Cerebroplacental Ratio as a Predictor of Perinatal Adverse Outcome in Appropriate for Gestational Age (AGA) fetuses

Cerebroplacental Ratio as a Predictor of Perinatal Adverse Outcome in Appropriate for Gestational Age (AGA) fetuses | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Cerebroplacental Ratio as a Predictor of Perinatal Adverse Outcome in Appropriate for Gestational Age (AGA) fetuses Uma Chillalshetti, Veena Kalmath, Antaraa Bhattacharya, Bhakti Vadodariya, and 2 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-8195874/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Background The cerebroplacental ratio (CPR) is the ratio of the Doppler pulsatility indices of the Middle Cerebral Artery and the Umbilical Artery. A value less than 1 can be used to screen for pregnancies at high risk of adverse perinatal outcomes. The objective of this study was to determine the accuracy of CPR in predicting adverse outcomes in appropriate for gestational age (AGA) fetuses. Methods This prospective observational study was conducted in the Department of Radiology at a tertiary care hospital in India. It included 144 pregnant women having singleton pregnancies at term. Exclusion criteria was patients with multiple pregnancies, unknown last menstrual period with no dating scan, complicated pregnancies, congenital malformations and chromosomal abnormalities, pregnancies with known fetal growth retardation (FGR), and women with known placental abnormalities. The cerebroplacental ratio was calculated using duplex Doppler ultrasonography. The possible outcomes were Caesarean section or instrumental delivery for fetal distress, NICU admission, APGAR score < 7 at 5 minutes, or a normal outcome. Results A total of one hundred and forty-four singleton pregnancies were included. According to study results, patients with CPR 1. Sensitivity was 63.6% and specificity was 92.1%. Conclusion The study results prove that a finding of CPR value < 1 at term is a strong predictor of adverse outcome. However, due to the low sensitivity of CPR, it should be used as an adjunctive method of detecting adverse outcomes, and not an independent measure. Nuclear Medicine & Medical Imaging cerebroplacental ratio adverse perinatal outcome Doppler ultrasound Figures Figure 1 Figure 2 Figure 3 Introduction Over the years, multiple attempts have been made to devise methods for predicting adverse perinatal outcomes. Of these, the Cerebroplacental Doppler ratio (CPR) has been more commonly used over the past few years. It is the ratio of the Doppler pulsatility indices of the Middle Cerebral Artery and the Umbilical Artery (MCA PI/UA PI). The CPR is considered more accurate at predicting adverse perinatal outcomes than its individual components, as well as other more conventional methods, such as biophysical profile, 1, 2 anthropometric models, 2 etc. One of the more conventional methods to detect high-risk pregnancies has been to screen for estimated fetal weight or to screen for growth restriction. A study found that a significant number of cases with adverse perinatal outcomes were in fetuses with normal anthropometric parameters, or appropriate for gestational age (AGA) fetuses. A suggestion has been made to shift the screening to detect impaired placentation and hypoxemia, instead of limiting it to anthropometric methods. This can be done by using the cerebroplacental ratio to screen for possible adverse perinatal outcome instead. 3 , 4 A low CPR value is considered to be a predictor of adverse perinatal outcome. This value may result from one of three Doppler patterns. One, the MCA PI is on the lower end and the UA PI is at the upper end of normal; this results in a low CPR. Two, the MCA PI and UA PI are abnormally low and high, respectively, resulting in an abnormally low CPR. And three, when MCA PI is abnormally low while UA PI is normal. 5 An abnormal CPR value is an indicator of both abnormal placental blood flow, as indicated by the UA PI, and fetal circulatory adaptations to these changes, evidenced by the MCA PI. 2 Increased vascular resistance in the UA may result in absent or even reversed end-diastolic flow, which results in fetal hypoxia and acidosis. Consequently, there is increased end-diastolic flow in the MCA to counteract these changes and create a “brain sparing effect”. 2, 6 We conducted this observational study to determine the utility of CPR in detecting the risk of adverse perinatal outcome. Methods This was a prospective observational study conducted in the Department of Radiology, Chhatrapati Shivaji Maharaj Hospital, Kalwa, Thane. This study was approved by the Institutional Clinical Ethics Committee (ICEC) of Rajiv Gandhi Medical College & Chhatrapati Shivaji Maharaj Hospital, Kalwa. Approval Number: RGMC/ICEC/31/2017. Date of Approval: 13/10/2017. Written and informed consent was obtained from all the participants. A hundred and fifty-six (156) patients with singleton pregnancies at term were included, with gestational age being at an average of 38 weeks at time of scan. 12 patients did not deliver in our hospital, and were lost to follow-up. So, a total of 144 singleton pregnancies were considered. The gestational age was determined by both the date of the last normal menstrual period, and by ultrasonographic dating scan conducted during the first trimester of gestation. In cases where the earliest available scan was between 14–20 weeks, dating was derived using fetal biometry and compared with the date of the last menstrual period to minimize error. Exclusion criteria included patients with multiple pregnancies, unknown last menstrual period with no dating scan, complicated pregnancies, congenital malformations and chromosomal abnormalities, pregnancies with known fetal growth retardation (FGR) and women with known placental abnormalities. Ultrasound examinations were performed using Sonoscape (Sonoscape Medical Corp., Shenzhen, China) and