Clinical applications of colour Doppler energy imaging in the female reproductive tract and pregnancy.

This review describes the usefulness of colour Doppler energy (CDE) (or power Doppler) imaging to measure vascularization in the female reproductive tract. CDE imaging is characterized by an increased sensitivity to flow, and thus may be useful in low-flow states and when optimal Doppler angles cannot be obtained. In addition, longer segments of vessels and more individual vessels can be visualized with CDE imaging. The role of CDE imaging in the evaluation of stromal vasculature in normal and in polycystic ovaries is described, and the relationship between follicular vascularity and outcome following in-vitro fertilization are discussed, together with the findings obtained from the evaluation of thecal arteriole of corpus luteum in early pregnancy. The fundamental role of CDE imaging in differentiation among ovarian masses is also reviewed. We summarize the role of CDE imaging in pregnancy, and describe two new applications of three-dimensional power Doppler sonography and the use of ultrasound contrast media. In conclusion, CDE imaging can replace conventional colour Doppler when the information on the direction of flow is not useful. Moreover, the technique appears superior to others for describing microvascular architecture and determining the presence or absence of flow.

The diagnosis of endometriomas using colour Doppler energy imaging.

We studied the role of colour Doppler energy (CDE) (or power Doppler) imaging in the differentiation between endometriomas and other adnexal masses in premenopausal non-pregnant women. A total of 170 consecutive patients with persistent adnexal masses was submitted to B-mode transvaginal ultrasonography associated with CDE imaging evaluation. Plasma concentrations of CA125 were measured before surgery. Using CDE imaging evaluation of vessel distribution, the occurrence of one of the following findings was considered to indicate the likely presence of endometrioma: (i) a round-shaped homogeneous hypoechoic 'tissue' of low-level echoes without papillary proliferations associated with 'poor' vascularization; (ii) a round-shaped homogeneous hypoechoic 'tissue' of low-level echoes with an echogenic portion in which no flow was detected. The overall agreement between the test result and the actual outcome was calculated using the k index. The CDE imaging evaluation was more accurate in the diagnosis of endometriomas compared with B-mode ultrasonography alone (k = 0.88 and 0.80 respectively). According to the logistic regression equation obtained, the probability of the presence of endometrioma varied between a minimum of 1.4% for patients with no risk factors to a maximum of 95.6% for patients with two risk factors (CDE result and value of CA125 >25 IU/ml).

Diagnosis of adnexal malignancies by using color Doppler energy imaging as a secondary test in persistent masses.

The purpose of this prospective study was to compare the accuracy of B-mode transvaginal ultrasonography alone and in combination with color Doppler energy (or power Doppler) imaging in differentiating benign from malignant adnexal masses. A total of 192 consecutive persistent adnexal masses (159 benign, 33 malignant) were studied before surgery by B-mode transvaginal ultrasonography with and without color Doppler energy. In addition, CA-125 plasma levels were determined and spectral Doppler analysis was performed. By color Doppler energy imaging, a mass was considered malignant when arterial flow was visualized in an echogenic portion of a mass defined as malignant by B-mode. Intratumoral arterial blood flow could be readily detected by color Doppler energy imaging in all malignant tumors and in 94% of the benign tumors. The combined use of transvaginal B-mode ultrasonography and color Doppler energy imaging has greater accuracy in the diagnosis of ovarian malignancies than transvaginal ultrasonography alone (value of kappa: 0.81 and 0.63, respectively), reducing the number of false-positive results. The use of spectral Doppler analysis was of limited diagnostic value, with a kappa value of 0.17 for the pulsatility index (< 1) and of 0.41 for the resistance index (< 0.4). Also, the association with CA-125 increased the number of false-negative results. In conclusion, the use of color Doppler energy imaging seems to be a useful secondary test when a mass is suspected to be malignant by B-mode ultrasonography.

Color Doppler energy imaging in the diagnosis of fetal intracranial hemorrhage in the second trimester.

Unlike conventional color Doppler imaging; color Doppler energy (or power Doppler) displays the intensity of the returning Doppler signal, is less dependent on the orientation of the blood vessel, and is therefore better able to detect low blood velocities. For these reasons it could be useful in some investigations which are difficult to perform, such as transvaginal evaluation of fetal brain vessels. We report a case of a fetal intracranial hyperechoic lesion detected at 26 weeks by transabdominal sonography in a severely growth-retarded fetus. There was absence of diastolic flow in the umbilical artery and low impedance to diastolic flow in the middle cerebral arteries. The fetus was further investigated by transvaginal sonography for the evaluation of the nature and localization of the lesion and an intraventricular hemorrhage in the right brain parenchyma with disorganized supratentorial brain structure was observed. As color Doppler energy imaging is more sensitive to slow flow, it was more reliable than conventional Doppler imaging in confirming the absence of flow within and around the hyperechoic lesion in contrast to the normal vascularity of the contralateral ventricular system. After informed parental counselling, the mother, for psychological reasons, asked to be delivered by Cesarean section. The fetus died 24 h after birth. The autopsy corroborated the ultrasonographic diagnosis. This case report confirms the accuracy of transvaginal ultrasonography in the diagnosis of intracranial hemorrhage and suggests a specific role for color Doppler energy imaging.

Transvaginal ultrasound and computed tomography combined with clinical parameters and CA-125 determinations in the differential diagnosis of persistent ovarian cysts in premenopausal women.

The purpose of this prospective study was to compare the accuracy of computed tomography (CT) and transvaginal ultrasonography in the differential diagnosis of persistent cystic ovarian lesions. The candidates for this study were 161 premenopausal non-pregnant women with an adnexal mass. After a 3-month follow-up, 83 masses persisted and were examined by both techniques before surgery. We also evaluated the CA-125 plasma levels. The CT and ultrasonographic diagnoses were then compared with the histopathological diagnosis. The overall agreement between the test results and the actual outcome was calculated by means of the kappa statistic. Transvaginal ultrasonography has a closer accuracy in the diagnosis of serous cysts and serous cystadenoma, ovarian carcinoma and endometrioma (value of kappa: 0.78, 0.73 and 0.80, respectively) than CT, even if the latter is associated with clinical and biochemical parameters such as patient's age and CA-125 plasma levels. Only in the diagnosis of cystic teratoma, is transvaginal ultrasonography less accurate than CT. In conclusion, in premenopausal women, transvaginal ultrasonography remains a cost-effective method in the diagnosis of most cystic ovarian lesions.

The screening of embryonic viability in early asymptomatic pregnancy by a single endosonographic scan associated with plasma human chorionic gonadotropin determination.

PURPOSE: Our purpose was to assess, with a prospective study with random assignment of the day of the first evaluation, whether a single transvaginal ultrasonographic evaluation together with the determination of plasma hCG levels could be used to screen embryonic viability in early asymptomatic pregnancy. METHODS: In 260 pregnant women observed from January 1991 to November 1993 with spontaneous pregnancies where the exact date of ovulation was known, a single transvaginal ultrasonographic measurement of gestational sac with determination of plasma hCG levels, transformed to their natural logarithm (lnhCG), was performed. An abnormal result was defined as a value of lnhCG per mean gestational sac below the 95% lower confidence limit of the viable pregnancy group. RESULTS: The sensitivity was 31%, with a specificity of 97%. CONCLUSION: The study demonstrates that this method has a poor predictive capacity to distinguish viable pregnancy from nonviable pregnancy with a kappa value less than 0.4.