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Original Article

Retinal changes in pregnancy-induced


hypertension
Akash Pankaj Shah, Abhay Amrit Lune, Renu Mohan Magdum, Hemant Deshpande, Avani Pankaj Shah1,
Deepaswi Bhavsar
Department of Ophthalmology and Obstetrics and Gynaecology, Dr. D. Y. Patil Medical College and Research Centre, Pimpri, Pune, Maharashtra,
1
Department of Ophthalmology, Baroda Medical College, Vadodara, Gujarat, India

ABSTRACT Access this article online


Quick Response Code:
Aims: The aim was to determine the prevalence of retinal changes Website:
in pregnancy-induced hypertension (PIH) and any association www.mjdrdypu.org
between the retinal changes and age, parity, blood pressure,
proteinuria, and severity of the disease. Settings and Design: DOI:
Hospital-based cross-sectional study. Materials and Methods:
10.4103/0975-2870.157067
All the patients admitted with a diagnosis of PIH were included
in this study. Age, gravida, gestation period, blood pressure, and
proteinuria were noted from the case records. Fundus examination
was done with a direct ophthalmoscope. The findings were noted combination with generalized edema and/or proteinuria. PIH
and were analyzed using SPSS program. Results: A total of 150 which includes gestational hypertension, preeclampsia and
patients of PIH were examined. The mean age of patients was 25.1 eclampsia occurs after 20th week of pregnancy.[1] Gestational
years. The gestation period ranged from 27 weeks to 42 weeks;
76 (50.67%) were the primi gravida. 92 (61.33%) patients had
hypertension is characterized by hypertension without
gestational hypertension, 49 (32.67%) patients had preeclampsia, proteinuria and edema. Preeclampsia is characterized by
and 9 (6%) had eclampsia. Retinal changes (hypertensive hypertension, proteinuria, and generalized edema.[2] When
retinopathy) were noted in 18 (12%) patients - Grade 1 in 12 preeclampsia progresses and convulsions develop, the
(8%) and Grade 2 in 6 (4%). Hemorrhages or exudates or retinal
condition is termed as eclampsia.[2-4] The retina is a unique
detachment were not seen in any patient. There was statistically
significant positive association of retinal changes and blood site where the vasculature in the human body is visualized
pressure (P = 0.037), proteinuria (P = 0.0005), and severity of the directly with the help of ophthalmoscope. The eye serves
PIH (P = 0.004). Conclusions: Retinal changes were seen in 12% as a window through which the vessels of the body can be
of patients with PIH. Occurrence of hypertensive retinopathy in studied. Thus, a change in the retinal arterioles may indicate
PIH cases has been decreased due to better antenatal care and
a similar state of the placenta; hence, it gives a reasonable
early detection and treatment of PIH cases. There is a greater
chance of developing retinopathy with increase in blood pressure, idea of the state of placental circulation and fetal wellbeing.
severity of PIH, and proteinuria in cases of PIH. Fetal and maternal complication can be avoided if PIH is
detected early. The pathological changes of this disease
Keywords: Eclampsia, hypertensive retinopathy, preeclampsia, appear to be related to vascular endothelial dysfunction and
pregnancy-induced hypertension, retinal changes its consequences (generalized vasospasm and capillary leak).
Vasospastic manifestations are reversible, and the retinal
Introduction vessels rapidly return to normal after delivery.[5]

Pregnancy-induced hypertension (PIH) is a hypertensive Tadin et al., from Croatia had reported 45% of retinal
disorder in pregnancy that occurs in the absence of other changes in their study of 40 patients with PIH.[6] Reddy et al.,
causes of elevated blood pressure (140/90 mmHg, or a rise from Malaysia found 59% of retinal changes in their study of
of 30 mmHg of systolic pressure, or a rise of 15 mmHg of 78 patients.[7] Karki et al., from Nepal have reported 13.7%
diastolic pressure), taken on two occasions after rest, in of fundus changes in their study of 153 subjects with PIH.[8]

Address for correspondence:


Dr. Akash Shah, Department of Ophthalmology, Dr. D. Y. Patil Medical College and Research Centre, Pimpri, Pune - 411 018, Maharashtra, India.
E-mail: shahakashp@yahoo.com

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Shah, et al.: Retinal changes in PIH