Mindray Consona (Mindray Bio-Medical Electronics Co., Ltd., Shenzhen, China) ultrasound machines. All procedures were carried out according to standard protocols to ensure reproducibility. The convex probes used and settings were adjusted based on patient characteristics and examination requirements. Doppler velocimetry of the MCA and UA was performed while having the ultrasound beam be as parallel to the direction of blood flow as possible. The scan was performed by an experienced operator. Recordings were taken during periods of absent fetal movement, and the patient was asked to hold her breath. Pulsatility indices of MCA and UA were calculated. The mean of 3 consecutive waveforms was taken to obtain the most accurate result. The CPR was calculated as the ratio of MCA PI and UA PI. An abnormal value of CPR was defined as a value below 1 in this study. The perinatal outcomes considered for this study were 1) Caesarean section for fetal distress, 2) Instrumental delivery for fetal distress, 3) APGAR score < 7 at 5 minutes, 4) NICU admission 5) Normal outcome. Perinatal outcome for each patient was obtained from the Dept. of Obstetrics. The interval between the Doppler studies and delivery was 1–11 days, with an average of 4 days. No modifications were made to the standard operating procedures. The methods used followed established clinical guidelines for ultrasound. Statistical analysis was performed using statistical software. Results A hundred and forty-four singleton pregnancies were included in the study. A cerebroplacental ratio of < 1 was taken as a predictor of adverse outcome. [Table 1 ] shows cumulative data and outcomes seen in patients with CPR 1. Table 1 A summary of patient outcomes in relation to CPR score Cerebroplacental ratio(CPR) value Adverse outcome Normal outcome Total CPR 1 20 82 102 Total 55 89 144 [Table 2 ] shows the sensitivity, specificity, positive predictive value, negative predictive value, and odds ratio associated with these findings. Table 2 Statistical results Metric Result Sensitivity 63.6% Specificity 92.1% Positive Predictive Value(PPV) 83.3% Negative Predictive Value(NPV) 80.4% Odds Ratio 20.5 [Table 3 ] shows the various intrapartum and postpartum outcomes seen by patients expecting both normal outcome (CPR > 1) and adverse outcome (CPR < 1). According to our study, an abnormal CPR value is strongly associated with adverse perinatal outcome. While caesarean delivery for fetal distress, poor APGAR score at 5 mins and admission to NICU showed statistically significant association, instrumental delivery was not seen to be significantly associated with CPR < 1. Table 3 Perinatal outcomes and their associated antenatal CPR values Outcome Total number of patients Patients with CPR 1 p value* Caesarean delivery 22 12 10 0.0091 Instrumental delivery 7 2 5 1 APGAR score < 7 at 5 mins 9 9 0 < 0.00001 NICU Admission 17 12 5 0.0016 Normal outcome 89 7 82 < 0.00001 *p-value calculated using Fishers exact test at significance of p < .05. CPR- Cerebroplacental ratio, APGAR- Appearance, Pulse, Grimace, Activity, Respiration, NICU- Neonatal intensive care unit Doppler images of two patients, A and B have been included. Patient A shows normal Doppler parameters with a CPR > 1, while patient B shows impaired MCA PI and UA PI, with a CPR < 1. [ Figure 1 ] [ Figure 2 ] [ Figure 3] In case of patient B, there’s deranged MCA PI and UA PI. The Uterine artery PI remains within normal limits, despite elevated umbilical artery PI. This suggests that impaired circulation seen in case B is more likely a result of fetoplacental or intraplacental causes, than impaired uterine artery circulation. Discussion The results of this study prove that an abnormal CPR value (< 1) can and should be used to identify pregnancies with the potential for an adverse perinatal outcome, especially in AGA fetuses. While MCA PI & UA PI can also make similar predictions, it is not to the level of accuracy provided by the CPR. 1 , 6 , 7 , 8 Abnormal fetal UA PI is an independent indication of perinatal morbidity and mortality, especially fetal growth restriction. However, it is not a good predictor of morbidity in early labour. 9 On the other hand, Arias et al. 7 found that in some patients with pre-eclampsia who had abnormal CPR, the MCA PI was within normal limits, despite the UA PI being abnormal. This can happen in cases where the increase in resistance of placental blood flow disrupts fetal circulation, but not enough to cause redistribution. Additionally, even though MCA PI is a preferred indicator over UA PI in the third trimester, it has a low predictive value when used by itself. 10 Thus, CPR has a better accuracy in predicting adverse outcomes than its individual components. The threshold value for an abnormally low CPR has not yet been defined. While this study considers a value less than 1 to be abnormal, other cut-offs also exist. These include a value < 1.08, < 0.9, < 1.1, < 1.3, < 0.6765 multiples of median (MoM), < 10th percentile, <5th percentile, etc. 2 , 5 This lack of uniformity may contribute to the heterogeneity in predictive accuracy seen for various parameters over several studies. CPR is found to be an accurate predictor of outcomes like a) emergency caesarean section for fetal distress, 1, 6, 7, 9, 10, 11, 12 b) intrauterine growth retardation, 1, 6, 12, 13 (c) prolonged NICU admission, 1, 6, 7, 12 d) meconium stained liquor, 9,11 e) perinatal mortality, 1, 6, 7, 10 f) APGAR score < 7, 10, 12 g) instrumental delivery for intrapartum fetal distress, 14 and even an abnormal cardio topography tracing. 11 Abnormal CPR may also indicate the presence of genetic abnormalities, especially those associated with haemodynamic changes. 