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To investigate clinical and sonographic features associated with sonographic accuracy for the prediction of small for gestational age (SGA) and macrosomia at birth. The database of a tertiary medical center was retrospectively searched for women who gave birth at term to a singleton healthy neonate in 2007–2014 and underwent sonographic estimated fetal weight (sEFW) evaluation within 3 d before delivery. Fetal growth restriction (FGR) and SGA were defined as sEFW or birth weight &lt;10th percentile for gestational age; macrosomia was defined as birth weight &gt;4000 grams. Data on maternal age, parity, gestational age, fetal gender, presentation, placental location, diabetes, hypertension, and oligo/polyhydramnios were compared between pregnancies with a false-negative and false-positive diagnosis of SGA or macrosomia. Of the 5425 fetal weight evaluations, 254 (4.7%) deviated by &gt;15% from the actual birth weight. Nulliparity, absence of diabetes, neonatal female gender, anterior placenta, lower birth weight, and oligohydramnios were associated with a high deviation. We identified 482 SGA neonates (8.9%) and 633 macrosomic neonates (11.7%). A false-positive diagnosis of FGR was associated with oligohydramnios, absence of diabetes, and posterior placenta, and a false-negative diagnosis, with older maternal age, nulliparity, and male gender. A false-positive diagnosis of macrosomia was associated with older maternal age, multiparity, polyhydramnios, anterior placenta, and lack of hypertensive complications, and a false-negative diagnosis, with diabetes, hypertension, oligohydramnios, and vertex presentation. The accuracy of sEFW is affected by clinical and sonographic pregnancy characteristics. Further analyses should focus on improving accuracy especially at the fetal weight extremes.

False diagnosis of small for gestational age and macrosomia – clinical and sonographic predictors