International Journal of Reproduction, Contraception, Obstetrics and Gynecology

Srivastava S et al. Int J Reprod Contracept Obstet Gynecol. 2017 Apr;6(4):1200-1205

www.ijrcog.org pISSN 2320-1770 | eISSN 2320-1789

DOI: http://dx.doi.org/10.18203/2320-1770.ijrcog20170889
Original Research Article

PIERS calculator- predicting adverse maternal

outcome in preeclampsia
Shubha Srivastava*, Bharti Chaudhary Parihar, Neha Jain

Department of Obstetrics and Gynecology, Gandhi Medical College, Bhopal, Madhya Pradesh, India

Received: 11 February 2017

Accepted: 16 February 2017

*Correspondence:
Dr. Shubha Srivastava,
E-mail: drshubhasrivastava76@gmail.com

Copyright: © the author(s), publisher and licensee Medip Academy. This is an open-access article distributed under
the terms of the Creative Commons Attribution Non-Commercial License, which permits unrestricted non-commercial
use, distribution, and reproduction in any medium, provided the original work is properly cited.

ABSTRACT

Background: Preeclampsia is a multisystem, highly variable disorder unique to pregnancy. For preeclampsia arising
remote from term, supportive and temporizing measures are used to improve perinatal outcome. However, the
magnitude of the maternal risks associated with expectant management is unclear. The PIER (preeclampsia integrated
estimate of risk) score is a recently designed tool which assesses maternal signs, symptoms, and laboratory findings to
generate a valid and reliable algorithm for predicting maternal and perinatal outcome in patients with preeclampsia.
Methods: The present study was a prospective hospital based observational study carried out in Department of
Obstetrics and Gynecology, Sultania Zanana Hospital, Gandhi Medical College, Bhopal. A total of 125 women with
preeclampsia who fulfilled the inclusion criteria were included in the study. Along with history and examination, all
relevant and required investigations were done. The fullPIERS calculator was used to calculate the risk of adverse
maternal outcome.
Results: In the present study, 82(65.6%) women were in the low risk category and only 4 (4.87%) had adverse
maternal outcome. High risk patients were 6 (4.8%) and amongst them 5 (83.33%) women had adverse maternal
outcome (p-value <0.00001). The result was statistically significant in identifying high risk cases in our study.
Conclusions: The fullPIERS calculator gave good results in prediction of adverse maternal outcome according to risk
score in women with preeclampsia in our study. It will help the clinicians better manage the patients with
preeclampsia specially remote from term and also help health workers in primary and secondary care centres to
identify women who are or may become severely ill and who need specialist care and prevent delays in transporting
these women to facilities where they can receive appropriate care.

Keywords: Maternal outcome, PIERS calculator, Preeclampsia

INTRODUCTION Maternal illness may vary from mild asymptomatic

hypertension to neurological, renal, and cardiopulmonary
Preeclampsia is a multisystem, highly variable disorder compromise. Favorable maternal and perinatal outcomes
unique to pregnancy. Preeclampsia and other for women with preeclampsia/eclampsia depend on how
hypertensive disorders of pregnancy complicate up to soon the condition is identified and how quickly the
10% of pregnancies worldwide, constituting one of the woman has access to treatment.
greatest causes of maternal and perinatal morbidity and
mortality.1 An estimated 50,000 to 60,000 preeclampsia Outcomes are less favorable in women living in
related deaths occur every year worldwide.2,3 For every developing countries, regardless of gestation or severity
preeclampsia death that occurs, there are many more of clinical presentation.4 Management of preeclampsia
women who experience near miss maternal morbidity. may include increased maternal and fetal surveillance,

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blood pressure control, and seizure prophylaxis, but was to evaluate the ability of fullPIERS calculator to
ultimately delivery of the fetus is the only definitive predict complications and adverse maternal outcome in
treatment.5 For preeclampsia arising remote from term, preeclampsia.
supportive and temporizing measures (expectant
management) are used to improve perinatal outcome. METHODS
However, the magnitude of the maternal risks associated
with expectant management is unclear. Concerns around The present study was a prospective hospital based
maternal risk have caused experts to hesitate in observational study carried out in Department of
recommending expectant management either remote from Obstetrics & Gynecology, Sultania Zanana Hospital,
or close to term. Gandhi Medical College, Bhopal, Madhya Pradesh, India.
The data was collected for six months and analysed. A
The challenge to clinicians lies in identifying patients total of 125 women were included in the study. The study
who will suffer subsequent adverse outcomes from was done after approval from the institutional ethical
preeclampsia in order to intervene appropriately while committee.
minimizing unnecessary and potentially harmful
interventions in patients who do not require them. Inclusion criteria

