Research ajog.

org

OBSTETRICS
The association between fetal Doppler and
admission to neonatal unit at term
Asma A. Khalil, MD, MRCOG; José Morales-Rosello, MD; Malaz Elsaddig; Naila Khan;
Aris Papageorghiou, MD, MRCOG; Amar Bhide, MD, MRCOG; Basky Thilaganathan, PhD, MRCOG

OBJECTIVE: Fetal cerebroplacental ratio is emerging as a better proxy
than birthweight for placental insufficiency and as a marker of fetal
compromise at term. The extent to which these fetal Doppler changes
are related to neonatal outcomes has not been systematically assessed.
The main aim of this study was to evaluate the association between
estimated fetal weight percentile, cerebroplacental ratio recorded at
34þ0e35þ6 weeks’ gestation, and neonatal unit admission at term.
STUDY DESIGN: This was a retrospective cohort study in a tertiary
referral center over an 11 year period from 2002 to 2012. The um-
bilical artery pulsatility index (PI), middle cerebral artery PI, and cer-
ebroplacental ratio were recorded at 34þ0e35þ6 weeks. Weight
values were converted into percentiles and Doppler parameters into
multiples of the median (MoM), adjusting for gestational age. Logistic
regression analysis was performed to identify, and adjust for, potential
confounders.
RESULTS: We identified 2518 pregnancies in which a scan was
performed at 34þ0e35þ6 weeks and delivery occurred at or beyond
37 weeks. In the 2485 pregnancies included in the analysis, the
umbilical artery PI MoM was significantly higher, and the middle ce-
rebral artery PI and cerebroplacental ratio MoM significantly lower in
the babies requiring neonatal unit admission (P < .05). However,
the estimated fetal weight percentile was not significantly different
between those who required neonatal unit admission and those who
did not (P ¼ .087). According to multivariate logistic regression,
cerebroplacental ratio MoM (odds ratio, 0.39; 95% confidence inter-
val, 0.19e0.79; P ¼ .008) and gestational age at delivery (odds ra-
tio, 0.70; 95% confidence interval, 0.61e0.80; P < .001) were
significantly associated with the risk of neonatal unit admission,
whereas maternal age and birthweight percentile were not (P ¼ .183
and P ¼ .460, respectively). Irrespective of birthweight or estimated
fetal weight percentile, the fetal cerebroplacental ratio appears to be
a better predictor of the need for neonatal unit admission (P < .001).
CONCLUSION: Lower cerebroplacental ratio and gestational age at
delivery, but not fetal size, were independently associated with the
need for admission to the neonatal unit at term in a high-risk patient
group. The extent to which fetal hemodynamic assessment could be
used to predict perinatal morbidity and optimize the timing of delivery
merits further investigation.
Key words: birthweight, cerebroplacental ratio, Doppler, neonatal unit
admission, small for gestational age

Cite this article as: Khalil AA, Morales-Rosello J, Elsaddig M, et al. The association between fetal Doppler and admission to neonatal unit at term. Am J Obstet Gynecol
2015;213:57.e1-7.

