To determine the accuracy with which uterine artery Doppler in the first trimester of pregnancy predicts pre‐eclampsia and fetal growth restriction, particularly early‐onset disease.

We searched MEDLINE (1951–2012), EMBASE (1980–2012) and the Cochrane Library (2012) for relevant citations without language restrictions. Two reviewers independently selected studies that evaluated the accuracy of first‐trimester uterine artery Doppler to predict adverse pregnancy outcome and performed data extraction to construct 2 × 2 tables. We synthesized sensitivity and specificity for various Doppler indices using a bivariate random‐effects model.

From 1866 citations, we identified 18 studies (55 974 women). The sensitivity and specificity of abnormal uterine artery flow velocity waveform (FVW) in the prediction of early‐onset pre‐eclampsia were 47.8% (95% CI: 39.0–56.8) and 92.1% (95% CI: 88.6–94.6), and in the prediction of early‐onset fetal growth restriction were 39.2% (95% CI: 26.3–53.8) and 93.1% (95% CI: 90.6–95.0), respectively. The sensitivities for predicting any pre‐eclampsia and fetal growth restriction were 26.4% (95% CI: 22.5–30.8) and 15.4% (95% CI: 12.4–18.9), respectively, and the specificities were 93.4% (95% CI: 90.4–95.5%) and 93.3% (95% CI: 90.9–95.1), respectively. The number needed to treat (NNT) with aspirin to prevent one case of early‐onset pre‐eclampsia fell from 1000 to 173 and from 2500 to 421 for background risks varying between 1% and 0.4%, respectively.

First‐trimester uterine artery Doppler is a useful tool for predicting early‐onset pre‐eclampsia, as well as other adverse pregnancy outcomes. Based on the NNT, abnormal uterine artery Doppler in low‐risk women achieves a sufficiently high performance to justify aspirin prophylaxis in those who test positive. Copyright © 2013 ISUOG. Published by John Wiley & Sons Ltd.