SEVERE PREECLAMPSIA WITH RETINAL DETACHMENT AND CHORIORETINITIS
Anahita D Pandole, Ranjit Akolekar, Nagendra S Sardeshpande, Nischal Vaidya,Gauri Jainapur, Shailesh Kore, Vijay R Ambiye
Lecturer; **Registrar; ***Associate Professor; ***Head of Unit, Department of Obstetrics and Gynaecology, LTMM College and LTMG Hospital, Sion, Mumbai 400 022.
Hypertensive disorders are one of the commonest complications of all pregnancies and are responsible for a significant amount of maternal and foetal morbidity and mortality. Visual disturbance is a common symptom of severe preeclampsia and eclampsia. However, retinal detachment is one of the rare complications of severe hypertension in pregnancy. We had a case of severe preeclampsia with previous three caesarean sections with retinal detachment and chorioretinitis near term. The patient underwent an emergency caesarean section with TL.
INTRODUCTIONHypertensive disorders of pregnancy have undoubtedly existed since the days of the Cro-Magnon women. There is little evidence of an exact counterpart in comparative pathology.
These disorders have varied manifestations from mild, benign, uncomplicated disease with little bearing an maternal and foetal outcome to severe fulminating disease leading to complications like eclampsia, renal failure, DIC, abruptio placentae and maternal-foetal mortality.
Here, we are discussing a case of severe preeclampsia with retinal detachment and chorioretinitis in a patient with 3 previous Caesarean sections.
CASE REPORTMrs. XYZ, a 34 year old Hindu housewife, married since 10 years, was admitted to our labour ward. She was a G4P3L1D2A0 with history of blurring of vision, headache and giddiness since 7 days. There was no history of convulsions, labour pains, leaking or bleeding pervaginum, decrease or absent foetal movements.
Patient was antenatally registered in a private nursing home. Her LMP was not known and her antenatal USG not available. She had one living issue, a 5 year old female child delivered by Caesarean section, the indication of which was not known. Her second pregnancy ended in an IUFD (female) delivered by caesarean section for severe PIH three years ago. She developed severe PIH again in her 3rd pregnancy which was terminated by a full term caesarean section two years ago. The child expired after 15 days due to kernicterus. She also had an appendicectomy done 20 years ago.
On examination her pulse was 96 beats/minute, BP : 220/130. She had grade II pedal oedema. Her respiratory and cardiovascular examination was normal. Per abdomen examination revealed uterus to be 34 weeks in gestation, relaxed with cephalic presentation. The foetal heart rate was regular. Per vaginal examination showed the cervix to be posterior and uneffaced; the station of the presenting part was high and there was no show of any leak. Investigations were sent; Haemogram was normal, blood group was O+ve, BUN was mildly raised (5.8 mg%). Ophthalmoscopic examination was done, which revealed bilateral exudative retinal detachment.
Patient was started on Magnesium Sulphate as per Pritchardís regimen and C. nifedipine (10 mg) and T. methyldopa (500 mg) qds was given too. An emergency Caesarean section was performed, delivering a 1.6 kg female. Intraoperative and postoperative period were uneventful. She was continued on Magansium Sulphate 24 hrs after the surgery and her BP was stabilized with C. nifedipine and T. methyl dopa.
Her investigations revealed a haemoglobin of 10.0 gm%; serum proteins of 4.7 gm%, total Bilirubin count of 0.6 mg%, SGOT - 94, Bloodurea nitrogen of 8, Serum Uric acid of 8.5 mg%, Prothrombin time 12/11 seconds, Partial thromboplastin time of 30/22 seconds, Serum Fibrinogen of 282 mg% and a non reactive Kahn reaction. Her Cytomegalovirus titres and ELISA test for Human Immunodeficiency Virus were negative. She was treated with steroid and Indomethacin eye drops with a resultant significant improvement in the vision. She was discharged on day 15 in a good post operative condition and healthy operative wound. Indomethacin eye drops, were continued.
Hypertensive disorders complicate about 7-10% of all pregnancies. 
PIH is a disease of young primigravidas with an incidence of 14.7% against 5.7% in multiparas. Women with a past H/O severe preeclampsia/eclampsia have an increased risk of recurrence of eclampsia (1.4%) and preeclampsia (45%) in subsequent pregnancies.  The increased incidence of PIH amongst ptís above 35 yrs reflects undiagnosed chronic HT with superimposed PIH.Significant complications are seen in 16% of the untreated cases of severe PIH, the principal ones being eclampsia, DIC, abruption, IUGR and IUFD. 
Although visual disturbances are common with severe PIH, blindness is not. Visual disturbances may be attributed to central retinal artery vasospasm and ischaemia as demonstrated by radiography and transorbital doppler,1 which responded to a 6 gm. bolus dose of Magnesium Sulphate.  They may rarely be due to amaurosis as a result of extensive occipital lobe oedema, microhaemorrhages and micro infarcts.4 The blindness resolves completely within a period of 4 hrs to 8 days following delivery. 
Retinal detachment may also occur, usually being unilateral and seldom causing visual loss. Fundoscopic examination does not reveal more than focal or generalized vasospasm, rarely retinal detachment and retinal oedema, which may often be missed as it begins in the periphery of the retina correlating with severity of renal changes in biopsy. 
Prognosis is good as vision almost always returns to normal within a week of delivery. Surgical treatment is seldom indicated. CMV retinitis is the most common complication of CMV infection (20%) with symptoms like peripheral visual fields loss, floaters and decrease vision with stellate keratic precipitates, dense perivascular retinal whitening with haemorrhage ("pizza-pie" fundus), "frosted-branch" engatise or subtle granular retinal opacification often ending with retinal detachment and macular/optic nerve involvement requiring pars plana vitrectomy and endolaser photocoagulation. Chemotherapy consist of parenteral ganciclovir, foscarnet or cidofovir with or without ganciclovir intraocular implant. 
We thank our Head of the Department and Dean for allowing us to publish this case report.
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