172      Vol. 31, No. 4, Oct – Dec, 2015 Pakistan Journal of Ophthalmology 

Original Article 

 

Retinopathy in Pregnancy Induced 
Hypertension 
 
Muhammad Imran Janjua, Saira Bano, Ali Raza 

 
Pak J Ophthalmol 2015, Vol. 31 No. 4 

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See end of article for 
authors affiliations 
 
…..……………………….. 
 
Correspondence to: 
Muhammad Imran Janjua 
Postgraduate Trainee 
Ophthalmology 
Holy Family Hospital, 
Rawalpindi 
janjua.doc@gmail.com 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
…..……………………….. 

Purpose: The purpose of this study was to observe the prevalence of 
Hypertensive Retinopathy in patients with Pregnancy Induced Hypertension. 

Materials and Methods: This cross-sectional study was carried out at Holy 
Family Hospital, Rawalpindi from July 2013 to July 2015. 168 patients with 
Pregnancy Induced Hypertension were examined for any fundus changes. 
Patient’s age, number of pregnancies, gestation period, blood pressure and 
proteinuria were noted. Pupils were dilated and fundus examination was done by 
direct ophthalmoscope. The data was analyzed by SPSS program. 

Results: A total of 168 patients were examined, 42 (25%) were primi-gravida, 91 
(54.2%) were multi-gravida and 35 (20.8%) were grand multi-gravida. The mean 
age was 27.66 (± 5.20) years. The average gestation period was 33.36 (±3.91) 
weeks. 126 (75%) patients had gestational hypertension, 37 (22%) had pre-
eclampsia and 5 (3%) patients had eclampsia. Hypertensive retinopathy was 
observed in 87 (51.78%) patients. Central serous chorioretinopathy (CSCR) was 
seen in 3 (1.8%) patients. A statistically significant positive correlation was seen 
between the severity of retinal hypertensive changes and blood pressure 
(p = 0.005), the grade of proteinurea (p = 0.000), severity of disease (p = 0.000) 
and no of pregnancies (p = 0.001). 

Conclusion: The level of blood pressure, severity of disease and proteinuria are 
significantly related with severity of hypertensive retinopathy in cases of PIH. 
Retinal examination can greatly help in predicting the severity of PIH and also in 
timely diagnosis and management of such cases. 

Key Words: Retinopathy, hypertension, pregnancy. 

 
regnancy Induced Hypertension (PIH) is 
defined as an elevated blood pressure of 
≥ 140/90 mm Hg recorded at rest on two 

different occasions and emerging after 20 weeks of 
gestation in a pregnant woman. It is classified into 
three types according to associated features: 
Gestational Hypertension: BP of > 140/90 mm Hg 
without associated proteinurea. Pre-Eclampsia: BP of ≥ 
140/90 mm Hg with associated proteinurea of ≥ 300 
mg / 24 hours. Eclampsia: The onset of convulsions in 
a woman with pre-eclampsia that cannot be attributed 
to other causes.2 

Hypertensive disorders in pregnancy are a major 
cause of maternal and fetal morbidity and mortality. 
PIH is the most common cause of maternal mortality 
in Europe. It is also amongst the leading causes of 
maternal deaths in developing countries like India and 
Pakistan.5 PIH, in its different forms, is responsible for 
10 – 15% maternal deaths worldwide.3 It is also 
associated with an increased risk of fetal and neonatal 
mortality.6 Nearly 5 – 11% of pregnant women develop 
hypertensive disorders and fundus changes are seen 
in 40 – 100% of these patients.4,11 The most common 
finding in such patients is attenuation of small retinal 

P 

mailto:janjua.doc@gmail.com


RETINOPATHY IN PREGNANCY INDUCED HYPERTENSION 

Pakistan Journal of Ophthalmology Vol. 31, No. 4, Oct – Dec, 2015      173 

blood vessels especially arterioles. These vascular 
changes are reversible and the resultant signs and 
symptoms resolve after delivery.1 The potential 
complications of hypertensive retinopathy in 
pregnancy are development of central serous choriore-
tinopathy (CSCR) and serous retinal detachment.8,9 

Retina is the only site in human body where blood 
vessels can be visualized directly with the help of an 
Ophthalmoscope. As hypertension has its effects on all 
the vessels of human body, retinal examination and 
assessment of vascular changes in pregnant women 
can provide valuable information about the status of 
placental circulation and fetal well being 12. 
Hypertensive retinopathy is a well known predictor of 
increased cardiovascular risk.10 Women affected with 
pre-eclampsia or eclampsia are twice at risk of 
cardiovascular and cerebrovascular accidents as 
compared with unaffected women.3 

This study was undertaken to determine the 
prevalence of retinal changes in PIH and association 
between the retinal changes and blood pressure, 
proteinuria and severity of the disease. 

