Detection Of Intrauterine Growth Retardation Research Articles

Comparison of Head Circumference and Abdominal Circumference Ratio in Normotensive and patients with Pregnancy Induced Hypertensive Disorders after 28 weeks of gestation

Background: Hypertensive disorders are an important medical problem of gestation. Hypertensive disorders of pregnancy (HDP) are a significant cause for maternal and fetal morbidity as well as mortality. Intrauterine growth retardation (IUGR) commonly describes the condition of fetus whose size or growth is subnormal. IUGR fetus is frequently described as symmetrical and asymmetrical IUGR in term of their body proportions. Asymmetric growth retardation is typically linked to uteroplacental inadequacy. Hypertension is one of the maternal causes of placental insufficiency. Aim: To compare head circumference and abdominal circumference ratio in normotensive and patients with pregnancy induced hypertensive disorders after 28 weeks of gestation. Methodology: A cross sectional analytical study was carried on 113 pregnant females in which 57 women were normotensive and 56 women were hypertensive. All individuals were scanned by two- dimensional ultrasound following 28 weeks of pregnancy to evaluate sonographic parameters HC and AC. The HC/AC ratio was estimated by dividing head circumference with abdominal circumference. Results: Out of 57 normotensive patients 27 (36.48%) fetuses were diagnosed with IUGR having HC/AC ratio more than 1, while 30 had normal HC/AC ratio. In 56 hypertensive patients 47(63.51%) fetuses were diagnosed with IUGR having HC/AC ratio greater than 1, however 9(23.07%) fetuses had HC/AC ratio within normal range. So out of total 113 patients, 74 fetuses were found with IUGR while 39 fetuses had HC/AC ratio within normal ranges. Our study found that a cut off value of ≥ 1.0974 for HC/AC ratio could be used as diagnostic parameter in predicting IUGR. Conclusion: HC/AC ratio is a useful parameter for the detection of IUGR. Keywords: Head Circumference, Abdominal Circumference, Intra Uterine Growth Retardation

Self-Administered Measurement of Symphysis-Fundus Heights

If small-for-gestational-age (SGA) fetuses are identified antenatally, perinatal outcomes are likely to improve. The most widely used method of screening for SGA fetuses is for midwives to repeatedly measure symphysis-fundus (SF) height, but this is not an efficient practice. Deviant growth might be more efficiently identified if pregnant women themselves started making SF measurements earlier during pregnancy and made them more frequently. In order to determine whether pregnant women can reliably measure SF height, 40 healthy women with ultrasound-dated singleton pregnancies were asked to make 4 consecutive SF measurements each week, starting at 20 to 25 weeks' gestation and continuing up to the time of delivery. Self-administered measurements were compared with those made by midwives. Measurements were made using blank paper tape measures from the upper limit of the pubic bone to the highest point of the uterus—the fundus—in the direction of the fetus. Thirty-three pregnant women made self-administered SF measurements over a median period of 14 weeks. The SF curves constructed from these measurements had the same shape as population-based reference curves. Variance in self-administered measurements was, however, higher than for measurements made by midwives. Intra-individual variance of self-administered SF measurements was about 5 times higher than for midwives' open measurements. The degree of variance remained constant throughout pregnancy and was not a function of fetal size. The midwives performed a median of 6 SF measurements on each pregnant woman. Their blinded measurements were, on average, higher than the corresponding open SF measurements. Self-administered SF values tended to be higher than the corresponding measurements made by the midwives. These findings show that pregnant women are able to measure SF height by themselves, and that this practice makes it possible to follow fetal growth more closely, starting at a relatively early stage of pregnancy. Self-administered SF measurements have some potential to improve the early detection of intrauterine growth retardation.

Intrauterine growth retardation and placental vacuolization as presenting features in a case of GM1 gangliosidosis

Diagnosis of GM1 gangliosidosis (OMIM 230500) is usually based on the presence of physical signs of storage such as coarse facial features, corneal clouding, cherry red macula, hepatosplenomegaly and skeletal dysostosis. More rarely it can present as nonimmune hydrops. We describe a male patient with GM1 gangliosidosis born to healthy first-cousin parents of Indian Asian descent. The disease was recognized on the basis of diffuse vacuolization of cyto- and syncytiotrophoblasts, stromal cells and amniocytes on histological analysis of the placenta. The placental examination was prompted by the prenatal detection of intrauterine growth retardation (IUGR) and oligohydramnios at 32 weeks of gestation. The diagnosis of GM1 gangliosidosis was supported by both biochemical and molecular data. The beta-galactosidase enzymatic activity on leukocytes was severely reduced, while the neuraminidase activity on fibroblasts was normal, thereby excluding galactosialidosis. The molecular analysis of the beta-galactosidase gene (GLB1) revealed a previously unreported splicing mutation (IVS1+2 insT) in homozygous state. Our case further illustrates the value of histological examination of the placenta in the diagnosis of lysosomal storage disorders and shows that either hydrops or IUGR can be presenting features of GM1 gangliosidosis in the neonatal period.