7 However, some studies did not find a statistically significant association between a low CPR and an adverse perinatal outcome. These include outcomes such as a) no association with a low APGAR score < 7, 1, 6, 7, 9 b) no association with meconium-stained liquor, 6 c) no association with prolonged NICU stay. 9 Additionally, Fiolna et al. 13 found that addition of CPR to screen for fetal distress and the requirement of operative delivery, did not improve performance of screening when performed by just using maternal factors and obstetric and medical history. The utility of CPR is multipolar. It has proved to be more accurate than other methods of predicting adverse perinatal outcome. This is especially true in cases of an appropriate for gestational age (AGA) fetus, in whom there are limited ways to detect perinatal compromise. 9 Anthropometric measurements can differentiate between average for gestational age(AGA) and small for gestational age (SGA) babies. They are even able to detect fetal growth restrictions (FGR). The risks associated with SGA and FGR fetuses are well documented, but an AGA fetus is not free from adverse perinatal outcome. This is because anthropometric parameters are unable to assess abnormalities in placental or fetal circulation, especially those that would not significantly affect fetal growth. CPR allows us to predict possible adverse outcomes early, and prepare for them. Identifying high risk cases via CPR value before delivery can help determine which pregnancies need safe confinement. It can also allow for timely decisions regarding the plan of delivery. High risk cases can also be transferred to centres that are more equipped to deal with emergencies. Furthermore, one can choose to perform an elective Caesarean section in cases at risk for fetal distress. This will do away with the risks of an emergency operative delivery. 4 It has more recently also been touted to be an accurate indicator of late FGR. 10 It has been found that the detection rate of CPR is the highest for pregnancies closer to term. It is most accurate in cases where the delivery occurs within 2 weeks of the screening. 2 , 3 This is in line with our study, which has been conducted among pregnancies at term. Despite all this, there is no consensus on whether CPR is a reliable indicator of adverse perinatal outcome. Different studies have found variations in predictive accuracy for different parameters, making it difficult to reach a final opinion. Furthermore, several studies are conducted retrospectively, which provides weaker evidence than a prospective study. It is advised that CPR should not be used as an independent parameter, but should be used alongside other factors like maternal history, to predict adverse outcomes. 2 , 4 , 7 , 11 This finding is consistent with the study results, as the low sensitivity suggests CPR is better used as an adjunctive method of predicting fetal outcome. Limitations: The possible limitations of this study include the small sample size of 144 participants, and limited possible outcomes considered in adverse perinatal outcome. Declarations Consent: Informed consent to participate in the study was obtained from all participants. Data availability : The datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request. Conflict of Interest : The authors declare no competing interests. Funding : No external funding to declare. Author Contributions : UC: Conceptualization, Project administration, Resources, Supervision, Writing - Review & Editing; VK: Investigation, Resources, Supervision, Validation; AB: Data curation, Methodology, Writing - Original Draft, Writing - Review & Editing; BV: Supervision, Validation, Writing - Review & Editing; DM: Data curation, Formal analysis, Software; DB: Writing - Original Draft, Writing - Review & Editing, Software; Acknowledgements : NA References Makhseed M, Jirous J, Ahmed MA, Viswanathan DL (2000) Middle cerebral artery to umbilical artery resistance index ratio in the prediction of neonatal outcome. Int J Gynaecol Obstet 71(2):119–125. 10.1016/s0020-7292(00)00262-9 Dunn L, Sherrell H, Kumar S, Review Systematic review of the utility of the fetal cerebroplacental ratio measured at term for the prediction of adverse perinatal outcome. Placenta 2017 June 1; 54:68–75. 10.1016/j.placenta.2017.02.006 Akolekar R, Syngelaki A, Gallo DM, Poon LC, Nicolaides KH (2015) Umbilical and fetal middle cerebral artery Doppler at 35–37 weeks’ gestation in the prediction of adverse perinatal outcome. Ultrasound Obstet Gynecol 46(1):82–92. 10.1002/uog.14842 Kumar A, Singh A, Kumari S, Saha SC, Singh T, Saini SS Role of Cerebroplacental Ratio in Predicting Perinatal Outcome. Cureus 16(2):e54816. 10.7759/cureus.54816 DeVore GR (2015) The importance of the cerebroplacental ratio in the evaluation of fetal well-being in SGA and AGA fetuses. Am J Obstet Gynecol 213(1):5–15. 10.1016/j.ajog.2015.05.024 Bahado-Singh RO, Kovanci E, Jeffres A, Oz U, Deren O, Copel J et al (1999) The Doppler cerebroplacental ratio and perinatal outcome in intrauterine growth restriction. Am J Obstet Gynecol 180(3 Pt 1):750–756. 10.1016/s0002-9378(99)70283-8 Arias F (1994) Accuracy of the middle-cerebral-to-umbilical-artery resistance index ratio in the prediction of neonatal outcome in patients at high risk for fetal and neonatal complications. Am J Obstet Gynecol 171(6):1541–1545. 10.1016/0002-9378(94)90398-0 Cruz-Martínez R, Figueras F, Hernandez-Andrade E, Oros D, Gratacos E (2011) Fetal brain Doppler to predict cesarean delivery for nonreassuring fetal status in term small-for-gestational-age fetuses. Obstet Gynecol 117(3):618–626. 10.1097/AOG.0b013e31820b0884 Prior T, Mullins E, Bennett P, Kumar S (2013) Prediction of intrapartum fetal compromise using the cerebroumbilical ratio: a prospective observational study. Am J Obstet Gynecol 208(2):124e1–124e6. 10.1016/j.ajog.2012.11.016 Elmes C, Phillips R (2022) Systematic review evaluating the efficacy of the cerebroplacental ratio (CPR) in saving babies lives. Ultrasound 30(3):184–193. 