 
MATERIALS AND METHODS 

This cross – sectional study was carried out at Holy 
Family Hospital, Rawalpindi from July 2013 to July 
2015. A total of 168 patients diagnosed with Pregnancy 
Induced Hypertension were included in this study. 
The patients with known diabetes or hypertension or 
any other ocular pathology which hindered posterior 
segment examination were excluded from the study. 
Similarly patients who had any renal disease were also 
excluded. 

Patient’s age, number of pregnancies, gestation 
period in weeks, blood pressure and proteinuria were 
noted from their clinical records. The pupils were 
dilated with Tropicamide 1% eye drops and retina was 
examined with a direct ophthalmoscope. The 
examination was carried out by two senior residents of 
ophthalmology department to minimize the observer’s 
bias. Any pathological findings were noted and the 
Keith – Wagener classification7 was used to grade the 
hypertensive retinopathy as shown below: 

Grade 1: Mild generalized arterial attenuation, 
particularly of small branches; 

Grade 2: More severe Grade 1 + focal arteriolar 
attenuation; 

Grade 3: Grade 2 + hemorrhages, hard exudates, 
cotton wool spots; 

Grade 4: Grade 3 + optic disc swelling 

The dipstick method was used to test proteinurea 
and it was graded as nil = not detectable, + = ≥ 0.3 
gm/L, ++ = ≥ 1 gm/L and +++ = ≥ 3 gm/L. The 
severity of PIH was classified as gestational 
hypertension, pre-eclampsia and eclampsia according 
to clinical and laboratory findings as described above. 

The data was analyzed by Statistical Package for 
Social Sciences (SPSS) version 20.0 and values were 
expressed in terms of frequencies, percentages and 
means. Bi-variate correlation was used to determine 
the association between retinal changes and blood 
pressure, proteinuria, and severity of the disease. P-
value < 0.05 was considered statistically significant. 

 
RESULTS 

A total of 168 patients were examined, of which 42 
(25%) were primi-gravida (first time pregnant), 91 
(54.2%) were multi-gravida (2 to 4 pregnancies) and 35 
(20.8%) were grand multi-gravida (5 or more 
pregnancies). The age ranged from 18 to 42 years with 
a mean of 27.66 (±5.20) years. The gestation period 
was between 25 and 41 weeks with an average of 33.36 
(±3.91) weeks. 126 (75%) patients were diagnosed with 
gestational hypertension, 37 (22%) had pre-eclampsia 
and 5 (3%) patients had eclampsia. 94 (56%) patients 
had a BP < 150/100 mm Hg while 74 (44%) patients 
had > 150/100 mm Hg. 126 (75%) patients did not 
have any detectable proteinurea, 13 (7.7%) had a 
proteinurea of +, 24 (14.3%) had ++ and 5 (3%) 
patients had +++. 81 (48.2%) patients did not show 
any retinal changes. Hypertensive retinopathy was 
observed in 87 (51.78%) patients. Grade 1 changes 
were seen in 51 (30.4%) patients, grade 2 in 28 (16.7%), 
grade 3 in 5 (3%) and grade 4 in 3 (1.8%) patients. 
Central serous chorioretinopathy (CSCR) was seen in 3 
(1.8%) patients (table 1). 

A statistically significant positive correlation was 
seen between the severity of retinal hypertensive 
changes and blood pressure (p=0.005). Similarly, a 
highly positive correlation was observed between the 
severity of retinopathy and the grade of proteinurea 
(p = 0.000), severity of disease (p = 0.000) and no of 
pregnancies (p = 0.001) (table 1). 



MUHAMMAD IMRAN JANJUA, et al 

174      Vol. 31, No. 4, Oct – Dec, 2015 Pakistan Journal of Ophthalmology 

 

 
DISCUSSION 

Hypertensive disorders are a common cause of 
morbidity and mortality in pregnant women. In 
Pakistan 10 – 12% women suffer from pregnancy 
induced hypertension.3 In the developed countries like 
US the reported incidence is much less and only 4% of 
pregnant women suffer from PIH6. This study 
included 168 women who were diagnosed with 

pregnancy induced hypertension. The mean age was 
about 27 years. It is similar to the average age of 
women as shown in previous studies from Malaysia1 

(30 years) and India12 (25 years). However, in the US, 
most of the women who suffered from PIH were 
either younger than 20 years or older than 35 years of 
age.6 

Out of the 168 patients examined, 87 (51.78%) 
showed signs of hypertensive retinopathy. Previous 
literature shows a prevalence of retinal changes from 
13% to 59%1. Most of the previous studies showed 
only grade 1 and grade 2 hypertensive changes in 
pregnant women1, 12, while this study showed grade 3 
changes in 5 (3%) and grade 4 changes in 3 (1.8%) 
patients. 3 (1.8%) patients also showed CSCR. This is 
very high as compared to a study by Said – Ahmed, 
et al9 which showed a rate of only 0.008%. This may be 
due to delayed presentation of patients for medical 
care in our setup. 

