Ocular Fundus changes in pregnancy induced hypertension – A case series study

Back ground: Pregnancy Induced Hypertension is a challenging stigma in the fi eld of obstetrics and one of major contributors to maternal and perinatal mortality. PIH is a hypertensive disorder in pregnancy that occurs after 20 weeks of pregnancy in the absence of other causes of elevated blood pressure. Aims and objectives: · To determine the proportion of different groups of PIH patients i.e., gestational hypertension, preeclampsia and eclampsia having retinal changes. · To study the correlation of retinal changes with severity. Methods: It is a is a Prospective (hospital based) study done on 150 patients of PIH Age, gravida, gestation period, B.P. and proteinuria were noted. Ocular examination done using direct and indirect ophthalmoscope. The fi ndings were noted and analysed using chi square test. Results: A total of 150 patients were examined. The mean age of patients was 24.34±4.01 years. The gestation period ranged from 28 to 40 weeks. 72(48%) were primigravida, 74(49.3%) were multigravida and 4 (2.7%) were grand multi gravida. Out of all patients, most of the patients had severe preeclampsia i.e., 71(47.3%), 34(22.6%) had mild preeclampsia, 32(21.3%) had eclampsia and 13 (8.7%) had gestational hypertension. In our study, 32 patients (21.3%) had arteriolar attenuation which included generalised arteriolar attenuation in 12(37.5%) and focal arteriolar attenuation in 20 (62.5%) which is the most common retinal fi nding. Retinal detachment was seen in 1 patient. There was statistically signifi cant positive association of retinal changes with blood pressure (p) and severity of PIH (p). Conclusion: Fundus examination in PIH is important in monitoring and managing cases as it correlates with severity as it indirectly implies severity of changes in placental micro-circulation that can help to predict the foetal outcome and ocular morbidity. Case Study Ocular Fundus changes in pregnancy induced hypertension – A case series study Jayashree MP1, Niveditha RK2*, NG Kuntoji3, Vishalakshi Bhat4, Shravan GM5, Brijesh A Patil6 and Harika JVL7 1Associate professor, Department of Ophthalmology, S. Nijalingappa Medical College, Bagalkot, RGUHS, Banglore, India 2Junior Resident, Department of Ophthalmology, S. Nijalingappa Medical College, Bagalkot, RGUHS, Banglore, India 3Professor, Department of Ophthalmology, S. Nijalingappa Medical College, Bagalkot, RGUHS, Banglore, India 4Assistant professor, Department of Ophthalmology, S. Nijalingappa Medical College, Bagalkot, RGUHS, Banglore, India 5Assistant Professor, Department of Ophthalmology, S. Nijalingappa Medical College, Bagalkot, RGUHS, Banglore, India 6Professor and HOD, Department of Ophthalmology, S. Nijalingappa Medical College, Bagalkot, RGUHS, Banglore, India 7Junior resident, Department of Ophthalmology, S. Nijalingappa Medical College, Bagalkot, RGUHS, Banglore, India Received: 03 December, 2018 Accepted: 12 December, 2018 Published: 13 December, 2018 *Corresponding author: Dr. Niveditha RK, Post graduate student, Department of Ophthalmology, RGUHS, Banglore, India. Email: https://www.peertechz.com


Introduction
Pregnancy Induced Hypertension is a challenging stigma in the fi eld of obstetrics and one of major contributors to maternal and perinatal mortality. Pregnancy is associated with a group of physiological and pathological changes. Pregnancy Induced Hypertension (PIH) is a hypertensive disorder in pregnancy that occurs after 20 weeks of pregnancy in the absence of other causes of elevated blood pressure (B.P.) i.e., >140/90 mm Hg measured 2 times with at least of 6-hour interval. PIH is the hypertension that develops as a direct result of gravid state. Hypertensive disorders complicate 5-10% of all pregnancies [1]. Most important pathologies accompanying pregnancy is pregnancy induced hypertension which includes gestational hypertension, preeclampsia and eclampsia. Gestational hypertension is diagnosed when blood pressure reach140/90mm Hg or greater for the fi rst time after mid pregnancy [1]. Gestational hypertension associated with signifi cant proteinuria is termed as preeclampsia (>300mg/ haematological, hepatic, renal, neurological abnormalities and ocular manifestations [2,3]. Severe toxaemia is the main cause for visual system involvement. The retinal vascular changes majority of times but not always correlate with systemic hypertension. The constriction of vessels may take days to develop and may last for weeks to months.
Retinal changes are liable to occur when the systolic pressure raises above 160 and the diastolic above 100mm hg and are marked when these limits reach 200/130 mm of Hg [4,5]. Choroid is also frequently affected in the disease; choroidal ischemia and infarction may occur.

