Ultrasound Obstet Gynecol 2004; 24: 647–653

Published online in Wiley InterScience (www.interscience.wiley.com). DOI: 10.1002/uog.1761

Reference ranges for umbilical and middle cerebral artery

pulsatility index and cerebroplacental ratio in prolonged
pregnancies
M. PALACIO, F. FIGUERAS, L. ZAMORA, J. M. JIMÉNEZ, B. PUERTO, O. COLL, V. CARARACH
and J. A. VANRELL
Institut Clı́nic de Ginecologia, Obstetrı́cia i Neonatologia, Hospital Clı́nic de Barcelona, Barcelona, Spain

K E Y W O R D S: cerebroplacental ratio; Doppler ultrasonography; middle cerebral artery; prolonged pregnancy; pulsatility
index; reference ranges; umbilical artery

ABSTRACT systems in which induction of labor is safe and acceptable.

Objective To construct normal ranges for umbilical
artery pulsatility index (UA PI), middle cerebral artery
pulsatility index (MCA PI) and cerebroplacental ratio
(CPR) in prolonged pregnancies according to strict
methodological criteria using polynomial regression
analysis.
Methods This was a retrospective, cross-sectional obser-
vational study involving 140 women, 10 women for each
gestational day between 287 and 300 days of gestation.
Fetal Doppler parameters were assessed to construct nor-
mal reference ranges for UA PI and MCA PI. CPR was
calculated as a ratio of MCA PI/UA PI.
Results Mathematical modeling of the data demonstrated
that the optimal fit was a linear polynomial one. Mean,
5th and 95th centiles were calculated for UA, MCA and
CPR and centile curves from the regression analysis were
constructed.
Conclusions Reference ranges for UA PI, MCA PI and
CPR in prolonged pregnancies have been constructed.
MCA PI shows a wider range than previously reported in
the literature. Copyright  2004 ISUOG. Published by
John Wiley & Sons, Ltd.
INTRODUCTION
Management of uncomplicated prolonged pregnancies
has always been a dilemma. The Cochrane meta-analysis1
on this topic concluded that induction of labor should be
discussed with women after 41 weeks’ gestation in health
Nevertheless, this review aroused a great deal of clinical
controversy2 and the appropriate management remains
unclear. The most common reason given for routine labor
induction is that current fetal surveillance tests cannot
accurately identify which pregnancies are at risk for
an adverse outcome. The abovementioned meta-analysis
recommended that further trials are necessary to assess
the effectiveness of the antenatal fetal testing methods.
Morbidity and mortality in post-dates pregnancies are
thought to be the result of placental insufficiency3 but data
available in the literature have yielded inconsistent results.
Most authors have shown that increase in fetal umbilical
resistance index in prolonged pregnancies is related to an
increase in the adverse perinatal outcome4 – 9 but other
authors have failed to demonstrate this relationship10 – 13 .
Zimmerman et al.14 and Malcus et al.12 showed that
placental aging was not related to an increase in the
resistance of the fetal umbilical artery (UA) and that most
prolonged pregnancies with adverse outcome had normal
resistance values. Middle cerebral artery (MCA) resistance
is known to decrease at the end of pregnancy15 – 20 .
This may represent a physiological change associated
with an increase in cerebral metabolic requirements18,21 ,
a brain-sparing effect to protect intracranial structures
during labor22 or secondary to a mild degree of
placental insufficiency. A ratio of MCA to UA, the
cerebroplacental ratio (CPR), has been proposed as a
better predictor of fetal compromise than either vessel
considered alone, even when umbilical resistance index is
within normal range23 – 28 . This is thought to be because
the CPR evaluates the fetal hemodynamics and quantifies
redistribution of cardiac output better than the umbilical

Correspondence to: Dr M. Palacio, Institut Clı́nic de Ginecologia, Obstetrı́cia i Neonatologia, Hospital Clı́nic de Barcelona, Sabino de Arana
1, 08028 Barcelona, Catalonia, Spain (e-mail: mpalacio@clinic.ub.es)
Accepted: 1 June 2004