Sinn und Grenzen dergeburtshilflichen Sonographie

Die geburtshilfliche Sonographie wird in Deutschland, Österreich und der Schweiz weitgehend als Screening (= Massenuntersuchung) für alle Schwangerschaften durchgeführt. Obwohl die ersten Ziele dieser Screenings bei ihrer Einführung in Deutschland 1981 vor allem die genaue Überprüfung und eventuell Korrektur des Gestationsalters, Erkennung von Mehrlingsschwangerschaften und von Wachstumsretardierung waren, hatten sich die Ziele bis zur Einführung eines 3-Punkte-Screenings 1995 in Richtung Fehlbildungsdiagnostik verschoben. Um eine befriedigende Qualität zu erzeugen, wurde im Sinne einer Arbeitsteilung das Mehrstufenkonzept eingeführt. So können heute sowohl für die 3 Screeninguntersuchungen (10/20/30 Wochen) als auch für die 3 Stufen und die Ultraschallgeräte Inhalte und Qualitäten definiert werden, die helfen können, die teilweise noch unzureichenden Ergebnisse der geburtshilflichen Sonographie zu verbessern. Gleichzeitig soll vor übertriebenen Erwartungen gewarnt werden.

Effectiveness of detection of intrauterine growth retardation by abdominal palpation as screening test in a low risk population: an observational study

Objective: To evaluate the performance of abdominal palpation as a screening test for intrauterine growth retardation (IUGR) in a low risk population, under standard practice conditions. Study design: Population based observational study of 6318 consecutive low risk singleton pregnancies. The Dutch obstetric system distinguishes low from high risk pregnancies. In the low risk group abdominal palpation as a screening test is performed by midwives. If a complication, like IUGR, during prenatal care is assessed, the women is referred to a consulted obstetrician. Ultrasound is performed by the consulted obstetrician. In case of sustained suspicion the women is selected as high risk. Outcome parameters: severe small for gestational age (SGA) birthweight below 2.3rd centile, all SGA birthweight below 10th centile, operative delivery, neonatal morbidity and perinatal mortality. Screening value of abdominal palpation, abdominal palpation combined with ultrasound, and the performance of high risk selection was assessed by conventional performance measures. Results: Abdominal palpation as a screening test for IUGR is of limited value: the observed sensitivities were 28% for severe SGA and 21% for SGA p≤10, respectively. After ultrasound in case of sustained suspicion, the sensitivity in detection of severe SGA was 25% and positive predictive value (PPV) 16%. In detection of SGA p≤10 sensitivity was 15% and PPV 55%, which means 45% were false positives. The sensitivity of the Dutch obstetric system in selection of high risk pregnancies in detection of severe SGA was 53%, in detection of SGA p≤10 was 37%. Perinatal mortality was 0.9% (57/6318) and 32% of these cases were SGA. Six cases of fetal death were unrecognised during prenatal care (0.09%) and seem preventable. The prevalence of a 5 min Apgar Score≤7 was significantly higher in the SGA infants if SGA was defined as p≤10. Conclusions: The diagnostic performance of abdominal palpation as a screening test for IUGR detection in a low risk population is disappointing. However, various stratagems such as routine ultrasound do not improve detection rate or perinatal morbidity and mortality.