Methods and Materials
It is a hospital based Case Series study. All Pregnant women attending OPD and admitted in the obstetric ward, S.

Nijalingappa Medical College and Sri Hanagal Kumareshwara
Hospital, Bagalkot b/w the study period of November 2016 to June 2018 in the age group of 18 to 35 years with more than 20 weeks of gestation having systolic blood pressure of more than 140 mm of Hg and Diastolic Blood pressure of more than 90 mm of Hg were included in the study. The study was conducted on 150 diagnosed PIH ases. This study was approved by the institutional ethical committee.

Methodology
After taking informed consent, baseline data for all patients was recorded. All the patients were initially evaluated by an obstetrician. Detailed history, general physical examination and systemic examination were done and noted down in the case sheet. History of eye symptoms and visual acuity was evaluated. As most of the patients were admitted and examination was done on the bed side, counting fi nger at 3 metres is considered as normal. Bedside ocular examination was done using torch light to see ocular alignment and motility, pupillary examination and to exclude gross anterior segment pathology. Patients were dilated with Tropicacyl plus eye drops (Tropicamide 0.8%W/V Phenylephrine 5%W/V). Fundus examination was done using direct ophthalmoscope/indirect ophthalmoscope and retinopathy in both eyes was noted.
Fundus photos were taken using Volk in view fundus camera.
The age, B.P. values, gravida, para, severity and level of disease was noted down. The patients were divided into 2 groups based on their mean B.P. values at the time of presentation whether greater than or less than 160/110 mm Hg for analysis. The fi ndings were noted down in the case sheet. The PIH was graded as gestational hypertension, mid preeclampsia, severe preeclampsia and eclampsia. Proteinuria was tested using dipstick method was graded as + = 30mg/dl, ++ = 100mg/dl, +++ = 300mg/dl, ++++ >= 2000mg//dl.  Patients with malignancy, leukaemia.
The clinical course of the disease in the more acute cases may be divided into 3

stages*:
This classifi cation is used in this study. · Spastic stage arterial irritation during which the toxin excites angiospastic phenomena. · Stage of sclerosis when organic changes appear in the vessels. · Stage of retinopathy when oedema, haemorrhages and damage to tissue occur.

Statistical analysis :
Statistical analysis: Data was analysed statistically by using SPSS version 15.
Ocular fundus changes was evaluated using unpaired t-test.
Categorical data's analysed using Chi-square test. P value <0.05 is considered signifi cant.
Data was collected and tabulated in excel sheet.

