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We have demonstrated previously the feasibility of applying four\u2010dimensional (4D) flow magnetic resonance imaging (MRI) to evaluate UtA hemodynamics during pregnancy, allowing flow quantification of the entire course of the vessel. In this study, we sought to further validate the physiological relevance of 4D flow MRI measurement of UtA blood flow by exploring its association with pregnancy outcome relative to US\u2010based metrics.<\/jats:p><\/jats:sec><jats:sec><jats:title>Methods<\/jats:title><jats:p>Recruited into this prospective, cross\u2010sectional study were 87 women with a singleton pregnancy who underwent 4D flow MRI between May 2016 and April 2019 to measure the UtA pulsatility index (MRI\u2010PI) and blood flow rate (MRI\u2010flow, in mL\/min). UtA\u2010PI was also measured using US (US\u2010PI). The primary outcome was a composite (COMP) of pre\u2010eclampsia (PE) and\/or small\u2010for\u2010gestational\u2010age (SGA) neonate, and secondary outcomes were PE and SGA neonate individually. We assessed the ability of MRI\u2010flow, MRI\u2010PI and US\u2010PI to distinguish between outcomes, and evaluated whether MRI\u2010flow changed as gestation progressed.<\/jats:p><\/jats:sec><jats:sec><jats:title>Results<\/jats:title><jats:p>Following 4D flow postprocessing and exclusions from the analysis, 74 women had 4D flow MRI data analyzed for both UtAs. Of these, 18 developed a COMP outcome: three developed PE only, 11 had a SGA neonate only and four had both. A comparison of the COMP group <jats:italic>vs<\/jats:italic> the no\u2010COMP group found no differences in maternal age, body mass index, nulliparity, gravidity or race. For 66 of the 74 subjects, US data were also available. In these subjects, both median MRI\u2010PI (0.95 <jats:italic>vs<\/jats:italic> 0.70; <jats:italic>P<\/jats:italic>\u2009&lt;\u20090.01) and median US\u2010PI (0.95 <jats:italic>vs<\/jats:italic> 0.73; <jats:italic>P<\/jats:italic>\u2009&lt;\u20090.01) were significantly increased in subjects in the COMP group compared with those in the no\u2010COMP group. The UtA blood\u2010flow rate, as measured by MRI, did not increase significantly from the second to the third trimester (median flow (interquartile range (IQR)), 543 (419\u2013698) <jats:italic>vs<\/jats:italic> 575 (440\u2013746)\u2009mL\/min; <jats:italic>P<\/jats:italic>\u2009=\u20090.77), but it was significantly lower overall in the COMP compared with the no\u2010COMP group (median flow (IQR), 486 (366\u2013598) <jats:italic>vs<\/jats:italic> 624 (457\u2013749)\u2009mL\/min; <jats:italic>P<\/jats:italic>\u2009=\u20090.04). The areas under the receiver\u2010operating\u2010characteristics curves for MRI\u2010flow, MRI\u2010PI and US\u2010PI in predicting COMP were not significantly different (0.694, 0.737 and 0.731, respectively; <jats:italic>P<\/jats:italic>\u2009=\u20090.87).<\/jats:p><\/jats:sec><jats:sec><jats:title>Conclusions<\/jats:title><jats:p>4D flow MRI can yield physiological measures of UtA blood\u2010flow rate and PI that are associated with adverse pregnancy outcome. This may open up new avenues in the future to expand the potential of this technique as a robust tool with which to evaluate UtA hemodynamics in pregnancy. \u00a9 2020 International Society of Ultrasound in Obstetrics and Gynecology<\/jats:p><\/jats:sec>","DOI":"10.1002\/uog.23112","type":"journal-article","created":{"date-parts":[[2020,9,27]],"date-time":"2020-09-27T06:54:12Z","timestamp":1601189652000},"page":"722-731","update-policy":"https:\/\/doi.org\/10.1002\/crossmark_policy","source":"Crossref","is-referenced-by-count":8,"title":["Cross\u2010modality and <i>in\u2010vivo<\/i> validation of <scp>4D<\/scp> flow <scp>MRI<\/scp> evaluation of uterine artery blood flow in human pregnancy"],"prefix":"10.1002","volume":"58","author":[{"ORCID":"https:\/\/orcid.org\/0000-0002-7376-2810","authenticated-orcid":false,"given":"E.","family":"Hwuang","sequence":"first","affiliation":[{"name":"Department of Biomedical Engineering University of Pennsylvania  Philadelphia PA USA"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"P. H.","family":"Wu","sequence":"additional","affiliation":[{"name":"Department of Radiology University of Pennsylvania  Philadelphia PA USA"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"A.","family":"Rodriguez\u2010Soto","sequence":"additional","affiliation":[{"name":"Department of Radiology University of Pennsylvania  Philadelphia PA USA"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"M.","family":"Langham","sequence":"additional","affiliation":[{"name":"Department of Radiology University of Pennsylvania  Philadelphia PA USA"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"F. W.","family":"Wehrli","sequence":"additional","affiliation":[{"name":"Department of Radiology University of Pennsylvania  Philadelphia PA USA"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"M.","family":"Vidorreta","sequence":"additional","affiliation":[{"name":"Siemens Healthineers, Getafe  Madrid Spain"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"B.","family":"Moon","sequence":"additional","affiliation":[{"name":"Department of Biomedical Engineering University of Pennsylvania  Philadelphia PA USA"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"K.","family":"Kochar","sequence":"additional","affiliation":[{"name":"Drexel School of Medicine  Philadelphia PA USA"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"S.","family":"Parameshwaran","sequence":"additional","affiliation":[{"name":"Maternal and Child Health Research Center University of Pennsylvania  Philadelphia PA USA"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"N.","family":"Koelper","sequence":"additional","affiliation":[{"name":"Center for Research on Reproduction and Women's Health University of Pennsylvania  Philadelphia PA USA"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"M. 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