Copyright  2004 ISUOG. Published by John Wiley & Sons, Ltd. ORIGINAL PAPER
648
or the cerebral flow alone. This might be particularly
useful to evaluate post-dates pregnancies9,14,29,30 but
different indices and techniques that have been used make
the results difficult to compare.
Doppler information may play a role in the surveillance
of uncomplicated prolonged pregnancies. Data from
reliable, well-constructed normal curves during this
gestational age are lacking. While there are well-
constructed normal ranges for all Doppler indices
between 22 and 40 weeks, most reference ranges for
41 and 42 completed weeks have not been constructed
with an adequate number of women and with strict
methodological criteria. This study presents reference
nomograms for UA and MCA pulsatility indices (UA PI
and MCA PI, respectively) and the CPR between 41.0 and
42.6 weeks of gestation. These values are derived from
a uniform technique and constructed with an adequate
number of women with uncomplicated pregnancies with
normal maternal and neonatal outcomes. The definition
of these ranges is an essential prerequisite for future
investigations on their validity in the prediction of
perinatal complications in prolonged pregnancy.
METHODS
This was a cross-sectional study involving 140 fetuses
in cephalic presentation referred to the Fetal Day
Assessment Unit of the Department of Obstetrics and
Gynaecology of our institution between September 2000
and March 2003. Ten fetuses for each gestational
day between 287 (41.0 weeks) and 300 (42.6 weeks)
days (total 140 fetuses) were studied. Our management
protocol for prolonged pregnancies includes a Doppler
examination and assessment of biophysical profile
(the latter according to Manning’s criteria31 ) twice
a week from 41.0 to 42.6 weeks. When there is
reactive cardiotocography, a biophysical profile above
6, and normal UA Doppler velocimetry, pregnancies are
managed expectantly. Otherwise, induction of labor is
warranted. Doppler measurements from all consecutive
pregnant women referred to the unit for prolonged
pregnancy beyond 41 weeks and bound to deliver in
our center were prospectively entered in a database. For
the purpose of this study, Doppler measurements were
collected retrospectively and each fetus contributed just
one value to the reference sample. A computerized and
randomized procedure was used to select the women and,
from each woman, one scan if more than one had been
done during the study period.
Gestational age was established by the last menstrual
period and confirmed by first-trimester sonography. When
a discrepancy greater than 7 days was detected, first-
trimester ultrasound was used to calculate gestational
age. Women were excluded from the study if induction of
labor or Cesarean section had been planned, if in labor
or with ruptured membranes, or if there were risk fac-
tors known to increase perinatal morbidity or mortality
such as diabetes mellitus, pregnancy-induced hyperten-
sion or multiple pregnancy. Also excluded were cases
Copyright  2004 ISUOG. Published by John Wiley & Sons, Ltd.
Palacio et al.
of congenital or chromosomal abnormalities, oligohy-
dramnios (amniotic fluid index (AFI) < 5) according to
Phelan’s criteria32 , biophysical profile < 6, non-reassuring
or pathological cardiotocography, or estimated fetal
weight outside the 90% normality range33 . Indications
for labor induction included a Bishop score ≥ 6, bio-
physical profile < 6, abnormal cardiotocography, reduced
amniotic fluid (AFI < 5 cm) and 43 completed gestational
weeks.
After delivery, detailed information on the antepartum,
intrapartum and postpartum course, in addition to
neonatal outcome, was obtained for all women.
Doppler examinations were performed by two exam-
iners (M.P. and F.F.) using a 3.5-MHz convex probe
(Toshiba Eccoccee CX, Toshiba Medical Systems Europe,
The Netherlands) with spatial peak temporal average
intensities below 50 mW/cm2 and the high-pass filter at
50–100 Hz. All readings were performed in the absence
of gross fetal body or breathing movements. For each
examination, the mean value of three clear consecutive
waveforms was recorded. The angle of insonation was
kept below 60◦ . The following variables were recorded:
(1) UA PI obtained from a free loop of the umbilical cord;
(2) MCA PI measured in the straight portion of the artery
avoiding head compression by the transducer and (3) the
CPR was derived as a simple ratio of the MCA PI divided
by the UA PI.
The statistical method to estimate reference intervals
described by Royston and Wright34 was used. Separate
linear, linear-cubic and linear-quadratic regression models
were fitted to estimate the relationship between fetal
variables and gestational age (in days). The best fitting
model for each variable was selected. SD curves as
functions of gestational age were calculated by means of
a quadratic polynomial regression procedure of absolute
residuals of the measurement of interest. The Z-scores
(measurement – mean/SD) were calculated for assessing
model fit. Normal distribution of the Z-scores was
checked with the Shapiro–Francia W-test. Equations of
the polynomial regression curves were used to calculate
the mean and the 5th and 95th centiles for each gestational
age (centiles = estimated mean ± SD 1.645). A value of
P < 0.05 was considered as statistically significant.
RESULTS
Maternal characteristics and perinatal outcomes are
summarized in Table 1. Mathematical modeling of
the data demonstrated that the optimal fit was a
linear polynomial one. Although a very slight negative
correlation was observed for UA PI (R2 = 0.008), MCA
PI (R2 = 0.001) and CPR (R2 = 0.001), they were not
significant. Whereas the SD was constant throughout
the gestational age for the UA and MCA, for CPR
it showed an increasing trend, which resulted in a
progressively wider 90% normality range. Regression
equations that represented the relationships between the
studied variables and gestational age are shown in Table 2.
Mean and 5th and 95th centiles for UA PI, MCA PI and
CPR calculated for individual values of gestational age are
Ultrasound Obstet Gynecol 2004; 24: 647–653.
Fetal Doppler velocimetry reference ranges 649

