A risk prediction model for the assessment and triage of women with hypertensive disorders of pregnancy in low-resourced settings: the miniPIERS (Pre-eclampsia Integrated Estimate of RiSk) multi-country prospective cohort study.

BACKGROUND: Pre-eclampsia/eclampsia are leading causes of maternal mortality and morbidity, particularly in low- and middle- income countries (LMICs). We developed the miniPIERS risk prediction model to provide a simple, evidence-based tool to identify pregnant women in LMICs at increased risk of death or major hypertensive-related complications. METHODS AND FINDINGS: From 1 July 2008 to 31 March 2012, in five LMICs, data were collected prospectively on 2,081 women with any hypertensive disorder of pregnancy admitted to a participating centre. Candidate predictors collected within 24 hours of admission were entered into a step-wise backward elimination logistic regression model to predict a composite adverse maternal outcome within 48 hours of admission. Model internal validation was accomplished by bootstrapping and external validation was completed using data from 1,300 women in the Pre-eclampsia Integrated Estimate of RiSk (fullPIERS) dataset. Predictive performance was assessed for calibration, discrimination, and stratification capacity. The final miniPIERS model included: parity (nulliparous versus multiparous); gestational age on admission; headache/visual disturbances; chest pain/dyspnoea; vaginal bleeding with abdominal pain; systolic blood pressure; and dipstick proteinuria. The miniPIERS model was well-calibrated and had an area under the receiver operating characteristic curve (AUC ROC) of 0.768 (95% CI 0.735-0.801) with an average optimism of 0.037. External validation AUC ROC was 0.713 (95% CI 0.658-0.768). A predicted probability ≥25% to define a positive test classified women with 85.5% accuracy. Limitations of this study include the composite outcome and the broad inclusion criteria of any hypertensive disorder of pregnancy. This broad approach was used to optimize model generalizability. CONCLUSIONS: The miniPIERS model shows reasonable ability to identify women at increased risk of adverse maternal outcomes associated with the hypertensive disorders of pregnancy. It could be used in LMICs to identify women who would benefit most from interventions such as magnesium sulphate, antihypertensives, or transportation to a higher level of care

Maternal health and survival in Pakistan: issues and options.

Although its measurement may be difficult, the maternal mortality ratio (MMR) is a key indicator of maternal health globally. In Pakistan each year over five million women become pregnant, and of these 700,000 (15% of all pregnant women) are likely to experience some obstetrical and medical complications. An estimated 30,000 women die each year from pregnancy-related causes, and the most recent estimates indicate that the MMR is 276 per 100,000 births annually. In this review, we describe the status of maternal health and survival in Pakistan and place it in its wider context of key determinants. We draw attention to the economic and social vulnerability of pregnant women, and stress the importance of concomitant broader strategies, including poverty reduction and women\u27s empowerment. Undernutrition for girls, early marriage, and high fertility rates coupled with unmet needs for contraception are important determinants of maternal ill health in Pakistan. Our review also examines factors influencing the under-utilization of maternal health services among Pakistani women, such as the lack of availability of skilled care providers and poor quality services. Notwithstanding these observations, there are evidence-based interventions available that, if implemented at scale, could make important contributions towards reducing the burden of maternal mortality in Pakistan

Calibration plot of the miniPIERS model applied 2,081 women in the cohort (H–L goodness of fit <i>p</i> = 0.1616).

<p>Green line represents line of perfect fit between observed and predicted outcomes and orange line is a smoothed fit line between predicted probability and mean observed probability in each range.</p

Results of sensitivity analysis using the miniPIERS model to predict adverse maternal outcome in subsets of the data or to predict restricted definition of the combined adverse outcome, as described, in the miniPIERS and fullPIERS cohorts.

a<p>Other hypertensive disorders excluded: chronic hypertension, gestational hypertension without proteinuria, or other adverse conditions, partial HELLP.</p><p>GA, gestational age.</p

Performance of the model in each study site region as a predictor of combined adverse maternal outcome occurring within 48

<p>Performance of the model in each study site region as a predictor of combined adverse maternal outcome occurring within 48</p

Demographic table comparing characteristics of women in the development and validation cohorts.

<p>Results for continuous variables presented as mean (± standard deviation [SD]) when data normally distributed or median (interquartile range) for skewed data.</p>*<p><i>p</i>-Values calculated using chi-squared test for categorical variables and Student's t-test or Mann-Whitney U for continuous variables.</p><p>EDD, estimated date of delivery; GA, gestational age.</p

Receiver operating characteristic curve of the miniPIERS model applied to the fullPIERS (11) external validation cohort.

<p>AUC 0.713 (95% CI 0.658–0.768).</p

Receiver operating characteristic curve of the miniPIERS model developed in 2,081 women in the miniPIERS cohort.

<p>AUC 0.768 (95% CI 0.735–0.801).</p

Demographics of women in the total cohort comparing women with and without adverse maternal outcomes (<i>N</i> = 2,081).

<p>Results for continuous variables presented as mean (± standard deviation [SD]) when data normally distributed or median [interquartile range] for skewed data.</p>*<p><i>p</i>-Values calculated using chi-squared test for categorical variables and Student's t-test or Mann-Whitney U for continuous variables.</p><p>EDD, estimated date of delivery; GA, gestational age.</p

Maternal adverse outcomes occurring in the total miniPIERS cohort, outcome counts not mutually exclusive when listed within 48

<p>Full definitions of all outcomes available at <a href="http://pre-empt.cfri.ca/OBJECTIVES/miniPIERS/Reference.aspx" target="_blank">http://pre-empt.cfri.ca/OBJECTIVES/miniPIERS/Reference.aspx</a>.</p>a<p>Includes five cases of pulmonary embolism, two cardiac arrests, one ruptured uterus.</p><p>SpO₂, blood oxygen saturation; FiO₂, fractional inspired oxygen; PPH, postpartum haemorrhage.</p