CEREBROPLACENTAL RATIO AS A PREDICTOR OF PERINATAL OUTCOME IN TERM PREGNANCY
Main Article Content
Keywords
cerebroplacental ratio, MCA-PI, UA-PI, Doppler, fetal growth restriction, intrapartum fetal compromise, NICU admission, Apgar
Abstract
Background: The cerebroplacental ratio (CPR) the middle cerebral artery pulsatility index (MCA-PI) divided by the umbilical artery pulsatility index (UA-PI) reflects fetal blood-flow redistribution in response to placental insufficiency. Its value as a late-gestation screening tool for perinatal risk in unselected/heterogeneous high‑risk cohorts warrants clarification.
Objective: To evaluate CPR (<1 vs ≥1) as a predictor of adverse perinatal outcomes among late preterm and term pregnancies.
Methods: Prospective observational analytical study at a tertiary center (August 2018–July 2019). Singleton pregnancies ≥34 weeks underwent Doppler ultrasound within 7 days before delivery. CPR<1 was considered abnormal. Primary outcomes included operative delivery for fetal compromise (ODFC), birthweight <10th percentile, Apgar <7 at 5 minutes, and NICU admission. Diagnostic metrics were calculated.
Results: Among 100 participants, 34 (34%) had CPR <1. Compared with CPR ≥1, abnormal CPR was associated with higher rates of: ODFC (64.7% vs 12.1%; sensitivity 73.3%, specificity 82.9%), birth weight <10th percentile (94.1% vs 15.2%; sensitivity 76.2%, specificity 96.6%), Apgar <7 at 5 minutes (50.0% vs 4.5%; sensitivity 85.0%, specificity 78.8%), and NICU admission (79.4% vs 19.7%; sensitivity 67.5%, specificity 88.3%). Mean gestational age at delivery was earlier with CPR<1 (36.17±1.41 vs 37.94±1.45 weeks, p<0.001) and mean birth weight was lower (2.05±0.40 vs 2.83±0.37 kg, p<0.001).
Conclusion: In late preterm/term pregnancies, CPR<1 identifies fetuses at increased risk of intrapartum compromise and adverse neonatal outcomes. Incorporating CPR into third‑trimester surveillance—especially when timing delivery—may improve risk stratification beyond isolated UA or MCA Dopplers.
References
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9. Baker DW. Pulsed ultrasonic Doppler blood flow sensing IEEE Trans Sonic ultra-sonics. SU 1970;17(3):170-85.
10. Fitzgerald DE, Drum JE. Non-invasive measurement of the human fetal circulation using ultrasound: A new method. BM J. 1977; 2:1450-1.
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12. Kamini Rao, Supriya Sheshadri. Fetal Doppler. Asian J Obstet Gynecol.2003 Aug; 7(7): 17-22.
13. Reid JM, Spencer MP. Ultrasonic Doppler technique for imaging blood vessels. Science 1972; 176:1235.
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20. Brar HS, Medearis AL, De Yore GR. A comparative study of fetal umbilical velocimetry with continuous and pulsed wave Doppler ultrasonography in high pregnancies its outcome. Am J Obstet Gynecol. 1989; 160:375.
21. Rochelson B, Schuman H, Farmakides G, Bracero L, Ducey J. Fleischer A et al. Significance of absent end diastolic velocity in umbilical artery velocity waveforms Am J Obstet. Gynecol. 1987; 156:1213-8.
22. Degani S, Paltieli Y, Gonem R, Sharf M. Fetal internal carotid artery pulsed Doppler flow velocity waveforms and maternal plasma glucose levels. Obstet Gynecol.1991; 77:379.
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26. Brosens I, Robertson WB, Dixon HG. The role of spiral arteries in the pathogenesis of pre-eclampsia. Obstet Gynecol Annu. 1972; 1:177-91.
27. Hendrick SK, Seguin EM, Wang KY, Breshnell JM, Sorensen TK, Seingheid RN. Doppler umbilical artery waveforms indices normal values from fourteen to forty-two vessels. Am J Obstet Gynecol. 1989; 161:761.
28. Schulman H, Fleischer A, Farmark Ides G, Bracerol, Rochelson B, Carunfield. Development of uterine artery compliance in pregnancy as detected by Doppler ultrasound. Am J Obstet Gynecol. 1986; 155:1031.
29. Fleischer A, Schulman H, Farmakides G. uterine artery Doppler velocimetry in pregnant women with hypertension. Am J Obstet Gynecol. 1986; 154:806.