10.1177/1742271X211048213 Prior T, Paramasivam G, Bennett P, Kumar S (2015) Are fetuses that fail to achieve their growth potential at increased risk of intrapartum compromise? Ultrasound Obstet Gynecol 46(4):460–464. 10.1002/uog.14758 Gramellini D, Folli MC, Raboni S, Vadora E, Merialdi A (1992) Cerebral-umbilical Doppler ratio as a predictor of adverse perinatal outcome. Obstet Gynecol 79(3):416–420. 10.1097/00006250-199203000-00018 Fiolna M, Kostiv V, Anthoulakis C, Akolekar R, Nicolaides KH (2019) Prediction of adverse perinatal outcome by cerebroplacental ratio in women undergoing induction of labor. Ultrasound Obstet Gynecol 53(4):473–480. 10.1002/uog.20173 Gupta N, Agarwal M, Akanksha, Kapoor A (2023) The role of cerebroplacental ratio as a predictor of adverse perinatal outcome in uncomplicated term pregnancies. Int J Reprod Contracept Obstet Gynecol 12(12):3592–3598 Additional Declarations The authors declare no competing interests. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-8195874","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":550105476,"identity":"04a5c334-da30-450d-bbe1-f01140828974","order_by":0,"name":"Uma Chillalshetti","email":"","orcid":"https://orcid.org/0009-0006-6893-387X","institution":"Rajiv Gandhi Medical College (RGMC) \u0026 Chhatrapati Shivaji Maharaj Hospital (CSMH), Kalwa, Maharashtra, India.","correspondingAuthor":false,"prefix":"","firstName":"Uma","middleName":"","lastName":"Chillalshetti","suffix":""},{"id":550105477,"identity":"becfd87c-71c6-4d75-a7d5-b0e7ae3241c7","order_by":1,"name":"Veena Kalmath","email":"","orcid":"https://orcid.org/0009-0000-8407-9729","institution":"Rajiv Gandhi Medical College (RGMC) \u0026 Chhatrapati Shivaji Maharaj Hospital (CSMH), Kalwa, Maharashtra, India.","correspondingAuthor":false,"prefix":"","firstName":"Veena","middleName":"","lastName":"Kalmath","suffix":""},{"id":550105478,"identity":"49f51903-3d84-41e1-8d52-c7ffa36c20b4","order_by":2,"name":"Antaraa Bhattacharya","email":"","orcid":"https://orcid.org/0009-0007-3522-541X","institution":"Formerly at Department of Anesthesiology, Rajiv Gandhi Medical College (RGMC) \u0026 Chhatrapati Shivaji Maharaj Hospital (CSMH), Kalwa, Maharashtra, India. 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10:06:04","extension":"html","order_by":10,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":63883,"visible":true,"origin":"","legend":"","description":"","filename":"earlyproof.html","url":"https://assets-eu.researchsquare.com/files/rs-8195874/v1/590139e32ece02a5b4dc3ee7.html"},{"id":97125166,"identity":"5e31b944-685c-44c6-8e33-eecebbbab0ed","added_by":"auto","created_at":"2025-12-01 08:14:50","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":195178,"visible":true,"origin":"","legend":"\u003cp\u003eFetal middle cerebral artery (MCA) Doppler indices. (a) shows Case A (AGA = 38 weeks + 4 days) with MCA PI = 1.14, within normal limit for gestational age. (b) shows Case B (AGA = 37 weeks + 3 days) with MCA PI = 0.97 - reduced value of MCA PI and increased diastolic flow suggestive of cerebral vasodilatation. This demonstrates the brain-sparing effect of fetal circulation in response to chronic hypoxemia or placental insufficiency.\u003c/p\u003e","description":"","filename":"Fig1.png","url":"https://assets-eu.researchsquare.com/files/rs-8195874/v1/8e807c113c1cb8c5f5ad0cdb.png"},{"id":97125169,"identity":"21e22037-ad9a-4a65-ac6e-5c03bc2f7aa5","added_by":"auto","created_at":"2025-12-01 08:14:50","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":190145,"visible":true,"origin":"","legend":"\u003cp\u003eUmbilical artery Doppler indices. (a) shows Case A (AGA = 38 weeks + 4 days) with Umbilical artery PI = 0.99, within normal limit for gestational age. The waveform demonstrates good forward diastolic flow, indicating normal fetoplacental circulation. (b) is of Case B (AGA = 37 weeks + 3 days) with Umbilical artery PI = 2.82- markedly elevated value and absent end-diastolic flow, indicative of increased resistance within the placental circulation.\u003c/p\u003e","description":"","filename":"Fig2.png","url":"https://assets-eu.researchsquare.com/files/rs-8195874/v1/734aaa4ba9d4487b04c99eab.png"},{"id":97141938,"identity":"12e049f1-60e0-4277-b5fb-2e12c4576402","added_by":"auto","created_at":"2025-12-01 10:07:10","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":206324,"visible":true,"origin":"","legend":"\u003cp\u003e(a) shows Case A (AGA = 38 weeks + 4 days) with Uterine artery PI = 0.58, which is within normal limit for gestational age- adequate placental blood supply and no evidence of uteroplacental insufficiency. (b) shows Case B (AGA = 37 weeks + 3 days) with Uterine artery PI = 0.61- also within normal limit for gestational age.\u003c/p\u003e","description":"","filename":"Fig3.png","url":"https://assets-eu.researchsquare.com/files/rs-8195874/v1/79fcbe3d9c2e99afb0690dcb.png"},{"id":97145112,"identity":"2319423d-08c8-4741-8f1c-995abc4f1195","added_by":"auto","created_at":"2025-12-01 10:13:04","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1047856,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-8195874/v1/89fb69be-d242-4fba-ae2e-7c5cd8cbf44d.pdf"}],"financialInterests":"The authors declare no competing interests.","formattedTitle":"\u003cp\u003eCerebroplacental Ratio as a Predictor of Perinatal Adverse Outcome in Appropriate for Gestational Age (AGA) fetuses\u003c/p\u003e","fulltext":[{"header":"Introduction","content":"\u003cp\u003eOver the years, multiple attempts have been made to devise methods for predicting adverse perinatal outcomes. Of these, the Cerebroplacental Doppler ratio (CPR) has been more commonly used over the past few years. It is the ratio of the Doppler pulsatility indices of the Middle Cerebral Artery and the Umbilical Artery (MCA PI/UA PI). The CPR is considered more accurate at predicting adverse perinatal outcomes than its individual components, as well as other more conventional methods, such as biophysical profile,\u003csup\u003e1, 2\u003c/sup\u003e anthropometric models,\u003csup\u003e2\u003c/sup\u003e etc.