Angiogenic factors and fetal Doppler for predicting adverse pregnancy outcome in early‐onset small fetuses with and without pre‐eclampsia

ABSTRACT Objectives To assess the predictive performance of angiogenic factors and fetal Doppler, alone and in combination, for composite adverse perinatal outcome (CAPO) in early‐onset small‐for‐gestational age (SGA) and fetal growth restriction (FGR), in cases both with and without pre‐eclampsia (PE), in order to evaluate the ability of these markers to predict adverse outcomes beyond their established association with PE and to better delineate the specific contribution of PE to their predictive value. Methods This was a retrospective observational study conducted at Vall d'Hebron University Hospital, Barcelona, Spain, between January 2016 and January 2022. The study population included singleton pregnancies with an estimated fetal weight 48 h; stillbirth; neonatal death; respiratory distress syndrome; bronchopulmonary dysplasia; neonatal sepsis; necrotizing enterocolitis; Grade‐III–IV retinopathy of prematurity; Grade‐III–IV intraventricular hemorrhage; or periventricular leukomalacia. Predictive performance for CAPO and subsequent PE was assessed using receiver‐operating‐characteristics (ROC)‐curve analysis and area under the ROC curve (AUC) comparisons for fetal Doppler and angiogenic factors, alone and combined, within logistic regression models. Sensitivity, false‐positive rate, positive predictive value and negative predictive value were calculated. All analyses were stratified according to PE development at any time before delivery. Results Overall, 469 women with an early‐onset small fetus were included. PE was present at diagnosis in 74/469 (15.8%) cases and developed later in 83 (17.7%) cases. CAPO occurred in 46.5% of cases. In the overall cohort, PlGF combined with fetal Doppler findings showed the highest predictive performance for CAPO (AUC, 0.866 (95% CI, 0.833–0.899)), outperforming fetal Doppler alone. Notably, the performance of the combined model was not significantly different from PlGF alone (AUC, 0.862 (95% CI, 0.828–0.895); P = 0.621). These findings were consistent in pregnancies without PE, in which PlGF remained the best‐performing single predictor of CAPO (AUC, 0.797 (95% CI, 0.740–0.854)). In pregnancies with PE at any time, the best‐performing single predictor was the sFlt‐1/PlGF ratio (AUC, 0.802 (95% CI, 0.728–0.876)). For the prediction of subsequent PE after enrolment, the sFlt‐1/PlGF ratio alone (AUC, 0.861 (95% CI, 0.821–0.901)) and in combination with fetal Doppler (AUC, 0.862 (95% CI, 0.822–0.902)) achieved the highest predictive performance. Combining fetal Doppler findings with angiogenic factors reduced false‐positive rates, but did not improve sensitivity. Conclusion This study confirmed the robust predictive performance of PlGF and the sFlt‐1/PlGF ratio for identifying CAPO and PE in early‐onset SGA/FGR. The predictive value of PlGF and fetal Doppler remained consistent irrespective of PE status, while the sFlt‐1/PlGF ratio showed reduced predictive accuracy in non‐PE pregnancies, but still outperformed Doppler. These findings support the integration of angiogenic factors into the clinical assessment of early‐onset SGA/FGR, for both cases with and those without PE. © 2026 The Author(s). Ultrasound in Obstetrics & Gynecology published by John Wiley & Sons Ltd on behalf of International Society of Ultrasound in Obstetrics and Gynecology.