30. Abuhamad A (ed.). ULTRASOUND in Obstetrics and Gynecology: A Practical Approach. GLOWM. 2014: p.93-95.
31. Figueras rancesc, Eduard Gratacós. Update on the Diagnosis and Classification of Fetal Growth Restriction and Proposal of a Stage-Based Management Protocol. Fetal Diagn Ther 2014; 36:86–98.
32. Lausman A, Kingdom J; Maternal Fetal Medicine Committee. Intrauterine growth restriction: screening, diagnosis, and management. J Obstet Gynaecol. 2013; 35: 741–48.
33. Figueras F, Savchev S, Triunfo S, Crovetto F. An integrated model with classification criteria to predict small-for-gestational-age fetuses at risk of adverse perinatal outcome. Ultrasound Obstet Gynecol. 2015; 45: 279–285.
34. Bahado-Singh RO, Kovanci E, Jeffres A, Oz U, Deren O, Copel J, Mari G. The Doppler cerebroplacental ratio and perinatal outcome in intrauterine growth restriction. Am J Obstet Gynecol. 1999 Mar;180(3 Pt 1):750-6.
35. Shaheen S, Bano I, Ahmad I, Singh A. Doppler Cerebroplacental Ratio and Adverse Perinatal Outcome. Journal of South Asian Federation of Obstetrics and Gynaecology, January-April 2014;6(1):25-27.
36. Gramellini D, Folli MC, Raboni S, Vadora E, Merialdi A. Cerebral-umbilical Doppler ratio as a predictor of adverse perinatal outcome. Obstet Gynecol. 1992; 79:416-20.
37. Deshmukh V, Yelikas KA, Deshmukh P. Cerebral-umbilical Doppler ratio as predictor of perinatal outcome in pregnancies with hypertension disorders. Journal of Evolution of Medical and Dental Sciences. 2013 Sep;2(38):7366-72.
38. Moreta D, Samuel Vo, Guy DE, Ronald Benzie. Re-evaluating the role of cerebroplacental ratio in predicting adverse perinatal outcome. European journal of obstetrics and Gynecology and Reproductive biology. 2019;242: 17-28.
39. Sherrell H, Clifton V, Kumar S. Predicting intrapartum fetal compromise at term using the cerebroplacental ratio and placental growth factor levels (PROMISE) study: randomised controlled trial protocol. BMJ Open. 2018 Aug 13;8(8):e022567. doi: 10.1136/bmjopen-2018-022567.
40. Vollgraff Heidweiller-Schreurs CA, van Osch IR, Heymans MW, Ganzevoort W, Schoonmade LJ, Bax CJ et al. Cerebroplacental ratio in predicting adverse perinatal outcome: a meta-analysis of individual participant data. BJOG. 2021 Jan;128(2):226-35.
41. MacDonald TM, Hui L, Robinson AJ, Dane KM, Middleton AL, Tong S, Walker Cerebral-placental-uterine ratio as novel predictor of late fetal growth restriction: prospective cohort study. Ultrasound Obstet Gynecol. 2019 Sep;54(3):367-375.
42. Jain M, Farooq T, Shukla RC. Doppler cerebroplacental ratio for the prediction of adverse perinatal outcome. International Journal of Gynecology & Obstetrics. 2004 Sep 1;86(3):384-5.
43. Flood K, Unterscheider J, Daly S, Geary MP, Kennelly MM, McAuliffe FM et al. The role of brain sparing in the prediction of adverse outcomes in intrauterine growth restriction: results of the multicenter PORTO Study. American Journal of Obstetrics and Gynecology. 2014;211(3):288-e1. http://dx.doi.org/10.1016/j.ajog.2014.05.008.
44. Kibaru JG, Outcome of pregnancies in patients with Hypertensive disease: MMED thesis – UON 1992, East African Medical Journal 2002.
45. Makhseed M, Jirous J, Ahmed MA, Viswanathan DL. Middle cerebral artery to umbilical artery resistance index ratio in the prediction of neonatal outcome. Int J Gynaecol Obstet 2000; 71:119-25.
46. Grüttner B, Ratiu J, Ratiu D, Gottschalk I, Morgenstern B, Abel JS et al. Correlation of Cerebroplacental Ratio (CPR) With Adverse Perinatal Outcome in Singleton Pregnancies. In Vivo. 2019 Sep-Oct;33(5):1703-06.