\u003c/p\u003e\u003cp\u003eOne of the more conventional methods to detect high-risk pregnancies has been to screen for estimated fetal weight or to screen for growth restriction. A study found that a significant number of cases with adverse perinatal outcomes were in fetuses with normal anthropometric parameters, or appropriate for gestational age (AGA) fetuses. A suggestion has been made to shift the screening to detect impaired placentation and hypoxemia, instead of limiting it to anthropometric methods. This can be done by using the cerebroplacental ratio to screen for possible adverse perinatal outcome instead.\u003csup\u003e\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e\u003cp\u003eA low CPR value is considered to be a predictor of adverse perinatal outcome. This value may result from one of three Doppler patterns. One, the MCA PI is on the lower end and the UA PI is at the upper end of normal; this results in a low CPR. Two, the MCA PI and UA PI are abnormally low and high, respectively, resulting in an abnormally low CPR. And three, when MCA PI is abnormally low while UA PI is normal.\u003csup\u003e\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e\u003c/sup\u003e An abnormal CPR value is an indicator of both abnormal placental blood flow, as indicated by the UA PI, and fetal circulatory adaptations to these changes, evidenced by the MCA PI.\u003csup\u003e2\u003c/sup\u003e Increased vascular resistance in the UA may result in absent or even reversed end-diastolic flow, which results in fetal hypoxia and acidosis. Consequently, there is increased end-diastolic flow in the MCA to counteract these changes and create a \u0026ldquo;brain sparing effect\u0026rdquo;.\u003csup\u003e2, 6\u003c/sup\u003e\u003c/p\u003e\u003cp\u003eWe conducted this observational study to determine the utility of CPR in detecting the risk of adverse perinatal outcome.\u003c/p\u003e"},{"header":"Methods","content":"\u003cp\u003eThis was a prospective observational study conducted in the Department of Radiology, Chhatrapati Shivaji Maharaj Hospital, Kalwa, Thane. This study was approved by the Institutional Clinical Ethics Committee (ICEC) of Rajiv Gandhi Medical College \u0026amp; Chhatrapati Shivaji Maharaj Hospital, Kalwa. Approval Number: RGMC/ICEC/31/2017. Date of Approval: 13/10/2017. Written and informed consent was obtained from all the participants. A hundred and fifty-six (156) patients with singleton pregnancies at term were included, with gestational age being at an average of 38 weeks at time of scan. 12 patients did not deliver in our hospital, and were lost to follow-up. So, a total of 144 singleton pregnancies were considered. The gestational age was determined by both the date of the last normal menstrual period, and by ultrasonographic dating scan conducted during the first trimester of gestation. In cases where the earliest available scan was between 14\u0026ndash;20 weeks, dating was derived using fetal biometry and compared with the date of the last menstrual period to minimize error. Exclusion criteria included patients with multiple pregnancies, unknown last menstrual period with no dating scan, complicated pregnancies, congenital malformations and chromosomal abnormalities, pregnancies with known fetal growth retardation (FGR) and women with known placental abnormalities.\u003c/p\u003e\u003cp\u003eUltrasound examinations were performed using Sonoscape (Sonoscape Medical Corp., Shenzhen, China) and Mindray Consona (Mindray Bio-Medical Electronics Co., Ltd., Shenzhen, China) ultrasound machines. All procedures were carried out according to standard protocols to ensure reproducibility. The convex probes used and settings were adjusted based on patient characteristics and examination requirements.\u003c/p\u003e\u003cp\u003eDoppler velocimetry of the MCA and UA was performed while having the ultrasound beam be as parallel to the direction of blood flow as possible. The scan was performed by an experienced operator. Recordings were taken during periods of absent fetal movement, and the patient was asked to hold her breath. Pulsatility indices of MCA and UA were calculated. The mean of 3 consecutive waveforms was taken to obtain the most accurate result. The CPR was calculated as the ratio of MCA PI and UA PI. An abnormal value of CPR was defined as a value below 1 in this study.\u003c/p\u003e\u003cp\u003eThe perinatal outcomes considered for this study were 1) Caesarean section for fetal distress, 2) Instrumental delivery for fetal distress, 3) APGAR score\u0026thinsp;\u0026lt;\u0026thinsp;7 at 5 minutes, 4) NICU admission 5) Normal outcome. Perinatal outcome for each patient was obtained from the Dept. of Obstetrics. The interval between the Doppler studies and delivery was 1\u0026ndash;11 days, with an average of 4 days.\u003c/p\u003e\u003cp\u003eNo modifications were made to the standard operating procedures. The methods used followed established clinical guidelines for ultrasound. Statistical analysis was performed using statistical software.\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003eA hundred and forty-four singleton pregnancies were included in the study. A cerebroplacental ratio of \u0026lt;\u0026thinsp;1 was taken as a predictor of adverse outcome. [Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e] shows cumulative data and outcomes seen in patients with CPR\u0026thinsp;\u0026lt;\u0026thinsp;1 and CPR\u0026thinsp;\u0026gt;\u0026thinsp;1.