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42 Med J Malaysia Vol 66 No 1 March 2011 SUMMARY The aim of this study was to determine the prevalence of hypertensive retinopathy, features of hypertensive retinopathy and visual outcome in hypertensive disorders in pregnancy in Hospital Universiti Sains Malaysia, Kelantan, Malaysia. A prospective observational hospital based study involving 154 patients (308 eyes) with hypertensive disorders in pregnancy was conducted. All subjects were examined once during an
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  42 Med J Malaysia Vol 66 No 1 March 2011 SUMMARYThe aim of this study was to determine the prevalence ofhypertensive retinopathy, features of hypertensiveretinopathy and visual outcome in hypertensive disorders inpregnancy in Hospital Universiti Sains Malaysia, Kelantan,Malaysia. A prospective observational hospital based studyinvolving 154 patients (308 eyes) with hypertensivedisorders in pregnancy was conducted. All subjects wereexamined once during antenatal period, at a minimum of 35weeks of gestation for blood pressure, visual acuity andfunduscopy. The similar protocol was repeated at six weekspostnatal period. Thirty-two point five percent hadhypertensive retinopathy. Ninety eight percent had visualacuity 6/6 during antenatal assessment, while 100.00%gained 6/6 at postnatal period. Generalized arteriolarnarrowing was the most common retinopathy observed.There was no statistically significant association betweenpresence of hypertensive retinopathy and maternal age,presenting visual acuity, systolic/diastolic blood pressure(p>0.05). We conclude that prevalence of hypertensiveretinopathy is 32.5%, and majority had good visual acuityduring antenatal and postnatal period. Hypertensiveretinopathy is insignificantly associated with maternal age,presenting visual acuity and blood pressure.KEY WORDS:  Hypertensive retinopathy, Visual outcome, Hypertensive disorders in pregnancy  INTRODUCTION Hypertensive disorder in pregnancy is the major concern of public health issue world wide and affects 5-10% of allpregnancies. It is a common obstetric problem contributing tomaternal deaths. In Malaysia, maternal death from associatedmedical problem accounted for 20.6%, followed by post partumhaemorrhage (19.1%), hypertensive disorders in pregnancy(14.1%) and obstetric embolism (13.9%) 1 . Other significantcauses include obstetric trauma, unspecific complication of pregnancy and puerperium, and puerperal sepsis.Hypertensive disorders in pregnancy affect both mother andfetus. Eye can be affected by the disease and requires seriousattention from the managing team of obstetricians andophthalmologists. There were numerous case reportsillustrated visual threatening conditions in patients withpreeclampsia and eclampsia. These included acute ischemicoptic neuropathy, macula tear, central serous retinopathy,retinal detachment, central retinal vein occlusion, retinalarteriole occlusion and choroidal ischaemia 2-7 . There is a limited available data regarding hypertensiveretinopathy among pregnant mothers with hypertensivedisorders. Published literatures were mainly confined toretinopathy observed during pre-eclampsia and eclampsiacrisis 8-10 . This study is designed to evaluate at a widerspectrum of hypertensive disorders in pregnancy andretinopathy changes. We aimed to determine the prevalenceof hypertensive retinopathy, with emphasis on visual acuityand retinopathy features at 35 weeks antenatal period tilldelivery, and at six weeks postnatal period. Associationsbetween hypertensive retinopathy during antenatal periodwith maternal age, presenting visual acuity and bloodpressure were also studied. MATERIALS AND METHODS This prospective observational study was conducted between June 2008 till May 2010 at Ophthalmology Clinic, AntenatalClinic and Obstetric Ward of Hospital Universiti SainsMalaysia, Kelantan, Malaysia. The study protocol wasapproved by the Research and Ethical Committee, School of Medical