Abstract
Background/aims
To report the proportion and risk factors associated with retinal changes in Chinese pregnant women diagnosed with HELLP syndrome.
Methods
A retrospective review of medical records was conducted for all pregnant women with HELLP syndrome delivered at the Second Affiliated Hospital of Wenzhou Medical University between September 2010 and August 2023. Retinal changes were identified and were categorized into retinal vascular changes and serous retinal detachment based on the ophthalmology consultation records. The proportion of retinal changes was calculated, and associated risk factors were analyzed.
Results
A total of 70 cases with HELLP syndrome were included, with a mean age of 30.1 ± 5.2 years. Forty-nine cases received ophthalmology consultation, presenting a consultation rate of 70.0%. The proportion of retinal changes was 55.1% (27/49) in cases with HELLP syndrome. The proportion of retinal vascular changes and serous retinal detachment were 30.6% (15/49) and 24.5% (12/49), respectively. Patients with retinal vascular change (120.7 ± 8.0 mmHg) and those with serous retinal detachment (116.7 ± 14.5 mmHg) demonstrate significantly elevated diastolic blood pressure at the time of HELLP syndrome diagnosis compared to case without retinal changes (110.1 ± 12.4 mmHg, P = 0.032). HELLP syndrome cases treated with corticosteroids were more likely to develop serous retinal detachment compared to those not receiving corticosteroids (40.0% vs. 13.8%, P = 0.040).
Conclusion
The proportion of retinal changes was 55.1% among Chinese pregnant women with HELLP syndrome. Elevated diastolic blood pressure was identified as associated risk factor for developing retinal changes. The use of corticosteroids may have more risk of developing serous retinal detachment.
Keywords: Proportion, HELLP syndrome, Retinal change, Retinal vascular change, Serous retinal detachment
Introduction
HELLP syndrome is a serious complication of pregnancy characterized by hemolysis, elevated liver enzymes and low platelet count, occurring in 0.5 to 0.9% of pregnancies and in 10–20% of cases with severe preeclampsia [1]. While hepatic and hematologic complications have been extensively characterized, ocular manifestations remain underrecognized in clinical practice, despite their substantial potential for visual morbidity. Serious ocular complications associated with HELLP syndrome including serous retinal detachment (SRD) [2], central retinal vein occlusion [3], macular hemorrhage [4], Purtscher-like retinopathy [5] have been reported, in the form of various funduscopic findings. Among these, SRD is the most commonly documented finding, often reversible with prompt blood pressure control and deliver [6]. Despite the substantial risk of visual impairment and blindness, previous literature on HELLP syndrome-related ocular complications mainly focus on case reports [7, 8]. Therefore, further investigation into these ocular complications associated with HELLP syndrome is critical.
Given the increasing awareness of the ocular complications associated with HELLP syndrome, obstetricians are more frequently requesting ophthalmology consultations to identify retinal changes, and the detection rate of such changes has recently increased. In 1993, Sibai BM et al. [9] first reported a 0.9% incidence of retinal detachment in pregnancies with HELLP syndrome. In 2017, Morikawa M et al. [10] reported an overall incidence of 5.9% for central serous chorioretinopathy (CSC) at the Hokkaido University Hospital over a 6-year study. In 2021, Xu et al. [11] conducted a retrospective clinical study, revealing a proportion of SRD of 36.90% among Chinese pregnant women with HELLP syndrome. These relatively high rates of retinal changes underscore the necessity for routine ophthalmology consultation in pregnancies complicated by HELLP syndrome. However, in clinical practice, the number of inpatients with HELLP syndrome exceeds the number of pregnant women who actually receive such consultations, as the decision to request an ophthalmology consultation is at the discretion of the obstetric team.
The purpose of this study was to determine the proportion and risk factors of retinal changes in Chinese pregnant women with HELLP syndrome, and to identify characteristics that predispose these women to receiving ophthalmology consultation, thereby enhancing clinical decision-making.
Materials and methods
Study design and participants
This retrospective study reviewed the medical records from a hospital-based cohort of pregnant women aged 20–48 years with HELLP syndrome, who delivered in the Second Affiliated Hospital of Wenzhou Medical University over the 13-year study period from September 1, 2010 to August 31, 2023. The study was approved by the Ethics committee of the Second Affiliated Hospital of Wenzhou Medical University (Approval number: 2024-K-132-01) and was carried out in accordance with the tenets of the Declaration of Helsinki. Informed consent of study population was not required in this retrospective study.
