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INTRODUCTION: Cerebroplacental ratio (CPR) estimation is a valuable diagnostic tool for assessing fetal well-being, particularly in high-risk pregnancies. A reversal of CPR is typically associated with fetal hypoxia, placental insufficiency, or other pathologies, and requires close monitoring. While CPR abnormalities are often linked to growth restriction or pre-eclampsia, their association with rare fetal conditions such as arteriovenous malformations (AVMs) is less frequently discussed. CASE PRESENTATION: Mrs. X, a 23-year-old primigravida with Rh-negative blood group and moderate anemia, was treated with iron sucrose and had routine antenatal care. At 37 weeks, a growth scan and Doppler ultrasound showed elevated CPR, with the right middle cerebral artery (MCA) Doppler index greater than 3.4 MoM. This raised suspicion of abnormal fetal hemodynamics. Expert radiological consultation suggested a fetal AVM. After counseling, the patient opted to continue the pregnancy. At 39 weeks, the patient delivered a term female infant vaginally, with normal Apgar scores. Postnatally, cranial ultrasound was normal, but MRI brain and MR venography revealed dilated veins in the right frontal lobe, draining into the superior sagittal sinus, suggesting an AV fistula or vein of Galen malformation. Abdominal ultrasound was normal. The patient was referred for pediatric neurosurgical consultation, with corrective surgery planned after six months of age. DISCUSSION: Fetal AVMs can cause abnormal blood flow dynamics, leading to altered CPR values. In this case, the elevated MCA Doppler and reversed CPR likely resulted from cerebral blood flow redistribution due to the AVM. Although rare, AVMs should be considered when CPR abnormalities are detected. Early diagnosis via advanced imaging, such as MRI, aids in timely management. CONCLUSION: This case highlights that abnormal CPR can indicate rare fetal conditions like AVMs. Early detection and a multidisciplinary approach are essential for managing complex cases and improving fetal outcomes.