Table 1 Clinical characteristics of the study population 1.30

1.20
Characteristic Mean (SD) or n (%)
1.10
Participants (n) 140 1.00

UA PI
Maternal age (years) 29.5 (5.3)
Nulliparity 108 (77.1%) 0.90
GA at delivery (days) 293.2 (2.7) 0.80
Mode of delivery
Spontaneous 47 (33.6%) 0.70
Vacuum or forceps 53 (37.9%) 0.60
Cesarean section 40 (28.5%)
Birth weight (g) 3519 (420) 0.50
287 288 289 290 291 292 293 294 295 296 297 298 299 300
Meconium staining 38 (27.1%)
UA pH 7.23 (0.04) Gestational age (days)
UA pH < 7.10 6 (4.3%)
Apgar score Figure 1 Estimated mean and centile curves (5th, 95th) from the
1 min < 7 6 regression analysis for umbilical artery pulsatility index (UA PI).
5 min < 7 0
2.00
GA, gestational age; UA, umbilical artery. 1.90
1.80
1.70
1.60
Table 2 Regression equations for umbilical artery pulsatility index 1.50
(UA PI), middle cerebral artery pulsatility index (MCA PI) and 1.40
MCA PI

cerebroplacental ratio (CPR) as a function of gestational age in days 1.30

1.20
1.10
Constant Linear 1.00
Parameter ( e) coefficient (a) R2 0.90
0.80
0.70
UA PI 1.5967 −0.0130 0.008 0.60
MCA PI 5.09451 −0.0022 0.001 0.50
CPR 2.2966 −0.0029 0.001 0.40
287 288 289 290 291 292 293 294 295 296 297 298 299 300
y = e + (a × GA). R2 , squared correlation (determination Gestational age (days)
coefficient). GA, gestational age.
Figure 2 Estimated mean and centile curves (5th, 95th) from the
regression analysis for middle cerebral artery pulsatility index
(MCA PI).
Table 3 Mean and 5th and 95th centiles for umbilical artery
pulsatility index (UA PI), middle cerebral artery pulsatility index
(MCA PI) and cerebroplacental ratio (CPR) for individual values of 2.30
gestational age (GA) in days
2.10
1.90
UA PI MCA PI CPR
GA 1.70
(days) p5 Mean p95 p5 Mean p95 p5 Mean p95 1.50
CPR