The PIER (preeclampsia integrated estimate of risk) score • Blood pressure ≥140/90 (two readings more than 4
is a recently designed tool which assesses maternal signs, hours apart) after 20 weeks of gestation.
symptoms, and laboratory findings to generate a valid • Urine albumin ≥1+ (heat coagulation and dip stick
and reliable algorithm for predicting maternal and method)
perinatal outcome in patients with preeclampsia.6 The • Patient with HELLP syndrome even in absence of
fullPIERS calculator includes gestational age at hypertension or proteinuria
diagnosis, the symptom complex of chest pain and/or • Superimposed preeclampsia (pre-existing
dyspnea, oxygen saturation by pulse oximetry, and hypertension with accelerated hypertension (systolic
laboratory estimation of platelet count, serum creatinine, blood pressure ≥170 mmHg or diastolic blood
and aspartate transaminase (Figure 1). pressure ≥120 mmHg) or new onset of proteinuria.

Exclusion criteria

• If the patient experienced an adverse outcome prior

to fulfilling the PIERS eligibility criteria or prior to
the collection of study predictor variables.
• If they were admitted to hospital in spontaneous
labor.

All patients who fulfilled the inclusion criteria and gave

consent were enrolled in the study. A detailed history and
meticulous clinical examination including general,
systemic and obstetric examination was done. The
investigation performed included:
Figure 1: The fullPIERS calculator.
• Hematology: Complete blood count, blood sugar,
The final fullPIERS equation platelet count, coagulation profile (INR, PT, APTT
and fibrinogen).
logit(π) = 2.8+(-5.1×10–2;×gestational age at • Hepatic Function Test: Serum bilirubin, SGPT,
eligibility)+1.23 (chest pain or dyspnea)+(-2.71×10– SGOT, Alkaline phosphatase, LDH, A:G ratio.
•
2
×creatinine)+(2.07×10-1×platelets)+(4.0×105×platelets2) Renal Function Test: Blood urea, serum creatinine,
+(1.01×10–2×aspartate transaminase)+(-3.05×10–6×AST2) serum electrolytes, uric acid, urine albumin (dipstick
+ (2.50×10–4×creatinine×platelet)+ (-6.99×10- as well as 24 hour urine protein).
5
×platelet×aspartate transaminase)+(-2.56×10- • Oxygen saturation by pulse oximetry.
3
×platelet×SpO2).
The fullPIERS calculator was used to calculate the risk of
This tool is meant to aid caregivers in determining adverse feto-maternal outcome. Patients with gestation
maternal risk in the setting of preeclampsia, in order to <34 weeks, received 2 doses of betamethasone, 12 mg
guide decisions around triage, transport, and treatment, in each, 24 hours apart. Patients with imminent eclampsia
combination with an assessment of neonatal risk based on received magnesium sulphate and were intensively
gestational age at presentation. The purpose of this study monitored to prevent maternal and fetal complications.

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Antihypertensive drugs like labetalol and nifedepine were existing renal disease), acute renal failure (creatinine
used to control hypertension and dose adjusted >200 μmol/l; pre-existing renal disease), dialysis,
accordingly to the severity. placental abruption, severe ascites, bell’s palsy.

