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Background: Pregnancy-induced hypertension (PIH) can affect the eyes of pregnant women. There is dysfunction of vascular endothelium among them. There can be further leakage from capillaries and vasospasm if it is left untreated.
Objective: The objective of this study was to study the prevalence and risk factors of ocular fundus changes among pregnant women with PIH.
Materials and Methods: A hospital-based, cross-sectional study was carried out among 130 pregnant women with PIH. History of symptoms related to the eyes, age, and gravida was recorded. Torchlight was used to examine the anterior segment. One percentage of tropicamide was used to dilate pupils. Direct ophthalmoscope was used to examine the fundus. Blood pressure was measured as per the standard guidelines. Urine sample was taken to look for the presence of proteins in urine.
Results: The majority belonged to 23–27 years (50%) and the majority (54.6%) had gestational age >37 weeks. The majority (75.38%) had gestational hypertension. The prevalence of retinopathy was 11.5%. Grade I retinopathy was the most common (7.7%). Age was not associated with retinopathy. The prevalence of PIH among women with preeclampsia was 29.1% compared to 5.1% in women with gestational hypertension and it was significant (P < 0.05). The prevalence of PIH among women with blood pressure >150/100 mmHg was 43.3% compared to 2% in women with blood pressure <150/100 mmHg, and it was significant (P < 0.05). The prevalence of PIH among women with severe proteinuria (+++) was 60% compared to 42.9% in moderate proteinuria (++), 20% in mild proteinuria (+), and only 5.4% in women without proteinuria. These differences were significant (P < 0.05).
Conclusion: The prevalence of retinopathy among pregnant women with PIH was high. High blood pressure and severe proteinuria and preeclampsia were significantly associated with retinopathy.
Keywords: Preeclampsia, pregnant women, proteinuria, retinopathy
How to cite this URL:
Muduthanapally C. Prevalence and risk factors of ocular fundus changes among pregnant women with pregnancy induced hypertension at a tertiary care center. MRIMS J Health Sci [Epub ahead of print] [cited 2023 Mar 22]. Available from: http://www.mrimsjournal.com/preprintarticle.asp?id=362529 |
| Introduction | |  |
The management of pregnancy-induced hypertension (PIH) among pregnant women is not simple for obstetricians. PIH can lead to mortality not only among pregnant women but also during the perinatal period. It is an important cause of maternal morbidity during the gestational period.[1],[2],[3],[4],[5],[6],[7]
PIH can be categorized as “gestational hypertension, preeclampsia, severe preeclampsia, and eclampsia.” It is commonly seen after 20 weeks of gestation if no other causes are present like renal disease, already a known case of hypertension, etc., PIH is a hypertensive disorder of pregnancy. The systolic and diastolic blood pressure is >140 and 90 mmHg, respectively. The reading should be taken in the sitting position with a gap of 4 h. If the reading is more than normal in both measurements, then it is high blood pressure among pregnant women. Along with this high blood pressure, if there is the presence of generalized edema in combination with proteinuria with >300 mg in 24 h, the diagnosis of PIH is made. When proteinuria is high or significant along with high blood pressure and edema, it is called preeclampsia.[8],[9]
Pregnant women with preeclampsia but without any diseases of the cerebrum when develops convulsions, it is called eclampsia. PIH can affect the eyes of most pregnant women.[5],[6],[7]
Hence, an eye examination should be done for all pregnant women with PIH. It helps in the early diagnosis of any eye problems due to PIH and proper management of the case. However, the single examination is of not much use. Hence, pregnant women should be asked to undergo regular eye screening at regular intervals. This helps in finding the effect of PIH on the eyes, its severity, and how the patients are responding to the underlying treatment.[3],[5],[6],[7]
There is dysfunction of the vascular endothelium among pregnant women with PIH. There can be further leakage from the capillaries and vasospasm if the condition is left untreated. The vascular changes occurring in the retina will not always correspond with the control of hypertension. However, these vasospastic changes are reversible. After delivery, the affected vessels of the retina can come back to normalcy.[10]
Hence, it is important to know the prevalence of ocular fundus changes among pregnant women with PIH as well as to know the risk factors which are associated with the ocular fundus changes among pregnant women with PIH. Therefore, the present study was carried out to study the prevalence and risk factors of ocular fundus changes among pregnant women with PIH.
| Materials and Methods | | |
A hospital-based cross-sectional study was carried out in the Department of Ophthalmology, Malla Reddy Institute of Medical Sciences, Hyderabad. The study was carried out from January 2017 to January 2020. Pregnant women were recruited for the present study who were admitted in the obstetrics ward of the same hospital.
The institutional ethics committee approval was obtained before the study. Written informed consent was taken from all eligible pregnant women after explaining the nature of the study. Data confidentiality was maintained. All pregnant women with ocular fundus changes were treated as per the standard guidelines. After the study, they were asked to come for a regular follow-up examination in the department of ophthalmology.
Reddy et al.[11] found that the prevalence of Grades I and II retinal changes among pregnant women with PIH was 59%. Taking this as prevalence with a 95% confidence level and an allowable error of 15% of the prevalence, the sample size came out to be 123. During the study period, we could include 130 pregnant women with PIH.
Pregnant women having confirmed diagnosis of PIH and belonging to the age group of 18–35 years irrespective of gestational age were included in the present study. Known cases of hypertension before pregnancy, history of convulsions in the recent past, complicated cases of preeclampsia, and patients with associated diseases such as diabetes, HIV, disorders of the thyroid gland, and disorders of the hematological system were excluded from the present study. Known cases of kidney disease were also excluded from the study. On examination, if the fundus was hazy, such cases were also not included in the study.