\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eA summary of patient outcomes in relation to CPR score\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"4\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eCerebroplacental ratio(CPR) value\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eAdverse outcome\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eNormal outcome\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003eTotal\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eCPR\u0026thinsp;\u0026lt;\u0026thinsp;1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e35\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e7\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e42\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eCPR\u0026thinsp;\u0026gt;\u0026thinsp;1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e20\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e82\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e102\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eTotal\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e55\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e89\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e144\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003e[Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e] shows the sensitivity, specificity, positive predictive value, negative predictive value, and odds ratio associated with these findings.\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eStatistical results\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"2\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eMetric\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eResult\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eSensitivity\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e63.6%\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eSpecificity\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e92.1%\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePositive Predictive Value(PPV)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e83.3%\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eNegative Predictive Value(NPV)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e80.4%\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eOdds Ratio\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e20.5\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003e[Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e] shows the various intrapartum and postpartum outcomes seen by patients expecting both normal outcome (CPR\u0026thinsp;\u0026gt;\u0026thinsp;1) and adverse outcome (CPR\u0026thinsp;\u0026lt;\u0026thinsp;1). According to our study, an abnormal CPR value is strongly associated with adverse perinatal outcome. While caesarean delivery for fetal distress, poor APGAR score at 5 mins and admission to NICU showed statistically significant association, instrumental delivery was not seen to be significantly associated with CPR\u0026thinsp;\u0026lt;\u0026thinsp;1.\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003ePerinatal outcomes and their associated antenatal CPR values\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"5\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eOutcome\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eTotal number of patients\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003ePatients with CPR\u0026thinsp;\u0026lt;\u0026thinsp;1\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003ePatients with CPR\u0026thinsp;\u0026gt;\u0026thinsp;1\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c5\"\u003e\u003cp\u003ep value*\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eCaesarean delivery\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e22\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e12\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e10\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.0091\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eInstrumental delivery\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e7\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e5\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eAPGAR score\u0026thinsp;\u0026lt;\u0026thinsp;7 at 5 mins\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e9\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e9\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e\u0026lt;\u0026thinsp;0.00001\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eNICU Admission\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e17\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e12\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e5\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.0016\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eNormal outcome\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e89\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e7\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e82\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e\u0026lt;\u0026thinsp;0.00001\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003ctfoot\u003e\u003ctr\u003e\u003ctd colspan=\"5\"\u003e\u003cem\u003e*p-value calculated using Fishers exact test at significance of p\u0026thinsp;\u0026lt;\u0026thinsp;.05. CPR- Cerebroplacental ratio, APGAR- Appearance, Pulse, Grimace, Activity, Respiration, NICU- Neonatal intensive care unit\u003c/em\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tfoot\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eDoppler images of two patients, A and B have been included. Patient A shows normal Doppler parameters with a CPR\u0026thinsp;\u0026gt;\u0026thinsp;1, while patient B shows impaired MCA PI and UA PI, with a CPR\u0026thinsp;\u0026lt;\u0026thinsp;1. \u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003e[\u003c/span\u003eFigure \u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e\u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003e] [\u003c/span\u003eFigure \u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e\u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003e]\u003c/span\u003e [\u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003eFigure 3]\u003c/span\u003e\u003c/p\u003e\u003cp\u003eIn case of patient B, there\u0026rsquo;s deranged MCA PI and UA PI. The Uterine artery PI remains within normal limits, despite elevated umbilical artery PI. This suggests that impaired circulation seen in case B is more likely a result of fetoplacental or intraplacental causes, than impaired uterine artery circulation.