***TASK*** the task is to summarize an input biomedical literature in six sentences 
    ***INPUT*** the input is a biomedical literature 
    ***OUTPUT*** the output is the summary of an input biomedical literature in six sentences 
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    Input: BACKGROUND In severe intrauterine growth restriction ( IUGR ) due to placental insufficiency a haemodynamic adaptation occurs , result ing in preferential blood flow to the fetal brain ( brain sparing ) . With Doppler ultrasound an increased ratio between the umbilical and the cerebral artery pulsatility index ( U/C ratio ) can be demonstrated . IUGR is associated with impaired neurodevelopmental outcome . OBJECTIVE Evaluation of the effect of fetal brain sparing on behavioural problems at eleven years in premature born children . METHODS Prospect i ve cohort study in premature children born in 1989 , with a gestational age of 26 0/7 to 33 0/7 weeks . An U/C ratio>0.72 was defined as brain sparing . Behavioural problems were assessed with the  parent-reported Child Behaviour Check List ( CBCL ) and the Teacher 's Report Form ( TRF ) . T scores > 60 for total problem score and subscales of internalizing and externalizing behaviour , were considered abnormal . RESULTS Ninety-eight of the 116 survivors were assessed , of which 31 with antenatally established fetal brain sparing . According to the CBCL-total problem score 23.3 % of the premature born babies in the brain sparing group had behavioural problems compared with 22.8 % of those without brain sparing . According to the TRF-total problem score the percentages were 21.4 % and 20.0 % , respectively . Logistic regression analysis failed to show a significant association of U/C ratio with behavioural problems . In this model oxygen dependency at 28 days , IQ<85 at five years , cranial ultrasound abnormalities , fetal growth ratio<0.80 , Apgar scores<7 after 5 min and birth OBJECTIVE To identify the temporal sequence of abnormal Doppler changes in the fetal circulation in a subset of early and severely growth-restricted fetuses . METHODS This was a prospect i ve observational study in a tertiary care/teaching hospital . Twenty-six women who were diagnosed with growth-restricted fetuses by local st and ards before 32 weeks ' gestation and who had abnormal uterine and umbilical artery Doppler velocimetry were enrolled onto the study . To compare Doppler changes as a function of time , pulsed-wave Doppler ultrasound was performed on five vessels in the fetal peripheral and central circulations . Doppler examinations were performed twice-weekly and on the day of delivery if the fetal heart rate tracing became abnormal . Doppler indices were scored as abnormal when their values were outside the local reference limits on two or more consecutive measurements . Biometry for assessment of fetal growth was performed every 2 weeks . Computerized fetal heart rates were obtained daily . Delivery was based on a non-reactive fetal heart rate tracing and not on Doppler information . Patients with a severely growth-restricted fetus who were delivered for maternal indications such as pre-eclampsia were excluded . Perinatal outcome endpoints included : intrauterine death , gestational age at delivery , newborn weight , central nervous system damage of grade 2 or greater , intraventricular hemorrhage and neonatal mortality . RESULTS Mean gestational age and newborn weight at delivery were 29 ( st and ard deviation ( SD ) , 2 ) weeks and 818 ( SD , 150 ) g , respectively . The sequence of Doppler velocimetric changes was described by onset time cumulative curves that showed two time-related events . First , for each vessel there was a progressive increase in the percent of fetuses developing a Doppler abnormality . Second , severely growth-restricted fetuses followed a progressive sequence of acquiring Doppler abnormalities which were categorized into ' early ' and ' late ' Doppler changes . Early changes occurred in peripheral vessels ( umbilical and middle cerebral arteries ; 50 % of patients affected 15 - 16 days prior to delivery ) . Late changes included umbilical artery reverse flow , and abnormal changes in the ductus venosus , aortic and pulmonary outflow tracts ( 50 % of patients affected 4 - 5 days prior to delivery ) . The time interval between the occurrence of early and late changes was significantly different ( P < 0.0001 ) and late changes were significantly associated with perinatal death ( P < 0.01 ) . CONCLUSIONS Doppler velocimetry abnormalities develop in different vessels of the severely growth-restricted fetus in a sequential fashion . Late changes in vascular adaptation by the severely growth-restricted fetus are the best predictor of perinatal death Objective To compare the effect of induction of labour with a policy of expectant monitoring for intrauterine growth restriction near term . Design Multicentre r and omised equivalence trial ( the Disproportionate Intrauterine Growth Intervention Trial At Term ( DIGITAT ) ) . Setting Eight academic and 44 non-academic hospitals in the Netherl and s between November 2004 and November 2008 . Participants Pregnant women who had a singleton pregnancy beyond 36 + 0 weeks ’ gestation with suspected intrauterine growth restriction . Interventions Induction of labour or expectant monitoring . Main outcome measures The primary outcome was a composite measure of adverse neonatal outcome , defined as death before hospital discharge , five minute Apgar score of less than 7 , umbilical artery pH of less than 7.05 , or admission to the intensive care unit . Operative delivery ( vaginal instrumental delivery or caesarean section ) was a secondary outcome . Analysis was by intention to treat , with confidence intervals calculated for the differences in percentages or means . Results 321 pregnant women were r and omly allocated to induction and 329 to expectant monitoring . Induction group infants were delivered 10 days earlier ( mean difference −9.9 days , 95 % CI −11.3 to −8.6 ) and weighed 130 g less ( mean difference −130 g , 95 % CI −188 g to −71 g ) than babies in the expectant monitoring group . A total of 17 ( 5.3 % ) infants in the induction group experienced the composite adverse neonatal outcome , compared with 20 ( 6.1 % ) in the expectant monitoring group ( difference −0.8 % , 95 % CI −4.3 % to 3.2 % ) . Caesarean sections were performed on 45 ( 14.0 % ) mothers in the induction group and 45 ( 13.7 % ) in the expectant monitoring group ( difference 0.3 % , 95 % CI −5.0 % to 5.6 % ) . Conclusions In women with suspected intrauterine growth restriction at term , we found no important differences in adverse outcomes between induction of labour and expectant monitoring . Patients who are keen on non-intervention can safely choose expectant management with intensive maternal and fetal monitoring ; however , it is rational to choose induction to prevent possible neonatal morbidity and stillbirth . Trial registration International St and ard R and omised Controlled Trial number IS RCT N10363217 OBJECTIVES Few data exist for counseling and perinatal management of women after an antenatal diagnosis of early-onset fetal growth restriction . Yet , the consequences of preterm delivery and its attendant morbidity for both mother and baby are far reaching . The objective of this study was to describe perinatal morbidity and mortality following early-onset fetal growth restriction based on time of antenatal diagnosis and delivery . METHODS We report cohort outcomes for a prospect i ve multicenter r and omized management study of fetal growth restriction ( Trial of R and omized Umbilical and Fetal Flow in Europe ( TRUFFLE ) ) performed in 20 European perinatal centers between 2005 and 2010 . Women with a singleton fetus at 26 - 32 weeks of gestation , with abdominal circumference < 10(th ) percentile and umbilical artery Doppler pulsatility index > 95(th ) percentile , were recruited . The main outcome measure was a composite of fetal or neonatal death or severe morbidity : survival to discharge with severe brain injury , bronchopulmonary dysplasia , proven neonatal sepsis or necrotizing enterocolitis . RESULTS Five-hundred and three of 542 eligible women formed the study group . Mean ± SD gestational age at diagnosis was 29 ± 1.6 weeks and mean ± SD estimated fetal weight was 881 ± 217 g ; 12 ( 2.4 % ) babies died in utero . Gestational age at delivery was 30.7 ± 2.3 weeks , and birth weight was 1013 ± 321 g. Overall , 81 % of deliveries were indicated by fetal condition and 97 % were by Cesarean section . Of 491 liveborn babies , outcomes were available for 490 amongst whom there were 27 ( 5.5 % ) deaths and 118 ( 24 % ) babies suffered severe morbidity . These babies were smaller at birth ( 867 ± 251 g ) and born earlier ( 29.6 ± 2.0 weeks ) . Death and severe morbidity were significantly related to gestational age , both at study entry and delivery and also with the presence of maternal