Modified umbilical artery Doppler scoring system based on multisite assessment: association with perinatal outcome in early and late fetal growth restriction

Abstract Objectives To evaluate a novel bilateral, segment‐based umbilical artery (UA) Doppler scoring system in pregnancies complicated by early‐ or late‐onset fetal growth restriction (FGR) and to investigate its association with adverse perinatal outcome. Methods This single‐center prospective cohort study, conducted between May 2025 and December 2025, included singleton pregnancies diagnosed with FGR according to Delphi consensus criteria. Bilateral UA Doppler measurements were obtained from six predefined anatomical sites: the perivesical segment, the free‐loop segment and the placental insertion site in each UA. End‐diastolic flow at each site was categorized as present, absent or reversed and incorporated into a cumulative UA Doppler score (0–18 points). Composite adverse perinatal outcome (CAPO) was defined as the occurrence of at least one of the following: neonatal hypoglycemia, need for phototherapy, neonatal sepsis, respiratory distress syndrome, need for continuous positive airway pressure, need for mechanical ventilation, 5‐min Apgar score < 7 or admission to the neonatal intensive care unit (NICU). Participants were stratified by UA Doppler score (< 3 vs ≥ 3 points). Multivariable logistic regression analysis was used to assess the association between UA Doppler score as a continuous or dichotomized variable and CAPO, adjusting for maternal age, body mass index, parity, mode of conception, estimated fetal weight percentile and gestational age at delivery. In addition, the prevalence of individual markers of fetoplacental hemodynamic deterioration, including abnormal ductus venosus Doppler, cerebroplacental ratio < 5 th percentile, intrauterine fetal demise, fetal distress leading to delivery and 5‐min Apgar score < 7, was analyzed across UA Doppler score categories (0–2, 3–5, 6–8, 9–12 and > 12 points). Results A total of 251 pregnancies with FGR were included, of which 117 were early onset (< 32 weeks' gestation) and 134 were late onset (≥ 32 weeks' gestation). Higher UA Doppler scores (≥ 3 points) were associated significantly with preterm delivery and higher rates of NICU admission and CAPO in both early‐ and late‐onset FGR. In early‐onset FGR, higher scores were associated additionally with lower birth weight. The UA Doppler score remained associated independently with CAPO on multivariable logistic regression analysis. A significant linear trend was observed across increasing UA Doppler score categories for the rate of CAPO and individual markers of fetoplacental hemodynamic deterioration. Conclusions In pregnancies complicated by early‐onset or late‐onset FGR, a higher UA Doppler score based on a multisite bilateral scoring system is associated independently with adverse perinatal outcome. These findings support the feasibility of a segment‐based approach to UA Doppler assessment. Further studies are required to determine the clinical benefit and feasibility of adoption within current surveillance strategies. © 2026 International Society of Ultrasound in Obstetrics and Gynecology.