OBJECTIVES: To determine the quality of Doppler images of the fetal middle cerebral artery (MCA) and umbilical artery (UA) using an objective scale, and to determine the reliability of this scale, within a multicenter randomized controlled trial (Revealed versus concealed criteria for placental insufficiency in unselected obstetric population in late pregnancy (Ratio37)). METHODS: The Ratio37 trial is an ongoing randomized, open-label, multicenter controlled study of women with a low-risk pregnancy recruited at 20 weeks. Doppler measurements of the fetal MCA and UA were performed at 37 weeks. Twenty patients from each of the six participating centers were selected randomly, with two images evaluated per patient (one each for the MCA and UA). The quality of a total of 240 images was evaluated by six experts, scored on an objective scale of six items. Inter- and intrarater reliability was assessed using the Fleiss-modified kappa statistic for ordinal scales. RESULTS: On average, 89.2% of MCA images and 85.0% of UA images were rated as being of perfect (score of 6) or almost perfect (score of 5) quality. Kappa values for intrarater reliability of quality assessment were 0.90 (95% CI, 0.88-0.92) and 0.90 (95% CI, 0.88-0.93) for the MCA and UA, respectively. The corresponding inter-rater reliability values were 0.85 (95% CI, 0.81-0.89) and 0.84 (95% CI, 0.80-0.89), respectively. CONCLUSION: The quality of MCA and UA Doppler ultrasound images can be evaluated reliably using an objective scale. Over 85% of images, which were obtained by operators from a broad range of clinical practices within a multicenter study, were rated as being of perfect or almost perfect quality. Intra- and inter-rater reliability of quality assessment was very good. Copyright © 2019 ISUOG. Published by John Wiley & Sons Ltd.

2nd Department of Obstetrics and Gynecology Faculty of Medicine Aristotle University of Thessaloniki Thessaloniki Greece

Aragon Institute for Health Research Obstetrics Department Hospital Clínico Univeristario Zaragoza Zaragoza Spain

Charles University Prague Faculty of Medicine Hradec Kralove Department of Obstetrics and Gynecology University Hospital Hradec Kralove Prague Czech Republic

Department of Fetal Medicine and Surgery Children's and Women's Specialty Hospital of Querétaro Querétaro Mexico

Department of Obstetrics and Gynecology Division of Maternal Fetal Medicine Wayne State University Hutzel Women's Hospital Perinatology Research Branch NICHD NIH DHHS Detroit MI USA

Department of Obstetrics and Gynecology Hospital Universitario y Politécnico la Fe Valencia Spain

Department of Obstetrics and Gynecology Palacky University Olomouc Faculty of Medicine and Dentistry University Hospital Olomouc Olomouc Czech Republic

Department of Obstetrics and Gynecology University of Brescia Brescia Italy

Fetal Medicine Research Center BCNatal Barcelona Center for Maternal Fetal and Neonatal Medicine Institut Clínic de Ginecología Obstetricia y Neonatología IDIBAPS Obstetrics and Gynecology University of Barcelona Barcelona Spain

Fetal Medicine Unit Obstetrics and Gynecology University of Chile Hospital Santiago de Chile Chile

Sociedad Argentina de Ultrasonografía en Medicina y Biología Buenos Aires Argentina

Tel Aviv Sourasky Medical Center and Sackler School of Medicine Lis Maternity and Women's Hospital University Tel Aviv University Tel Aviv Israel

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