hypertensive morbidity . The median time to delivery was 13 days for women without hypertension , 8 days for those with gestational hypertension , 4 days for pre-eclampsia and 3 days for HELLP syndrome . CONCLUSIONS Fetal outcome in this study was better than expected from contemporary reports : perinatal death was uncommon ( 8 % ) and 70 % survived without severe neonatal morbidity . The intervals to delivery , death and severe morbidity were related to the presence and severity of maternal hypertensive conditions OBJECTIVE After intrauterine growth restriction we found at the age of 6 months an acceleration of neurophysiologic maturation . However , at later ages impaired cognitive outcome has been reported . Therefore , we investigated in children with and without fetal hemodynamic adaptation to intrauterine growth restriction whether the accelerated neurophysiologic maturation in infancy might be associated with impaired cognitive outcome at preschool age . DESIGN At 5 years of age cognitive function was assessed using the Revision of the Amsterdam Children 's Intelligence Test in 73 preterm infants ( 26 - 33 weeks ) who were prospect ively followed from the antenatal period up to the age of 5 years . Maternal educational level was used as a background variable to estimate the confounding effects of socioeconomic status on cognitive function . Fetal Doppler studies were performed and the umbilical artery pulsatility index ( PI ) divided by the middle cerebral artery PI ratio ( U/C ratio ) was calculated . A U/C ratio > 0.725 was considered as an indication of fetal cerebral hemodynamic adaptation to a compromised placental perfusion , ie , fetal brain-sparing . Visual-evoked potentials ( VEPs ) were recorded at 6 months and 1 year of age . In addition , data on neurologic status at 3 years were available . RESULTS Mean IQ score was significantly lower for children born with a raised U/C ratio ( 87 + /- 16 ) compared with children with a normal U/C ratio ( 96 + /- 17 ) . VEP latencies decreased significantly in infants with a normal U/C ratio , whereas no decrease was found in infants with a raised U/C ratio . Variables contributing significantly to the variance of cognitive function were : U/C group , VEP latency maturation , level of maternal education , and neurodevelopmental outcome at 3 years . The linear regression model explained 33 % of the variance in cognitive function . CONCLUSIONS Both being born with a raised U/C ratio and an acceleration of VEP latencies are negatively associated with cognitive outcome at 5 years of age . Fetal brain-sparing , although a seemingly beneficial adaptive mechanism for intact neurologic survival , is , however , later associated with a poorer cognitive outcome OBJECTIVE To identify the sequence of progression of arterial and venous Doppler abnormalities from the onset of placental insufficiency in intrauterine growth restriction ( IUGR ) . METHODS Prospect i ve observational study of singletons with IUGR ( abdominal circumference < 5(th ) percentile ) who underwent serial st and ardized umbilical artery ( UA ) , middle cerebral artery ( MCA ) , ductus venosus ( DV ) and umbilical vein ( UV ) Doppler surveillance .  Time intervals between progressive Doppler abnormalities and patterns of deterioration were related to UA Doppler status and gestational age . RESULTS Six hundred and sixty-eight longitudinal examinations were performed in 104 fetuses , identifying three patterns of progression : ( 1 ) Mild placental dysfunction ( n = 34 ) that remained confined to the UA/MCA . The UA became abnormal at a median of 32 weeks ' gestation but the pulsatility index never exceeded 3 SD above normal . Progression took a median of 33 days , requiring delivery at a median of 35 weeks . ( 2 ) Progressive placental dysfunction ( n = 49 ) . Initially normal UA Doppler PI at 29 weeks ' gestation increased beyond 3 SD , progressing to abnormal MCA , absent/reversed UA diastolic flow , abnormal DV , UV pulsations in 9-day intervals requiring delivery by 33 weeks . ( 3 ) Severe early-onset placental dysfunction ( n = 21 ) . Markedly elevated UA PI established by 27 weeks ' gestation was associated with rapid ( 7-day intervals ) progression to abnormal venous Doppler with median delivery at 30.6 weeks . Gestational age at onset , time to delivery and progression intervals were different between patterns ( 
    Output:
    
SGA fetuses with cerebral redistribution may be at higher risk of neurodevelopmental problems .