Fetal growth velocity as a predictor of small for gestational age at birth and adverse perinatal outcomes: systematic review and meta-analysis.

The role of umbilical vein blood flow assessment in the prediction of fetal growth velocity and adverse outcome: a prospective observational cohort study.

Although fetal size is associated with adverse perinatal outcome, the relationship between fetal growth velocity and adverse perinatal outcome is unclear. This study aimed to evaluate the relationship between fetal growth velocity and signs of cerebral blood flow redistribution, and their association with birthweight and adverse perinatal outcome. This study was a secondary analysis of the TRUFFLE-2 multicenter observational prospective feasibility study of fetuses at risk of fetal growth restriction between 32+0 and 36+6 weeks of gestation (n=856), evaluated by ultrasound biometry and umbilical and middle cerebral artery Doppler. Individual fetal growth velocity was calculated from the difference of birthweight and estimated fetal weight at 3, 2, and 1 week before delivery, and by linear regression of all available estimated fetal weight measurements. Fetal estimated weight and birthweight were expressed as absolute value and as multiple of the median for statistical calculation. The coefficients of the individual linear regression of estimated fetal weight measurements (growth velocity; g/wk) were plotted against the last umbilical-cerebral ratio with subclassification for perinatal outcome. The association of these measurements with adverse perinatal outcome was assessed. The adverse perinatal outcome was a composite of abnormal condition at birth or major neonatal morbidity. Adverse perinatal outcome was more frequent among fetuses whose antenatal growth was <100 g/wk, irrespective of signs of cerebral blood flow redistribution. Infants with birthweight <0.65 multiple of the median were enrolled earlier, had the lowest fetal growth velocity, higher umbilical-cerebral ratio, and were more likely to have adverse perinatal outcome. A decreasing fetal growth velocity was observed in 163 (19%) women in whom the estimated fetal weight multiple of the median regression coefficient was <-0.025, and who had higher umbilical-cerebral ratio values and more frequent adverse perinatal outcome; 67 (41%; 8% of total group) of these women had negative growth velocity. Estimated fetal weight and umbilical-cerebral ratio at admission and fetal growth velocity combined by logistic regression had a higher association with adverse perinatal outcome than any of those parameters separately (relative risk, 3.3; 95% confidence interval, 2.3-4.8). In fetuses at risk of late preterm fetal growth restriction, reduced growth velocity is associated with an increased risk of adverse perinatal outcome, irrespective of signs of cerebral blood flow redistribution. Some fetuses showed negative growth velocity, suggesting catabolic metabolism.

To assess the additive value of fetal growth velocity between 32 and 36 weeks' gestation to the performance of ultrasonographic estimated fetal weight (EFW) at 35 + 0 to 36 + 6 weeks' gestation for prediction of delivery of a small-for-gestational-age (SGA) neonate and adverse perinatal outcome. This was a prospective study of 14 497 singleton pregnancies undergoing routine ultrasound examination at 30 + 0 to 34 + 6 and at 35 + 0 to 36 + 6 weeks' gestation. Multivariable logistic regression analysis was used to determine whether addition of growth velocity, defined as the difference in EFW Z-score or abdominal circumference (AC) Z-score between the early and late third-trimester scans divided by the time interval between the scans, improved the performance of EFW Z-score at 35 + 0 to 36 + 6 weeks in the prediction of, first, delivery of a SGA neonate with birth weight < 10th and < 3rd percentiles within 2 weeks and at any stage after assessment and, second, a composite of adverse perinatal outcome, defined as stillbirth, neonatal death or admission to the neonatal unit for ≥ 48 h. Multivariable logistic regression analysis demonstrated that significant contributors to the prediction of a SGA neonate were EFW Z-score at 35 + 0 to 36 + 6 weeks' gestation, fetal growth velocity, by either AC Z-score or EFW Z-score, and maternal risk factors. The area under the receiver-operating characteristics curve (AUC) and detection rate (DR), at a 10% screen-positive rate, for prediction of a SGA neonate < 10th percentile born within 2 weeks after assessment achieved by EFW Z-score at 35 + 0 to 36 + 6 weeks (AUC, 0.938 (95% CI, 0.928-0.947); DR, 80.7% (95% CI, 77.6-83.9%)) were not significantly improved by addition of EFW growth velocity and maternal risk factors (AUC, 0.941 (95% CI, 0.932-0.950); P = 0.061; DR, 82.5% (95% CI, 79.4-85.3%)). Similar results were obtained when growth velocity was defined by AC rather than EFW. Similarly, there was no significant improvement in the AUC and DR, at a 10% screen-positive rate, for prediction of a SGA neonate < 10th percentile born at any stage after assessment or a SGA neonate < 3rd percentile born within 2 weeks or at any stage after assessment, achieved by EFW Z-score at 35 + 0 to 36 + 6 weeks by addition of maternal factors and either EFW growth velocity or AC growth velocity. Multivariable logistic regression analysis demonstrated that the only significant contributor to adverse perinatal outcome was maternal risk factors. Multivariable logistic regression analysis in the group with EFW < 10th percentile demonstrated that significant contribution to prediction of delivery of a neonate with birth weight < 10th and < 3rd percentiles and adverse perinatal outcome was provided by EFW Z-score at 35 + 0 to 36 + 6 weeks, but not by AC growth velocity < 1st decile. The predictive performance of EFW at 35 + 0 to 36 + 6 weeks' gestation for delivery of a SGA neonate and adverse perinatal outcome is not improved by addition of estimated growth velocity between 32 and 36 weeks' gestation. Copyright © 2019 ISUOG. Published by John Wiley & Sons Ltd.

