Background: Complicating 2–8% of pregnancies, pre-eclampsia (PE) is a major cause of maternal and perinatal morbidity and mortality worldwide, especially in developing countries. The middle cerebral artery (MCA) to uterine artery (UTA) pulsatility index (PI) ratio and MCA to umbilical artery (UA) PI ratio have been described to be good predictors of perinatal outcome in pre-eclamptic patients in the third trimester, and have been proposed to identify fetuses at risk of morbidity and mortality. Objective: To demonstrate the predictive value of middle cerebral artery (MCA) / uterine artery (UTA) pulsatility index (PI) ratio compared with that of the MCA/umbilical artery (UA) PI ratio in the assessment of fetal well-being in pregnant women with preeclampsia. Patients and methods: This case control study included 200 pregnant females attended the outpatient clinic at the Maternity Hospital of Al-Azhar University (Bab Elshaariya Hospital) during the period of one year, starting from January 2020 till December 2020, Cairo, Egypt. There were divided into two equal groups; Control group (100 females with normal pregnancy) and Preeclampsia group (100 pregnant females with preeclampsia). Transabdominal ultrasonography was conducted for the assessment of the pulsatility indices of MCA, UA and UTA followed by estimation of the previous ratios. Results: The duration of pregnancy was shorter in the preeclampsia group compared to controls. Cesarean section rates were higher in cases with preeclampsia with a significant difference between the two groups. The incidence of perinatal death, preterm birth, NICU admission and IUGR was significantly higher in preeclampsia cases. The mean MCA PI, mean MCA/UA ratio and MCA/UTA ratio were statistically significantly higher, while the mean UA PI and mean UTA PI were significantly lower in the control group as compared with preeclampsia group. MCA/UTA ratio revealed better ability in prediction of all the adverse effects of preeclampsia when compared to MCA/UA ratio. Conclusion: Low middle cerebral artery/ uterine artery pulsatility index ratio in cases with preeclampsia is significantly associated with adverse perinatal outcomes. Middle cerebral artery/ uterine artery pulsatility index ratio had significantly higher predictive value for adverse outcomes compared to middle cerebral artery/umbilical artery pulsatility index ratio.