|Year : 2015 | Volume
| Issue : 3 | Page : 304-307
Retinal changes in pregnancy-induced hypertension
Akash Pankaj Shah1, Abhay Amrit Lune1, Renu Mohan Magdum1, Hemant Deshpande1, Avani Pankaj Shah2, Deepaswi Bhavsar1
1 Department of Ophthalmology and Obstetrics and Gynaecology, Dr. D. Y. Patil Medical College and Research Centre, Pimpri, Pune, Maharashtra, India
2 Department of Ophthalmology, Baroda Medical College, Vadodara, Gujarat, India
|Date of Web Publication||15-May-2015|
Akash Pankaj Shah
Department of Ophthalmology, Dr. D. Y. Patil Medical College and Research Centre, Pimpri, Pune - 411 018, Maharashtra
Source of Support: None, Conflict of Interest: None
Aims: The aim was to determine the prevalence of retinal changes in pregnancy-induced hypertension (PIH) and any association between the retinal changes and age, parity, blood pressure, proteinuria, and severity of the disease. Settings and Design: Hospital-based cross-sectional study. Materials and Methods: 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 and were analyzed using SPSS program. Results: A total of 150 patients of PIH were examined. The mean age of patients was 25.1 years. The gestation period ranged from 27 weeks to 42 weeks; 76 (50.67%) were the primi gravida. 92 (61.33%) patients had gestational hypertension, 49 (32.67%) patients had preeclampsia, and 9 (6%) had eclampsia. Retinal changes (hypertensive retinopathy) were noted in 18 (12%) patients - Grade 1 in 12 (8%) and Grade 2 in 6 (4%). Hemorrhages or exudates or retinal detachment were not seen in any patient. There was statistically significant positive association of retinal changes and blood pressure (P = 0.037), proteinuria (P = 0.0005), and severity of the PIH (P = 0.004). Conclusions: Retinal changes were seen in 12% of patients with PIH. Occurrence of hypertensive retinopathy in PIH cases has been decreased due to better antenatal care and early detection and treatment of PIH cases. There is a greater chance of developing retinopathy with increase in blood pressure, severity of PIH, and proteinuria in cases of PIH.
Keywords: Eclampsia, hypertensive retinopathy, preeclampsia, pregnancy-induced hypertension, retinal changes
|How to cite this article:|
Shah AP, Lune AA, Magdum RM, Deshpande H, Shah AP, Bhavsar D. Retinal changes in pregnancy-induced hypertension. Med J DY Patil Univ 2015;8:304-7
|How to cite this URL:|
Shah AP, Lune AA, Magdum RM, Deshpande H, Shah AP, Bhavsar D. Retinal changes in pregnancy-induced hypertension. Med J DY Patil Univ [serial online] 2015 [cited 2020 Aug 7];8:304-7. Available from: http://www.mjdrdypu.org/text.asp?2015/8/3/304/157067
| Introduction|| |
Pregnancy-induced hypertension (PIH) is a hypertensive disorder in pregnancy that occurs in the absence of other causes of elevated blood pressure (140/90 mmHg, or a rise of 30 mmHg of systolic pressure, or a rise of 15 mmHg of diastolic pressure), taken on two occasions after rest, in combination with generalized edema and/or proteinuria. PIH which includes gestational hypertension, preeclampsia and eclampsia occurs after 20 th week of pregnancy.  Gestational hypertension is characterized by hypertension without proteinuria and edema. Preeclampsia is characterized by hypertension, proteinuria, and generalized edema.  When preeclampsia progresses and convulsions develop, the condition is termed as eclampsia. ,, The retina is a unique site where the vasculature in the human body is visualized directly with the help of ophthalmoscope. The eye serves as a window through which the vessels of the body can be studied. Thus, a change in the retinal arterioles may indicate a similar state of the placenta; hence, it gives a reasonable idea of the state of placental circulation and fetal wellbeing. Fetal and maternal complication can be avoided if PIH is detected early. The pathological changes of this disease appear to be related to vascular endothelial dysfunction and its consequences (generalized vasospasm and capillary leak). Vasospastic manifestations are reversible, and the retinal vessels rapidly return to normal after delivery. 