Pregnancies complicated by late-onset fetal growth restriction (FGR) are at increased risk of short- and long-term morbidities. Despite this, identification of cases at higher risk of adverse perinatal outcome, at the time of FGR diagnosis, is challenging. The aims of this study were to elucidate the strength of association between fetoplacental Doppler indices at the time of diagnosis of late-onset FGR and adverse perinatal outcome, and to determine their predictive accuracy. This was a prospective study of consecutive singleton pregnancies complicated by late-onset FGR. Late-onset FGR was defined as estimated fetal weight (EFW) or abdominal circumference (AC) < 3rd centile, or EFW or AC < 10th centile and umbilical artery (UA) pulsatility index (PI) > 95th centile or cerebroplacental ratio (CPR) < 5th centile, diagnosed after 32 weeks. EFW, uterine artery PI, UA-PI, fetal middle cerebral artery (MCA) PI, CPR and umbilical vein blood flow normalized for fetal abdominal circumference (UVBF/AC) were recorded at the time of the diagnosis of FGR. Doppler variables were expressed as Z-scores for gestational age. Composite adverse perinatal outcome was defined as the occurrence of at least one of emergency Cesarean section for fetal distress, 5-min Apgar score < 7, umbilical artery pH < 7.10 and neonatal admission to the special care unit. Logistic regression analysis was used to elucidate the strength of association between different ultrasound parameters and composite adverse perinatal outcome, and receiver-operating-characteristics (ROC)-curve analysis was used to determine their predictive accuracy. In total, 243 consecutive singleton pregnancies complicated by late-onset FGR were included. Composite adverse perinatal outcome occurred in 32.5% (95% CI, 26.7-38.8%) of cases. In pregnancies with composite adverse perinatal outcome, compared with those without, mean uterine artery PI Z-score (2.23 ± 1.34 vs 1.88 ± 0.89, P = 0.02) was higher, while Z-scores of UVBF/AC (-1.93 ± 0.88 vs -0.89 ± 0.94, P ≤ 0.0001), MCA-PI (-1.56 ± 0.93 vs -1.22 ± 0.84, P = 0.004) and CPR (-1.89 ± 1.12 vs -1.44 ± 1.02, P = 0.002) were lower. On multivariable logistic regression analysis, Z-scores of mean uterine artery PI (P = 0.04), CPR (P = 0.002) and UVBF/AC (P = 0.001) were associated independently with composite adverse perinatal outcome. UVBF/AC Z-score had an area under the ROC curve (AUC) of 0.723 (95% CI, 0.64-0.80) for composite adverse perinatal outcome, demonstrating better accuracy than that of mean uterine artery PI Z-score (AUC, 0.593; 95% CI, 0.50-0.69) and CPR Z-score (AUC, 0.615; 95% CI, 0.52-0.71). A multiparametric prediction model including Z-scores of MCA-PI, uterine artery PI and UVBF/AC had an AUC of 0.745 (95% CI, 0.66-0.83) for the prediction of composite adverse perinatal outcome. While CPR and uterine artery PI assessed at the time of diagnosis are associated independently with composite adverse perinatal outcome in pregnancies complicated by late-onset FGR, their diagnostic performance for composite adverse perinatal outcome is low. UVBF/AC showed better accuracy for prediction of composite adverse perinatal outcome, although its usefulness in clinical practice as a standalone predictor of adverse pregnancy outcome requires further research. Copyright © 2019 ISUOG. Published by John Wiley & Sons Ltd.

