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.


RESULTS
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.
Department of Obstetrics and Gynaecology and the CFRI Reproductive and Healthy Pregnancy Cluster, University of British Columbia, Vancouver, Canada.
Beth A
BA
Payne
Department of Obstetrics and Gynaecology and the CFRI Reproductive and Healthy Pregnancy Cluster, University of British Columbia, Vancouver, Canada ; School of Population and Public Health, University of British Columbia, Vancouver, Canada.
Jennifer A
JA
Hutcheon
Department of Anesthesiology, Pharmacology and Therapeutics, University of British Columbia, Vancouver, Canada.
J Mark
JM
Ansermino
Department of Obstetrics and Gynaecology, Stellenbosch University and Tygerberg Hospital, Cape Town, South Africa.
David R
DR
Hall
Centre of Excellence Division of Women and Child Health, Aga Khan University, Karachi, Pakistan.
Zulfiqar A
ZA
Bhutta
Jinnah Post-graduate Medical College, Karachi, Pakistan.
Shereen Z
SZ
Bhutta
Department of Obstetrics and Gynecology, Makerere University, Kampala, Uganda.
Christine
C
Biryabarema
Department of Obstetrics and Gynecology, Feinberg School of Medicine Northwestern University, Chicago, Illinois, United States of America.
William A
WA
Grobman
Department of Epidemiology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands.
Henk
H
Groen
Department of Obstetrics and Gynaecology, Colonial War Memorial Hospital, Suva, Fiji.
Farizah
F
Haniff
Department of Obstetrics and Gynaecology and the CFRI Reproductive and Healthy Pregnancy Cluster, University of British Columbia, Vancouver, Canada.
Jing
J
Li
Department of Obstetrics and Gynaecology and the CFRI Reproductive and Healthy Pregnancy Cluster, University of British Columbia, Vancouver, Canada ; School of Population and Public Health, University of British Columbia, Vancouver, Canada ; Department of Medicine, University of British Columbia, Vancouver, Canada.
Laura A
LA
Magee
UNDP/UNFPA/WHO/World Bank Special Programme of Research, Development and Training in Human Reproduction (HRP), Department of Reproductive Health and Research (RHR), Geneva, Switzerland.
Mario
M
Merialdi
Department of Obstetrics and Gynecology, Makerere University, Kampala, Uganda.
Annettee
A
Nakimuli
Department of Obstetrics and Gynaecology and the CFRI Reproductive and Healthy Pregnancy Cluster, University of British Columbia, Vancouver, Canada.
Ziguang
Z
Qu
Division of Women and Child Health, Aga Khan University, Karachi, Pakistan.
Rozina
R
Sikandar
Department of Obstetrics and Gynaecology, Universidade Federal de São Paulo, Maternidade de Vila Nova Cachoeirinha, São Paulo, Brazil.
Nelson
N
Sass
Department of Obstetrics and Gynaecology and the CFRI Reproductive and Healthy Pregnancy Cluster, University of British Columbia, Vancouver, Canada.
Diane
D
Sawchuck
Department of Obstetrics and Gynaecology, Stellenbosch University and Tygerberg Hospital, Cape Town, South Africa.
D Wilhelm
DW
Steyn
UNDP/UNFPA/WHO/World Bank Special Programme of Research, Development and Training in Human Reproduction (HRP), Department of Reproductive Health and Research (RHR), Geneva, Switzerland.
Mariana
M
Widmer
Department of Obstetrics, Tongji University, Shanghai, P.R. China.
Jian
J
Zhou
Department of Obstetrics and Gynaecology and the CFRI Reproductive and Healthy Pregnancy Cluster, University of British Columbia, Vancouver, Canada ; School of Population and Public Health, University of British Columbia, Vancouver, Canada.
Peter
P
von Dadelszen
D000328:Adult; D019540:Area Under Curve; D003906:Developing Countries; D005260:Female; D006801:Humans; D016015:Logistic Models; D011225:Pre-Eclampsia / Q000453:epidemiology* / Q000209:etiology; D011247:Pregnancy; D011446:Prospective Studies; D012372:ROC Curve; D018570:Risk Assessment / Q000379:methods; D012307:Risk Factors; D055815:Young Adult