S mall for gestational age (SGA),

defined as birthweight (BW) less
than the 10th percentile for gestation, is
commonly used as a proxy to identify
fetuses at risk of adverse outcomes sec-
ondary to fetal growth restriction.1,2
However, the majority of SGA babies
are not pathologically growth restricted
From the Fetal Medicine Unit, St George’s
Hospital, St George’s University of London,
London, England, UK.
Received June 15, 2014; revised Aug. 23, 2014;
accepted Oct. 7, 2014.
The authors report no conflict of interest.
Corresponding author: Asma Khalil, MD,
MRCOG. asmakhalil79@googlemail.com
0002-9378/$36.00
ª 2015 Published by Elsevier Inc.
http://dx.doi.org/10.1016/j.ajog.2014.10.013
and do not demonstrate signs of
placental insufficiency. The clinical
definition of SGA is further confused by
the finding that a proportion of average
for gestational age (AGA) infants also fail
to meet their growth potential or, more
correctly, suffer from occult placental
insufficiency.3,4
We and others have recently reported
that fetal Doppler assessment immedi-
ately prior to delivery at term might be of
value in detecting AGA pregnancies that
are at increased risk of adverse outcome
from fetal hypoxemia secondary to
placental insufficiency and failure to
reach growth potential.4,5 Fetal Doppler
indices assessed just prior to delivery
appear to be a better marker than BW
or BW percentile for adverse pregnancy
outcomes, such as the need for operative
delivery for fetal compromise in an
average risk group for fetal growth re-
striction (FGR).4,5 However, national
guidance in the United Kingdom and the
United States does not recommend the
use of fetal Doppler as a screening tool
for placental insufficiency, except when
the fetus is already known to be SGA.1,2
The antenatal diagnosis of FGR using
fetal biometry alone has recently been
challenged, and the use of fetal Doppler
assessment has been proposed as a
potentially better marker.4,6,7
It is now increasingly routine in many
hospitals and individual practices to
undertake a 34-36 week ultrasound scan
for fetal assessment. There is a paucity
of data to support such routine assess-
ment, but nevertheless its proponents
are convinced of its utility. The main
aim of this study was to investigate the
association between fetal Doppler and

