Objective: To explore the predictive efficacy of serum miR-23a-3p and miR-124-3p for fetal growth restriction (FGR) in patients with hypertensive disorders of pregnancy (HDP). Methods: A total of 196 patients with HDP were selected as the research subjects. Based on ultrasound imaging interpretation of fetal growth restriction, subjects were categorized into non-FGR (n = 118) and FGR (n = 78) groups. Serum miR-23a-3p and miR-124-3p levels, as well as neonatal birth weight and placental mass, were compared between groups. Pearson correlation analysis was used to evaluate the relationship between serum markers and neonatal birth weight/placental weight. Univariate and multivariate Logistic regression analyses were performed to identify independent factors associated with FGR in HDP patients. Receiver operating characteristic (ROC) curves were constructed to assess the predictive value of serum markers for FGR. Results: Patients in the FGR group exhibited higher serum miR-23a-3p and miR-124-3p expression levels compared to the non-FGR group (P < 0.05), while both neonatal birth weight and placental weight were lower than in the non-FGR group (P < 0.05). Correlation analysis revealed that serum miR-23a-3p expression negatively correlated with both neonatal birth weight and placental weight (r = ?0.560, ?0.527; P < 0.05), and serum miR-124-3p expression levels were negatively correlated with neonatal birth weight and placental weight (r = ?0.357, ?0.310; P < 0.05). Multivariate analysis revealed that elevated miR-23a-3p and miR-124-3p levels, along with decreased folate, vitamin B12, and placental growth factor levels, were independent risk factors for FGR in HDP patients (P < 0.05). ROC curve analysis revealed that the combined AUC for predicting FGR in HDP patients using miR-23a-3p and miR-124-3p was 0.925, higher than that of miR-124-3p alone (P < 0.05). Conclusion: Elevated serum miR-23a-3p and miR-124-3p expression correlates with the occurrence of FGR in patients with HDP. Combined detection of these two markers demonstrates potential as serum diagnostic factors for FGR, offering clinical application value.