Tadin et al., from Croatia had reported 45% of retinal changes in their study of 40 patients with PIH.  Reddy et al., from Malaysia found 59% of retinal changes in their study of 78 patients.  Karki et al., from Nepal have reported 13.7% of fundus changes in their study of 153 subjects with PIH.  Rasdi et al., from Malaysia found prevalence of retinopathy of 21.5%.  Ranjan et al., from India found 40% of retinal changes in their study of 75 patients.  Javadekar et al., from India observed retinal changes in 42% of patients of PIH. 
Fundoscopic findings in PIH include arteriovenous crossing changes, hemorrhages, exudates in retina, exudative retinal detachment, and choroidal infarcts. 
Cortical blindness is one of the important causes of blindness in toxemia of pregnancy. One study concluded that cortical blindness associated with toxemia resulted from petechial hemorrhages and focal edema in the occipital cortex. 
This study was undertaken to determine the prevalence of retinal changes in PIH and association between the retinal changes and age, parity, blood pressure, proteinuria, and severity of the disease.
| Materials and Methods|| |
This cross-sectional, observational study was conducted over a period of 17 months (January 2013 to May 2014). All the patients who fulfilled the diagnostic criteria of PIH admitted in the obstetric ward, Dr. D. Y. Patil Hospital and Research Centre, Pune were included in this study. Patients who had preexisting diabetes or hypertension or renal disease 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 light on the bed itself. Both pupils were dilated with 1% tropicamide eye drops, and fundus examination was done by ophthalmologist with a direct ophthalmoscope in the ward. Hypertensive retinopathy changes seen on right or left or both eyes was taken as positive findings in that patient. Age, race, para, gravida, blood pressure, proteinuria were noted from the case records. The PIH was graded as gestational hypertension, preeclampsia, and eclampsia. All the findings were noted on a data sheet. Consent was taken for fundus examination. The retinal changes (hypertensive retinopathy) were graded according to Keith Wagener classification into:
Grade 1: Mild generalized arterial attenuation, particularly of small branches;
Grade 2: More severe Grade 1 + focal arteriolar attenuation;
Grade 3: Grade 2 + hemorrhages, hard exudates, cotton wool spots;
Grade 4: Grade 3 = optic disc swelling (papilledema). 
Proteinuria was tested using dipstick method and was graded as + = 30 mg/dL, ++ = 100 mg/dL, +++ = 300 mg/dL and ++++ ≥2000 mg/dL as provided by manufacturer.
The results were analyzed using SPSS program. Chi-square test was used to determine the association between the retinal changes and blood pressure, proteinuria, and severity of PIH. A P < 0.05 was taken as significant. Institute Ethical Committee approval was taken.
| Results|| |
A total of 150 patients of PIH were examined. The mean age of patients was 25.1 years (range: 18-45 years). The gestation period ranged from 27 weeks to 42 weeks; 76 (50.67%) were the primi gravida. 92 (61.33%) patients had gestational hypertension, 49 (32.67%) patients had preeclampsia, and 9 (6%) had eclampsia. 40 patients (26.67%) had complaints of headache which was the most common symptom, while 19 (12.67%) patients had complained of blurred vision. Diplopia was seen in one patient and scotoma was seen in one patient. Retinal changes (hypertensive retinopathy) were noted in 18 (12%) patients - Grade 1 in 12 (8%) and Grade 2 in 6 (4%) [Table 1]. Hemorrhages or exudates or retinal detachment were not seen in any patient. There was statistically significant positive association of retinal changes and blood pressure (P = 0.037), proteinuria (P = 0.0005) and severity of the PIH (P = 0.004) [Table 2]. Age (P = 0.865) and gravida (P = 0.07) were not associated with retinopathy changes.
| Discussion|| |
Pregnancy-induced hypertension is one of the most common problems encountered in obstetrics. In a study of Tadin et al., the average age of 40 patients was 29.1 years. 