Substandard factors in perinatal care in The Netherlands:

To determine: 1) whether substandard factors were present in cases of perinatal death, and to what extent another course of action might have resulted in a better outcome, and 2) whether there were differences in the frequency of substandard factors by level of care, particularly between midwives and gynecologists/obstetricians and between home and hospital births. Population-based perinatal audit, with explicit evidence-based audit criteria. The northern part of the province of South-Holland in The Netherlands. All levels of perinatal care (primary, secondary and tertiary care, and home and hospital births) were included. Three hundred and forty-two cases of perinatal mortality (24 weeks of pregnancy--28 days after birth). Scores by a Dutch and a European audit panel. Score 0: no substandard factors identified; score 1, 2 or 3: one or more substandard factors identified, which were unlikely (1), possibly (2) or probably (3) related to the perinatal death. In 25% of the perinatal deaths (95% Confidence Interval: 20-30%) a substandard factor was identified that according to the Dutch panel was possibly or probably related to the perinatal death. These were mainly maternal/social factors (10% of all perinatal deaths; most frequent substandard factor: smoking during pregnancy), and antenatal care factors (10% of all perinatal deaths; most frequent substandard factor: detection of intra-uterine growth retardation). We did not find statistically significant differences in scores between midwives and gynecologists/obstetricians or between home and hospital births. The European panel identified more substandard factors, but these were again equally distributed by level of care. Perinatal deaths might be partly preventable in The Netherlands. There is no evidence that the frequency of substandard factors is related to specific aspects of the perinatal care system in The Netherlands.

IUGR detection by ultrasonographic examinations using neural networks.

This article presents a study that supports a computer-based diagnostic approach to detection of intrauterine growth retardation (IUGR). As an aid to clinical decisions, fetuses that are truly growth retarded and at risk for increased morbidity and mortality should be differentiated from those who have reached their genetic growth potential and are not at increased risk. A wide variety of mathematical formulas (or composite tables) have been proposed for the estimation of fetal weight from ultrasonographic measurements. For these formulas, the timing of the examinations to estimate fetal weight has become controversial due to the poor correlation of early results with the outcomes several weeks later, and also the technical difficulty and poor reproduction of late results. Among the attempts to improve accuracy, one may use more accurate estimated fetal-weight formulas or a single biometric parameter to identify growth abnormalities. This study confirms the following results: 1) in the ultrasound examination the prediction using multiple parameters is better than the prediction using a single parameter; 2) the experiments also show that multiple examinations give a better insight for the diagnosis of IUGR than does a single examination; 3) a neural net is a very helpful tool for correlating many variables.

Modified neonatal growth assessment score: a multivariate approach to the detection of intrauterine growth retardation in the neonate.

The objective of this investigation was the development of a modified Neonatal Growth Assessment Score (mNGAS) for use in the evaluation of neonatal growth status. The growth of 74 fetuses at risk for intrauterine growth retardation (IUGR) was followed longitudinally, beginning in the first or early second trimester. Rossavik growth models derived from data obtained in the second trimester were used to predict the weight (WT), crown-heel length (CHL) and head (HC), abdominal (AC) and thigh circumferences (ThC) at birth, which were then actually measured within 24 h after delivery. These measurements were compared to age-specific size curves and used to calculate sets of five growth potential index (GPRIi) values, which in turn were used to calculate five-variable Neonatal Growth Assessment Scores (NGAS5). Neonates were initially classified as normal or IUGR on the basis of NGAS5, GPRIi, and anatomic measurements. A final classification based on principal component analysis and linear discriminant analysis was carried out. The score obtained using the first principal component function was defined to be mNGAS51. The effectiveness of mNGASij values, determined from 1-4 GPRIi values, in separating normal and IUGR neonates was also evaluated. Neonates initially considered to be normal had very few abnormal GPRI values or anatomic measurements, whereas the frequency of these abnormalities in IUGR neonates was significantly increased. However, no single anatomic variable was 100% normal in the normal neonates and 100% abnormal in IUGR neonates. Only 40% of IUGR neonates were small for gestational age. Classification of these neonates using principal component analysis and linear discriminant analysis was essentially the same (98.6%) as that made initially after reclassification of two IUGR neonates as normal. The characteristics of the initial and final normal and IUGR groups were very similar and the mNGAS51 was strongly correlated with the NGAS5 in the IUGR group. The effectiveness of mNGASij in separating normal and IUGR neonates increased with the number of GPRIi values included and the types used. GPRIThC and GPRIWT were the most important, followed by GPRIAC. GPRICHL and GPRIHC were much less important and in some cases detrimental. These findings support the concepts of a decrease in soft tissue mass as the initial step in the development of IUGR and the protection of head growth (brain-sparing). The characteristics of mNGAS51, particularly its comprehensiveness, its independence of differences in growth potential, its weighting of GPRIi values according to their importance in the detection of IUGR and its ability to detect different manifestations of IUGR in different individuals, indicate that this should be a most effective parameter for separating normal and IUGR neonates.