Disscussion
This study was undertaken to evaluate the fundus changes in patients of pre-eclampsia and eclampsia. PIH is one of the most common causes of morbidity and mortality in obstetrics.
In our study of 150 patients, hypertensive retinopathy changes were seen in 38 patients. Majority of them were in the age group of 20 -30 years (72.7%). Age in our study was not associated with retinopathy changes which is similar to the results quoted by Reddy et al, [4].
Mean age of the cases in our study was 24.34±4.01 years.
In study conducted by Shukla et al. [6], they examined 20 cases of preeclampsia and eclampsia and noted incidence of retinal changes in 70% of the cases in different age group. In their study, 60% cases aged less than 25 years. Mean age group of patients in the present study matches with the studies by Karki et al. [7] and Shukla et al, [6].      [9]. In Z. Kurdoglu et al study all cases 148 (100%) were preeclamptic [10]. In Jaffe and Schatz study 17 cases had mild preeclampsia and 14 cases had severe preeclampsia [11].
According to Duke Elder the most common retinal changes is attenuation of retinal arterioles, occurring in approximately 60% of patients with pre-eclampsia [12]. In our study, 32 patients (21.3%) showed arteriolar attenuation which included generalised arteriolar attenuation in 12(37.5%) and focal arteriolar attenuation in 20 (62.5%). From above, it is seen that arteriolar attenuation is the major retinal change seen in PIH. AV crossing changes and silver wiring was present in 5 cases; out of which 4 had associated hard exudates and therefore staged as stage 3.
Overall 7(4.6%) patients had stage 3 retinopathy; 5 with hard exudates; 1 case had superfi cial haemorrhage and 1 patient had serous retinal detachment. Fry W [13] have stated in their study that the serous retinal detachment occurs in approximately 1% of patients with pre-eclampsia and 10% of those with eclampsia. Reddy et al., found 6 cases (3%) with retinal haemorrhages and 6 cases (3%) with cotton wool spots belonging to severe pre-eclampsia [8].
Francis et al., found 5% of cases with cotton wool spots and retinal haemorrhage [14]. These studies showed observations close to what we found in our study.
Karki et al., mentioned optic nerve head changes in 8 cases [7]. Shukla et al., found 10% case of papilledema [6]. In our study 4 cases (2.6%) had papilledema. Decline in the percentage regarding papilledema in our study could be due to early and prompt obstetrical and medical management of PIH.
Headache was the most common symptom seen in our patients i.e., 42/ 150 (28%) whereas in Z. Kurdoglu et al. [10], study showed headache, fl oating specks or blurred vision was most common while blurring of vision was seen in 3 cases in S.C. Reddy et al study [4]. In our study blurred vision was seen in 38(25.3%) cases.
In our study fundus fi ndings were seen in 38/150 (25.33%) cases with Pregnancy Induced Hypertension. Tadin I. et al., from Croatia had reported 45% of retinal changes in their study of 40 patients with PIH (9) . Reddy et al., in a study of 275 cases of preeclampsia and 125 cases of eclampsia found an incidence of 53.4% in preeclampsia and 71.6% in eclampsia of hypertensive retinopathy [8]. S.C. Reddy et al., studied 78 cases with PIH and found a prevalence rate of 59% [4].
Zehra Kurdoglu et al., studied 148 cases of PIH retrospectively in Turkey [10]. The prevalence rate of hypertensive retinopathy in their study was 48%. Karki et al from Nepal have reported 13.7% of fundus changes in their study of 153 subjects with PIH [7].
In our study, 38/150 cases Stage I changes were seen in 30 cases (79%), Stage II changes were seen in 1 case (2.6%) and Stage III changes were seen in 7cases (18.4%). Papilledema was seen in 4 cases.
In our study there was a statistically signifi cant correlation between the retinopathy changes and the degree of blood pressure and the severity of the disease. S.C. Reddy et al., found a statistical correlation between proteinuria, blood pressure and hypertensive retinopathy [8]. The degree of retinopathy was directly proportional to severity of preeclampsia with which our study was in accordance. Tadin I. et al found that the degree of retinopathy was directly related to the blood pressure and to the severity of disease [9]. They stated that hypertensive retinopathy is a valid and reliable prognostic factor in determining the severity of preeclampsia.
Z. Kurdoglu et al., found no signifi cant correlation with severity of disease which was against our observation [10]. Karki et al., assessed the foetal outcome in these patients and concluded that retinal and optic nerve head changes were associated with low birth weight; choroidal and optic nerve head changes were associated with low Apgar score; and fundus evaluation in patients with PIH is an important procedure to predict adverse foetal outcomes [7].
Vision is important criteria to be seen in these patients including on follow-up after delivery. Most cases of late onset severe eclampsia present with exudative retinal detachment which usually resolves with termination of pregnancy. Vision and the retinal fi ndings documented need to be followed up after the termination of pregnancy and any residual optic nerve affection should be correlated.

Conclusion
The