Sciences, Universiti Sains Malaysia, and writtenconsents were obtained from all the patients. Those who fulfilled the diagnosis of hypertensive disorders inpregnancy were included into this study. Patients wereexcluded if they had co-existing diabetes mellitus, patientswith underlying ocular co-morbidity e.g. glaucoma, cataract,corneal opacities, history of ocular trauma or ocular surgeryand previous laser treatment. Sample size was calculatedusing single proportion formula, based on 9.8% prevalence of hypertensive disorders in pregnancy, with 95% confidenceinterval 11 .Clinical evaluations were performed twice, that included aminimum of 35 weeks of gestation till delivery and at sixweeks postnatal period. All patients with clinical diagnosis of hypertensive disorders in pregnancy were recruited by anindependent obstetrician. A complete ocular history and Hypertensive Retinopathy and Visual Outcome inHypertensive Disorders in Pregnancy A R Rasdi, MD*, N Lah Nik-Ahmad-Zuky, MMed (O&G)**, S Bakiah, MMed (Ophthal)***, I Shatriah, M Med(Ophthal)* *Department of Ophthalmology, **Department of Obstetric and Gynaecology, School of Medical Sciences, Universiti SainsMalaysia, 16150 Kubang Kerian, Kelantan, Malaysia, ***Advanced Medical and Dental Institute, Universiti Sains Malaysia, 13200Kepala Batas, Penang, Malaysia ORIGINAL ARTICLE This article was accepted: 5 April 2011Corresponding Author: Ismail Shatriah, Universiti Sains Malaysia, Department of Ophthalmology, Department of Ophthalmology, School of MedicalSciences, Health Campus, Universiti Sains Malaysia, Kubang Kerian, Kelantan 16150, Malaysia Email: shatriah@kck.usm.my   Hypertensive Retinopathy and Visual Outcome in Hypertensive Disorders in Pregnancy Med J Malaysia Vol 66 No 1 March 2011 43detailed examination that included presenting visual acuity,anterior segment examination by slit lamp biomicroscopy,intraocular pressure measurement by applanation tonometeror tonopen, and posterior segment examination with indirectophthalmoscopy were performed in all patients by anotherinvestigator who was blinded types of hypertensive disorders.A well dilated funduscopy examination was performed in allpatients. Fundus photographs were reviewed by anothermasked investigator. The hypertensive retinopathy was graded according to theKeith-Wagner and Barker classification 12 . Repeat evaluation of the similar protocol was performed at six weeks postnatalperiod by the previous identified investigators. The patientswere examined at the Ophthalmology Clinic, HospitalUniversiti Sains Malaysia, Kelantan, Malaysia as outpatient orinward basis for those who were medically stable. For themedically unstable patients who were admitted for bloodpressure stabilization or induced delivery, they wereexamined at the respective wards. Patient’s blood pressure was recorded before ocularexamination was carried out during each phase of evaluation.All the relevant data with examination findings wererecorded in separate data collection forms for both duringantenatal and postnatal period. If a patient did not turn upfor postnatal assessment at six weeks, she would be notifiedby phone calls and reminders. Failure to do so after 2 weeksof reminders, the patient would be considered disqualifiedfrom the study. The data collected were analyzed using Statistical Package forSocial Science (SPSS) software version 12.0.1. Data wasfurther analyzed using statistical test of Chi-Square todetermine the association between retinopathy duringantenatal period and maternal age, presenting visual acuityand level of recorded blood pressure. The p-value of < 0.05was considered statistically significant. RESULTS A total of 204 participants were recruited into this study.Among them, 50 patients were excluded because theydefaulted repeat assessment at six weeks postnatal period.Therefore, total 154 patients with 308 eyes participated andcompleted this study. Patients’ demographic data includedage, ethnicity, type of hypertensive disorders in pregnancyand period