1.30
287 0.75 0.97 1.18 0.89 1.36 1.83 0.95 1.46 1.97
1.10
288 0.75 0.96 1.18 0.88 1.35 1.82 0.94 1.46 1.99
289 0.74 0.96 1.18 0.87 1.34 1.81 0.92 1.46 2.00 0.90
290 0.74 0.96 1.18 0.85 1.32 1.79 0.90 1.46 2.02 0.70
291 0.74 0.96 1.18 0.84 1.31 1.78 0.88 1.45 2.03 0.50
292 0.73 0.95 1.18 0.83 1.30 1.77 0.86 1.45 2.04 287 288 289 290 291 292 293 294 295 296 297 298 299 300
293 0.73 0.95 1.18 0.82 1.29 1.75 0.84 1.45 2.06 Gestational age (days)
294 0.72 0.95 1.18 0.80 1.27 1.74 0.82 1.44 2.07
295 0.72 0.95 1.18 0.79 1.26 1.73 0.80 1.44 2.08 Figure 3 Estimated mean and centile curves (5th, 95th) from the
296 0.72 0.95 1.17 0.78 1.25 1.72 0.78 1.44 2.10 regression analysis for cerebroplacental ratio (CPR).
297 0.71 0.94 1.17 0.76 1.23 1.70 0.76 1.44 2.11
298 0.71 0.94 1.17 0.75 1.22 1.69 0.74 1.43 2.13
299 0.70 0.94 1.17 0.74 1.21 1.68 0.72 1.43 2.14 DISCUSSION
300 0.70 0.94 1.17 0.73 1.19 1.66 0.70 1.43 2.15
We have constructed new reference ranges for UA
PI, MCA PI and CPR in prolonged pregnancies.
Comparability of published reference ranges is limited
shown in Table 3. Figures 1–3 show the estimated mean by methodological and technical aspects. Study design
and centile curves from the regression analysis for each is a major factor: we adopted a cross-sectional design
parameter. in which each fetus was measured once in contrast