\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eThe results of this study prove that an abnormal CPR value (\u0026lt;\u0026thinsp;1) can and should be used to identify pregnancies with the potential for an adverse perinatal outcome, especially in AGA fetuses. While MCA PI \u0026amp; UA PI can also make similar predictions, it is not to the level of accuracy provided by the CPR.\u003csup\u003e\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e\u003c/sup\u003e Abnormal fetal UA PI is an independent indication of perinatal morbidity and mortality, especially fetal growth restriction. However, it is not a good predictor of morbidity in early labour.\u003csup\u003e\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e\u003cp\u003eOn the other hand, Arias et al.\u003csup\u003e7\u003c/sup\u003e found that in some patients with pre-eclampsia who had abnormal CPR, the MCA PI was within normal limits, despite the UA PI being abnormal. This can happen in cases where the increase in resistance of placental blood flow disrupts fetal circulation, but not enough to cause redistribution. Additionally, even though MCA PI is a preferred indicator over UA PI in the third trimester, it has a low predictive value when used by itself.\u003csup\u003e\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e\u003c/sup\u003e Thus, CPR has a better accuracy in predicting adverse outcomes than its individual components.\u003c/p\u003e\u003cp\u003eThe threshold value for an abnormally low CPR has not yet been defined. While this study considers a value less than 1 to be abnormal, other cut-offs also exist. These include a value\u0026thinsp;\u0026lt;\u0026thinsp;1.08, \u0026lt;\u0026thinsp;0.9, \u0026lt;\u0026thinsp;1.1, \u0026lt;\u0026thinsp;1.3, \u0026lt;\u0026thinsp;0.6765 multiples of median (MoM), \u0026lt;\u0026thinsp;10th percentile, \u0026lt;5th percentile, etc.\u003csup\u003e\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e\u003c/sup\u003e This lack of uniformity may contribute to the heterogeneity in predictive accuracy seen for various parameters over several studies.\u003c/p\u003e\u003cp\u003eCPR is found to be an accurate predictor of outcomes like a) emergency caesarean section for fetal distress,\u003csup\u003e1, 6, 7, 9, 10, 11, 12\u003c/sup\u003e b) intrauterine growth retardation,\u003csup\u003e1, 6, 12, 13\u003c/sup\u003e (c) prolonged NICU admission,\u003csup\u003e1, 6, 7, 12\u003c/sup\u003e d) meconium stained liquor,\u003csup\u003e9,11\u003c/sup\u003e e) perinatal mortality,\u003csup\u003e1, 6, 7, 10\u003c/sup\u003e f) APGAR score\u0026thinsp;\u0026lt;\u0026thinsp;7,\u003csup\u003e10, 12\u003c/sup\u003e g) instrumental delivery for intrapartum fetal distress,\u003csup\u003e14\u003c/sup\u003e and even an abnormal cardio topography tracing.\u003csup\u003e\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e\u003c/sup\u003e Abnormal CPR may also indicate the presence of genetic abnormalities, especially those associated with haemodynamic changes.\u003csup\u003e\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e\u003cp\u003eHowever, some studies did not find a statistically significant association between a low CPR and an adverse perinatal outcome. These include outcomes such as a) no association with a low APGAR score\u0026thinsp;\u0026lt;\u0026thinsp;7,\u003csup\u003e1, 6, 7, 9\u003c/sup\u003e b) no association with meconium-stained liquor,\u003csup\u003e6\u003c/sup\u003e c) no association with prolonged NICU stay.\u003csup\u003e\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e\u003c/sup\u003e Additionally, Fiolna et al.\u003csup\u003e13\u003c/sup\u003e found that addition of CPR to screen for fetal distress and the requirement of operative delivery, did not improve performance of screening when performed by just using maternal factors and obstetric and medical history.\u003c/p\u003e\u003cp\u003eThe utility of CPR is multipolar. It has proved to be more accurate than other methods of predicting adverse perinatal outcome. This is especially true in cases of an appropriate for gestational age (AGA) fetus, in whom there are limited ways to detect perinatal compromise.\u003csup\u003e\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e\u003c/sup\u003e Anthropometric measurements can differentiate between average for gestational age(AGA) and small for gestational age (SGA) babies. They are even able to detect fetal growth restrictions (FGR). The risks associated with SGA and FGR fetuses are well documented, but an AGA fetus is not free from adverse perinatal outcome. This is because anthropometric parameters are unable to assess abnormalities in placental or fetal circulation, especially those that would not significantly affect fetal growth. CPR allows us to predict possible adverse outcomes early, and prepare for them.\u003c/p\u003e\u003cp\u003eIdentifying high risk cases via CPR value before delivery can help determine which pregnancies need safe confinement. It can also allow for timely decisions regarding the plan of delivery. High risk cases can also be transferred to centres that are more equipped to deal with emergencies. Furthermore, one can choose to perform an elective Caesarean section in cases at risk for fetal distress. This will do away with the risks of an emergency operative delivery.\u003csup\u003e\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e\u003c/sup\u003e It has more recently also been touted to be an accurate indicator of late FGR.\u003csup\u003e\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e\u003cp\u003eIt has been found that the detection rate of CPR is the highest for pregnancies closer to term. It is most accurate in cases where the delivery occurs within 2 weeks of the screening.