Background: Multi-vessel Doppler ultrasonography and biophysical profile scoring are the principal surveillance tools in pregnancies complicated by fetal growth restriction. The interpretation of these tests done concurrently may be complex.Objective: To determine and compare the sensitivity, specificity and diagnostic accuracy of the fetal umbilical artery, middle cerebral artery pulsatility indices and their ratio for the prediction of adverse perinatal outcome in intrauterine growth restricted fetuses. Design: Prospective cohort study. Patients and Methods: Thirty patients were studied that had been diagnosed clinically and ultrasonographically as intra-uterine growth restriction (IUGR). All patients in the study underwent uniform antenatal assessment protocol that includes a four component biophysical profile score, umbilical artery (UA) and middle cerebral artery (MCA) Doppler ultrasound studies. These were conducted either twice weekly or daily according to the severity of the condition. Thirty normal pregnancies were also studied as a control group. Patients were delivered by caesarean section or vaginally.Outcome: Predictive value of UA and MCA pulsatility indices and ratio in diagnosing and following IUGR as well as their ability to predict adverse perinatal outcome. Results: Abnormal UA PI was found in 18 cases, 17 cases (56.7%) of the IUGR group and only 1 case (3.3%) of the control group. Abnormal MCA PI was found in 24 cases, 18 cases (60%) of the IUGR group and 6 cases (20%) of the control group. Abnormal C/U Ratio was found in 21 cases, 20 cases (66.7%) of the IUGR group and only 1 case (3.3%) of the control group. Sensitivity, specificity, PPV, NPV and diagnostic accuracy were 56.6%, 96.6%, 94.4%, 90.6% and 76.6% for the UA PI, 60%, 80%, 75%, 66.6% and 66.6% for the MCA PI and 66.6%, 96.6%, 95.2%, 74.3% and 81.6% for the C/U Ratio. UA PI and C/U Ratio were well correlated with adverse fetal perinatal outcome. Conclusion: Among the Doppler indices, the C/U ratio is a better predictor of IUGR fetuses and adverse perinatal outcome than either the UAPI or the MCA PI alone, with a high specificity and PPV. However, measurement of the UAPI (among all the Doppler indices) is enough to detect IUGR per se, probably because UAPI is a direct reflection of the resistance in the placental vascular bed. The MCA PI alone is not a reliable indicator. We also concluded that multi-vessel Doppler ultrasonography and BPP scoring combined use is likely to be complementary in determining the optimum time of delivery and predicting adverse fetal perinatal outcome.