JULY 2015 American Journal of Obstetrics & Gynecology 57.e1

Research Obstetrics
ultrasound parameters at the 34-36 week
growth scan and the need for neonatal
unit admission at term.
M ATERIALS AND M ETHODS
This was a retrospective cohort study
in a single tertiary referral center over
an 11 year period from 2002 to 2012.
Cases were identified by searching
the ViewPoint database (ViewPoint
5.6.8.428; ViewPoint Bildverarbeitung
GmbH, Weßling, Germany) in the Fetal
Medicine Unit, St George’s Hospital.
The inclusion criteria were singleton
morphologically normal fetuses born at
term that had previously had an ultra-
sound scan at 34þ0e35þ6 weeks’ gesta-
tion for a variety of indications such as
suspected poor/excessive fetal growth,
reduced fetal movements, history of
SGA or large for gestational age baby,
high midtrimester uterine artery Dop-
pler indices, and gestational diabetes.
Therefore, these pregnancies were at
risk of fetal growth disorders.
Pregnancies complicated by fetal ab-
normality, aneuploidy, or antepartum
stillbirth were excluded from the anal-
ysis. Gestational age (GA) was calculated
from the crown-rump length measure-
ment at 11-13 weeks, and only 1 exam-
ination (the last in the 34þ0e35þ6
week window) per fetus was included
in the analysis.8 Routine fetal biometry
was performed according to a stand-
ard protocol and the estimated fetal
weight (EFW) calculated using Had-
lock’s formula.9 Data on pregnancy
outcomes were collected from hospital
obstetric and neonatal records.
The umbilical artery (UA) and middle
cerebral artery (MCA) Doppler were
recorded using color Doppler, and the
pulsatility index (PI) calculated accord-
ing to a standard protocol.10,11 The cer-
ebroplacental ratio (CPR) was calculated
as the simple ratio of the MCA PI to the
UA PI.12 All Doppler indices were con-
verted into multiples of the median
(MoM) correcting for GA using refer-
ence ranges, and BW values were con-
verted into percentiles.4,13,14
The study cohort was divided into 4
groups according to a combination of a
BW cutoff of the 10th percentile and an
optimal CPR cutoff of 0.6765 MoM4 to
57.e2 American Journal of Obstetrics & Gynecology JULY 2015
assess the difference between the SGA
model, which relies on fetal biometry,
and the placental insufficiency model,
which relies on fetal hemodynamic
assessment. This was derived from our
previous work in which, to define the
threshold for the failure to achieve
growth potential, we calculated the fifth
centile of the CPR in the group least
likely to present with failure to achieve
growth potential (those with BW greater
than the 90th percentile). This value
corresponded to 0.6765.4
Data on admission to the neonatal
unit were ascertained from the maternity
and neonatal records. The indications
for admission to the neonatal unit were
respiratory complications (defined as
respiratory distress syndrome and tran-
sient tachypnea of the newborn, use of
continuous positive airway pressure,
endotracheal intubation), hypoglycemia,
sepsis, need for phototherapy, post-
resuscitation observation, seizures, and
hypothermia.
Statistical analysis
Categorical data were presented as
number (percentage) and were com-
pared using the Fisher exact test or the
c2 test. Continuous data were presented
as median (interquartile range [IQR]).
The D’Agostino and Pearson Omnibus
test was used to assess the normality of
the data. Nonparametric analysis using
the Mann-Whitney U test was then used
to compare continuous data between the
study groups. A logistic regression anal-
ysis was performed to identify, and
adjust for, potential confounders. Both
unadjusted and adjusted odds ratios
(ORs) were calculated. The analysis was
performed using the statistical software
packages SPSS 18.0 (SPSS Inc, Chicago,
IL), Stata 11 (release 11.2; College Sta-
tion, TX), and GraphPad Prism 5.0 for
Windows (InStat; GraphPad Software
Inc, San Diego, CA).
R ESULTS
We identified 2518 pregnancies with
fetal Doppler assessment at 34þ0e35þ6
weeks, in which the delivery occurred at
or beyond 37 weeks’ gestation. We
excluded 33 pregnancies (1.3%) because
they had aneuploidy, major structural
ajog.org
abnormalities, stillbirth, or missing out-
come data, leaving 2485 pregnancies
included in the analysis. The maternal
characteristics, ultrasound, and birth
indices in the groups requiring and not
requiring admission to the neonatal unit
are shown in Table 1. The prevalence of
SGA, defined as BW less than the 10th
percentile and the fifth percentile, was
25.8% and 14.0%, respectively.
The overall neonatal admission rate
in the study cohort was 6.7%. This fell
with advancing gestation from 16.8%
to 8.7%, 4.2% and 4.2% at 37, 38, 39,
and longer than 40 weeks, respectively.
The most common indications for
admission to the neonatal unit were
respiratory complications and post-
resuscitation observation. There were 2
early neonatal deaths and 1 late neonatal
death.
The scatter plot of CPR MoM values
against BW percentiles showed a signif-
icant linear relationship (Figure 1: CPR
MoM ¼ (0.0019  BW percentile) þ
0.9705, R2 ¼ 0.049). At the ultrasound
assessment, UA PI MoM was signifi-
cantly higher and MCA PI and CPR
MoM were significantly lower in the
neonates requiring neonatal unit ad-
mission (P < .05, Table 1, Figure 2), but
the EFW percentile was not significantly
different between the 2 study groups
(P ¼ .087).
The results of the regression analysis
are shown in Tables 2 and 3. According
to a multivariate logistic regression, CPR
MoM, GA at delivery, maternal ethni-
city, and male gender were significantly
associated with the risk of neonatal unit
admission (P < .05), whereas maternal
age and BW percentile were not (P ¼
.183 and P ¼ .460, respectively). When
divided into 4 groups according to a
combination of a BW cutoff of the 10th
percentile and an optimal CPR cutoff of
0.6765 MoM, the rates of neonatal unit
admission were significantly different
(P < .001, Figure 3).
The incidence of admission to the
neonatal unit in the AGA neonates with
low CPR (9.8%) was almost double that
in the group of AGA with normal CPR
(5.5%). However, the difference in the
admission rates between the groups of
AGA with low CPR and AGA with
ajog.org Obstetrics Research