Copyright  2004 ISUOG. Published by John Wiley & Sons, Ltd. Ultrasound Obstet Gynecol 2004; 24: 647–653.
650
to longitudinal studies in which measurements of each
fetus are made at different gestational ages. Longitudinal
studies are more likely to result in biased estimates
(e.g. high-risk fetuses and/or pregnancies are more likely
to be intensively scanned) and require more complex
statistical models than cross-sectional studies. Conversely,
the strong correlation between measurements of the same
fetus means that the effective sample size will be nearer
to the number of fetuses than to the total number of
measurements. In addition, we selected a cross-sectional
design to avoid methodological pitfalls given the fact
that data were collected retrospectively from a database,
as well as to achieve a better comparison of results
with previously published data. Imprecise estimates of
the reference interval are obtained when the sample
size is too small. Some published curves have not been
accompanied by information on the number of cases in
each gestational week and some have included too few
fetuses at 41–43 weeks, deriving the normal ranges from
data of women below these weeks. Although gestational
age is a continuous variable, it has been previously
analyzed at 1-week intervals, which is inappropriate
in prolonged pregnancies in which exact values in
completed days should be used. In addition, selection
criteria are not always described and this is an important
source of discrepancy among studies. In agreement with
Altman and Chitty35 , in our study the cases with
adverse perinatal outcome or with any condition for
which no information was available at the time of
the examination were not excluded from the analysis.
Besides methodological factors, technical differences also
account for discrepancies between studies: some curves
were constructed from Doppler values obtained without
color Doppler, some studies have evaluated vessels that
are not currently used, and others describe Doppler indices
that are not the standard ones (Tables 4 and 5).
It has been postulated that placental aging with
increasing uteroplacental insufficiency is responsible for
the morbidity and mortality in post-term pregnancy3 .
Thus, one could expect diminished uteroplacental flow
and increased vascular resistance in the UA as reported
for placental insufficiency in growth-restricted fetuses.
However, Zimmerman et al.14 found no correlation
between umbilical resistance and placental maturity if this
was evaluated by Grannum et al.’s grades36 . Moreover,
fetuses that showed signs of some degree of fetal distress
had Doppler values within normal ranges. Malcus et al.12
showed that flow velocity waveforms in the UA did not
change compared to values at term and that abnormal
flow velocity had no significant relationship with fetal
asphyxia, indicating that aging of the placenta did not
alter fetal blood flow. This author suggested that this
implies that structural changes on the maternal or fetal
side of the placenta are not pronounced enough to
alter flow resistance during prolonged pregnancy. These
observations could be explained by the fact that umbilical
velocimetry is a test of placental function that does
not always directly reflect fetal status. However, severe
degrees of umbilical Doppler abnormalities such as absent
Copyright  2004 ISUOG. Published by John Wiley & Sons, Ltd.
Palacio et al.
or reversed end-diastolic velocities are a rare finding but
are associated with poor outcome8 . In our study, the
UA PI showed ranges comparable to those published
in the literature and, according to the findings of other
authors, does not increase significantly when pregnancy
is prolonged9,12,14 . Umbilical resistance in the post-
term days probably does not increase in uncomplicated
pregnancy.
Most authors have demonstrated a decrease in cerebral
indices during late pregnancy. However, information
about normal ranges during 41 and 42 weeks is scarce,
although Arduini and Rizzo did include a significant
number of women at 41 and 42 weeks (approximately
n = 40 and 25, respectively)23 . Our data suggest that the
MCA PI decreases even more dramatically during the post-
term period. Our normal range is consistently wider than
that reported by Arduini and Rizzo23 . Using the ranges of
Arduini and Rizzo, some of our cases would have been
misclassified into the group with cerebral vasodilatation.
However, our values are slightly higher than those
obtained in the cross-sectional study by Mari and Deter18 ,
which may not be explained by differences in the site of
sampling. When examining the MCA, the sampling site
has significant effects on Doppler measurements when
the PI is used. Measurements from the middle and distal
third have significantly higher indices than those from the
proximal third20 . It is, therefore, important to describe the
MCA sample site when this index is used. In our study,
we measured the PI in the straight portion of the MCA,
which is clearly seen with color Doppler ultrasonography
when the greater wing of the sphenoid is obtained in a
transverse view of the fetal head. Mari and Deter and
Arduini and Rizzo also measured the PI at this site and
discrepancy in the range could not be explained by this
fact. Another source of differences may be the low number
of women analyzed to construct the normal ranges.
In a recent study Baschat and Gembruch27 report that
CPR offers the advantage of detecting redistribution of
blood flow due to two potential mechanisms: either
an increase of the placental resistance or decrease in
the cerebral blood flow due to a ‘brain-sparing’ effect.
Gramellini et al.24 , in common with other authors25 ,
found that CPR is constant during the last 10 weeks
of pregnancy. Therefore, a single cut-off (1.08) was
determined by calculating 2 SDs below the mean, above
which Doppler velocimetry was considered normal.
However, Gramellini et al. did not explore Doppler
measurements beyond 41 weeks and the number of
women beyond 40 weeks was unknown. Devine et al.30
found a single cut-off value of 1.05 to be the best
predictor of adverse outcome in uncomplicated post-date
pregnancies but the authors acknowledged that a small
sample of women had been included in the study (49
women of 41 or more weeks’ gestation). Our data show
that although the CPR mean is stable during the post-term
days, the 5th centile clearly decreases during gestation as
a result of an increasing SD. A single cut-off value derived
from the SD from the mean facilitates interpretation of
Ultrasound Obstet Gynecol 2004; 24: 647–653.
 Table 4 Reference ranges at 41 and 42 weeks of the reviewed series