Medical records were independently reviewed by 2 researchers, and each diagnosis of HELLP syndrome was reconfirmed by a senior obstetrician based on the medical records. The diagnostic criteria [12] for HELLP syndrome included: (1) haemolysis with increased lactate dehydrogenase (LDH), bilirubin level ≥ 20.5 µmol/L, (2) alanine aminotransferase (ALT) (≥ 40 U/L) or aspartate aminotransferase (AST) (≥ 70 U/L), (3) platelet count < 100 * 10(9)/L. Exclusion criteria included: (1) any history of eye diseases (such as retinal disease, optic nerve disease, uveitis, glaucoma, cataracts) and/or any history of eye surgeries (except for myopia laser surgery), (2) presenting visual acuity of 20/67 (Snellen chart) or worse in either eye, (3) history of chronic hypertension, diabetes, systemic lupus erythematosus or other systemic diseases before pregnancy.
Data collection
Demographic data such as maternal age, height, bodyweight, and gestational week (GW) at diagnosis of HELLP syndrome were collected. Clinical data including blood pressure (systolic blood pressure [SBP] and diastolic blood pressure [DBP]) at the time of HELLP syndrome diagnosis, early-onset preeclampsia, delivery method, corticosteroid use, relevant blood tests like routine blood count, liver and renal function, as well as occurrence of ophthalmology consultation was obtained. Preeclampsia was defined as a blood pressure of at least 140/90 mmHg on two occasions 4–6 h apart, after the 20th week of pregnancy; and in women who were previously normotensive, along with proteinuria of at least 300 mg/24 hours. Early-onset preeclampsia was defined as preeclampsia diagnosed before 34 weeks of gestation [13].
For individuals who requested ophthalmology consultation, ophthalmic examination was conducted by an ophthalmologist and detailed fundus examination were performed via bilateral direct ophthalmoscopy. When retinal changes were suspected or detected on fundus examination, further imaging such as fundus photography, optical coherence tomography (OCT) and/or ocular ultrasound may be arranged depending on the patient’s systemic stability and ability to cooperate with the examination. We reviewed the ophthalmology consultation records to identify date of examination, and findings from the ophthalmic examination. For the purposes of the current study, the consultation records were categorized into those indicating positive retinal changes and those indicating negative retinal changes, as assessed by a senior ophthalmologist. Positive retinal changes were further classified into retinal vascular change and SRD. The SRD (Fig. 1) was diagnosed when localized retinal detachment in the macular region was observed on direct ophthalmoscopy, with or without accompanying retinal vascular changes. Retinal vascular changes were recorded when there was evidence of constriction or narrowing of retinal arterioles, sclerosis of retinal arterioles, or arteriovenous nipping, in the absence of retinal edema and retinal detachment.
Fig. 1.
Fundus photography and spectral domain optical coherence tomography (OCT) of a HELLP syndrome case presenting a pronounced central serous retinal detachment in both eyes. A, B. right eye, C, D. left eye
Statistical analysis
The primary outcome was the proportion of the study population exhibiting positive retinal changes. Continuous variables are presented as means with standard deviation. An independent Student’s t test was conducted for all preselected risk factors, including age, GW at diagnosis of HELLP syndrome, SBP and DBP to compare the differences between HELLP syndrome who were seen by an ophthalmologist and those who were not assessed. Continuous variables were compared between the three groups using the one-way ANOVA. Categorical variables were compared using the fisher exact test. All statistical analyses were performed using SPSS (version 24.0 for Windows, SPSS, Inc., Chicago, IL, USA). A P-value < 0.05 was considered statistically significant.
Results
Over the 13-year study period, 70 cases with HELLP syndrome that met the inclusion criteria were identified from our medical records and were included in our analysis. The mean age of the participants was 30.1 ± 5.2 years (range 20–42 years). Among them, 49 cases received ophthalmology consultation, corresponding to a consultation rate of 70.0%. The characteristics of the study population are presented in Table 1. While no significant differences were observed in age, body mass index at the time of HELLP syndrome diagnosis, corticosteroid use, or cesarean section rates, women who received ophthalmology consultation had an earlier GW (30.9 ± 4.2 weeks vs. 34.3 ± 3.5 weeks, P = 0.001), higher SBP (176.8 ± 19.7 mmHg vs. 160.8 ± 19.8 mmHg, P = 0.003), higher DBP (115.0 ± 12.5 mmHg vs. 100.6 ± 12.9 mmHg, P<0.001), greater proteinuria (5.0 ± 4.2 g/24 h vs. 1.5 ± 2.6 g/24 h, P<0.001), and lower albumin levels (27.0 ± 5.0 g/L vs. 32.5 ± 6.0 g/L, P<0.001) compared to those who did not receive consultation. Pregnancies complicated by preeclampsia were more frequently associated with ophthalmology consultation than other cases (74.2% vs. 0%, P = 0.007). Furthermore, Pregnancies with early-onset preeclampsia were more likely to receive ophthalmology consultation than late-onset preeclampsia (83.3% vs. 45.0%, P = 0.009).