\u003csup\u003e\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e,\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e\u003c/sup\u003e This is in line with our study, which has been conducted among pregnancies at term.\u003c/p\u003e\u003cp\u003eDespite all this, there is no consensus on whether CPR is a reliable indicator of adverse perinatal outcome. Different studies have found variations in predictive accuracy for different parameters, making it difficult to reach a final opinion. Furthermore, several studies are conducted retrospectively, which provides weaker evidence than a prospective study. It is advised that CPR should not be used as an independent parameter, but should be used alongside other factors like maternal history, to predict adverse outcomes.\u003csup\u003e\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e\u003c/sup\u003e This finding is consistent with the study results, as the low sensitivity suggests CPR is better used as an adjunctive method of predicting fetal outcome.\u003c/p\u003e\u003cp\u003eLimitations: The possible limitations of this study include the small sample size of 144 participants, and limited possible outcomes considered in adverse perinatal outcome.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eConsent:\u0026nbsp;\u003c/strong\u003eInformed consent to participate in the study was obtained from all participants.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData availability\u003c/strong\u003e: The datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConflict of Interest\u003c/strong\u003e: The authors declare no competing interests.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e: No external funding to declare.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthor Contributions\u003c/strong\u003e: UC: Conceptualization, Project administration, Resources, Supervision, Writing - Review \u0026amp; Editing; VK: Investigation, Resources, Supervision, Validation; AB: Data curation, Methodology, Writing - Original Draft, Writing - Review \u0026amp; Editing; BV: Supervision, Validation, Writing - Review \u0026amp; Editing; DM: Data curation, Formal analysis, Software; DB: Writing - Original Draft, Writing - Review \u0026amp; Editing, Software;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements\u003c/strong\u003e: NA\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eMakhseed M, Jirous J, Ahmed MA, Viswanathan DL (2000) Middle cerebral artery to umbilical artery resistance index ratio in the prediction of neonatal outcome. 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Int J Reprod Contracept Obstet Gynecol 12(12):3592\u0026ndash;3598\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":true,"hideJournal":true,"highlight":"","institution":"Maharashtra University of Health Sciences","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"cerebroplacental ratio, adverse perinatal outcome, Doppler ultrasound","lastPublishedDoi":"10.21203/rs.3.rs-8195874/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-8195874/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e\u003cp\u003eThe cerebroplacental ratio (CPR) is the ratio of the Doppler pulsatility indices of the Middle Cerebral Artery and the Umbilical Artery. A value less than 1 can be used to screen for pregnancies at high risk of adverse perinatal outcomes. The objective of this study was to determine the accuracy of CPR in predicting adverse outcomes in appropriate for gestational age (AGA) fetuses.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e\u003cp\u003eThis prospective observational study was conducted in the Department of Radiology at a tertiary care hospital in India. It included 144 pregnant women having singleton pregnancies at term. Exclusion criteria was patients with multiple pregnancies, unknown last menstrual period with no dating scan, complicated pregnancies, congenital malformations and chromosomal abnormalities, pregnancies with known fetal growth retardation (FGR), and women with known placental abnormalities. The cerebroplacental ratio was calculated using duplex Doppler ultrasonography. The possible outcomes were Caesarean section or instrumental delivery for fetal distress, NICU admission, APGAR score\u0026thinsp;\u0026lt;\u0026thinsp;7 at 5 minutes, or a normal outcome.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e\u003cp\u003eA total of one hundred and forty-four singleton pregnancies were included. According to study results, patients with CPR\u0026thinsp;\u0026lt;\u0026thinsp;1 were more likely to experience adverse outcomes than patients with CPR\u0026thinsp;\u0026gt;\u0026thinsp;1. Sensitivity was 63.6% and specificity was 92.1%.\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e\u003cp\u003eThe study results prove that a finding of CPR value\u0026thinsp;\u0026lt;\u0026thinsp;1 at term is a strong predictor of adverse outcome. However, due to the low sensitivity of CPR, it should be used as an adjunctive method of detecting adverse outcomes, and not an independent measure.\u003c/p\u003e","manuscriptTitle":"Cerebroplacental Ratio as a Predictor of Perinatal Adverse Outcome in Appropriate for Gestational Age (AGA) fetuses","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-12-01 08:14:45","doi":"10.21203/rs.3.rs-8195874/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"8013094f-069c-4bec-a638-1c31dfe15997","owner":[],"postedDate":"December 1st, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[{"id":58690580,"name":"Nuclear Medicine \u0026 Medical Imaging"}],"tags":[],"updatedAt":"2025-12-01T08:14:45+00:00","versionOfRecord":[],"versionCreatedAt":"2025-12-01 08:14:45","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-8195874","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-8195874","identity":"rs-8195874","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}