Mode of termination of pregnancy depended on the Adverse Fetal outcome included still birth, small for
period of gestation, favorability of cervix and urgency of gestational age, NICU admission (Neonatal Intensive
termination. Cervical priming agents like PGE 2 gel or Care Unit) and neonatal death.
PGE 1 were used if the cervix was unfavorable.
Caesarean section was performed for obstetric indications Statistical analysis
and when urgent termination was indicated as for fetal
distress and failure of induction. Statistical analysis was carried out by using χ2 -test and p
value of <0.05 was taken as statistically significant.
Adverse maternal outcome included maternal death,
eclampsia (≥1), glasgow coma score <13, stroke or RESULTS
reversible ischemic neurological deficit, transient
ischemic attack, cortical blindness or retinal detachment, During the study period, a total of 383 patients were
posterior reversible encephalopathy, positive inotropic admitted with preeclampsia. Out of these 125 women
support, infusion of a third parenteral antihypertensive fulfilled the study criteria and were included in the study.
drug, myocardial ischemia or infarction, SPO2 <90%,
≥50% FIO2 for >1 h, intubation (other than for caesarean Most of the patients (69.6%) were in the age group 20-29
section), pulmonary edema, transfusion of any blood years. 69 (55.2%) were primigravidas. Most women were
product, platelet count <50×10⁹ per l, with no from rural areas and belonged to low socioeconomic class
transfusion, hepatic dysfunction, hematoma or rupture, (Table 1).
acute renal insufficiency (creatinine >150 μmol/l; no pre-

Table 1: Demographic profile of the patients.

Socio-economic Area of
Age Number Parity Number Number Number
class residence
<20 08 (6.4%) Primigravida 69 (55.2%) 1 04 (3.2%) Rural 89 (71.2%)
20-29 87 (69.6%) Multigravida 36 (28.8%) 2 16 (12.8%) Urban 36 (28.8%)
30-39 27 (21.6%) Grandmulti 20 (16%) 3 21 (16.8%)
>40 03 (2.4%) 4 32 (25.6%)
5 52 (41.6%)

The most common symptom was swelling, which was While some patients had combination of symptoms, 20
present in 61 (48.8%) patients. Chest pain and/or dyspnea (16%) patients had no symptoms (Table 2).Amongst the
was present in 24 (19.2%) patients and of these 13 27 women with gestational age <34 weeks, 9 (33.33%)
(54.16%) patients had adverse maternal outcomes, women had adverse maternal outcome. There were 98
forming the largest symptom group with adverse women with gestational age ≥34 weeks and 12 (12.24%)
outcome. women had adverse maternal outcome. Our study shows
the heterogeneity of preeclampsia and the fact that the
Table 2: Maternal symptoms and adverse outcome. timing of disease onset is one important indicator of
disease severity and maternal outcome (Table 3).
Women with Women with
Symptoms symptom n adverse Table 3: Gestational age and adverse
(%) outcome n (%) maternal outcome.
Swelling 61 (48.8%) 15 (24.59%)
Nausea and Gestational Number of Number of women with
23 (18.4%) 03 (13%)
vomiting Age women adverse outcome
Headache 35 (28%) 12 (34.2%) <34 week 27 09 (33.33%)
Epigastric pain 21 (16.8%) 02 (9.5%) ≥34week 98 12 (12.24%)
Chest pain and/or
24 (19.2%) 13 (54.16%)
dyspnea In our study, SpO2 successfully predicted adverse
Visual disturbance 18 (14.4%) 04 (22.22%) maternal outcome. Adverse maternal outcome increased
No symptom 20 (16%) 01 (5.0%) with the decrease in SpO2 value. 5 of 6 (83.33%) patients
with SpO2 90-93% had adverse maternal outcome. In

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patients with SpO2 >97%, 7 (12.06%) had adverse In the present study, 21 (16.8%) women experienced
maternal outcome (The p-value is <0 .00001, Table 4). adverse maternal outcome. 82 (65.6%) patients were in
the low risk category and amongst them only 4 (4.87%)
Table 4: SpO2 and adverse maternal outcome. showed adverse maternal outcome. There were 6 (4.8%)
high risk patients according to PIERS score and 5
Number of Number of women with (83.33%) women showed adverse maternal outcome
SpO2
women adverse outcome (Table 6 and 7). The rest of the patients had intermediate
90-93% 06 (4.8%) 05 (83.33%) risk.
94-97% 61 (48.8%) 9 (14.9%)
>97% 58 (46.4%) 7 (12.06%) DISCUSSION