Table 1.
Characteristics of cases with HELLP syndrome
| Characteristics | Overall (n = 70) |
No consultation (n = 21) |
Consultation (n = 49) |
Statistic | P-value |
|---|---|---|---|---|---|
| Age(years), mean ± SD | 30.1 ± 5.2 | 31.2 ± 4.7 | 29.6 ± 5.4 | 1.150 | 0.254 |
| Height(cm), mean ± SD | 157.7 ± 52.5 | 156.5 ± 51.2 | 158.2 ± 52.8 | -1.217 | 0.228 |
| Preeclampsia, n(%) | 66(94.3) | 17(81.0) | 49(100) | 0.007 a | |
| Early-onset preeclampsia, n(%) | 48(68.6) | 8(38.1) | 40 (81.6) | 0.009 a | |
| GW (weeks) at diagnosis of HELLP syndrome, mean ± SD | 31.9 ± 4.2 | 34.3 ± 3.5 | 30.9 ± 4.2 | 3.343 | 0.001 |
| <30 weeks, n (%) | 27(38.6) | 3(14.3) | 24(49.0) | 0.005 a | |
| Weight(kg) at diagnosis of HELLP syndrome, mean ± SD | 67.4 ± 11.3 | 66.7 ± 12.7 | 67.6 ± 10.8 | -0.301 | 0.764 |
| Body mass index (kg/m2) at diagnosis of HELLP syndrome, mean ± SD | 27.1 ± 4.1 | 27.1 ± 4.2 | 27.0 ± 4.2 | 0.134 | 0.894 |
| SBP (mmHg) at diagnosis of HELLP syndrome, mean ± SD | 172.0 ± 20.9 | 160.8 ± 19.8 | 176.8 ± 19.7 | -3.105 | 0.003 |
| DBP (mmHg) at diagnosis of HELLP syndrome, mean ± SD | 110.6 ± 14.2 | 100.6 ± 12.9 | 115.0 ± 12.5 | -4.379 | <0.001 |
| Platelet count(*10(9)/L), mean ± SD | 98.1 ± 48.1 | 113.3 ± 64.2 | 91.5 ± 38.3 | 1.450 | 0.159 |
| Hematocrit, mean ± SD | 0.37 ± 0.05 | 0.38 ± 0.04 | 0.37 ± 0.05 | 0.700 | 0.486 |
| Albumin (g/L), mean ± SD | 28.7 ± 5.9 | 32.5 ± 6.0 | 27.0 ± 5.0 | 3.948 | <0.001 |
| Proteinuria(g/24 h), mean ± SD | 4.1 ± 4.2 | 1.5 ± 2.6 | 5.0 ± 4.2 | -3.882 | <0.001 |
| Blood urea nitrogen (mmol/L), mean ± SD | 6.0 ± 2.4 | 6.5 ± 3.3 | 5.8 ± 1.9 | 1.046 | 0.299 |
| Serum creatinine (µmol/L), mean ± SD | 77.7 ± 53.0 | 89.6 ± 89.2 | 72.6 ± 25.3 | 0.858 | 0.400 |
| ALT(U/L), mean ± SD | 97.2 ± 115.6 | 104.8 ± 159.3 | 94.0 ± 92.6 | 0.289 | 0.775 |
| AST(U/L), mean ± SD | 86.5 ± 101.4 | 65.7 ± 62.3 | 95.6 ± 113.7 | -1.103 | 0.274 |
| LDH(U/L), mean ± SD | 870.0 ± 1021.1 | 691.4 ± 755.9 | 941.4 ± 1109.1 | -0.876 | 0.384 |
| Serum D-dimer (ug/ml), mean ± SD | 4.6 ± 4.3 | 5.2 ± 5.4 | 4.4 ± 4.0 | 0.615 | 0.541 |
| Fibrinogen (g/L), mean ± SD | 3.8 ± 1.0 | 3.8 ± 1.0 | 3.8 ± 1.0 | 0.197 | 0.844 |
| Cesarean section, n(%) | 60(85.7) | 17(80.9) | 43(87.8) | 0.344a | |
| Corticosteroid use, n(%) | 27(38.6) | 7(33.3) | 20(40.8) | 0.377a |
Values are percentages for categorical variables, means ± SD for continuous variables. Differences in maternal characteristics were tested using Student’s t test, and Fisher exact test.