In another study by Jaeffe and Schatz, mean age of patients was 28 years.  Mean age of the patients in this study was 25.1 years which was similar to previously published literature. In our study, out of 4 patients in age group of <19 years, none developed retinopathy fundus changes. While out of 119 patients in age group of 20-29 years, 14 (11.76%) cases showed hypertensive retinopathy changes. 27 cases were of age >30 years, among them 4 (14.81%) cases showed retinopathy changes (χ2 = 0.029, P = 0.865). Age was not associated with retinopathy changes (P > 0.05) in this study which is similar to the results of Reddy et al. 
In the present study of 150 patients with PIH, 76 (50.67%) patients were primigravida. Of 76 patients who were primigravida, 5 (6.58%) patient developed hypertensive retinopathy. While out of 74 patients who were the multigravida, 13 (17.57%) patients developed hypertensive retinopathy. Retinopathy was 2.6 times more in multigravida than primigravida. But the result was not statistically significant (P = 0.07). Gravida was not associated with retinopathy changes in our study which is similar to the results of Reddy et al. 
In the present study, 6% (9 out of 150) of all PIH patients had eclampsia which is similar to previous studies which reported approximately 5% of PIH patients developed eclamptic seizures. , Of nine patients who had eclampsia, 3 (33.33%) patients had retinopathy. Among 49 preeclampsia patients, 10 (20.41%) patients had retinopathy. 5 out of 92 (5.43%) gestational hypertension patients had hypertensive retinopathy. Severity of PIH was significantly (P = 0.004) associated with retinopathy which is similar to previous studies. ,,,
Tadin et al., from Croatia had reported 45% of retinal changes in their study of 40 patients with PIH.  Reddy et al., from Malaysia found 59% of retinal changes in their study of 78 patients.  Karki et al., from Nepal have reported 13.7% of fundus changes in their study of 153 subjects with PIH.  Rasdi et al., from Malaysia found prevalence of retinopathy of 21.5%  Ranjan et al., from India found 40% of retinal changes in their study of 75 patients.  Javadekar et al., from India observed retinal changes in 42% of patients of PIH. 
In our study, out of 150 patients, 18 (12%) patients developed retinopathy, which is similar to 13.7% reported by Karki et al.  It is <45%,  59%,  and 21.5%,  40%,  42%. 
In our study, out of 18 cases that developed hypertensive retinopathy, 12 (66.67%) patients developed Grade 1 hypertensive retinopathy and 6 (33.33%) Grade 2 hypertensive retinopathy. Our result is similar to results of Reddy et al.,  who found Grade 1 retinal changes in 41 (89.13%) and Grade 2 in 5 (10.87%) out of 46 patients developing retinopathy changes.
In our study, none of the patient developed hemorrhages, exudates, or retinal detachment. The absence of hemorrhages and exudates observed in the present study has been supported by Jaffe and Schatz  and Reddy et al.  This can be attributed to proper antenatal care and early detection of PIH cases, thereby preventing them to progress to Grade 3 hypertensive retinopathy.
Of 72 patients who had <160 mmHg systolic and <100 mmHg diastolic blood pressure, 4 (5.56%) patients had developed hypertensive retinopathy changes while out of 78 patients who had >160 mmHg systolic and/or >100 mmHg diastolic blood pressure, 14 (17.95%) patients developed hypertensive retinopathy changes. There was significant (P = 0.037) association between retinopathy changes and blood pressure readings in the present study which is similar to reported by Tadin et al.,  Reddy et al.,  and Karki et al. 
In our study, 58 patients had proteinuria of +1 to +4 on the dipstick. Of 58 patients, 13 (22.41%) patients developed retinopathy compared to 5 (5.43%) patients from 92 who did not have proteinuria. 8 patients who had proteinuria of 4+ on dipstick, 4 (50%) developed hypertensive retinopathy changes. Proteinuria was significantly (P = 0.0005) associated with retinopathy which is similar to reported by Reddy et al.,  Karki et al.,  Reddy. 
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[Table 1], [Table 2]