Relationship of blood rheology to lipoprotein profile during normal pregnancies and those with intrauterine growth retardation.

The effects on fetal growth of hyperlipidaemia in pregnancy are not well understood at present. In this study the different lipid fractions in normal pregnancies and pregnancies complicated by intrauterine growth retardation (IUGR) were determined and related to changes in plasma and serum viscosity. Two groups of pregnant women were studied. Group 1 consisted of 35 healthy pregnant women aged between 21 and 38 years with no previous pathology and a normal pregnancy to term. Group 1 patients were studied at four periods defined at the start of the study: (1) < or = 17 weeks; (2) 18-24 weeks; (3) 25-32 weeks, (4) > or = 33 weeks. Group 2 consisted of 24 pregnant women aged between 16 and 34 years with ultrasound diagnosed IUGR confirmed after birth. Plasma lipids and plasma and serum viscosity were measured. Plasma triglycerides, low density lipoprotein cholesterol, and total cholesterol increased progressively throughout pregnancy, with significantly higher values after week 25. Apolipoprotein A (ApoA) and triglyceride concentrations were significantly lower in the IUGR group than in the normal group. The HDL/ApoA ratio was greater in the IUGR group than in the control group, as was the ApoB/ApoA ratio. There were no differences in the other lipids. Plasma and serum viscosity was higher in the IUGR group than in the normal group. Haemorheological modifications in the IUGR group are partly secondary to changes in high density lipoprotein metabolism and the competitive inhibition of fibrinolysis by ApoB, which is increased in pregnancies with IUGR. Changes in ApoA, and more specifically in the ApoB/ApoA ratio, could be good markers for the early detection of IUGR.

Symphysis-fundus height: construction of a new Swedish reference curve, based on ultrasonically dated pregnancies.

Repeated measurements of the symphysis-fundus (SF) distance is generally regarded as an acceptable screening instrument for antenatal detection of intrauterine growth retardation (IUGR). In the present investigation an SF curve is constructed, based on measurements from 1650 Swedish women with ultrasound dated pregnancies. The SF measurements were included in a cross-sectional stratified manner; only one measurement from each woman was used and the same number of measurements (n = 75) was used for each gestational week from 20 through 41. A regression analysis by a polynomial equation of third degree was applied on the means and standard deviations of the SF measurements in each week respectively to construct a graph of fundal height. This SF curve was compared with the SF curve in common use in Sweden (constructed by Westin); in the new curve the mean measurement was about one cm higher up to 37 gestational weeks, after which time the curves almost coincided. Neither did the mean SF height differ between smokers and non-smokers nor between nulliparous and parous women. The mean SF difference between the heaviest women (> or = 79 kg) and the lightest (> or = 53 kg) was about two cm throughout pregnancy. The validity of the constructed SF curve as a screening instrument for IUGR needs to be investigated in a different study.

Ratios between the abdominal circumference, head circumference, or femur length and the transverse cerebellar diameter of the growth-retarded and macrosomic fetus.

The purpose of our investigation was twofold: to provide normative data for the ratios between head circumference and cerebellum, abdominal circumference and cerebellum, and femur length and cerebellum; and to evaluate the predictive accuracy of an abnormal ratio in the detection of growth retardation and macrosomia. Data on 675 women with normal gestations between 14 and 42 weeks were used to estimate reference curves for the three ratios to be evaluated. We then compared the ratios of 34 fetuses with intrauterine growth retardation and 28 macrosomic fetuses to the control group. Of the three ratios that we investigated, abdominal circumference to transverse cerebellar diameter was the most efficacious. However, the sensitivity of this ratio for the detection of intrauterine growth retardation and macrosomia was only 52.9% and 46.6%, respectively. A ratio between head circumference, abdominal circumference, or femur length and the transverse cerebellar diameter cannot reliably distinguish between normally growing fetuses and those that are growth retarded or macrosomic.

Detection of intrauterine growth retardation in twins using individualized growth assessment. II. Evaluation of third-trimester growth and prediction of growth outcome at birth.

