INTRODUCTION: Fetal growth restriction (FGR) is the failure of fetal growth to attain inherent genetic potential owing to a diverse array of factors. Limited studies have investigated the correlation between varying levels of maternal-placental vascular malperfusion (MVM)-type FGR and adverse neonatal outcomes. Thus, we sought to explore the maternal-fetal characteristics of different degrees of MVM-type FGR and their correlation with adverse neonatal outcomes. METHODS: We collected all cases of FGR from 2018 to 2023 and observed the pregnancy, delivery, and newborn characteristics of FGR cases managed by a fetal medical center. General information, clinical examinations, and neonatal outcomes were recorded. Placental lesions were sampled and classified according to the 2016 Amsterdam standard, then divided into two groups based on MVM level: low-grade and high-grade. RESULTS: The high-grade MVM-type FGR group (30/94) had a higher prevalence of pregnant mothers with diabetes mellitus (P＝0.022) and hypertension (P＝0.013), higher incidence of abnormal umbilical artery pulsatility index (UA-PI) (P＝0.022) and uterine artery pulsatility index (UtA-PI) (P <
0.001), higher incidence of incomplete distal villus development (P＝0.027) and placental vascular disease (P＝0.008), higher incidence of cerebral hemorrhage (P＝0.006) and poor outcomes (P＝0.04), lower fetal weight (P＝0.026), and longer hospital stays for newborns (P＝0.018). Logistic regression analysis showed that body mass index (P＝0.04), diabetes (P＝0.033), assisted reproduction (P＝0.048), pathological placental villus overmaturity (P＝0.033) High-grade MVM (P＝0.014) were independent risk factors for adverse neonatal outcomes, fetal birth weight (P＝0.004) is an independent protective factor. DISCUSSION: High-grade MVM FGR is associated with the incidence rate of adverse neonatal outcomes, with a series of differences in the pre-pregnancy state, clinical auxiliary examination, and pathological characteristics compared with low grade MVM. Simultaneously, we found five independent risk factors and one protective factor that led to adverse neonatal outcomes in MVM group.