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ORIGINAL ARTICLE
Year : 2014  |  Volume : 2  |  Issue : 3  |  Page : 97-101

Relation of ocular fundus changes with blood pressure and proteinuria in pregnancy induced hypertension


Department of Ophthalmology, Rural Medical College, Pravara Institute of Medical Sciences, Loni, Ahmednagar, Maharashtra, India

Date of Web Publication7-Sep-2015

Correspondence Address:
Dr. Akshay J Bhandari
Department of Ophthalmology, Rural Medical College, Pravara Institute of Medical Sciences, Loni, Ahmednagar - 413 736, Maharashtra
India
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Source of Support: Nil., Conflict of Interest: There are no conflicts of interest.


DOI: 10.4103/2347-5617.164631

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  Abstract 

Context: Pregnancy induced hypertension (PIH) is defined as hypertensive disorder of pregnancy, which occurs in the absence of other causes of elevated blood pressure (BP) and is associated with pedal edema, proteinuria or both. Aims: To evaluate the ocular fundus changes and its relation with the severity of proteinuria and BP in PIH patients. Settings and Design: Hospital based prospective observational study. Subjects and Methods: Study conducted over a period of 2 years. A total 100 patients of pregnancy having preeclampsia and eclampsia were included. Statistical Analysis Used: Chi-square test. Results: Of 100 cases 32 (32%) had mild preeclampsia while 50 (50%) had severe preeclampsia. Eighteen (18%) patients had eclampsia. All cases had proteinuria of varying degree ranging from 1+ to 4+. Forty-four cases (44%) had retinal changes. Cases with severe proteinuria and higher BP had more severe grades of retinopathy. Conclusions: Examination of fundus by ophthalmoscope is simple, noninvasive, safe, and reliable procedure, which can be done in out-patient department or at bedside. It should be done routinely in all patients of PIH. It is the BP, systolic and diastolic to which the severity of the retinal changes was found to be directly proportional. Higher grades of proteinuria were associated with higher grades of retinal changes.

Keywords: Blood pressure, eclampsia, grades of retinopathy of pregnancy-induced hypertension, ocular fundus changes, preeclampsia, pregnancy-induced hypertension, proteinuria


How to cite this article:
Bhandari AJ, Bangal SV, Padghan DD, Gogri PY. Relation of ocular fundus changes with blood pressure and proteinuria in pregnancy induced hypertension. Egypt Retina J 2014;2:97-101

How to cite this URL:
Bhandari AJ, Bangal SV, Padghan DD, Gogri PY. Relation of ocular fundus changes with blood pressure and proteinuria in pregnancy induced hypertension. Egypt Retina J [serial online] 2014 [cited 2021 May 7];2:97-101. Available from: https://www.egyptretinaj.com/text.asp?2014/2/3/97/164631


  Introduction Top


The hypertensive disorders in pregnancy are common medical disorders encountered in obstetric practice. Pregnancy-induced hypertension (PIH) is one of the common complications met with pregnancy and contributes significantly to maternal and fetal morbidity and mortality. PIH includes gestational hypertension, preeclampsia, and eclampsia. Preeclampsia is best described as multisystem disorder of unknown etiology characterized by development of hypertension to the extent of 140/90 mm of Hg or more with proteinuria after the 20th week of pregnancy in a previously normotensive and nonproteinuric patient.[1] It is associated with proteinuria >300 mg/h or >1+ dipstick which acts an important objective diagnostic criteria. Preeclampsia is divided into two groups according to its severity as mild and severe. Blood pressure (BP) more than 160/110 mm of Hg and proteinuria more than 2 g/24 h or >+2 are included in severe preeclampsia. If convulsions are associated with it, then it is termed as eclampsia. The overall incidence of PIH in hospital practice varies widely from 5% to 15%.[1] The incidence in primigravida is 10% and in multigravida is 5%.[2] Ocular involvement in PIH is common, and the occurrence rate varies from 30% to 100% in different studies.[3] The events in the retina and other organs in the body are so similar, to comment that retina not only imprints the image of the other organs in the body but also reflects and invites us to read the reaction at the various tissues of the body. The present study was undertaken to evaluate the ocular fundus changes and its relation with the severity of proteinuria and BP in 100 cases of preeclampsia and eclampsia presenting to tertiary health care center.


  Subjects and Methods Top


The study was a hospital-based, prospective, observational study conducted over a period of 2 years at a Tertiary Rural Hospital in Western Maharashtra of India. Ethical clearance was taken from the review board and written informed consent was taken from all the patients.

Sample size

One-hundred patients diagnosed for either preeclampsia or eclampsia were studied.