ABSTRACTObjectivesTo evaluate the predictive value of markers of placental insufficiency and fetal growth restriction for a composite adverse perinatal outcome (CAPO) in a small‐for‐gestational‐age (SGA) population. We also aimed to identify profiles that discriminate fetuses as low or high risk for CAPO, and to evaluate the association of onset of labor and mode of birth with CAPO.MethodsThis was a preplanned post‐hoc analysis of the DRIGITAT study, a Dutch multicenter cohort study of management strategy in 690 singleton SGA pregnancies at 32.0–36.9 weeks' gestation, between 2018 and 2022. We used data from 440 participants with available biomarker measurements, who were not randomized for immediate birth before 36 weeks' gestation on the basis of recurrent abnormal Doppler velocimetry. We defined CAPO as fetal death, adverse condition at birth, major neonatal morbidity and/or neonatal mortality. We analyzed the predictive value for CAPO of maternal body mass index (BMI), gestational age, estimated fetal weight (EFW) and soluble fms‐like tyrosine kinase‐1 to placental growth factor ratio (sFlt‐1/PlGF ratio) at inclusion, development of pre‐eclampsia, highest value of the umbilicocerebral ratio (UCR) and fetal growth velocity. We also used these variables to develop a prediction model for CAPO using forward stepwise logistic regression to emulate real‐world clinical evaluation.ResultsIn this population of 440 singleton SGA pregnancies, maternal BMI at inclusion (P = 0.02), gestational age at inclusion (P ≤ 0.001), EFW at inclusion (P ≤ 0.001), sFlt‐1/PlGF ratio at inclusion (P ≤ 0.001), development of pre‐eclampsia (P ≤ 0.001), highest value of the UCR measured at any time during pregnancy (P ≤ 0.001) and fetal growth velocity (P ≤ 0.001) were all associated significantly with CAPO. When combined into a prediction model using logistic regression analysis, maternal BMI at inclusion, gestational age at inclusion, development of pre‐eclampsia and fetal growth velocity did not add to the predictive value of the model, because of their correlation with other variables. The area under the receiver‐operating‐characteristics curve of the final prediction model, comprising EFW at inclusion, sFlt‐1/PlGF ratio at inclusion and the highest UCR value at any time, was 0.75 (95% CI, 0.70–0.81). At false‐positive rates of 5%, 10% and 25%, the sensitivities of the prediction model for CAPO were 35.6%, 44.2% and 63.5%, respectively. The median gestational age at birth and birth weight were lower in neonates that experienced CAPO compared with those that did not (37.0 weeks vs 38.3 weeks and 1.993 kg vs 2.518 kg, respectively). Vaginal birth occurred in 69.3% of our population. In the group that experienced CAPO, a higher number of (emergency) Cesarean sections were performed.ConclusionsIn a SGA population, maternal BMI, gestational age, EFW and sFlt‐1/PlGF ratio at inclusion, highest UCR at any time, development of pre‐eclampsia and fetal growth velocity were associated with CAPO. A model incorporating EFW at inclusion, sFlt‐1/PlGF ratio at inclusion and highest UCR was most effective for the prediction of CAPO. © 2025 The Author(s). Ultrasound in Obstetrics & Gynecology published by John Wiley & Sons Ltd on behalf of International Society of Ultrasound in Obstetrics and Gynecology.

407 Accelerated fetal abdominal circumference growth velocity (ACGV): a predictor of adverse outcomes in diabetic pregnancies

Unified standard for fetal growth velocity: the Eunice Kennedy Shriver National Institute of Child Health and Human Development Fetal Growth Studies

