Background: Fetal growth restriction (FGR) is a major contributor to perinatal morbidity and mortality. Doppler ultrasound plays a crucial role in assessing fetal hemodynamics and predicting adverse outcomes.

Objective: To evaluate the role of advanced ultrasound and Doppler indices, particularly the cerebroplacental ratio (CPR), in predicting fetal growth restriction and adverse perinatal outcomes.

Methods: A prospective observational study was conducted among 90 pregnant women between 28 and 40 weeks of gestation with suspected FGR. Fetal biometry and Doppler indices, including umbilical artery pulsatility index (UA PI), middle cerebral artery pulsatility index (MCA PI), and CPR, were assessed serially. Diagnostic accuracy was evaluated using sensitivity, specificity, and receiver operating characteristic (ROC) curve analysis. Multivariate logistic regression was performed to identify independent predictors.

Results: Abnormal CPR (<1) was observed in 67.8% of cases and showed the highest predictive performance (AUC = 0.85). UA PI and MCA PI were also significantly associated with adverse outcomes (p < 0.001). CPR demonstrated superior sensitivity (86.2%) compared to individual Doppler indices. Multivariate analysis identified CPR as the strongest independent predictor (AOR = 4.5, p < 0.001). High rates of preterm delivery (68.9%) and NICU admission (53.3%) were observed.

Conclusion: CPR is a reliable and superior predictor of adverse perinatal outcomes in FGR. Integration of Doppler indices, particularly CPR, into routine antenatal surveillance can improve early detection and clinical decision-making.