Table 5: Biochemical parameters and The present study was undertaken to evaluate the ability
maternal outcome. of fullPIERS calculator in predicting adverse maternal in
patients of preeclampsia within 48 hours of admission.
Number of 125 women were included in the study. 21 (16.8%)
Biochemical Number of women experienced adverse maternal outcome.
women with
parameters women
Adverse outcome
Platelet count (lakh/cumm) Of the 21 women with adverse outcome, 3 women
<1.5 45 (36%) 16 (35.5%) required blood and blood products transfusion, 1 woman
had pulmonary edema, 1 woman had acute renal failure
>1.5 80 (64%) 05 (6.2%)
and required dialysis, 2 women had cerebral vascular
Serum creatinine (mg/dl) accident, 2 women had placental abruption, 2 patients had
<1 99 (79.2%) 29 (15.3%) hepatic dysfunction and another 2 had platelet count
>1 26 (20.8%) 06 (23.07%) <50,000/ml. 2 women required intubation and 1 required
Serum AST ionotropic support. 2 women had eclamptic seizures.
≤40U/L 68 (54.4%) 07 (10.2%) There was 1 maternal death. Many patients had more than
>40U/L 57 (45.6%) 14 (24.56%) one adverse outcome parameter.

In the study, 45 patients had platelet count <1.5 Maternal symptoms are markers of maternal end-organ
lakh/cumm. Of these, 16 (35.5%) had adverse maternal damage and play a very important role in patient
outcome while only 5 out of 80 (6.2%) patients with management. In our study we found 61(48.8%) patients
platelet count >1.5 lakh/cumm had adverse outcome. 6 having swelling, making the most common presenting
(23.07%) women with serum creatinine >1mg/dl had symptom. Adverse maternal outcome was most
adverse maternal outcome. 14 (24.56%) women with frequently associated with chest pain/dyspnea. 13
AST >40U/L had adverse maternal outcome whereas (54.16%) women with dyspnea had adverse outcome.
7(10.2%) with AST ≤40U/L had adverse outcome (Table This was followed by headache (34.2%) and blurring of
5). vision (22.22%). Martin et al. in their study found that
nausea, vomiting and epigastric pain were predictive of
Table 6: Distribution of cases according the increased maternal morbidity.7 Cavkaytar et al in their
PIERS score. study found that the symptoms of headache, visual
changes, epigastric pain and vomiting in a cohort of
Number Number of women patients with HELLP were more predictive of adverse
Score of women with adverse maternal outcome than laboratory values.8 Yen et al
outcome analysed data from the PIERS study to predict adverse
Low risk (<2.5%) 82 (65.6%) 04 (4.87%) maternal outcome using clinical symptoms. They found
High (≥30%) 06 (4.8%) 05 (83.33%) that maternal symptoms of preeclampsia are not
independently valid predictors of adverse maternal
Table 7: PIERS score and adverse maternal outcome outcome and caution should be used when making
in high risk patients. clinical decisions on the basis of symptoms alone in these
patients.9
PIERS score PIERS score Total
≥30% <30% There were 27 women in our cohort with gestational age
Adverse 05 (83.33%) 16 (13.44%) 21 <34weeks of pregnancy. 9 (33.33%) of these had adverse
outcome outcome. In contrast 12 of 98 (12.24%) women with
present gestational age >34weeks had adverse outcome. Gaugler-
Senden et al in their study on maternal and perinatal
Adverse 01(16.66%) 103 (86.5%) 104
outcome in early onset preeclampsia, found that with an
outcome
onset before 24 weeks of gestation, there is considerable
absent
maternal and perinatal morbidity and mortality.
Total 06 119 125
Therefore, expectant management should not be

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 Srivastava S et al. Int J Reprod Contracept Obstet Gynecol. 2017 Apr;6(4):1200-1205

considered as a routine treatment option in these specially remote from term and also help health workers
patients.10 Ni Y and Cheng W in their study on early and in primary and secondary care centers to identify women
late onset preeclampsia found that early onset who are or may become severely ill and who need
preeclampsia is a distinct and more severe clinical entity specialist care and prevent delays in transporting these
with earlier gestational age onset and delivery.11 women to facilities where they can receive appropriate
care.
In our study 5 out of 6 (83.33%) patients with SpO 2 90-
93% had adverse maternal outcome. In a study by Funding: No funding sources
Millman et al using the data from the PIERS multicenter Conflict of interest: None declared
study found that SpO2 ≤93% confers a particular risk and Ethical approval: The study was approved by the
successfully predicts adverse maternal outcome.12 Institutional Ethics Committee

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