Objective Growth velocities derived from fetal biometrics have been proposed to improve prediction of small for gestational age (SGA) neonates. We sought to determine if ultrasound growth velocities for abdominal circumference (AC) and estimated fetal weight (EFW) improve the prediction of SGA infants when compared to using EFW alone. Study design This is a secondary analysis from a prospective study of women referred for growth ultrasounds during the third trimester. Growth velocities for AC and EFW were derived from the difference in Z-scores between measurements at the anatomy survey (18–22 weeks gestation) and later growth ultrasound (26–36 weeks gestation). Change in AC and EFW growth velocities <10th percentile were compared with prenatally suspected SGA from Hadlock EFW <10th percentile for prediction of SGA neonates. The primary outcome was defined as the sensitivity and specificity of the growth velocities and Hadlock EFW in predicting SGA neonates. Logistic regression modeling was used to determine if the growth velocities improved prediction of neonatal SGA. Area under the ROC curves (AUC) were determined and compared. Results Of 612 singleton pregnancies meeting inclusion criteria, 68 (11.1%) resulted in SGA neonates. Hadlock EFW <10th percentile had higher sensitivity and specificity when compared to AC growth velocity and EFW growth velocity. Only AC growth velocity and Hadlock EFW had significant odds ratios for association with neonatal SGA. The AUC were 0.54, 0.53, and 0.61 using AC growth velocity, EFW growth velocity, and Hadlock EFW, respectively. The AUC did not significantly improve when the growth velocities were combined with Hadlock EFW (0.63). Adjustment of Z-scores for gestational age at anatomy scan or third trimester growth scan did not significantly change these results (AUC = 0.69). Conclusion EFW determined by Hadlock formula has the highest predictive value in detecting SGA neonates when compared to both AC and EFW growth velocities.

Summary Background Fetal growth restriction is a major determinant of adverse perinatal outcome. Screening procedures for fetal growth restriction need to identify small babies and then differentiate between those that are healthy and those that are pathologically small. We sought to determine the diagnostic effectiveness of universal ultrasonic fetal biometry in the third trimester as a screening test for small-for-gestational-age (SGA) infants, and whether the risk of morbidity associated with being small differed in the presence or absence of ultrasonic markers of fetal growth restriction. Methods The Pregnancy Outcome Prediction (POP) study was a prospective cohort study of nulliparous women with a viable singleton pregnancy at the time of the dating ultrasound scan. Women participating had clinically indicated ultrasonography in the third trimester as per routine clinical care and these results were reported as usual (selective ultrasonography). Additionally, all participants had research ultrasonography, including fetal biometry at 28 and 36 weeks' gestational age. These results were not made available to participants or treating clinicians (universal ultrasonography). We regarded SGA as a birthweight of less than the 10th percentile for gestational age and screen positive for SGA an ultrasonographic estimated fetal weight of less than the 10th percentile for gestational age. Markers of fetal growth restriction included biometric ratios, utero-placental Doppler, and fetal growth velocity. We assessed outcomes for consenting participants who attended research scans and had a livebirth at the Rosie Hospital (Cambridge, UK) after the 28 weeks' research scan. Findings Between Jan 14, 2008, and July 31, 2012, 4512 women provided written informed consent of whom 3977 (88%) were eligible for analysis. Sensitivity for detection of SGA infants was 20% (95% CI 15–24; 69 of 352 fetuses) for selective ultrasonography and 57% (51–62; 199 of 352 fetuses) for universal ultrasonography (relative sensitivity 2·9, 95% CI 2·4–3·5, p interaction =0·005) if the fetal abdominal circumference growth velocity was in the lowest decile (RR 3·9, 95% CI 1·9–8·1, p=0·0001). 172 (4%) of 3977 pregnancies had both an estimated fetal weight of less than the 10th percentile and abdominal circumference growth velocity in the lowest decile, and had a relative risk of delivering an SGA infant with neonatal morbidity of 17·6 (9·2–34·0, p Interpretation Screening of nulliparous women with universal third trimester fetal biometry roughly tripled detection of SGA infants. Combined analysis of fetal biometry and fetal growth velocity identified a subset of SGA fetuses that were at increased risk of neonatal morbidity. Funding National Institute for Health Research, Medical Research Council, Sands, and GE Healthcare.