TABLE 1
Maternal and fetal characteristics in the study cohort according to admission to the neonatal unit
Neonatal unit admission No neonatal unit admission
Characteristic (n [ 167) (n [ 2318) P value
Maternal age, y, median (IQR) 31.0 (27.0e34.0) 31.0 (26.0e34.0) .133
Ethnicity .276
White, n (%) 101 (60.5) 1230 (53.1)
African, n (%) 30 (18.0) 416 (18.0)
Asian, n (%) 30 (18.0) 522 (22.5)
Mixed, n (%) 4 (2.4) 100 (4.3)
Other, n (%) 2 (1.2) 50 (2.2)
Gestational age at ultrasound (wks), median (IQR) 34.9 (34.4e35.4) 35.0 (34.4e35.6) .113
Estimated fetal weight (g), median (IQR) 2356 (2085e2651) 2426 (2183e2690) .025
Estimated fetal weight percentile, median (IQR) 28.92 (11.45e54.01) 32.89 (15.60e55.77) .087
UA PI 0.95 (0.85e1.08) 0.91 (0.80e1.03) .008
UA PI MoM 1.01 (0.89e1.14) 0.97 (0.85e1.09) .014
MCA PI 1.73 (1.50e1.98) 1.80 (1.60e2.02) .002
MCA PI MoM 1.17 (1.00e1.30) 1.21 (1.08e1.37) .001
Cerebroplacental ratio 1.87 (1.50e2.25) 2.00 (1.70e2.31) < .001
Cerebroplacental ratio MoM 0.95 (0.76e1.15) 1.02 (0.87e1.18) < .001
Gestational age at delivery (wks), median (IQR) 38.9 (37.7e40.0) 39.6 (38.6e40.6) < .001
Birthweight (g), median (IQR) 2955 (2500e3470) 3140 (2780e3520) < .001
Birthweight percentile, median (IQR) 19.01 (4.67e57.80) 28.32 (10.09e58.43) .005
Fetal sex male, n (%) 98 (59.4) 1140 (49.3) .012
IQR, interquartile range; MCA, middle cerebral artery; PI, pulsatility index; MoM, multiples of median; UA, umbilical artery.
Khalil. Doppler and neonatal unit admission. Am J Obstet Gynecol 2015.

normal CPR was not statistically signif-
icant (P ¼ .203). This could be related
to the small number of cases in these
2 groups because admission to the
neonatal unit in healthy newborns at
term is a relatively uncommon event.
We also investigated the association
between fetal Doppler parameters and
the risk of admission to the neonatal unit
in the pregnancies that were SGA (BW
less than 10th percentile, n ¼ 640) in
which the rate of admission to the
neonatal unit was 10%. Compared with
those not requiring admission, neonates
requiring neonatal unit admission had
significantly lower median BW percen-
tile (2.70, IQR, 0.73e5.89 vs 4.69,
IQR, 2.34e7.38), GA at delivery in
weeks (38.35, IQR, 37.45e39.40 vs
39.10, IQR, 38.30e40.10), MCA PI
MoM (1.11, IQR, 0.97e1.24 vs 1.19,
IQR, 1.06e1.35), and CPR MoM
(0.84, IQR, 0.67e0.99 vs 0.94, IQR,
0.80e1.09). BW percentile, MCA PI
MoM, and CPR MoM were significantly
associated with the risk of neonatal unit
admission (P < .001, Table 4), whereas
the UA PI MoM and EFW percentile
were not (P ¼ .115 and P ¼ .213,
respectively).
According to the multivariate logistic
regression in SGA neonates, both BW
percentile (OR, 0.87; 96% confidence
interval [CI], 0.78e0.96; P ¼ .008) and
CPR MoM (OR, 0.21; 96% CI,
0.06e0.77; P ¼ .018) were significantly
and independently associated with the
risk of neonatal unit admission. The
prevalence of SGA, defined as BW less
than the third percentile, was 8.5%. The
neonatal unit admission rate in this
cohort was 15.8%, which was
significantly higher in those with low
CPR MoM compared with those with
normal CPR MoM (30.2% vs 12.2%, P ¼
.004).
C OMMENT
The findings of this study suggest that
neonates that were admitted to the
neonatal unit at term had significantly
lower CPR at 34-36 weeks, whereas both
ultrasound EFW and BW percentiles
were not significantly different from
those not admitted. A multivariate lo-
gistic regression demonstrated that CPR
MoM at 34-36 weeks was almost twice as
likely as GA at delivery to determine the
need for neonatal unit admission. It was
also the case that, among the SGA neo-
nates at term, those with a lower CPR
MoM at 34-36 weeks had a higher risk