Second- and third-trimester growth in 34 twin fetuses was evaluated with ultrasonography by measurement of five anatomic parameters. Rossavik growth models, derived from second-trimester measurements, were used to specify expected third-trimester growth curves. Actual measurements were compared to predicted measurements by calculation of the percent deviations. Growth outcome at birth [normal, intrauterine growth retardation (IUGR)] was determined from Neonatal Growth Assessment Scores. Growth in the second trimester was similar in normal and IUGR twins. In the third trimester, abnormal negative deviations were larger and more numerous in IUGR twins. However, there was considerable individual variability and normal twins also had abnormal negative deviations. In IUGR twins, the first appearance of an abnormal negative deviation was quite variable (range: 28.6 weeks to 35.1 weeks), as was the parameter to show such a deviation. Prediction of neonatal outcome was poor using individual anatomic parameters but improved considerably with use of all five parameters. However, some fetuses were misclassified when only the number of abnormal negative deviations was used. The Prenatal Growth Assessment Score (PGAS), determined by both the number and magnitude of abnormal negative deviations, predicted neonatal outcomes with a sensitivity of 100% and specificity of 100%. On average, PGAS values were abnormal 5 weeks before delivery. These results indicate that normal and IUGR twins can be separated, using third-trimester growth patterns, if multiple parameter Individualized Fetal Growth Assessment is employed.

Detection of intrauterine growth retardation in twins using individualized growth assessment: I. Evaluation of growth outcome at birth.

The growth of 17 sets of twins was evaluated at 2 to 3 week intervals from 15 weeks to delivery by measurement of the head circumference, abdominal circumference, and thigh circumference, and estimation of weight. The birth characteristics of these twins were compared to those predicted by Rossavik growth models, derived from second-trimester ultrasound measurements, using the Growth Potential Realization Index (GPRI) and by comparison to population standards. Newborns were classified as normal or intrauterine growth retarded (IUGR) based on their Neonatal Growth Assessment Score, determined from GPRI values. All normal twins had birth weights that were appropriate-for-gestational-age and had few abnormal birth measurements. The birth weight differences between normal twin fetuses were all < 20%. IUGR twins were both small for gestational age (78%) and appropriate-for-gestational-age (22%), and all had 3 or 4 abnormal GPRI values. In only 40% of the cases was the birth-weight difference between a normal and an IUGR twin > 20%. No single anatomic parameter evaluated at birth adequately separated the normal twins from those with IUGR. These results indicate the need for multiple parameter Individualized Growth Assessment in the detection of IUGR in twins.

Prenatal diagnosis in multiple pregnancies

Multiple pregnancy, with its high rate of fetal loss and increasing incidence, merits greater clinical attention and research. Prenatal diagnosis in multiple pregnancy poses particular difficulties in terms of safety and technique of invasive procedures, interpretation of laboratory results, and the human dilemmas produced by the demonstration of discordant abnormality. Recent applications of ultrasound, including Doppler ultrasound, are also discussed in the context of the monochorionic placenta, prediction of preterm labor, and detection of intrauterine growth retardation.

Evaluation of early third-trimester ultrasound screening for intrauterine growth retardation.

Ultrasound fetal biometry is widely used for detection of intrauterine growth retardation (IUGR). Since fetal growth is a dynamic process, studies estimating validity of ultrasound near term may not be applicable earlier in pregnancy. This study applied receiver operating characteristic (ROC) curve analysis to ultrasound biometric data obtained at 26-34 weeks gestation to predict fetuses destined to be IUGR at birth. In this method, the area under the curve (theta) is the index of performance. Sixty-nine (9%) of the 768 singleton infants studied were IUGR at birth. Ultrasound estimated fetal weight (theta = .793) and abdominal circumference (theta = .785) had equivalent performance, significantly better than head circumference (theta = .724) or femur length/abdominal circumference ratio (theta = .619). Performance was not as good as suggested by studies conducted within 2 weeks of delivery.

355 Detection of intrauterine growth retardation in twins using individual growth curve standards

355 Detection of intrauterine growth retardation in twins using individual growth curve standards

Detection of Intrauterine Fetal Growth Retardation with Abdominal Circumference and Estimated Fetal Weight Using Cross‐Sectional Growth Curves