SummaryBackgroundFetal growth restriction is a major determinant of adverse perinatal outcome. Screening procedures for fetal growth restriction need to identify small babies and then differentiate between those that are healthy and those that are pathologically small. We sought to determine the diagnostic effectiveness of universal ultrasonic fetal biometry in the third trimester as a screening test for small-for-gestational-age (SGA) infants, and whether the risk of morbidity associated with being small differed in the presence or absence of ultrasonic markers of fetal growth restriction.MethodsThe Pregnancy Outcome Prediction (POP) study was a prospective cohort study of nulliparous women with a viable singleton pregnancy at the time of the dating ultrasound scan. Women participating had clinically indicated ultrasonography in the third trimester as per routine clinical care and these results were reported as usual (selective ultrasonography). Additionally, all participants had research ultrasonography, including fetal biometry at 28 and 36 weeks' gestational age. These results were not made available to participants or treating clinicians (universal ultrasonography). We regarded SGA as a birthweight of less than the 10th percentile for gestational age and screen positive for SGA an ultrasonographic estimated fetal weight of less than the 10th percentile for gestational age. Markers of fetal growth restriction included biometric ratios, utero-placental Doppler, and fetal growth velocity. We assessed outcomes for consenting participants who attended research scans and had a livebirth at the Rosie Hospital (Cambridge, UK) after the 28 weeks' research scan.FindingsBetween Jan 14, 2008, and July 31, 2012, 4512 women provided written informed consent of whom 3977 (88%) were eligible for analysis. Sensitivity for detection of SGA infants was 20% (95% CI 15–24; 69 of 352 fetuses) for selective ultrasonography and 57% (51–62; 199 of 352 fetuses) for universal ultrasonography (relative sensitivity 2·9, 95% CI 2·4–3·5, p<0·0001). Of the 3977 fetuses, 562 (14·1%) were identified by universal ultrasonography with an estimated fetal weight of less than the 10th percentile and were at an increased risk of neonatal morbidity (relative risk [RR] 1·60, 95% CI 1·22–2·09, p=0·0012). However, estimated fetal weight of less than the 10th percentile was only associated with the risk of neonatal morbidity (pinteraction=0·005) if the fetal abdominal circumference growth velocity was in the lowest decile (RR 3·9, 95% CI 1·9–8·1, p=0·0001). 172 (4%) of 3977 pregnancies had both an estimated fetal weight of less than the 10th percentile and abdominal circumference growth velocity in the lowest decile, and had a relative risk of delivering an SGA infant with neonatal morbidity of 17·6 (9·2–34·0, p<0·0001).InterpretationScreening of nulliparous women with universal third trimester fetal biometry roughly tripled detection of SGA infants. Combined analysis of fetal biometry and fetal growth velocity identified a subset of SGA fetuses that were at increased risk of neonatal morbidity.FundingNational Institute for Health Research, Medical Research Council, Sands, and GE Healthcare.

Evidence Evaluation Process and Management of Potential Conflicts of Interest: 2020 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations.

IntroductionThe perinatal risk of reduced growth velocity among small for gestational age (SGA) has been poorly studied. Therefore, we assessed the impact of abdominal fetal growth velocity on perinatal morbidity and mortality among SGA fetuses with positive umbilical artery end‐diastolic flow.Material and MethodsThis retrospective, single‐center cohort study was conducted between January 1, 2018, and May 31, 2022, at a tertiary center. We included women with a singleton pregnancy, at least two ultrasounds with an estimated fetal weight in the <10th percentile at least 2 weeks apart between gestational weeks 24 and 36, and a positive umbilical artery end‐diastolic flow. Abdominal circumference growth velocity (ACGV) was calculated. For each ACGV, a z‐score was calculated using INTERGROWTH‐21 standards. Reduced growth velocity (ACGV z score < −2) and normal (ACGV z score ≥ −2) groups were compared based on a composite perinatal criterion defined as one of the following: stillbirth, 5‐min Apgar score <7, arterial pH at birth <7.10, neonatal intensive care unit admission, or infant death before discharge.ResultsAmong the 216 women included, 14.4% (31/216) had a fetus with reduced abdominal circumference growth velocity group and 85.6% (185/216) had a fetus with normal ACGV. Adverse neonatal outcomes occurred significantly more often in the reduced growth velocity group (58% in the reduced ACGV group vs 33% in the normal ACGV; p = 0.007). Nulliparous women, hypertensive disorders, and cerebroplacental redistribution at baseline and final Doppler examinations were significantly more frequent in the reduced ACGV group. After adjustment for confounding factors, ACGV z score < −2 was not significantly associated with an increased risk of perinatal adverse outcome (adjusted odds ratio [ORa] = 1.99), (95% confidence interval [CI]: [0.8–4.91]). However, hypertensive disorders (ORa = 4.48, 95% CI: [2–10.02]), cerebroplacental redistribution on the final Doppler examination (ORa = 3.12, 95% CI: [1.07–9.05]), and gestational diabetes (ORa = 3.72, 95% CI: [1.62–8.54]) remained statistically associated with increased perinatal morbidity risk.ConclusionsAmong SGA fetuses, reduced abdominal circumference growth velocity was not associated with an increased adverse perinatal outcome risk. Further studies are needed to determine the impact of growth velocity on the issues of SGA fetuses.

