Patients with abnormally elevated resistance to flow in the uterine arteries also had a significant increase in the resistance index in the renal vessels.(ABSTRACT TRUNCATED AT 250 WORDS)
Localization of renin gene expression to monkey ovarian theca cells by in situ hybridization.
To investigate the sites of renin gene expression and localization of renin in primate ovaries, five cynomolgus (Macaca fascicularis) and one rhesus (Macaca mulatta) monkey were treated with gonadotropins to induce multiple follicle development. One ovary was removed before hCG injection (1200 IU) from three monkeys and one ovary was removed 36 h after hCG administration from three monkeys. In three monkeys, the remaining ovary was removed 3, 5, and 7 days after injection of hCG. To detect and localize renin messenger RNA, 35S-radiolabelled 1.1 kb length complementary DNA and RNA probes of human renin were used for in situ hybridization. To compare the synthesis with the presence and the storage of renin or prorenin, renin antigen was assessed by immunohistochemistry in the same tissues using a polyclonal antibody against human renin (R15). Renin mRNA was detected by in situ hybridization only in ovaries collected within 5 days of exposure to hCG. All such ovaries exhibited a positive signal. Renin mRNA was localized to the theca interna and theca lutein cells. Positive cells were observed in a few growing antral follicles, in occasional mature preovulatory follicles, in corpus luteum, and most strikingly in atretic follicles. No signal was detected in primordial, primary, or in small antral follicles of ovaries exposed to hCG. In contrast with the in situ hybridization data, no signal was detected by immunohistochemistry using antirenin antibodies which exhibited a positive signal in monkey kidney. These results indicate that hCG turns on renin gene expression. Renin is synthesized without significant intracellular storage in monkey ovarian theca interna cells and in corpus luteum. The absence of storage of renin is consistent with the high concentrations of prorenin found in ovarian follicular fluid of hCG stimulated primates and with our knowledge of cellular renin processing which indicate that prorenin is secreted constitutively as it is synthesized.
Growth and development of children conceived by in vitro fertilization.
To assess the physical and mental development of infants born after in vitro fertilization (IVF), we performed a general physical and developmental examination (Bayley and Stanford-Binet scales) on a cohort of 116 IVF children, conceived and born at our institution between February 1985 and March 1989, and on 116 non-IVF matched controls. Study and control groups were each composed of 66 singletons, 19 pairs of twins and 4 sets of triplets, whose age at examination ranged from 12 to 45 months. The developmental indices of IVF infants were within the normal range and did not differ from those of their matched controls. The indices were positively correlated to gestational age, birth weight, head circumference at birth and at examination, and mother's education. Mean birth weight, gestational age, and birth weight percentile of IVF infants were lower than the mean of the healthy population. Mean percentiles of weight and length at examination (mean age 22.4 months) were equally low but did not differ from those of the matched controls. However, mean percentiles of head circumference at birth and at examination compare well with the normal mean, both in IVF and control groups. Twins and triplets (IVF and controls) had significantly lower physical and mental indices as compared to singletons.
Systolic or diastolic notch in uterine artery blood flow velocity waveforms in hypertensive pregnant patients: relationship to outcome.
To identify the relationship between a systolic or diastolic notch in uterine artery flow velocity waveforms and pregnancy outcome, we studied 140 hypertensive pregnant women with transvaginal, image-directed pulsed Doppler ultrasound. The subjects were classified according to the presence or absence of a systolic or diastolic notch. In 14 with a systolic and 25 with a diastolic notch, the resistance indexes in the uterine arteries on both sides of the uterus were significantly higher than in 101 subjects without a notch. Those with notches had significantly higher rates of fetal growth retardation and cesarean delivery because of fetal distress. Significantly more infants born to women with a notch spent longer than 48 hours in the neonatal intensive care unit. Subjects with a systolic notch also had significantly higher rates of abnormal fetal heart rate patterns during labor and low Apgar scores at 5 minutes. Fifty-one women with elevated resistances indexes in both uterine arteries were divided into two groups according to the resistance index in the umbilical artery. Each group was subdivided according to the presence or absence of a systolic or diastolic notch in the uterine artery flow velocity waveforms. In the group with a normal resistance index in the umbilical artery, five women had growth-retarded fetuses when a notch was present (N = 8), compared with none in women without a notch (N = 11) (P less than .005). The respective figures for the group with abnormal umbilical artery resistance indexes were 14 of 19 (73.7%) and two of 13 (15.4%) (P less than .002).(ABSTRACT TRUNCATED AT 250 WORDS)
Differentiating malignant from benign ovarian tumors with transvaginal color flow imaging.
The impedance to blood flow was examined by transvaginal color flow imaging in 53 ovarian masses before exploratory laparotomy. Serum CA 125 levels were measured in all subjects. Thirty-six had benign ovarian tumors and 17 had malignant ovarian tumors confirmed by histopathologic examination. Intratumoral blood vessels, detected in 16 of the malignant tumors, consistently demonstrated low impedance to flow, with a pulsatility index (PI) always below 1. The PI of the intraovarian or intratumoral blood vessels was greater than 1 in 35 of the 36 benign tumors, although 11 had suspicious sonographic findings (P less than .01) and 14 had elevated CA 125 levels (P less than .001). The sensitivity and specificity of the preoperative PI in detecting malignant ovarian tumors were 94 and 97%, respectively. The sensitivity and specificity of preoperative suspicious sonographic findings in detecting malignant ovarian tumors were 94 and 69%, and those of elevated preoperative serum CA 125 levels were 82 and 61%, respectively. Our results suggest that transvaginal color flow imaging may be a useful clinical tool in the preoperative evaluation of ovarian masses.