The usefulness of a cross-sectional growth curve method in the detection of intrauterine growth retardation by ultrasonography was evaluated for abdominal circumference and estimated fetal weight. The patient sample consisted of 771 women with singleton pregnancy who delivered within seven days of an ultrasound scan. One hundred fifty-one (19.6%) women had infants with birth weight below the 10th percentile for menstrual age. Of these infants, 72.2% were symmetrically growth retarded on the basis of their neonatal ponderal index. The neonatal weight outcomes were correlated with the abdominal circumference and estimated fetal weight percentile values. Both measurements were more specific than sensitive and had much higher negative than positive predictive values. The sensitivity was influenced by menstrual age, and severity and type of intrauterine growth retardation. Overall, estimated fetal weight was more accurate than abdominal circumference, but the difference was too small to be clinically important. Both measurements were better suited to confirm than to detect, exclude, or predict intrauterine growth retardation. Normal results predicted a normal neonatal weight outcome with a very high probability when the prevalence of the condition was low. In spite of the limitations of the cross-sectional method, both tests had strengths that can be advantageously used to enhance clinical decision making in the management of intrauterine growth retardation.

Neonatal growth assessment score: A new approach to the detection of intrauterine growth retardation in the newborn

To develop an improved means for evaluation of the outcome of fetal growth in utero, a growth study of 37 fetuses at risk for intrauterine growth retardation was undertaken. Intrauterine growth was evaluated with ultrasonography at 2- to 3-week intervals beginning at 15 weeks' gestation. Measurements obtained in the second trimester were used to specify Rossavik growth models for various anatomic parameters. Values for weight, head circumference, abdominal circumference, and thigh circumference at birth were predicted with the use of these models. Growth potential realization index values for these four parameters were calculated from actual and predicted birth measurements. The growth potential realization index values were combined to form a neonatal growth assessment score. With the use of cluster analysis and neonatal growth assessment score values, the 37 infants were separated into 24 group I (neonatal growth assessment score values between 3.7 and 18.6) and 13 group II (neonatal growth assessment score values between 19.4 and 50.0) infants. In group I, 66.7% of the infants had no growth abnormalities; a single abnormality, usually borderline, was found in an additional 20.8% (total = 87.5%). In group II all infants had growth abnormalities (range, 2 to 6) although only 46.2% had birth weights below the 10th percentile. No differences in risk factors (except for the incidence of smoking) or second trimester growth were found in these two groups. The neonatal growth assessment score appears to be a sensitive indicator of third trimester growth retardation, is not affected by differences in growth potential, can separate normal infants from those with evidence of intrauterine growth retardation, and provides a quantitative assessment of growth problems in individual fetuses.

Detection of Intrauterine Growth Retardation Based on Measurements of Size of the Liver

A total of 646 ultrasonic measurements of fetal liver size were made from 18 weeks of gestation through to term. After 29 weeks, size of the liver in the growth-retarded fetuses was significantly small as compared to findings in the control fetuses. The sensitivity and specificity for the detection of growth retardation were 0.86 and 0.89 at 33 weeks, 0.89 and 0.94 at 38 weeks and 0.89 at 40 weeks of gestation. Growth rate of the liver in the growth-retarded fetus was diminished as compared with findings in the control fetus. Also, a method of estimating fetal weight by ultrasonic measurement of the fetal liver size is described.

Antenatal Screening for Intrauterine Growth Retardation with Umbilical Artery Doppler Ultrasonography

To assess the usefulness of continuous wave Doppler ultrasonography as an antenatal screening tool for the detection of intrauterine growth retardation and fetal compromise 2097 singleton pregnancies were studied. Umbilical artery velocity waveforms were obtained at 28, 34, and 38 weeks of gestation, from which the pulsatility index, A/B ratio, and resistance parameter were calculated. No abnormal features or indices of neonatal outcome were adequately predicted. The most sensitive index for being delivered of a growth retarded infant (less than 5th centile birth weight for gestation) was an A/B ratio at 34 weeks (sensitivity 40%, specificity 84%). Other measures that show poor neonatal nutritional state (ponderal index, skinfold thickness, and ratio of mid-arm circumference to head circumference) were even less well predicted. Acute and chronic hypoxia as determined by Apgar score, pH in blood from the cord artery, and packed cell volume correlated poorly with umbilical artery waveform indices, and there was no obvious difference between the indices of those who subsequently required operative or instrumental delivery for fetal distress and those requiring no intervention. There were three unexplained stillbirths in the series, in each of which the fetus had shown waveform patterns that suggested increased peripheral resistance, though the technique did not appear to be useful for predicting the time of subsequent death. Screening for small for dates babies in a three stage programme was of no value regardless of the threshold or index chosen. Obstetricians should resist the temptation to introduce screening with Doppler ultrasonography until its proper role has been determined.