Inclusion criteria

Patients diagnosed with preeclampsia or eclampsia admitted in the maternity ward and Intensive Care Unit.

Exclusion criteria

Patients with history of preexisting hypertension and convulsions, Patients with preeclampsia or eclampsia superimposed on chronic hypertension, Patients having other systemic disorders such as diabetes mellitus, thyroid disorders, hematological disorders, HIV were not included in the study. Patients with the preexisting renal disease were excluded.

All patients fulfilling above inclusion and exclusion criteria were studied for ocular fundus changes at admission and for follow-up changes at 1-week of termination of pregnancy. A detailed history and ocular examination of each patient were recorded. Direct, as well as indirect ophthalmoscope was used for examination of the fundus after full dilatation of pupil with 1% tropicamide (mydriatic) eye drops. Renal parameters like serum urea and creatinine levels were studied. The fundus examination was done by a single observer. Fundus photographs were taken whenever possible.

In this study following grading systems were used for evaluation of patients:

  • Grading of retinal changes: For grading of retinal changes Keith, Wagner and Barker (1939) classification was used
  • Grading of the severity of preeclampsia and eclampsia: For grading of severity of preeclampsia scheme of working group of National High BP Education Program (NHBPEP-2000) was adopted.


Retinal changes were classified in following grades:

  • Grade 1: Spastic narrowing of arterioles of the retina
  • Grade 2: Irregular constriction of the lumen
  • Grade 3: Narrowing and constriction are more fixed with cotton wool patches and hemorrhages
  • Grade 4: Diffuse retinitis with papilledema.



  Results Top


Of 100 cases enrolled in the study 32 cases (32%) had mild preeclampsia and 50 cases (50%) had severe preeclampsia. Eighteen cases (18%) in the present study had eclampsia. This shows that highest number of cases were belonged to severe preeclampsia (50%) followed by mild preeclampsia (32%) and eclampsia (18%). Ocular fundus changes were seen in 44 cases of PIH. It is seen that ocular fundus changes were more observed in cases with eclampsia (61%), severe preeclampsia (50%) followed by mild preeclampsia (25%).

The present study shows the highest percentage of ocular fundus changes in the age group of 18–22 years (50%).

Among the 48 cases of PIH in the age group 18–22 years, 24 cases (50%) showed fundus changes. This was followed by 12 cases (36%) from 33 cases of PIH in the age group 23–27 years. Next, commonly affected age group was 28–32 years with 14 cases and 7 cases (50%) of them showed fundus changes. Only 1 case out of 4 from the age group between 33 and 37 years showed changes in the fundus. This shows that younger the age, more are the possibilities of fundus changes in the eye.

[Table 1] shows the distribution of cases with systolic BP according to grades of retinal vascular changes. In this study, 46 cases belonged to a group with systolic BP <160 mm of Hg. In this group, 33 cases (72%) did not have any retinal change, and 13 cases (28%) had Grade 1 retinal vascular changes. In this study, 44 cases belonged to a group with systolic BP between 160 and 200 mm of Hg. In this 23 cases (52%) did not have any retinal change, 15 cases (34%) had Grade1, 2 cases (5%) had Grade 2 and 1 case (2%) had Grade 3 and 4 retinal vascular changes each. Other changes like macular edema were seen in 2 cases (5%) which were not associated with any grades of retinal changes.
Table 1: Distribution of systolic BP according to grades of retinal vascular changes

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By applying Chi-square test, there is a significant association between systolic BP and grades of retinal vascular changes (P < 0.05).

[Table 2] shows the distribution of cases with diastolic BP according to grades of retinal vascular changes. In this study, 65 cases belonged to a group with diastolic BP <110 mm of Hg. In this 51 cases (78%) did not have any retinal change. In this study, 35 cases belonged to a group with diastolic BP between 110 and 130 mm of Hg. Among the other changes, macular edema was seen in 4 cases, and retinal edema was seen in 1 case. Not a single case was found to have diastolic BP more than 130 mm of Hg in this study.
Table 2: Distribution of diastolic BP according to grades of retinal vascular changes

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By applying Chi-square test, there is a significant association between diastolic BP and grades of retinal vascular changes (P < 0.05).