41 weeks 42 weeks
Study Patients (n) and gestational
Reference Site design Equation used n p5 Mean p95 n p5 Mean p95 ages studied
Fetal Doppler velocimetry reference ranges

UA PI
Arström et al. (1989)15 Free loop* L Linear 22 0.50† 0.80† 1.00† 22 0.55† 0.75† 0.90† 22, 22–42 w
Arduini and Rizzo (1990)23 Free loop C-S Quadratic 40† 0.42 0.92 1.41 30† 0.43 0.93 1.42 1556, 20–42 w
Malcus et al. (1991)12 Free loop C-S Mean ± SD 101 0.68‡ 0.83 0.98‡ 101, 42–43 w
Anteby et al. (1994)9 Free loop C-S Mean ± SD ? 0.50‡ 1.00 1.50‡ ? 0.50‡ 1.00 1.50‡ 78, 41–42 w
Harrington et al. (1995)37 Free loop C-S Cubic ? 0.90 0.80 1.40 ? 0.95 0.80 1.45 167, 11–42 w, all values†

Copyright  2004 ISUOG. Published by John Wiley & Sons, Ltd.

Selam et al. (2000)38 Free loop C-S Median (range) ? 0.58** 0.86** 1.43** ? 0.58** 0.86** 1.43** 28, 41 w or more
Palacio et al. (present study) Free loop C-S Linear 70 0.75 0.97 1.18 70 0.72 0.95 1.18 140, 41.0–42.6 w
MCA PI
Vyas et al. (1990)39 Proximal C-S Quadratic 4† 0.40§ 1.25 2.20¶ 3† 0.25§ 1.12 2.00¶ 162, 18–42 w, all values†
Arduini and Rizzo (1990)23 Sphenoid C-S Quadratic 40† 1.08 1.55 2.01 30† 1.01 1.48 1.94 1556, 20–42 w
Battaglia et al. (1991)40 Proximal C-S Mean ± SD ? 1.94 2.48 3.02 ? 1.94 2.48 3.02 82, 41 w or more
Mari and Deter (1992)18 Sphenoid C-S Quadratic ? 0.78 1.24 1.70 ? 0.67 1.06 1.45 128, 15–42 w
Anteby et al. (1994)9 ? C-S Mean ± SD ? 0.80‡ 1.35 1.90‡ ? 0.80‡ 1.35 1.90‡ 78, 41–42 w
Harrington et al. (1995)37 Sphenoid C-S Cubic ? 0.75 1.30 1.70 ? 0.65 1.10 1.60 167, 11–42 w, all values†
Selam et al. (2000)38 Proximal C-S Median (range) ? 0.70** 1.33** 1.89** ? 0.70** 1.33** 1.89** 28, 41 w or more
Palacio et al. (present study) Straight portion C-S Linear 70 0.89 1.36 1.83 70 0.80 1.27 1.74 140, 41.0–42.6 w
CPR
Palacio et al. (present study) C-S Linear 70 0.89 1.36 1.83 70 0.80 1.27 1.74 140, 41.0–42.6 w

*No color Doppler available. †Derived from the charts. ‡Mean ± SD. §2.5 and ¶97.5 percentiles, respectively. **Median (range). CPR, cerebroplacental ratio; C-S, cross-sectional; L, longitudinal;
MCA PI, middle cerebral artery pulsatility index; UA PI, umbilical artery pulsatility index; w, weeks; ?, unknown.

Ultrasound Obstet Gynecol 2004; 24: 647–653.

651
652 Palacio et al.