47. Akolekar R, Syngelaki A, Gallo DM, Poon LC, Nicolaides KH. Umbilical and fetal middle cerebral artery Doppler at 35-37 weeks' gestation in the prediction of adverse perinatal outcome. Ultrasound Obstet Gynecol. 2015 Jul;46(1):82-92.
48. El Guindy AE, Nawara M, ElSanter O. Cerebroplacental ratio and cerebrouterine ratio in predicting neonatal outcome in preeclamptic pregnant Women. Int J Reprod Med Gynecol. 2018 Jun 29;4(1):022-7.
49. Regan J, Masters H, Warshak CR. Association between an abnormal cerebroplacental ratio and the development of severe pre-eclampsia. J Perinatol. 2015 May;35(5):322-7.
50. Arias F. 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 1994; 171:1541-5.
2. Asma A. Khalil, Jose Morales-Rossello et al. The association between fetal Doppler and admission to neonatal unit at term. American Journal of Obstetrics & Gynecology 2014. dx.doi.org/10.1016/j.ajog.2014.10.013.
3. Berkley, E. Chauhan et al. Doppler assessment of the fetus with intrauterine growth restriction. American Journal of Obstetrics and Gynecology.2012;206, 300–308.
4. Ebbing C, Rasmussen S et al. Middle cerebral artery blood flow velocities and pulsatility index and the cerebroplacental pulsatility ratio: longitudinal reference ranges and terms for serial measurements. Ultrasound Obstet Gynecol. 2007; 30: 287-296.
5. Arbeille P, Perrotin F et al. Fetal Doppler hypoxic index for the prediction of abnormal fetal heart rate at delivery in chronic fetal distress. Eur J Obstet Gynecol Reprod Biol. 2005; 121:1717.
6. Farmakides G, Bracero L et al. Umbilical artery flow velocity waveforms and intrauterine growth retardation. Am J Obstet Gynecol. 1985; 151:502-5.
7. Cunningham, Leveno, Bloom, Spong, Dashe et al. Williams Obstetrics. 24th Edition. United States of America. McGraw - Hill Education. 2014. \
8. Rajan R. Basics of Doppler ultrasound applied to obstetrics. Ultrasound and colour Doppler in Obstetrics, Gynaecology and Infertility. 1st ed. India: Indian Academy of Human Reproduction 2004 Sep;13(3):140.
9. Baker DW. Pulsed ultrasonic Doppler blood flow sensing IEEE Trans Sonic ultra-sonics. SU 1970;17(3):170-85.
10. Fitzgerald DE, Drum JE. Non-invasive measurement of the human fetal circulation using ultrasound: A new method. BM J. 1977; 2:1450-1.
11. McCallum WD, Olson RF, Daigle RE et al. Real time analysis of Doppler signals obtained from the fetoplacental circulation. Ultrasound Med. 1977;3B:1361-4.
12. Kamini Rao, Supriya Sheshadri. Fetal Doppler. Asian J Obstet Gynecol.2003 Aug; 7(7): 17-22.
13. Reid JM, Spencer MP. Ultrasonic Doppler technique for imaging blood vessels. Science 1972; 176:1235.
14. Namekawa K, Kasai C, Tsukamoto M, Koyano A. Imaging of blood flow using auto corrrelation. Ultrasound Med Biol.1982; 8:138.
15. Cunningham FG, John CH, Kenneth JL, Bloom SL, Wenstrom KD, Gilstrap L III. Ultrasonography and Doppler. In: Williams Obstetric. 22nd ed. New York McGraw-Hill; 2005. p.400-4.
16. Cunningham FG, Gnat NF, Leneno KJ, Gils LC, John C, Katherine DH. Wenstrom Williams Obstetrics. 21st ed. New York: McGraw-Hill; 2010. p.567,651,743-64,1132-6.
17. Porcelot L. Applications cliniques de I examen Doppler transcutane in: Perommeau P, ed. Velocimetric ultrasonoic Doppler. Paris: INSERM; 1974. p.213-40.
18. Maulik D, Yarlagadda P, Young Blood JP, Willoughby L. Components of variability of umbilical arterial Doppler velocimetry: a prospective analysis. Am J Obstet Gynecol.1989; 160:1406
19. Arias F, Daftary SN, Bhide AG. Fetal growth restriction. In: Practical Guide to high-risk pregnancy and delivery. 3rd ed. Delhi: Elsevier; 2011. p.119-20,126-7.