GW Gestational week, SBP Systolic blood pressure, DBP Diastolic blood pressure, ALT Alanine aminotransferase, AST Aspartate aminotransferase, LDH Lactate dehydrogenase, SD Standard deviation
Values in bold indicate statistical significance (P < 0.05)
a Fisher exact test
Among the 49 cases of HELLP syndrome that received ophthalmology consultation, positive retinal changes were observed in 27 cases, presenting an overall proportion of 55.1%. These cases with retinal changes were further categorized into those with retinal vascular change (n = 15) and SRD (n = 12) (Table 2). The DBP at the time of HELLP syndrome diagnosis was significantly higher in both the retinal vascular change group (120.7 ± 8.0 mmHg) and the SRD group (116.7 ± 14.5 mmHg) compared to the group with no retinal changes (110.1 ± 12.4 mmHg, F = 3.698, P = 0.032). The SBP at diagnosis was significantly elevated in the retinal vascular change group compared to the negative retinal change group (P = 0.022). Corticosteroid use was reported in 66.7% of cases in the SRD group, 45.5% in the negative retinal change group, and 13.3% in retinal vascular change group (P = 0.017). No statistically significant differences were found among the three groups concerning GW (31.9 ± 3.5 weeks vs. 29.8 ± 5.9 weeks vs. 30.4 ± 1.7 weeks, F = 1.210, P = 0.307) at diagnosis, proteinuria(4.4 ± 4.0 g/24 h vs. 5.9 ± 5.2 g/24 h vs. 5.3 ± 3.0 g/24 h, F = 0.568, P = 0.571), and albumin levels (28.2 ± 5.1 g/L vs. 26.0 ± 5.7 g/L vs. 26.1 ± 3.7 g/L, F = 1.065, P = 0.354) .
Table 2.
Characteristics of cases with negative or positive various retinal change
| Characteristics | Negative retinal changes (n = 22) | Positive retinal changes | Statistic | P-value | |
|---|---|---|---|---|---|
| Retinal vascular change(n = 15) | SRD (n = 12) | ||||
| Age(years), mean ± SD | 29.6 ± 4.6 | 29.9 ± 6.1 | 29.3 ± 6.3 | 0.031 | 0.969 |
| Height(cm), mean ± SD | 158.1 ± 4.9 | 159.1 ± 5.7 | 157.2 ± 5.6 | 0.458 | 0.635 |
| Early-onset preeclampsia, n(%) | 17(42.5) | 11(27.5) | 12(30.0) | 0.160a | |
| GW (weeks) at diagnosis of HELLP syndrome, mean ± SD | 31.9 ± 3.5 | 29.8 ± 5.9 | 30.4 ± 1.7 | 1.210 | 0.307 |
| Weight(kg) at diagnosis of HELLP syndrome, mean ± SD | 70.0 ± 11.7 | 64.4 ± 10.7 | 67.3 ± 8.9 | 1.186 | 0.315 |
| Body mass index (kg/m2) at diagnosis of HELLP syndrome, mean ± SD | 28.0 ± 4.3 | 25.5 ± 4.7 | 27.2 ± 2.9 | 1.544 | 0.224 |
| SBP (mmHg) at diagnosis of HELLP syndrome, mean ± SD | 169.7 ± 21.7 | 184.7 ± 11.5 b | 179.9 ± 20.7 | 3.017 | 0.059 |
| DBP (mmHg) at diagnosis of HELLP syndrome, mean ± SD | 110.1 ± 12.4 | 120.7 ± 8.0 | 116.7 ± 14.5 | 3.698 | 0.032 |
| Platelet count(*10(9)/L), mean ± SD | 92.8 ± 39.9 | 89.0 ± 34.3 | 92.3 ± 43.1 | 0.046 | 0.955 |
| Hematocrit, mean ± SD | 0.38 ± 0.0 | 0.35 ± 0.1 | 0.37 ± 0.1 | 2.041 | 0.142 |
| Albumin (g/L), mean ± SD | 28.2 ± 5.1 | 26.0 ± 5.7 | 26.1 ± 3.7 | 1.065 | 0.354 |
| Proteinuria(g/24 h), mean ± SD | 4.4 ± 4.0 | 5.9 ± 5.2 | 5.3 ± 3.0 | 0.568 | 0.571 |
| Blood urea nitrogen (mmol/L), mean ± SD | 5.8 ± 1.8 | 5.5 ± 2.3 | 6.3 ± 1.8 | 0.499 | 0.610 |
| Serum creatinine (µmol/L), mean ± SD | 67.6 ± 17.2 | 76.9 ± 34.5 | 76.4 ± 24.9 | 0.775 | 0.467 |
| ALT(U/L), mean ± SD | 100.7 ± 102.5 | 108.3 ± 101.5 | 63.8 ± 54.2 | 0.869 | 0.426 |
| AST(U/L), mean ± SD | 84.7 ± 75.9 | 123.5 ± 167.2 | 77.5 ± 79.3 | 0.672 | 0.516 |