Previous studies have demonstrated that fetuses with an estimated fetal weight (EFW) less than the 10th percentile with concomitant abdominal circumference (AC) growth velocity < 10th percentile are at increased risk for adverse perinatal outcomes. This was a retrospective case series of 104 fetuses who had a prior study in which the EFW was > 10th percentile and were identified with a subsequent EFW < 10th percentile with concomitant AC growth velocity between two examinations of < 10th percentile. The AC, head circumference (HC), and femur length (FL) growth velocity was computed as follows: [(AC, HC, FLEFW < 10th - AC, HC, FLEFW Previous Examination)/(weeks gestationEFW < 10th - weeks gestationEFW Previous Examination)]. Growth velocity 10th and 90th percentile reference values for the AC, HC, and FL, were derived from equations published from Intergrowth-21st Project of longitudinal fetal growth protocol. Once abnormal growth was identified (EFW plus AC growth velocity < 10th percentile), the patients were asked to begin a course of complete maternal rest for 2 weeks, lying in the left lateral recumbent position. Following 2 weeks of maternal rest, the EFW percentile and the growth velocity of the AC, HC, and FL were reassessed as follows: Period 1: pre-diagnosis of an EFW > 10th percentile versus EFW < 10th percentile; Period II: diagnosis of an EFW < 10th percentile versus 2 weeks following maternal rest. The velocity values were plotted on graphs and z-scores were computed. A p-value of < 0.05 was considered significant. For Period I, 100% (N = 104) had an EFW and AC growth velocity < 10th percentile, 29% (30/104) a HC growth velocity < 10th percentile. Fifty-four percent (56/104) a FL growth velocity < 10th percentile. Period II, which evaluated growth after 2 weeks of maternal rest, demonstrated the following significant findings (p < 0.05): (1) increased EFW > 10th percentile (0% vs. 81%, 84/104); (2) increased AC growth velocity > 10th percentile (0% vs. 94%, 98/104); (3) increased HC growth velocity > 10th percentile (71%, 74/104 vs. 81%, 84/104), and FL growth velocity > 10th percentile (46%, 48/104 vs. 83%, 86/104). Following maternal rest in fetuses with an EFW < 10th percentile and an AC growth velocity < 10th percentile, there was a significant increase in the EFW percentile as well as the AC, HC, and FL growth velocities.

Is cerebroplacental ratio a marker of impaired fetal growth velocity and adverse pregnancy outcome?

The GRADE (Grading of Recommendations Assessment, Development and Evaluation) approach is a system for transparent evaluation of the certainty of evidence used in clinical practice guidelines and systematic reviews. GRADE is a key part of evidence-based medicine (EBM) training of health care professionals. This study aimed to compare web-based and face-to-face methods of teaching the GRADE approach for evidence assessment. A randomized controlled trial was conducted on 2 delivery modes of GRADE education integrated into a course on research methodology and EBM with third-year medical students. Education was based on the Cochrane Interactive Learning "Interpreting the findings" module, which had a duration of 90 minutes. The web-based group received the web-based asynchronous training, whereas the face-to-face group had an in-person seminar with a lecturer. The main outcome measure was the score on a 5-question test that assessed confidence interval interpretation and overall certainty of evidence, among others. Secondary outcomes included writing a recommendation for practice and course satisfaction. In all, 50 participants received the web-based intervention, and 47 participants received the face-to-face intervention. The groups did not differ in the overall scores for the Cochrane Interactive Learning test, with a median of 2 (95% CI 1.0-2.0) correct answers for the web-based group and 2 (95% CI 1.3-3.0) correct answers for the face-to-face group. Both groups gave the most correct answers to the question about rating a body of evidence (35/50, 70% and 24/47, 51% for the web-based and face-to-face group, respectively). The face-to-face group better answered the question about the overall certainty of evidence question. The understanding of the Summary of Findings table did not differ significantly between the groups, with a median of 3 correct answers to 4 questions for both groups (P=.352). The writing style for the recommendations for practice also did not differ between the 2 groups. Students' recommendations mostly reflected the strengths of the recommendations and focused on the target population, but they used passive words and rarely mentioned the setting for the recommendation. The language of the recommendations was mostly patient centered. Course satisfaction was high in both groups. Training in the GRADE approach could be equally effective when delivered asynchronously on the web or face-to-face. Open Science Framework akpq7; https://osf.io/akpq7/.