Rasdi et al., from Malaysia found prevalence of retinopathy The results were analyzed using SPSS program. Chi-square
of 21.5%.[9] Ranjan et al., from India found 40% of retinal test was used to determine the association between the
changes in their study of 75 patients.[10] Javadekar et al., from retinal changes and blood pressure, proteinuria, and severity
India observed retinal changes in 42% of patients of PIH.[11] of PIH. A P < 0.05 was taken as significant. Institute Ethical
Committee approval was taken.
Fundoscopic findings in PIH include arteriovenous crossing
changes, hemorrhages, exudates in retina, exudative retinal Results
detachment, and choroidal infarcts.[12]
A total of 150 patients of PIH were examined. The mean
Cortical blindness is one of the important causes of blindness age of patients was 25.1 years (range: 18-45 years). The
in toxemia of pregnancy. One study concluded that cortical gestation period ranged from 27 weeks to 42 weeks; 76
blindness associated with toxemia resulted from petechial (50.67%) were the primi gravida. 92 (61.33%) patients
hemorrhages and focal edema in the occipital cortex.[13] had gestational hypertension, 49 (32.67%) patients had
preeclampsia, and 9 (6%) had eclampsia. 40 patients
This study was undertaken to determine the prevalence of (26.67%) had complaints of headache which was the
retinal changes in PIH and association between the retinal most common symptom, while 19 (12.67%) patients
changes and age, parity, blood pressure, proteinuria, and had complained of blurred vision. Diplopia was seen
severity of the disease. in one patient and scotoma was seen in one patient.
Retinal changes (hypertensive retinopathy) were noted
Materials and Methods in 18 (12%) patients - Grade 1 in 12 (8%) and Grade 2
in 6 (4%) [Table 1]. Hemorrhages or exudates or retinal
This cross-sectional, observational study was conducted over
detachment were not seen in any patient. There was
a period of 17 months (January 2013 to May 2014). All the
statistically significant positive association of retinal
patients who fulfilled the diagnostic criteria of PIH admitted
changes and blood pressure ( P = 0.037), proteinuria
in the obstetric ward, Dr. D. Y. Patil Hospital and Research
(P = 0.0005) and severity of the PIH (P = 0.004) [Table 2].
Centre, Pune were included in this study. Patients who
Age (P = 0.865) and gravida (P = 0.07) were not associated
had preexisting diabetes or hypertension or renal disease
with retinopathy changes.
or hazy media which did not permit fundus visualization
were excluded from the study. After taking history for any
eye symptoms, anterior segment was examined with torch Table 1: Distribution of cases according to different variables
light on the bed itself. Both pupils were dilated with 1% Variable Number of patients (n = 150) (%)
tropicamide eye drops, and fundus examination was done Age (years)
by ophthalmologist with a direct ophthalmoscope in the <19 4 (2.67)
20-29 119 (79.33)
ward. Hypertensive retinopathy changes seen on right
>30 27 (18)
or left or both eyes was taken as positive findings in that Gravida
patient. Age, race, para, gravida, blood pressure, proteinuria G1 76 (50.67)
were noted from the case records. The PIH was graded as G2 41 (27.33)
gestational hypertension, preeclampsia, and eclampsia. All G3 21 (14)
the findings were noted on a data sheet. Consent was taken G4 8 (5.33)
for fundus examination. The retinal changes (hypertensive G5 2 (1.33)
G6 1 (0.67)
retinopathy) were graded according to Keith Wagener
G7 1 (0.67)
classification into:
Duration of pregnancy (weeks)
Grade 1: M ild generalized arterial attenuation, particularly 20-28 1 (0.67)
of small branches; 29-32 6 (4)
Grade 2: More severe Grade 1 + focal arteriolar attenuation; >32 143 (95.33)
Grade 3: Grade 2 + hemorrhages, hard exudates, cotton Severity of PIH
wool spots; Gestational hypertension 92 (61.33)
Preeclampsia 49 (32.67)
Grade 4: G rade 3 = optic disc swelling (papilledema).[14]
Eclampsia 9 (6)
Retinopathy grading
Proteinuria was tested using dipstick method and was graded
Grade 1 12 (66.67)
as + = 30 mg/dL, ++ = 100 mg/dL, +++ = 300 mg/dL and ++++ Grade 2 6 (33.33)
≥2000 mg/dL as provided by manufacturer. PIH: Pregnancy-induced hypertension