Table 5 Methodological characteristics of the reviewed studies not suitable for comparison with our ranges

Study Patients (n) and GA

Reference design range Parameters and fetal vessels Reasons for unsuitability

Wladimiroff et al. (1986)41 C-S 42, 26–41 w UA PI, carotid artery, DAo Same range for 38–41 w
Wladimiroff et al. (1987)25 C-S 156, 26–39 w UAPI, PI carotid artery Up to 39 w only
Woo et al. (1987)16 L 14 Proximal MCA S/D S/D used, up to 39 w only
Rightmire and Campbell (1987)4 L 35, 42 w or more UA RI, DAo RI used
Kirkinen et al. (1987)17 L 83, 25–41 w RI intracranial (proximal RI used
MCA-carotid)
Pearce et al. (1988)42 L 40, 16 w until delivery UA PI Up to 40 w only
Arström et al. (1989)15 L 22, 22–42 w DAo, UA and MCA PI MCA up to 40 w only
Meerman et al. (1990)43 L 40, 28–40 w Proximal MCA PI Up to 40 w only
Battaglia et al. (1991)40 C-S 82, 41 w or more UA RI, MCA PI, DAo and renal PI Same range for 41 w or more
Pearce and McParland (1991)8 C-S 534, 42 w or more UA RI RI used
Gramellini et al. (1992)24 C-S 45, 30–41 w UA PI, MCA PI, CPR Same range for 39–41 w
Chandran et al. (1993)44 L 18, 24–39 w MCA PI Up to 39 w only
Devine et al. (1994)30 C-S 49, 41 w or more UA and MCA S/D, MCA (S/D)/UA Single cut-off MCA/UA < 1.05
(S/D) used
Anteby et al. (1994)9 C-S 78, 41–42 w UA PI, MCA PI, DAo Same range for 41 w or more
Zimmermann et al. (1995)14 C-S 153, 41.0 w or more UA RI, MCA RI RI used
Bar-Hava et al. (1995)45 C-S 42, 41 w or more UA, MCA and renal RI RI used
Strigini et al. (1997)46 C-S 576 high risk, 25–41 w UA S/D and PI, MCA PI Own normal range (25–41 w),
not referred
Kurmanavicius et al. (1997)47 C-S 1675, 24–42 w UA RI, MCA RI RI used
Bahado-Singh et al. (1999)26 C-S 82, 24–40 w CPR Up to 40 w only
Selam et al. (2000)38 C-S 28, 41 w or more UA PI, MCA PI Same range for 41 w or more
Baschat and Gembruch (2003)27 C-S 306, 20–40 w UA PI, MCA PI, CPR Up to 40 w only

CPR, cerebroplacental ratio; C-S, cross-sectional; DAo, descending aorta; GA, gestational age; L, longitudinal; MCA, middle cerebral artery;
PI, pulsatility index; RI, resistance index; S/D, systolic/diastolic ratio; UA, umbilical artery; w, weeks.

Doppler velocimetry, but centiles may have more clinical
value in determining fetuses with redistribution, which are
at risk for adverse outcome. Furthermore, our values for
the 5th centile were much lower than the single cut-offs
reported in other studies. This might be due to lower MCA
PI values. Whether we should use the 5th or 10th centile is
questionable, depending on the ability to predict normal
or adverse perinatal outcome and the false-positive and
false-negative results we can assume. In any case, the use
of CPR to monitor prolonged pregnancies and whether
this ratio can improve the prediction of adverse outcome
over UA or MCA Doppler velocimetry alone remains
unclear.
In conclusion, knowledge about Doppler indices in
prolonged pregnancies is poor. In the surveillance
of the uncomplicated prolonged pregnancy, Doppler
information may play a role in differentiating which
pregnancies may be followed by expectant management
or determine whether induction is a better option. The
definition of normal ranges is an essential prerequisite
for future investigations to determine their validity in
the prediction of perinatal complications in prolonged
pregnancy. New references for UA PI, MCA PI and
CPR in prolonged pregnancies are shown in this study.
Remarkably, the MCA PI shows a wider range than
previously reported in the literature.
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