20. Brar HS, Medearis AL, De Yore GR. A comparative study of fetal umbilical velocimetry with continuous and pulsed wave Doppler ultrasonography in high pregnancies its outcome. Am J Obstet Gynecol. 1989; 160:375.
21. Rochelson B, Schuman H, Farmakides G, Bracero L, Ducey J. Fleischer A et al. Significance of absent end diastolic velocity in umbilical artery velocity waveforms Am J Obstet. Gynecol. 1987; 156:1213-8.
22. Degani S, Paltieli Y, Gonem R, Sharf M. Fetal internal carotid artery pulsed Doppler flow velocity waveforms and maternal plasma glucose levels. Obstet Gynecol.1991; 77:379.
23. Bocking AD, Gagnon R, White SE, Homan J, Milne KM, Richardson BS. Circulatory responses to prolonged hypoxemia in fetal sheep. Am J Obstet Gynecol. 1988; 159:1418.
24. Vyas S, Nicolaides KH, Bower S, Campbell S. Middle cerebral artery flow velocity waveforms in fetal hypoxemia. Br J Obstet Gynaecol. 1990; 97:797-803.
25. Ferrazzi E, Bozzo M, Rigano S, Belloti M, Morabito A, Pardi G, et al. Temporal sequence of abnormal Doppler changes in the peripheral and central circulatory systems of the severely growth restricted fetus. Ultrasound Obstet Gynecol 2002; 19:140-6.
26. Brosens I, Robertson WB, Dixon HG. The role of spiral arteries in the pathogenesis of pre-eclampsia. Obstet Gynecol Annu. 1972; 1:177-91.
27. Hendrick SK, Seguin EM, Wang KY, Breshnell JM, Sorensen TK, Seingheid RN. Doppler umbilical artery waveforms indices normal values from fourteen to forty-two vessels. Am J Obstet Gynecol. 1989; 161:761.
28. Schulman H, Fleischer A, Farmark Ides G, Bracerol, Rochelson B, Carunfield. Development of uterine artery compliance in pregnancy as detected by Doppler ultrasound. Am J Obstet Gynecol. 1986; 155:1031.
29. Fleischer A, Schulman H, Farmakides G. uterine artery Doppler velocimetry in pregnant women with hypertension. Am J Obstet Gynecol. 1986; 154:806.
30. Abuhamad A (ed.). ULTRASOUND in Obstetrics and Gynecology: A Practical Approach. GLOWM. 2014: p.93-95.
31. Figueras rancesc, Eduard Gratacós. Update on the Diagnosis and Classification of Fetal Growth Restriction and Proposal of a Stage-Based Management Protocol. Fetal Diagn Ther 2014; 36:86–98.
32. Lausman A, Kingdom J; Maternal Fetal Medicine Committee. Intrauterine growth restriction: screening, diagnosis, and management. J Obstet Gynaecol. 2013; 35: 741–48.
33. Figueras F, Savchev S, Triunfo S, Crovetto F. An integrated model with classification criteria to predict small-for-gestational-age fetuses at risk of adverse perinatal outcome. Ultrasound Obstet Gynecol. 2015; 45: 279–285.
34. Bahado-Singh RO, Kovanci E, Jeffres A, Oz U, Deren O, Copel J, Mari G. The Doppler cerebroplacental ratio and perinatal outcome in intrauterine growth restriction. Am J Obstet Gynecol. 1999 Mar;180(3 Pt 1):750-6.
35. Shaheen S, Bano I, Ahmad I, Singh A. Doppler Cerebroplacental Ratio and Adverse Perinatal Outcome. Journal of South Asian Federation of Obstetrics and Gynaecology, January-April 2014;6(1):25-27.
36. Gramellini D, Folli MC, Raboni S, Vadora E, Merialdi A. Cerebral-umbilical Doppler ratio as a predictor of adverse perinatal outcome. Obstet Gynecol. 1992; 79:416-20.
37. Deshmukh V, Yelikas KA, Deshmukh P. Cerebral-umbilical Doppler ratio as predictor of perinatal outcome in pregnancies with hypertension disorders. Journal of Evolution of Medical and Dental Sciences. 2013 Sep;2(38):7366-72.
38. Moreta D, Samuel Vo, Guy DE, Ronald Benzie. Re-evaluating the role of cerebroplacental ratio in predicting adverse perinatal outcome. European journal of obstetrics and Gynecology and Reproductive biology. 2019;242: 17-28.