42 (25%) out of 168 patients were primi-gravida, of 
which 18 (42.8%) showed retinal changes. 91 (54.2%) 
were multi-gravida and 41 (45%) had retinopathy. 35 
(20.8%) patients were grand multi-gravida and retinal 
hypertensive changes were seen in 28 (80%). This 
shows that grand multi-gravida had almost twice the 
incidence of retinal hypertensive changes as compared 
to primi and multi-gravida. There was a significant 
correlation between number of pregnancies and 
severity of retinopathy (p = 0.001). This correlation 
was not seen in previous literature.1,12 

126 (75%) patients had gestational hypertension, 
37 (22%) had pre-eclampsia and 5 (3%) patients had 
eclampsia. A statistically significant positive 
correlation was seen between the severity of disease 
and the grade of retinopathy in this study (p = 0.000). 
This positive correlation was also observed in 
previous studies.1,12 94 (56%) patients had a blood 
pressure of < 150/100 mm Hg and 74 (44%) had a BP 
of > 150/100 mm Hg. Of these, retinopathy was seen 
in 41 (43.6%) and 46 (62.1%) patients respectively. A 
positive correlation was seen between blood pressure 
and grade of retinopathy (p = 0.005) as described by 
previous literature.1,12 

In this study, statistically significant positive 
correlation was observed between the grade of 
proteinurea and the grade of retinopathy (p=0.000). 
126 (75%) patients had no proteinurea and out of these 
58 (46%) showed retinopathy. 13 (7.7%) patients had a 
proteinurea of “+”, 24 (14.3%) had “++” and 5 (3%) 
had “+++”. Out of these 6 (46.1%), 18 (75%) and 5



RETINOPATHY IN PREGNANCY INDUCED HYPERTENSION 

Pakistan Journal of Ophthalmology Vol. 31, No. 4, Oct – Dec, 2015      175 

 

 
(100%) patients had hypertensive changes. 

Previous studies also showed similar positive 
correlation between grade of proteinurea and grade of 
retinopathy in patients of PIH.1,12 

Many physiological cardiovascular and 
hemodynamic changes occur in pregnant women to 
provide for the well being of the developing fetus.5 If a 
woman suffers from hypertension during pregnancy, 
it affects all the blood vessels in the body including 
placental vasculature1. If not properly managed, it 
results in significant maternal and fetal morbidity and 
can even lead to maternal or fetal mortality6. Presence 
of hypertensive retinopathy in pregnant women is a 
strong indicator of similar vascular changes in 
placental circulation and can be used as a predictor of 
fetal well – being.11 

 

CONCLUSION 

In conclusion, the level of blood pressure, grade of 
proteinurea and severity of PIH are all correlated with 
the severity of vascular changes in pregnant women. 
Routine ophthalmoscopy should be performed in 

women suffering from PIH so that the status of retinal 
vasculature in particular and placental vasculature in 
general can be assessed. With timely diagnosis and 
management of such patients significant loss in terms 
of maternal and fetal morbidity and mortality can be 
prevented. 

 
Author’s Affiliation 

Dr. Muhammad Imran Janjua 
Postgraduate Trainee Ophthalmology 
Holy Family Hospital, Rawalpindi 

Dr. Saira Bano 
Postgraduate Trainee Ophthalmology 
Holy Family Hospital, Rawalpindi 

Prof. Dr. Ali Raza 
Head of Ophthalmology Department 
Rawalpindi Medical College and Allied Hospitals 

 
Role of Authors 
Dr. Muhammad Imran Janjua 
Study conception, data collection, analysis and 
drafting. 



MUHAMMAD IMRAN JANJUA, et al 

176      Vol. 31, No. 4, Oct – Dec, 2015 Pakistan Journal of Ophthalmology 

Dr. Saira Bano 
Study conception, data collection and analysis. 

Prof. Dr. Ali Raza 
Critical Review, analysis and overall supervision. 

 
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