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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

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
Introduction
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DOI:
10.4103/0975-2870.157067
combination with generalized edema and/or proteinuria. PIH
which includes gestational hypertension, preeclampsia and
eclampsia occurs after 20th week of pregnancy.[1] Gestational
hypertension is characterized by hypertension without
proteinuria and edema. Preeclampsia is characterized by
hypertension, proteinuria, and generalized edema.[2] When
preeclampsia progresses and convulsions develop, the
condition is termed as eclampsia.[2-4] 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.[5]

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
Tadin et al., from Croatia had reported 45% of retinal
changes in their study of 40 patients with PIH.[6] Reddy et al.,
from Malaysia found 59% of retinal changes in their study of
78 patients.[7] Karki et al., from Nepal have reported 13.7%
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

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.[6]
In another study by Jaeffe and Schatz, mean age of
patients was 28 years.[15] 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 (c2 = 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.[7]
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.[7]
had eclampsia which is similar to previous studies which
reported approximately 5% of PIH patients developed
eclamptic seizures.[16,17] 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.[6-8,18]
Tadin et al., from Croatia had reported 45% of retinal
changes in their study of 40 patients with PIH.[6] Reddy
et al., from Malaysia found 59% of retinal changes in their
study of 78 patients.[7] Karki et al., from Nepal have reported
13.7% of fundus changes in their study of 153 subjects
with PIH.[8] Rasdi et al., from Malaysia found prevalence
of retinopathy of 21.5%[9] Ranjan et al., from India found
40% of retinal changes in their study of 75 patients.[10]
Javadekar et al., from India observed retinal changes in
42% of patients of PIH.[11]
In our study, out of 150 patients, 18 (12%) patients developed
retinopathy, which is similar to 13.7% reported by Karki
et al.[8] It is <45%,[19] 59%,[7] and 21.5%,[9] 40%,[10] 42%.[11]
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

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Shah, et al.: Retinal changes in PIH
hypertensive retinopathy. Our result is similar to results
of Reddy et al.,[7] 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[15] and Reddy et al.[7] 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.,[6] Reddy et al.,[7]
and Karki et al.[8]
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.,[7] Karki et al.,[8] Reddy.[18]
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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.
Source of Support: Nil. Conflict of Interest: None declared.