It is claimed that "if you are born small, you will die for the rest of your life". Small newborns are more prone to have a prenatal or intrapartum stillbirth.1Pregnancy survivors who are small for gestational age (SGA) often experience impaired early neonatal adaptation and are at higher risk for complications like necrotizing enterocolitis, respiratory distress, neurodevelopmental issues, and neonatal death.2 In contrast to SGA (birth weight less than the 10th centile), the American College of Obstetricians and Gynaecologists (ACOG) defines intra-uterine growth restriction (IUGR) as "a foetus that fails to reach its potential growth"3 Foetal growth restriction (FGR) is a complex and multifaceted condition affecting foetal development that is currently one of the primary causes of perinatal mortality and morbidity, including iatrogenic preterm birth.4,5 Additionally, it has been linked to poor neurodevelopmental outcomes and long-term health issues, such as cardiovascular disease.6

The Delphi consensus criteria categorise FGR into early and late onset phenotypes based on whether it is detected before or after 32 weeks of gestation. Uteroplacental insufficiency is recognised as the leading cause of decreased foetal growth .7,8Evidence suggests that early and late-onset FGR types have distinct clinical presentations. The former is a rare illness, frequently associated with hypertensive disorders of pregnancy (HDP) and a significant risk of preterm birth. While the latter is more common, it might be difficult to distinguish from non-pathological smallness.9

Although the TRUFFLE research has provided evidence for managing FGR between 26 and 32 weeks' gestation, there is currently no grade-A data to support monitoring strategies or delivery time for late-onset FGR. Furthermore, there is minimal data on prenatal problems associated with late-onset FGR.10

Quantitative evaluation of estimated foetal weight (EFW) and Doppler assessment of foetal haemodynamic response to hypoxaemia, evaluated by cerebroplacental ratio (CPR) or umbilical-to-cerebral ratio, and placental impedance to uterine perfusion, which can be assessed using uterine artery (UtA) Doppler.11 A sonographic evaluation of the foetus, placenta, and amniotic fluid is performed based on clinical suspicion or physical examination. In developing countries like India, with the scarcity of resources, clinical examination and ultrasound assessment with proper documentation and clear instructions to patients can be immensely helpful.

This study aims to explore the relationship between these two diagnostic methods. Clinical assessments, can sometimes be less reliable without objective measurements, whereas ultrasound provides direct fetal measurements but may not always be accessible in all healthcare settings. By comparing the effectiveness of both methods, this study can help refine diagnostic practices, ensuring more accurate identification of at-risk pregnancies, particularly in underserved areas where access to ultrasound may be limited.

The findings could enhance diagnostic accuracy, guide early interventions, and reduce healthcare disparities in India. This research will also contribute to global understanding and promote evidence-based policies for better maternal and neonatal care, ultimately improving the health of mothers and babies in India and other developing countries.

This prospective study was conducted at the Department of Obstetrics and Gynecology at Dr Rajendra Gode Medical College and Hospital, Amravati, from January 2024 to June 2024, after obtaining informed consent from the participants. The study included 125 women with singleton pregnancies, a longitudinal lie, and a gestational age of 24 weeks or more and clinical suspicion of intrauterine growth restriction of fetus. Around 25 patients were lost to follow up. Exclusion criteria included multiple pregnancies, polyhydramnios, transverse lie, uncertain gestational age (not confirmed by LMP or lacking first-trimester records), and fetal anomalies. The study group was formed by selecting women with clinical suspicion of intrauterine growth restriction of fetus, attending the ANC OPD, resulting in 125 cases, 25 patients were lost to follow up, so the study was carried out for 100 patients.

A detailed medical history was taken, focusing on menstrual, obstetric, and family histories. Gestational age was determined using LMP (Last Menstrual Period) or early ultrasound and clinical examination. Initial measurements, including abdominal circumference, symphysio-fundal height, and maternal weight, were recorded and monitored during subsequent visits. Participants then underwent Color Doppler and Obstetric ultrasound. Women were monitored every 2-4 weeks. FGR diagnosis was confirmed using Hadlock's formula via ultrasound. Birth weights of the infants were recorded, and clinical and ultrasound findings were compared to confirm the FGR diagnosis. Data were collected using a structured proforma, entered into Microsoft Excel, and analyzed with SPSS 20 software. Sensitivity, specificity, and predictive values for both diagnostic methods were calculated and compared.