History of symptoms related to the eyes, age, and gravida status was recorded in the predesigned, pretested, and semistructured study questionnaire. Torchlight was used to examine the anterior segment, and the findings were noted down. One percentage of tropicamide was used to dilate the pupils. Direct ophthalmoscope was used to examine the fundus. On fundus examination, it was taken as a positive eye finding if there are changes suggestive of hypertensive retinopathy. Blood pressure was measured in a sitting position using only one arm twice at an interval of 4 h as per the standard guidelines of blood pressure measurements. Urine sample was taken to look for the presence of proteins in the urine. The sample collection was done using the standard protocol. Urine sample was sent to the hospital laboratory and the results were collected. The dipstick method was used to assess the proteinuria. The proteinuria was taken as 1+ if the urine protein was up to 30 mg/dl, ++ if the urine protein was 31–100 mg/dl, 3+ if it was 101–300 mg/dl, and 4+ if it was >300 mg/dl as per the instructions from the manufacturer.
“PIH was graded as gestational hypertension, preeclampsia, and eclampsia.” Keith–Wagener classification[12] was used to grade the retinal changes. The grading is discussed in detail as follows. In Grade I, there is generalized attenuation of the small branches of the arteries but it is mild in nature. In Grade II, there is attenuation of the arterioles which is focal and there is more severity compared to Grade I. In Grade III, there are findings of Grade II plus hemorrhages and hard exudates, and cotton wool spots are seen. In Grade IV, there are findings of the Grade III plus and there is swelling of the optic disc.[12]
Data were entered into a Microsoft Excel spreadsheet. All data were categorical and hence Chi-square test was applied. For the significance of differences in the proportions, P < 0.05 was taken as statistically significant. OpenEpi Statistical Software version 3.01 was used for the Chi-square test and P value.
| Results | | |
The majority of pregnant women were in the age group of 23–27 years (50%) [Table 1].
The majority of pregnant women (54.6%) had a gestational age of >37 weeks [Table 2].
The majority (75.38%) had gestational hypertension. Only one woman was having eclampsia [Table 3]. | Table 3: Distribution as per the severity of pregnancy-induced hypertension
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The prevalence of retinopathy among pregnant women with PIH was 11.5% [Figure 1] Grade I retinopathy was most commonly seen in 7.7% of cases followed by Grade II retinopathy in 3.1% of the cases. Only one case had Grade III retinopathy while no one had Grade IV retinopathy [Table 4].
Age was not found to be associated with retinopathy among pregnant women with PIH. The prevalence of PIH among women with preeclampsia was 29.1% compared to only 5.1% in women with gestational hypertension and this difference was statistically significant (P < 0.05). The prevalence of PIH among women with blood pressure >150/100 mmHg was 43.3% compared to only 2% in women with blood pressure <150/100 mmHg and this difference was statistically significant (P < 0.05). The prevalence of PIH among women with severe proteinuria (+++) was 60% compared to 42.9% in women with moderate proteinuria (++), 20% among women with mild proteinuria (+) and only 5.4% in women without proteinuria. These differences were statistically significant (P < 0.05) [Table 5].
| Discussion | | |
In the present study, the majority of pregnant women were in the age group of 23–27 years (50%). The incidence of PIH as well as positive fundus findings is more common in the age group of 18 to 25 years. The probable reason for the higher incidence in the younger age group could be noncompensatory hypertension. The arteriolar sclerosis of retinal arterioles in elderly patients precludes the development of fundus changes in PIH. Tadin et al.[13] observed that the mean age of the study participants in their study was 29.1 years. Similarly, the mean age of the participants as observed by Jaeffe and Schatz[14] was 28 years. We also observed that the mean age of pregnant women in the present study was 27 years.
The prevalence of PIH among women with preeclampsia was 29.1% compared to only 5.1% in women with gestational hypertension and this difference was statistically significant (P < 0.05). These findings are similar to previous studies.[13],[14],[15],[16],[17],[18] The prevalence of ocular fundus changes was 13.7% in a study from Nepal which was conducted among 153 study participants by Karki et al.[15]
We found that the prevalence of PIH among women with blood pressure >150/100 mmHg was 43.3% compared to only 2% in women with blood pressure <150/100 mmHg, and this difference was statistically significant (P < 0.05). The prevalence of PIH among women with blood pressure >150/100 mmHg was 86.2% compared to only 42.8% in women with blood pressure <150/100 mmHg, and this difference was statistically significant (P < 0.05) as reported by Reddy et al.[11] Similar findings were also reported by Tadin et al.[13]
In the present study, 32 patients had proteinuria of +1–+4 on the dipstick. Of 32 patients, 10 (31.25%) patients developed retinopathy compared to 5 (5.1%) patients from 98 who did not have proteinuria. This difference was statistically significant (P < 0.05). Reddy et al.[11] also found that as the severity of proteinuria increased, the prevalence of retinopathy also increased among pregnant women with PIH. Similar findings were also reported by Tadin et al.[13]
| Conclusion | | |
The prevalence of retinopathy among pregnant women with PIH was high. High blood pressure, severe proteinuria, and preeclampsia were significantly associated with retinopathy. As the severity of proteinuria increased, the prevalence of retinopathy also increased among pregnant women with PIH.
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Conflicts of interest
There are no conflicts of interest.
| References | | |
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Correspondence Address:
Charani Muduthanapally,
Department of Ophthalmology, Malla Reddy Institute of Medical Sciences, Suraram, Hyderabad, Telangana
India
 Source of Support: None, Conflict of Interest: None DOI: 10.4103/mjhs.mjhs_31_22
[Figure 1]
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5] |
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