of gestation are shown in Table I. The antenatal and postnatal visual acuity in patients withhypertensive disorders in pregnancy is summarized in TableII. In 154 eyes examined, we observed that 50 eyes (32.5%)had retinopathy changes while the remaining 104 eyes(67.5%) displayed no retinopathy during the antenatalassessment. The retinopathy features were further classified based onKeith-Wagner and Barker classification and this is shown inTable III. Table IV illustrates retinopathy observed in all typesof hypertensive disorders in pregnancy during antenatalassessment. Table V displays the association between thehypertensive retinopathy during antenatal period andmaternal age, presenting visual acuity and level of recordedblood pressure. Table VI shows distribution of hypertensiveretinopathy according to classification and level of systolic/diastolic blood pressure recorded during antenatalassessment. ParametersGestational HypertensionChronic Hypertension Preeclampsia/Chronic HPT with n (%)n (%)Eclampsia superimposed PE/Eclampsian (%)n (%) Number of patients78 (50.65)43 (27.90)28 (18.20)5 (3.25) Maternal Age (years) <202 (2.56)1 (2.33)4 (14.29)0 (0.00)21-304 (43.59)7 (16.28)8 (28.57)2 (40.00)31-4033 (42.31)24 (55.81)15 (53.57)2 (40.00)41-509 (11.54)11 (25.58)1 (3.57)1 (20.00) Ethnicity Malay75 (96.15)42 (97.67)28 (100.00)5(100.00)Siamese2 (2.56)0 (0.00)0 (0.00)0 (0.00)Chinese0 (0.00)1 (2.33)0 (0.00)0 (0.00)Indian1 (1.29)0 (0.00)0 (0.00)0 (0.00) Gestational Weeks 35-3616 (20.52)20 (46.51)13 (46.42)4 (80.00)37-3831 (39.74)16 (37.21)11 (39.29)0 (0.00)39-4031 (39.74) 7 (16.28)4 (14.29)1 (20.00)41-420 (0.00)0 (0.00)0 (0.00)0 (0.00) Number of Pregnancies Primigravida30 (38.46)3 (6.98)11 (39.29) 0 (0.00)Gravida 2-533 (42.31)21 (48.84)13 (46.42)3 (60.00)Gravida 6 and above15 (19.23)19 (44.18)4 (14.29)2 (40.00) Table I: shows demographic data  Hypertensive Retinopathy and Visual Outcome in Hypertensive Disorders in Pregnancy Med J Malaysia Vol 66 No 1 March 2011 45 VariablesRetinopathy RE*p-valueRetinopathy LE*p-valuePresentAbsentPresentAbsentn=50 (%)n=104 (%)n=50 (%)n=104 (%)Age (years) < 202 (4.0)5 (4.7)0.0573 (6.0)4 (3.8)0.05721 - 3010 (20.0)41 (39.3)10 (20.0)41 (39.4)31 - 4027 (54.0)47 (45.5)26 (52.0)48 (46.2)41 – 5011 (22.0)11 (10.5)11 (10.5)11 (22.0) Visual acuity 6/645 (90.0)103 (99.0)0.07047 (94.0)103 (99.0)0.0666/95 (10.0)1 (1.0)3 (6.0)1 (10.0) Blood pressure (mmHg)Systolic Normal < 1200 (0.0)0 (0.0)0.6250 (0.0)0 (0.0)0.880Pre-hypertension 120 - 13912 (24.0)25 (24.0)12 (24.0)25 (24.0)HypertensionStage 1 140 - 15931 (62.0)58 (55.8)30 (60.0)59 (56.7)Stage 2 ≥ 1607 (14.0)21 (20.2)8 (16.0)20 (19.3) Diastolic Normal < 801 (2.0)2 (2.0)0.4311 (2.0)2 (2.0)0.431Pre-hypertension 80 - 8921 (42.0)30 (28.8)21 (42.0)30 (28.8)HypertensionStage 1 90 - 99 21 (42.0)56 (53.8)21 (42.0)56 (53.8)Stage 2 ≥ 1007 (14.0)16 (15.4)7 (14.0)16 (15.4) *p-value < 0.05 (Chi-Square test) Table V: shows association of retinopathy features during antenatal period with age, visual acuity and blood pressure Blood pressure (mmHg)Hypertensive retinopathyNo retinopathyGroup 1Group 2Group 2Group 4n=104 (%)n=25 (%)n=21(%)n=4 (%)n=1 (%)Systolic Normal< 1200 (0.0)0 (0.0)0 (0.0)0 (0.0)0 (0.0)Prehypertension 120 - 13925 (24.0)5 (20.0)6 (28.6)0 (0.0)0 (0.0)HypertensionStage 1 140 - 15958 (55.8)15 (60.0)14 (66.7)2 (50.0)0 (0.0)Stage 2 ≥ 16021 (20.2)5 (20.0)1 (4.7)2 (50.0)1 (100.0) Diastolic Normal < 802 (2.0)1 (4.0)0 (0.0)0 (0.0)0 (0.0)Prehypertension 80 - 8930 (28.8)7 (28.0)13 (61.9)0 (0.0)0 (0.0)HypertensionStage 1 90 - 99 56 (53.8)14 (56.0)6 (28.6)1 (25.0)0 (0.0)Stage 2 ≥ 10016 (15.4)3 (12.0)2 (9.5)3 (75.0)1 (100.0) Table VI: shows distribution of hypertensive retinopathy retinopathy (based on Keith-Wagner and Barker Classification)according to level of systolic and diastolic blood pressure during antenatal assessmentFig. 1: Fundus photographs show resolving serous retinal detachment in both eyes with multiple patches of choroidal ischaemia.
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