title: Is cerebroplacental ratio a marker of impaired fetal growth velocity and adverse pregnancy outcome?
abstract: The cerebroplacental ratio has been proposed as a marker of failure to reach growth potential near term. Low cerebroplacental ratio, regardless of the fetal size, is independently associated with the need for operative delivery for presumed fetal compromise and with neonatal unit admission at term.
  
  
  
  The main aim of this study was to evaluate whether the cerebroplacental ratio at term is a marker of reduced fetal growth rate. The secondary aim was to investigate the relationship between a low cerebroplacental ratio at term, reduced fetal growth velocity, and adverse pregnancy outcome.
  
  
  
  This was a retrospective cohort study of singleton pregnancies in a tertiary referral center. The abdominal circumference was measured at 20-24 weeks' gestation and both abdominal circumference and fetal Dopplers recorded at or beyond 35 weeks, within 2 weeks of delivery. Abdominal circumference and birthweight values were converted into Z scores and centiles, respectively, and fetal Doppler parameters into multiples of median, adjusting for gestational age. Abdominal circumference growth velocity was quantified using the difference in the abdominal circumference Z score, comparing the scan at or beyond 35 weeks with the scan at 20-24 weeks. Both univariable and multivariable logistic regression analyses were performed to investigate the association between low cerebroplacental ratio and the low abdominal circumference growth velocity (in the lowest decile) and to identify and adjust for potential confounders. As a sensitivity analysis, we refitted the model excluding the data on pregnancies with small-for-gestational-age neonates.
  
  
  
  The study included 7944 pregnancies. Low cerebroplacental ratio multiples of median was significantly associated with both low abdominal circumference growth velocity (adjusted odds ratio, 2.10; 95% confidence interval, 1.71-2.57, P <0.001) and small for gestational age (adjusted odds ratio, 3.60; 95% confidence interval, 3.04-4.25, P < .001). After the exclusion of pregnancies resulting in small-for-gestational-age neonates, a low cerebroplacental ratio multiples of the median remained significantly associated with both low abdominal circumference growth velocity (adjusted odds ratio, 1.76; 95% confidence interval, 1.34-2.30, P < .001) and birthweight centile (adjusted odds ratio, 0.99; 95% confidence interval, 0.998-0.995, P < .001). The need for operative delivery for fetal compromise was significantly associated with a low cerebroplacental ratio (adjusted odds ratio, 1.40; 95% confidence interval, 1.10-1.78, P = .006), even after adjusting for both the umbilical artery pulsatility index multiples of the median and middle cerebral artery pulsatility index multiples of median. The results were similar, even after the exclusion of pregnancies resulting in small-for-gestational-age neonates (adjusted odds ratio, 1.39; 95% confidence interval, 1.06-1.84, P = .018). Low cerebroplacental ratio multiples of the median remained significantly associated with the risk of operative delivery for presumed fetal compromise (P < .001), even after adjusting for the known antenatal and intrapartum risk factors. These associations persisted, even after the exclusion of small-for-gestational-age births. In appropriate-for-gestational-age-sized fetuses, abdominal circumference growth velocity was significantly lower in those with a low cerebroplacental ratio multiples of the median than in those with normal cerebroplacental ratio multiples of the median (P < .001).
  
  
  
  The cerebroplacental ratio is a marker of impaired fetal growth velocity and adverse pregnancy outcome, even in fetuses whose size is considered appropriate using conventional biometry.
authors.affiliation: St George's Hospital, St George's University of London, St George's University Hospitals NHS Foundation Trust, Molecular and Clinical Sciences Research Institute, London, United Kingdom. Electronic address: akhalil@sgul.ac.uk.
authors.forename: Asma
authors.initials: A
authors.lastname: Khalil
authors.affiliation: St George's Hospital, St George's University of London, St George's University Hospitals NHS Foundation Trust, Molecular and Clinical Sciences Research Institute, London, United Kingdom.
authors.forename: José
authors.initials: J
authors.lastname: Morales-Rosello
authors.affiliation: St George's Hospital, St George's University of London, St George's University Hospitals NHS Foundation Trust, Molecular and Clinical Sciences Research Institute, London, United Kingdom.
authors.forename: Naila
authors.initials: N
authors.lastname: Khan
authors.affiliation: Department of Cardiovascular Sciences and National Institute for Health Research Biomedical Research Unit in Cardiovascular Disease, University of Leicester, Leicester, United Kingdom.
authors.forename: Mintu
authors.initials: M
authors.lastname: Nath
authors.affiliation: St George's Hospital, St George's University of London, St George's University Hospitals NHS Foundation Trust, Molecular and Clinical Sciences Research Institute, London, United Kingdom.
authors.forename: Priya
authors.initials: P
authors.lastname: Agarwal
authors.affiliation: St George's Hospital, St George's University of London, St George's University Hospitals NHS Foundation Trust, Molecular and Clinical Sciences Research Institute, London, United Kingdom.
authors.forename: Amar
authors.initials: A
authors.lastname: Bhide
authors.affiliation: St George's Hospital, St George's University of London, St George's University Hospitals NHS Foundation Trust, Molecular and Clinical Sciences Research Institute, London, United Kingdom.
authors.forename: Aris
authors.initials: A
authors.lastname: Papageorghiou
authors.affiliation: St George's Hospital, St George's University of London, St George's University Hospitals NHS Foundation Trust, Molecular and Clinical Sciences Research Institute, London, United Kingdom.
authors.forename: Basky
authors.initials: B
authors.lastname: Thilaganathan
mesh_terms: D000005:Abdomen / Q000196:embryology; D000328:Adult; D001724:Birth Weight; D015331:Cohort Studies; D005260:Female; D047109:Fetal Development / Q000502:physiology*; D005317:Fetal Growth Retardation / Q000175:diagnosis* / Q000503:physiopathology; D005311:Fetal Hypoxia / Q000000981:diagnostic imaging; D005333:Fetus / Q000033:anatomy & histology; D005865:Gestational Age; D006801:Humans; D007236:Infant, Small for Gestational Age; D020768:Middle Cerebral Artery / Q000000981:diagnostic imaging / Q000196:embryology* / Q000503:physiopathology; D011247:Pregnancy; D011256:Pregnancy Outcome; D011673:Pulsatile Flow; D012189:Retrospective Studies; D016216:Ultrasonography, Prenatal; D014469:Umbilical Arteries / Q000000981:diagnostic imaging / Q000196:embryology* / Q000503:physiopathology
keywords: abdominal circumference; adverse pregnancy outcome; birthweight; cerebroplacental ratio; fetal growth restriction; growth velocity; impaired; lowest decile; second trimester; small for gestational age; third trimester