Of the 100 participants, 41 were confirmed to have FGR at birth, while 59 were not. Ultrasound findings suggested FGR in 35 cases, and Doppler changes were present in 54 cases. Significant correlations were observed between clinical findings, USG, and Doppler studies, with Doppler studies showing the highest diagnostic accuracy (90.2% sensitivity, 95.1% specificity). The p-values for the correlation between USG findings and Doppler changes were <0.001, indicating statistically significant associations.

Fetal Growth Restriction (FGR) is a critical condition that is linked to adverse pregnancy outcomes such as preterm birth, stillbirth, neonatal death, and long-term neurodevelopmental issues. Accurate diagnosis of FGR during pregnancy is essential to improve maternal and fetal outcomes, particularly in resource-limited settings like India. This study aimed to compare the diagnostic accuracy of clinical assessment, ultrasound (USG), and Doppler studies in identifying FGR in pregnant women .Our study revealed that the majority of the participants were in the age group of 21-30 years, with the 26-30 years group accounting for 49% and the 21-25 years group accounting for 45%. This is consistent with findings from Marhatta N et al. (2019)12, who also reported a higher incidence of FGR in younger women, particularly those aged between 19-25 years. The age distribution indicates that FGR is most common among women of reproductive age, highlighting the need for careful monitoring in this age group.

A significant proportion (84%) of the study participants were from rural areas, which aligns with findings from Kinare AS et al. (2017)13, who observed that rural populations often report smaller fetal sizes compared to urban populations. This could be due to limited access to healthcare facilities and prenatal care in rural areas, which emphasizes the importance of improving healthcare infrastructure in these regions to address FGR more effectively. Additionally, Sinha S et al. (2019)14 noted that socioeconomically backward groups are at higher risk of FGR, as evidenced by the 67.3% of participants in our study falling into the lower socio-economic categories.

Of the 100 cases, 41 newborns were diagnosed with Fetal Growth Restriction (FGR) at birth. The remaining 59 newborns (59%) were not diagnosed with FGR. This indicates that the majority of cases (59%) were not identified as having FGR at birth, highlighting the importance of accurate antenatal monitoring and diagnosis. Marhatta N et al12 studied 247 cases, they found sensitivity to be 71% using SFH measurement, specificity

43%, negative predictive value 33%, and positive predictive value 79%. They also found abdominal girth patterns inconsistent with SFH.1 In a study of 100 cases by Sinha S et al14, symphysio-fundal height was small for gestational age in 76% of cases and was found to be a sensitive predictor of FGR. Cnattingus S et al15, reported that SFH measurement has a sensitivity of 100%, specificity of 92% and a negative predictive value of 100%.

Ultrasound, specifically abdominal circumference (AC), was found to be a valuable tool in detecting FGR.Among the 100 patients reviewed, 35 (35%) had ultrasonography (USG) findings that indicated fetal growth restrictions. This implies that the majority of the individuals (65) had normal USG results. These findings align with Pillay P et al. (2012),16 who observed similar accuracy rates for ultrasound in detecting IUGR. Marhatta N et al. (2017)12 also found that ultrasound measurements, including AC, provided reliable diagnostic results for FGR. However, despite its high sensitivity, ultrasound missed 19.5% of confirmed FGR cases, which suggests that ultrasound alone is not always sufficient for diagnosing FGR. This supports the findings of Cnattingius S et al. (1985)15, who emphasized the importance of combining ultrasound with clinical assessments to achieve more reliable FGR detection.Sharma DD et al. (2016)17 also found that Doppler studies could detect placental insufficiency—a common cause of FGR—more effectively than clinical or ultrasound methods.Out of the 100 cases, Doppler changes were observed in 54 cases. This indicates that more than half of the participants exhibited abnormal Doppler findings, which may suggest issues with placental function or blood flow, commonly linked to conditions such as FGR.

When comparing clinical assessment, USG, and Doppler findings, our study showed that Doppler studies had the highest diagnostic accuracy, followed by ultrasound, and then clinical methods. The p-values of 0.04 for USG findings and 0.047 for Doppler changes indicate statistically significant associations between these diagnostic tools and the confirmation of FGR at birth. Pillay P et al. (2012)16 also found similar results, with Doppler studies demonstrating the highest accuracy in detecting FGR. Marhatta N et al. (2017)12 emphasized that Doppler studies are essential in cases of suspected placental insufficiency, as they provide detailed information on blood flow and placental function, which are critical in diagnosing FGR.

The findings of this study emphasize the importance of using a combination of clinical, ultrasound, and Doppler studies to diagnose FGR accurately. While clinical assessment is useful as a first-line screening tool, ultrasound and Doppler studies should be used to confirm the diagnosis and assess the severity of FGR.