JULY 2015 American Journal of Obstetrics & Gynecology 57.e3

Research Obstetrics
of a neonatal unit admission compared
FIGURE 1 with those with normal CPR MoMs.
Scatter plot of CPR MoM values
against BW percentile
Findings in term pregnancies
The novel observation in our cohort is
that CPR, but not BW, percentiles,
measured at 34-36 weeks’ gestation, are
significantly and independently associ-
ated with the need for neonatal unit
admission at term. In a recent prospec-
tive study including 400 term pregnan-
cies (37-42 weeks), the investigators
assessed fetal biometry and Doppler
parameters immediately before estab-
lished labor.5 Fetuses with CPR below
the 10th percentile were 6 times more
likely to be delivered by cesarean
delivery for presumed fetal compromise
Scatter plot of CPR MoM values against BW
than those with a CPR above the10th
percentile, showing a significant linear rela-
percentile.5 Even after the exclusion of
tionship (CPR MoM ¼ [0.0019  BW cases with a BW below the 10th per-
percentile] þ 0.9705, R2 ¼ 0.049).
centile, the rate of cesarean delivery for
BW, birthweight; CPR, cerebroplacental ratio; MoM, multiple of
median. presumed fetal compromise remained
Khalil. Doppler and neonatal unit admission. Am J Obstet significantly higher in fetuses with a
Gynecol 2015. CPR less than the 10th percentile.5 In the
Generation R Study (Rotterdam,
The Netherlands, 2003-2007), Roza
et al15 reported that, even in the general
FIGURE 2
Cerebroplacental ratio MoM values and percentiles
Box and whisker plots of cerebroplacental ratio MoM values and birthweight percentiles in newborns
who were admitted to the neonatal unit and those who were not. The horizontal line in the box
represents the median, the box represents the IQR, and the whiskers indicate the minimum and
maximum values.
IQR, interquartile range; MoM, multiple of median.
Khalil. Doppler and neonatal unit admission. Am J Obstet Gynecol 2015.
57.e4 American Journal of Obstetrics & Gynecology JULY 2015
ajog.org
population, an abnormal CPR at term
predicts neurobehavioral problems at
18 months of age on internalizing and
somatic complaints scales.
Findings in term SGA pregnancies
The role of fetal Doppler in term and
near-term pregnancies may currently
be underestimated because of the rarity
of abnormal UA Doppler indices at
this gestation and the fact that FGR-
related perinatal morbidity has been
noted to occur even when the UA blood
flow is normal.16-18 In our cohort the
rate of neonatal unit admission was
almost 3 times higher in SGA neonates
with low CPR MoM compared with
those SGA neonates with normal CPR
MoM (23% vs 8%).
The role of the MCA Doppler in SGA
pregnancies at term has been investi-
gated in previous studies.16,18-22 Chang
et al18 reported that fetal Doppler PI
ratios recorded in the third trimester
(aortic/middle cerebral and renal/mid-
dle cerebral PI ratios) were superior to
predelivery estimates of fetal size in
predicting suboptimal perinatal out-
come in small fetuses delivering at term.
The suboptimal perinatal outcome in
the latter study was defined as acidemia
at birth, fetal distress requiring emer-
gency cesarean delivery in labor, or
admission to the neonatal unit.18
Hershkovitz et al16 also demonstrated
an association between MCA blood
flow redistribution in structurally nor-
mal fetuses with an EFW below the fifth
percentile and an increased risk of ce-
sarean delivery and need for neonatal
unit admission. CPR has been shown to
correlate better with adverse outcome
than does UA and MCA Doppler.23,24
Findings in preterm SGA pregnancies
In pregnancies with SGA neonates, BW
percentiles and CPR MoMs at 34-36
weeks’ gestation, but not EFW percen-
tiles at 34-36 weeks, were independently
associated with neonatal unit admission
at term. These findings are consistent
with the recent Prospective Observa-
tional Trial to Optimize Pediatric Health
in Intrauterine Growth Restriction
study, in which in 1200 pregnancies
with EFW less than the 10th percentile
ajog.org Obstetrics Research

