First-trimester ophthalmic artery Doppler for prediction of early-onset and preterm preeclampsia: a systematic review and critical appraisal.

backgroundFirst-trimester screening for preterm preeclampsia (PE) is often performed using the Fetal Medicine Foundation (FMF) Bayes' theorem-based competing-risks model, which combines maternal factors with mean arterial pressure, uterine artery pulsatility index and placental growth factor, with pregnancy-associated plasma protein-A included in some models. Ophthalmic artery (OA) Doppler has been proposed as an additional marker of maternal vascular adaptation, but its clinical contribution remains uncertain. This review critically evaluates the predictive performance of first-trimester OA Doppler for early-onset and preterm PE, and assesses its incremental value beyond established screening models.

methodsA PRISMA-guided systematic review was conducted. Studies assessing first-trimester OA Doppler in singleton pregnancies for the prediction of early-onset or preterm PE were included. Risk of bias was assessed using PROBAST. Given heterogeneity in population risk, Doppler indices, outcome definitions, and model structure, results were synthesized narratively.

resultsFive prospective cohort reports, representing four unique cohorts, met the inclusion criteria. In large unselected cohorts, OA Doppler showed limited standalone predictive value. Its contribution within multivariable models was modest, with detection rates for preterm PE of approximately 56-59% at a 10% false-positive rate. Smaller selected or mixed-risk cohorts reported substantially higher discrimination, including AUROC values up to 0.98. However, these estimates were based on few outcome events, lacked validation, and were most consistent with overfitting. All reports had high risk of bias in the analysis domain; therefore, reported AUROC and detection-rate estimates should be interpreted as exploratory.

conclusionsReported performance of first-trimester OA Doppler is strongly influenced by population risk and model structure. Current evidence suggests limited standalone value and uncertain incremental benefit beyond established screening. Future studies should use standardised acquisition and reporting, consistent PE definitions and prespecified validation to enable data pooling and determine whether OA Doppler has clinically meaningful incremental value. SYSTEMATIC REVIEW REGISTRATION: PROSPERO CRD420261289728.