In conclusion, this study reinforces the significant role of Doppler studies in diagnosing FGR, with ultrasound serving as a valuable complementary tool. While clinical methods remain important for initial screening, especially in resource-constrained settings, combining all three diagnostic methods provides the most accurate and reliable assessment of FGR. Early detection of FGR is crucial in improving neonatal outcomes and reducing perinatal morbidity and mortality.

1. Vashevnik S, Walker SP and Permezel M. Stillbirths and neonatal deaths in appropriate, small and large for birthweight for gestational age infants. A NZ J Obstet Gynaecol 2007; 47: 302–6.
2. Rosenberg A. The IUGR Newborn. Sem Perinatol 2008; 32: 219–24.
3. ACOG practice bulletin . Intrauterine growth restriction. N.12 January 2000. Int J Gynecol Obstet 2001; 72: 85–96.
4. Alberry M, Soothill P. Management of fetal growth restriction. Arch Dis Child Fetal Neonatal Ed 2007; 92: 62–67.
5. Damodaram M, Story L, Kulinskaya E, Rutherford M, Kumar S. Early adverse perinatal complications in preterm growth‐restricted fetuses. Aust N Z J Obstet Gynaecol 2011; 51: 204–209.
6. Barker DJ, Osmond C, Golding J, Kuh D, Wadsworth ME. Growth in utero, blood pressure in childhood and adult life, and mortality from cardiovascular disease. BMJ 1989; 298: 564–567.
7. Dall'Asta A, Girardelli S, Usman S, Lawin‐O'Brien A, Paramasivam G, Frusca T, Lees CC. Etiology and perinatal outcome of periviablefetal growth restriction associated with structural or genetic anomaly. Ultrasound Obstet Gynecol 2020; 55: 368–374.
8. Lawin‐O'Brien AR, Dall'Asta A, Knight C, Sankaran S, Scala C, Khalil A, Bhide A, Heggarty S, Rakow A, Pasupathy D, Papageorghiou AT, Lees CC. Short‐term outcome of periviable small‐for‐gestational‐age babies: is our counseling up to date? Ultrasound Obstet Gynecol 2016; 48: 636–641.
9. Lees CC, Stampalija T, Baschat A, da Silva Costa F, Ferrazzi E, Figueras F, Hecher K, Kingdom J, Poon LC, Salomon LJ, Unterscheider J. ISUOG Practice Guidelines: diagnosis and management of small‐for‐gestational‐age fetus and fetal growth restriction. Ultrasound Obstet Gynecol 2020; 56: 298–312.
10. Frusca T, Todros T, Lees C, Bilardo CM; TRUFFLE Investigators . Outcome in early‐onset fetal growth restriction is best combining computerized fetal heart rate analysis with ductus venosus Doppler: insights from the Trial of Umbilical and Fetal Flow in Europe. Am J Obstet Gynecol 2018; 218: S783–789.
11. Figueras F, Caradeux J, Crispi F, Eixarch E, Peguero A, Gratacos E. Diagnosis and surveillance of late‐onset fetal growth restriction. Am J Obstet Gynecol 2018; 218: S790–S802.e1.
12. Marhatta N, Kaul I. Validity of clinical and sonographic diagnosis of IUGR: a comparative study. Int J Reprod Contracept Obstet Gynecol. 2017; 6: 2407-12.
13. Kinare AS, Chinchwadkar MC, Natekar AS, Coyaji KJ, Wills AK, Joglekar CV, et al. Patterns of fetal growth in a rural Indian cohort and a comparison with western European population. J Ultrasound Med. 2010; 29(2): 21523.
14. Sinha S, Kurude VN. Study of obstetric outcome in pregnancies with intrauterine growth retardation. Int J Reprod Contracept Obstet Gynecol. 2018; 7: 1858-63.
15. Cnattingius S, Axelsson O, Lindmark G. The clinical value of measurement of symphysio-fundal height and ultrasonic measurement of the biparietal diameter in the diagnosis of IUGR. J Perinat Med. 1985; 13: 227.
16. Pillay, P., Janaki S., Manjila C., "A Comparative Study of Gravidogram and Ultrasound in Detection of IUGR," J Obstet Gynaecol India, 2012; 62(4): 409-12.
17. Sharma, DD., Chandnani, KC., "Clinical study of IUGR cases and correlation of Doppler parameters with perinatal outcome," Int J Reprod Contracept Obstet Gynecol, 2016; 5: 4290-6.