In the present study of 100 cases, 49% of cases had 1+ proteinuria on urine dipstick test followed by 27% cases having 2+ proteinuria. Cases with 3+ and 4+ proteinuria constituted 17% and 7% respectively. Retinal vascular changes were seen in 27%, 44%, 71%, and 100% cases with proteinuria 1+, 2+, 3+ and 4+ respectively. This shows that retinal vascular changes were seen in more cases with a high degree of proteinuria [Figure 1] and [Table 3].
Figure 1: Distribution of cases of preeclampsia and eclampsia according to degree of proteinuria

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Table 3: Distribution of grades of retinal vascular changes according to degree of proteinuria

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In the present study of 100 cases, 49 cases had proteinuria 1+. Among these 13 cases (27%) had Grade 1 retinal vascular changes. Out of 27 cases with proteinuria 2+, 10 cases (37%) had Grade 1 retinal vascular changes and 1 case (4%) had Grade 2 and Grade 3 retinal vascular changes each. Out of 17 cases having proteinuria 3+, 6 cases (35%) had Grade 1 retinal vascular changes. Grade 2 and Grade 3 retinal vascular changes were seen in 2 cases (12%) and 1 case (6%) respectively. One case (6%) had Grade 4 retinal vascular changes. Among the other changes, retinal edema and macular edema was seen in 1 case each which was not associated with any grades of retinal changes. Seven cases had proteinuria 4+, of which 2 cases (29%) showed Grade 2 retinal vascular changes and 1 case (14%) showed Grade 3 and Grade 4 retinal vascular changes each. Among the other changes, macular edema was seen in 3 cases (43%).

By applying Chi-square test, there is a significant association between severity of proteinuria and grades of retinal vascular changes (P < 0.05).


  Discussion Top


The retinal vascular changes in PIH have been said to correlate with the severity of hypertension.[4] Many studies have considered the progression of retinal vascular changes as a sign of increasing severity of PIH. These changes help as a guideline for termination of pregnancy as they may reflect similar ischemic vascular changes in the placenta.[5],[6],[7]

The retinal changes were seen in 50% of patients in the age group of 18–22 years when compared with other age groups indicating that younger the age, more are the possibilities of fundus changes in the eye. Chi-square test revealed a significant association between ocular fundus changes and younger age group (P < 0.05).

There was increased the incidence of retinal changes with an increase in the systolic BP, indicating that there is a significant association between systolic BP and grades of retinopathy (P < 0.05). A similar observation was noted with the diastolic BP readings, showing that there is a significant association between diastolic BP and grades of retinopathy (P < 0.05). These findings suggest that higher the BP greater the retinal vascular changes.

In a study of 120 cases of toxemia of pregnancy, Kishor and Tandon reported 22.7% of retinal changes in patients with BP <150/90 mm of Hg and were found in 73% cases with BP >150/90 mm of Hg.[8] Our study correlates with the findings of above authors.

Shukla and Prasad examined 20 cases of preeclampsia and eclampsia, found that Grade 0 and Grade 1 changes were seen in cases with systolic BP up to 150 and 150–174 mm of Hg. Grade 2 and Grade 3 retinal changes were found in systolic BP ranging from 176 to 200 mm of Hg. They also found Grade 0 and Grade 1 change in cases with diastolic BP up to 100 and Grade 2 and Grade 3 retinal changes with higher diastolic pressure.[9] They, therefore, concluded that higher the BP more severe the retinal changes.

Reddy et al. examined 78 cases of PIH. In their study, 49 cases (62.82%) were having BP <150/100 mm of Hg and 29 cases (37.18%) with BP more than 150/100 mm of Hg. Retinal changes were seen in 25 cases (86.21%) with BP more than 150/100 mm of Hg. Thus, they concluded that higher the BP more the chances of retinal changes.[10] Tadin et al. in their study of 40 women with preeclampsia cases found statistically significant correlation between retinal changes and systolic and diastolic BP.[11] Mussey and Mundell had found a correlation between the frequency of retinal changes and the level of BP.[12]

The findings of all the above studies correlate with the findings of our study.

When we compared the relationship between varying grades of retinal changes and proteinuria, it was found that of 79% of women with urine albumin more than 2+ had retinal changes as compare to 33% of women with urine albumin <2+. This difference was found to be statistically significant (P < 0.05). In this study, 76 cases were with albuminuria ≤+2. Of these, 25 cases examined (33%) showed retinal changes. Of these, 23 cases were with Grade 1 retinal changes, 1 case with Grade 2 retinal changes and 1 case with Grade 3 retinal changes. Remaining 24 cases belonged to group with albuminuria more than 2+. Of these 6 cases (25%) showed Grade 1 retinal changes, 4 cases (17%) were observed to have Grade 2 retinal changes and 2 cases (8%) with Grade 3 and Grade 4 retinal changes each. These findings indicate there is a significant association between severity of proteinuria and grades of retinopathy (P < 0.05).