TABLE 2 FIGURE 3
Results of the logistic regression analysis of factors associated with the Rates of neonatal unit admission
risk of admission to the neonatal unit in the 4 study groups
Risk factor Unadjusted OR 95% CI P value
Maternal characteristics
Maternal age, y 1.02 (1.00e1.05) .106
Maternal ethnicity 0.83 (0.70e0.98) .026
Ultrasound indices
EFW percentile 1.00 (0.99e1.00) .245
UA PI MoM 3.00 (1.23e7.28) .016
MCA PI MoM 0.26 (0.12e0.55) < .001 The rates of neonatal unit admission in the
4 study groups according to a combination of a
Cerebroplacental ratio MoM 0.83 (0.70e0.98) < .001
BW cutoff of the 10th percentile and a CPR
Fetal sex (female) 0.67 (0.48e0.92) .013 cutoff of 0.6765 MoM.
Indices at birth AGA, average for gestational age; BW, birthweight; CPR, cere-
broplacental ratio; SGA, small for gestational age.
GA at delivery, wk 0.67 (0.59e0.76) < .001 Khalil. Doppler and neonatal unit admission. Am J Obstet
Gynecol 2015.
BW percentile 0.99 (0.99e1.00) .079
BW, birthweight; CI, confidence interval; EFW, estimated fetal weight; GA, gestational age; MCA, middle cerebral artery;
MoM, multiples of median; OR, odds ratio; PI, pulsatility index; UA, umbilical artery.
difference may be due to variations in
Khalil. Doppler and neonatal unit admission. Am J Obstet Gynecol 2015.
gestation at assessment and delivery
as well as in neonatal unit admission
prospectively followed up, 95% of those parameter that was significantly associ- policies in the 2 studies. Despite this
with abdominal circumference below ated with adverse outcome was EFW discrepancy, the findings of both studies
the 10th percentile had a normal preg- below the third percentile.25 Despite the question the currently accepted defini-
nancy outcome.25 Importantly, the au- fact that the authors stated in the tion of FGR and emphasize the impor-
thors noted that the presence of an methodology that MCA Doppler had tance of fetal hemodynamic assessment
abnormal UA Doppler was significantly been performed, these data were not as a predictor of adverse pregnancy
associated with adverse outcome, irre- reported in the results.25 The neonatal outcome in all fetal weight categories.
spective of EFW or abdominal circum- admission rate in that SGA cohort was
ference measurement.25 Furthermore, 28%, compared with 10% in our cohort Strengths and limitations
the only sonographic weight-related of 640 pregnancies with SGA. This The strengths of our study include the
large number of pregnancies, adjusting
for GA, ascertainment of the outcome
TABLE 3 data, and the narrow GA range at ultra-
Results of the multivariate logistic regression analysis of factors sound assessment. However, the retro-
associated with the risk of admission to the neonatal unit spective design, lack of detailed robust
Risk factor Adjusted OR 95% CI P value data on the intrapartum events, and the
higher proportion of SGA (25.8%) in the
Maternal characteristics
study population limit the generaliz-
Maternal age, y 1.02 (0.99e1.05) .183 ability of our findings. The higher prev-
Maternal ethnicity 0.81 (0.68e0.97) .020 alence of SGA in our cohort could be
explained by the fact that pregnancies at
Ultrasound indices
risk of SGA were more likely to have an
Cerebroplacental ratio MoM 0.39 (0.19e0.78) .008 ultrasound assessment at 34-36 weeks’
Fetal sex (female) 0.67 (0.48e0.94) .020 gestation. However, we see this as a
Indices at birth
strength because despite the bias toward
lower BW and higher prevalence of SGA,
GA at delivery, wks 0.70 (0.61e0.80) < .001 CPR was more strongly associated with
BW percentile 1.00 (0.99e1.00) .460 neonatal unit admission. A high pro-
BW, birthweight; CI, confidence interval; GA, gestational age; MoM, multiples of median; OR, odds ratio. portion of neonatal unit admissions are
Khalil. Doppler and neonatal unit admission. Am J Obstet Gynecol 2015. short term, with full recovery and
discharge home. Prolonged neonatal