| LDH(U/L), mean ± SD | 793.0 ± 1024.5 | 891.1 ± 711.0 | 1284.5 ± 1589.9 | 0.718 | 0.493 |
| Serum D-dimer (ug/ml), mean ± SD | 4.6 ± 4.3 | 4.6 ± 3.7 | 3.7 ± 3.9 | 0.201 | 0.819 |
| Fibrinogen (g/L), mean ± SD | 3.6 ± 1.0 | 4.3 ± 0.9 | 3.5 ± 1.0 | 3.109 | 0.054 |
| Corticosteroid use, n(%) | 10(45.5) | 2(13.3) | 8(66.7) | 0.017 a | |
Values are percentages for categorical variables, means ± SD for continuous variables. Differences in maternal characteristics were tested using one-way ANOVA, and Fisher exact test.
SRD Serous retinal detachment, GW Gestational week, SBP Systolic blood pressure, DBP Diastolic blood pressure, ALT Alanine aminotransferase, AST Aspartate aminotransferase, LDH Lactate dehydrogenase, SD Standard deviation
Values in bold indicate statistical significance (P < 0.05)
a Fisher exact test
b One-way analyses of variance followed by post hoc Tukey pairwise comparisons revealed significant differences between the Negative retinal changes and Retinal vascular change groups ( P = 0.022)
According to the ophthalmology consultation records, 49 cases of HELLP syndrome cases were categorized into SRD group (n = 12) and non-SRD group (n = 37). An analysis of potential risk factors revealed that the relative risk of developing SRD with corticosteroid use was 2.900 (95%CI: 1.001–8.341). Patients with HELLP syndrome who received corticosteroids were more likely to have SRD than those who did not receive corticosteroids (40.0% vs. 13.8%, P = 0.040) (Table 3). Eleven of 12 SRD cases (91.7%) achieved resolution with 1-month follow-up, whereas the retinal structure in macular area of one SRD case did not restore after 1-year year, resulting in decreased visual acuity.
Table 3.
Corticosteroid usage among patients with and without serous retinal detachment
| Characteristics | non-SRD (n = 37) | SRD (n = 12) | P-value |
|---|---|---|---|
| Corticosteroid use | 0.040 | ||
| Yes, n(%) | 12 (60.0) | 8 (40.0) | |
| No, n(%) | 25 (86.2) | 4 (13.8) |
SRD Serous retinal detachment
Discussion
In this retrospective hospital-based study, we described the proportion and risk factors of retinal changes among pregnant women with HELLP syndrome in a Chinese setting. The overall proportion of retinal changes was 55.1%, and demonstrated strong association with DBP.
In the current study, ophthalmology the rate of ophthalmology consultations among women with HELLP syndrome was 70.0%. Of note, not all women with HELLP syndrome undergo examination by an ophthalmologist. The demographic, clinical and laboratory characteristics of women with HELLP syndrome in our study align with those reported in previous studies [14, 15]. Ophthalmology consultations were more commonly conducted when woman presented with earlier GW, higher SBP, higher DBP, increased proteinuria, and lower albumin levels at the time of HELLP syndrome diagnosis. Furthermore, pregnancies complicated by preeclampsia, particularly early-onset preeclampsia, were more likely to prompt additional ophthalmology consultations by obstetricians. It appears that the severity of HELLP syndrome often triggers the need for ophthalmology consultation. Consequently, there was no significant difference in age or body mass index at the time of HELLP syndrome diagnosis concerning the consultation rate.
