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To study whether fetal main pulmonary artery (MPA) Doppler indices can predict the development of neonatal respiratory distress syndrome (RDS).This prospective cross-sectional study included pregnant women between 34 and 38+6 weeks gestation. The diagnostic accuracy of MPA Doppler measurements (systolic/diastolic (S/D) ratio, peak systolic velocity (PSV), pulsatility index (PI), resistance index (RI) and acceleration time/ejection time (At/Et)) for diagnosis of neonatal RDS was tested.Of the 698 eligible fetuses, 55 (7.87%) developed neonatal RDS. PSV, PI, RI and At/Et were positively correlated with gestational age. The strongest correlation was found with At/Et (r = 0.602, P < 0.001). PI and RI were significantly higher, whereas At/Et and PSV were significantly lower in fetuses that developed RDS. A cutoff value of 0.305 for At/Et predicted the development of RDS (sensitivity: 76.4%; specificity: 91.6%).Development of neonatal RDS can be predicted using the MPA At/Et with high sensitivity and specificity.