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Research Obstetrics
TABLE 4
Factors associated with neonatal unit admission in SGA newbornsa
Risk factor
Maternal characteristics
Maternal age, y
Maternal ethnicity
Ultrasound indices
EFW percentile
UA PI MoM
MCA PI MoM
Cerebroplacental ratio MoM
Fetal sex (female)
Indices at birth
GA delivery, wks
BW percentile
BW less than fifth percentile
BW, birthweight; CI, confidence interval; EFW, estimated fetal weight; GA, gestational age; MCA, middle cerebral artery;
MoM, multiples of median; OR, odds ratio; PI, pulsatility index; SGA, small for gestational age (defined as birthweight less than
10th percentile); UA, umbilical artery.
a
Determined by logistic regression analysis.
Khalil. Doppler and neonatal unit admission. Am J Obstet Gynecol 2015.
intensive care unit admission and
neonatal morbidity are the subjects of a
future study.
Approximately 10% of term babies
may require admission to the neonatal
unit.26 The commonest indications
include respiratory complications, post-
resuscitation observation, and hypogly-
cemia. These adverse events are more
likely to occur in FGR babies, or more
correctly, babies compromised by pla-
cental insufficiency. Admission to the
neonatal unit at term is usually an un-
expected event for both parents and
health care professionals. It also repre-
sents a burden on health care resources
and reflects the quality of intrapartum
care. For these reasons, it is one of the
national health care quality measures
in many Western countries, including
the United Kingdom and the United
States. We have shown that lower CPR
at 34-36 weeks and GA at delivery, but
not BW percentiles at 34-36 weeks, were
independently associated with the need
for admission to the neonatal unit at
term.
57.e6 American Journal of Obstetrics & Gynecology JULY 2015
Unadjusted OR 95% CI
1.03 0.98e1.07
0.69 0.53e0.91
0.98 0.96e1.01
3.06 0.76e12.27
0.88 0.24e0.32
0.12 0.03e0.42
0.70 0.42e1.18
0.68 0.55e0.86
0.84 0.76e0.92
2.13 1.22e3.74
These findings support the assertion
that fetal Doppler assessment could be
of value in detecting fetal hypoxemia
secondary to placental insufficiency
and failure to reach their genetic growth
potential in apparently AGA pregnan-
cies. AGA pregnancies can demonstrate
fetal cerebral and placental blood flow
redistribution indicative of an increased
risk of adverse pregnancy outcome as a
consequence of fetal hypoxemia sec-
ondary to placental insufficiency.4
Despite this significant association
between fetal Doppler and the need for
neonatal unit admission at term, its
predictive accuracy as an isolated marker
is likely to be poor because of the con-
founding effect of the process of labor
and birth.27 Whether fetal Doppler
assessment in AGA pregnancies is pre-
dictive of perinatal morbidity or neuro-
developmental delay is unknown. The
extent to which fetal hemodynamic
assessment could be used to optimize
the timing of delivery and reduce neu-
rodevelopmental impairment merits
further investigation. - culatory redistribution and behavioral problems
ajog.org
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