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Shah, et al.: Retinal changes in PIH

Table 2: Association between retinal changes and different variables


Variable Retinopathy present Retinopathy absent Total P
(n1 = 18) (%) (n2 = 132) (%) (n = 150)
Age (years)
<19 0 (0) 4 (100) 4 0.865
20-29 14 (11.76) 105 (88.24) 119
>30 4 (14.81) 23 (85.19) 27
Gravida
Primigravida 5 (6.58) 71 (93.42) 76 0.07
Multigravida 13 (17.57) 61 (82.43) 74
Blood pressure
<160 mmHg systolic and <100 mmHg diastolic 4 (5.56) 68 (94.44) 72 0.037
>160 mmHg systolic and/or >100 mmHg diastolic 14 (17.95) 64 (82.05) 78
Severity of PIH
Gestational hypertension 5 (5.43) 87 (94.57) 92 0.004
Preeclampsia 10 (20.41) 39 (79.59) 49
Eclampsia 3 (33.33) 6 (66.67) 9
Proteinuria
Nil 5 (5.43) 87 (94.57) 92 0.0005
+ 2 (11.76) 15 (88.24) 17
++ 3 (16.67) 15 (83.33) 18
+++ 4 (26.67) 11 (73.33) 15
++++ 4 (50) 4 (50) 8
+ = 30 mg/dL, ++ = 100 mg/dL, +++ = 300 mg/dL and ++++ ≥2000 mg/dL, PIH: Pregnancy-induced hypertension

Discussion In the present study, 6% (9 out of 150) of all PIH patients


had eclampsia which is similar to previous studies which
Pregnancy-induced hypertension is one of the most reported approximately 5% of PIH patients developed
common problems encountered in obstetrics. In a study of eclamptic seizures.[16,17] Of nine patients who had eclampsia,
Tadin et al., the average age of 40 patients was 29.1 years.[6] 3 (33.33%) patients had retinopathy. Among 49 preeclampsia
patients, 10 (20.41%) patients had retinopathy. 5 out of 92
In another study by Jaeffe and Schatz, mean age of (5.43%) gestational hypertension patients had hypertensive
patients was 28 years.[15] Mean age of the patients in this retinopathy. Severity of PIH was significantly (P = 0.004)
study was 25.1 years which was similar to previously associated with retinopathy which is similar to previous
published literature. In our study, out of 4 patients in studies.[6-8,18]
age group of <19 years, none developed retinopathy
fundus changes. While out of 119 patients in age group Tadin et al., from Croatia had reported 45% of retinal
of 20-29 years, 14 (11.76%) cases showed hypertensive changes in their study of 40 patients with PIH.[6] Reddy
retinopathy changes. 27 cases were of age >30 years, et al., from Malaysia found 59% of retinal changes in their
among them 4 (14.81%) cases showed retinopathy study of 78 patients.[7] Karki et al., from Nepal have reported
changes (c2 = 0.029, P = 0.865). Age was not associated 13.7% of fundus changes in their study of 153 subjects
with retinopathy changes (P > 0.05) in this study which with PIH.[8] Rasdi et al., from Malaysia found prevalence
is similar to the results of Reddy et al.[7] of retinopathy of 21.5%[9] Ranjan et al., from India found
40% of retinal changes in their study of 75 patients.[10]
In the present study of 150 patients with PIH, 76 (50.67%) Javadekar et al., from India observed retinal changes in
patients were primigravida. Of 76 patients who were 42% of patients of PIH.[11]
primigravida, 5 (6.58%) patient developed hypertensive
retinopathy. While out of 74 patients who were the In our study, out of 150 patients, 18 (12%) patients developed
multigravida, 13 (17.57%) patients developed hypertensive retinopathy, which is similar to 13.7% reported by Karki
retinopathy. Retinopathy was 2.6 times more in multigravida et al.[8] It is <45%,[19] 59%,[7] and 21.5%,[9] 40%,[10] 42%.[11]
than primigravida. But the result was not statistically
significant (P = 0.07). Gravida was not associated with In our study, out of 18 cases that developed hypertensive
retinopathy changes in our study which is similar to the retinopathy, 12 (66.67%) patients developed Grade
results of Reddy et al.[7] 1 hypertensive retinopathy and 6 (33.33%) Grade 2

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Shah, et al.: Retinal changes in PIH

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