39. Sherrell H, Clifton V, Kumar S. Predicting intrapartum fetal compromise at term using the cerebroplacental ratio and placental growth factor levels (PROMISE) study: randomised controlled trial protocol. BMJ Open. 2018 Aug 13;8(8):e022567. doi: 10.1136/bmjopen-2018-022567.
40. Vollgraff Heidweiller-Schreurs CA, van Osch IR, Heymans MW, Ganzevoort W, Schoonmade LJ, Bax CJ et al. Cerebroplacental ratio in predicting adverse perinatal outcome: a meta-analysis of individual participant data. BJOG. 2021 Jan;128(2):226-35.
41. MacDonald TM, Hui L, Robinson AJ, Dane KM, Middleton AL, Tong S, Walker Cerebral-placental-uterine ratio as novel predictor of late fetal growth restriction: prospective cohort study. Ultrasound Obstet Gynecol. 2019 Sep;54(3):367-375.
42. Jain M, Farooq T, Shukla RC. Doppler cerebroplacental ratio for the prediction of adverse perinatal outcome. International Journal of Gynecology & Obstetrics. 2004 Sep 1;86(3):384-5.
43. Flood K, Unterscheider J, Daly S, Geary MP, Kennelly MM, McAuliffe FM et al. The role of brain sparing in the prediction of adverse outcomes in intrauterine growth restriction: results of the multicenter PORTO Study. American Journal of Obstetrics and Gynecology. 2014;211(3):288-e1. http://dx.doi.org/10.1016/j.ajog.2014.05.008.
44. Kibaru JG, Outcome of pregnancies in patients with Hypertensive disease: MMED thesis – UON 1992, East African Medical Journal 2002.
45. Makhseed M, Jirous J, Ahmed MA, Viswanathan DL. Middle cerebral artery to umbilical artery resistance index ratio in the prediction of neonatal outcome. Int J Gynaecol Obstet 2000; 71:119-25.
46. Grüttner B, Ratiu J, Ratiu D, Gottschalk I, Morgenstern B, Abel JS et al. Correlation of Cerebroplacental Ratio (CPR) With Adverse Perinatal Outcome in Singleton Pregnancies. In Vivo. 2019 Sep-Oct;33(5):1703-06.
47. Akolekar R, Syngelaki A, Gallo DM, Poon LC, Nicolaides KH. Umbilical and fetal middle cerebral artery Doppler at 35-37 weeks' gestation in the prediction of adverse perinatal outcome. Ultrasound Obstet Gynecol. 2015 Jul;46(1):82-92.
48. El Guindy AE, Nawara M, ElSanter O. Cerebroplacental ratio and cerebrouterine ratio in predicting neonatal outcome in preeclamptic pregnant Women. Int J Reprod Med Gynecol. 2018 Jun 29;4(1):022-7.
49. Regan J, Masters H, Warshak CR. Association between an abnormal cerebroplacental ratio and the development of severe pre-eclampsia. J Perinatol. 2015 May;35(5):322-7.
50. Arias F. 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 1994; 171:1541-5.
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Sep 25, 2024
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Dr. Safora Shafaq, Madhunala Sravanthi, & Thejavathy G.V. (2024). CEREBROPLACENTAL RATIO AS A PREDICTOR OF PERINATAL OUTCOME IN TERM PREGNANCY. Journal of Population Therapeutics and Clinical Pharmacology, 31(9), 4495-4503. https://doi.org/10.53555/8q7cjq55
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Author Biographies
Dr. Safora Shafaq
Department of Obstetrics and Gynecology, Bhagwan Mahaveer Jain Hospital, Bengaluru, Karnataka, India
Madhunala Sravanthi
Department of Obstetrics and Gynecology, Bhagwan Mahaveer Jain Hospital, Bengaluru, Karnataka, India
Thejavathy G.V.
Department of Obstetrics and Gynecology, Bhagwan Mahaveer Jain Hospital, Bengaluru, Karnataka, India
How to Cite
Dr. Safora Shafaq, Madhunala Sravanthi, & Thejavathy G.V. (2024). CEREBROPLACENTAL RATIO AS A PREDICTOR OF PERINATAL OUTCOME IN TERM PREGNANCY. Journal of Population Therapeutics and Clinical Pharmacology, 31(9), 4495-4503. https://doi.org/10.53555/8q7cjq55