In our study total, 5 cases were having isolated ocular findings like retinal edema or macular edema, which was not associated with any grades of retinal changes. Termination of pregnancy was carried out in those cases. On follow-up after 1-week, there was a resolution of retinal and macular edema in those cases.

The finding of the present study was similar to study conducted by Shukla and Prasad, who examined 20 cases of preeclampsia and eclampsia and showed the relationship between albuminuria and severity of retinal changes.[9] They found that out of the 40% cases of mild albuminuria, 30% belonged to Grade 0 and 10% cases were having Grade 1 retinal changes. There were 40% cases of moderate albuminuria, of which, 25% belonged to Grade 1 and 15% to Grade 2 retinopathy. 20% cases were of severe albuminuria of which 5% belonged to Grade 1, 5% cases were having Grade 2 retinal changes and 10% cases with Grade 3 changes. Hence, they concluded that as the severity of albuminuria increases, the degree of retinal changes also increase.

Reddy et al. examined 78 cases of PIH. In this study, 40 cases (51.28%) were having proteinuria +, 14 cases (17.95%) with proteinuria 2+ and 12 cases (15.38%) were having proteinuria 3+. Retinal changes were seen in 12 cases (100%) with proteinuria 3+ and 7 cases (50%) with proteinuria 2+. Thus, they concluded that there is a significant statistical association between retinal changes and proteinuria.[10] Tadin et al. in their study in preeclampsia cases found statistically significant correlation between retinal changes and proteinuria.[11]

The findings of our study are in agreement with the above studies.


  Conclusion Top


It is the BP, systolic and diastolic to which the severity of the retinal changes was found to be directly proportional. Higher the BP and grade of proteinuria more severe the grades of retinopathy in PIH patients. Therefore, routine fundus examination of all patients of preeclampsia and eclampsia for retinal changes will help the obstetrician in better management of these patients.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
  References Top

1.
Dutta DC. Hypertensive disorders in pregnancy. Textbook of Obstetrics. 6th ed., Ch. 17. Calcutta: New Central Book Agency; 2001. p. 221-42.  Back to cited text no. 1
    
2.
Sibai BM, Cunningham FG. Prevention of preeclampsia and eclampsia. In: Lanheimer MD, Roberts JM, Cunningham FG, editors. Chesley's Hypertensive Disorders of Pregnancy. 3rd ed. New York: Elsevier, In Press; 2009. p. 215.  Back to cited text no. 2
    
3.
Hallum AV. Eye changes in hypertensive toxaemia of pregnancy: A study of three hundred cases. J Am Med Assoc 1936;106:1649-51.  Back to cited text no. 3
    
4.
Landesman R, Douglas RG, Snyder SS. Retinal changes in the toxemias of pregnancy. I. History, vomiting of pregnancy, mild and severe pre-eclampsia, and eclampsia. Am J Obstet Gynecol 1951;62:1020-33.  Back to cited text no. 4
    
5.
Ballantyne AJ, Michaelson IC. Textbook of the Fundus of the Eye. Philadelphia: Williams and Wilkins; 1962. p. 193-4.  Back to cited text no. 5
    
6.
Ober RR. Pregnancy-induced hypertension (preeclampsia and eclampsia). In: Ryan SJ, editor. Retina. Vol. 2. St Louis: CV Mosby; 1994. p. 1405-12.  Back to cited text no. 6
    
7.
Jaffe G, Schatz H. Ocular manifestations of preeclampsia. Am J Ophthalmol 1987;103(3 Pt 1):309-15.  Back to cited text no. 7
    
8.
Kishor N, Tandon SJ. Significance of the biochemical and ophthalmoscopic changes in the retina in toxaemia of pregnancy. J Obstet Gynaecol India 1965;15:551.  Back to cited text no. 8
    
9.
Shukla BK, Prasad GN. Retinal changes in eclampsia and pre-eclampsia. J Indian Med Assoc 1976;66:8-10.  Back to cited text no. 9
    
10.
Reddy SC, Sivalingam N, Rani KG, Tham SW. Fundus changes in pregnancy induced hypertension. Int J Ophthalmol 2012;5:694-7.  Back to cited text no. 10
    
11.
Tadin I, Bojic L, Mimica M, Karelovic D, Dogas Z. Hypertensive retinopathy and pre-eclampsia. Coll Antropol 2001;25 Suppl: 77-81.  Back to cited text no. 11
    
12.
Mussey RD, Mundell BJ. Retinal examinations: A guide in the management of the toxic hypertensive syndrome of pregnancy. Am J Obstet Gynecol 1939;37:30-6.  Back to cited text no. 12
    


    Figures

  [Figure 1]
 
 
    Tables

  [Table 1], [Table 2], [Table 3]



 

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