Visualizing the fundus is a critical skill as identification of retinal signs can be both life-saving and sight saving, as signs may have systemic relevance [16]. Bakhda, R. N found that 153 out of 300 (51.0%) cases of pregnancy-induced hypertension (PIH) showed positive retinal changes during the period of 2003 to 2006 [17]. Similarly, Wang Z et al. demonstrated that 56.76% of eyes affected by PIH demonstrated positive retinal changes [18]. In contrast, Warad, C et al. reported that retinal changes were present in 33.33% of PIH cases [19]. Notably, retinal changes in HELLP syndrome have not been previously reported. Our study revealed a proportion of 55.1% for retinal changes among individuals with HELLP syndrome. Categorized as a gestational hypertensive disorder and seen as the more severe variant of preeclampsia [20], the majority of women (80–90%) with the HELLP syndrome is reported to have had hypertension and proteinuria [21]. Progressive hypertension, causing the constriction of systemic arterioles and narrowness of the retinal vessels, can result in ischemia and contribute to physiological disturbances such as severe retinopathy and other perinatal morbidities [22]. HELLP syndrome-related retinal vascular change resembles hypertensive retinopathy, which has long been considered a marker of systemic target organ damage elsewhere in the body [23]. In our study, women with retinal vascular change had significantly higher SBP and DBP than women without retinal change. This is consistent with previous studies [17, 24]. Given the established correlation between retinal vascular changes and blood pressure, it is strongly recommended that patients, particularly those with severe hypertension (160/110 mmHg), undergo retinal examinations conducted by experienced clinicians as a routine practice. Furthermore, for pregnant women with hypertension, incorporating retinal examinations into prenatal assessments may be beneficial for risk stratification.
Most retinal changes tend to normalize following the resolution of HELLP syndrome. However, permanent visual function loss can occur in cases of HELLP syndrome accompanied by SRD. [11] Bilateral SRD due to HELLP syndrome, which was first reported in 1989 [25], is a rare but well-described, ocular complication, and also is the main cause of blurred vision in HELLP syndrome patients. Consequently, the early identification and management of SRD in pregnant individuals are of critical importance. Sibai BM et al. [9] performed a prospective cohort study on 442 pregnant women with HELLP syndrome from August 1977 through July 1992, and reported the serious maternal morbidity included retinal detachment (0.9%). Morikawa M et al. [10] observed 1 of 17 (5.9%) pregnant women with HELLP syndrome developed central serous retinopathy (CSC) examined by OCT between January 2009 and December 2014. A study in Chinese pregnant women with HELLP syndrome between Jan 2015 and Mar 2021, reported a proportion of 36.9% for SRD examined by OCT or direct ophthalmoscopy. [11] The proportion of SRD examined by direct ophthalmoscopy in our study was 24.5%, which was slightly lower than that reported by Xu et al. [11] The fundus examined by direct ophthalmoscopy in our study may explain the lower detection rate of SRD. The fundus examination especially retinal detachment, heavily dependent on equipment, and different equipment can influence the detection rate of retinal change. As a non-invasively and valuable imaging technology [26], OCT utilizes a low coherence light source near the infra-red spectrum to penetrate biological tissue [27], providing cross-sectional images of the retinal and choroidal layers, which enables more detailed visualization of the retina in patients, and assessed the SRD more sensitively. However, as a progressive condition, HELLP syndrome patients always need bedside ocular examination timely. OCT examinations are not easily accessible for patients who are inconvenient to move around. The easy and rapid nature of direct ophthalmoscopy underscores its irreplaceability as a valuable tool for patients in the supine position. Therefore, direct ophthalmoscopy is still used in many clinical settings to objectively document the presence of retinopathy signs.
On the other hand, most pregnant women with SRD, especially those not easily detected by direct ophthalmoscopy, have good visual prognosis. Pregnant women with severe SRD may have sustained damage in RPE layer and ellipsoid zone, and lead to irreversible visual impairment [11, 28]. In our study, almost all cases showed recovery of visual function within a few weeks to months after treatment of the mother (e.g., emergency cesarean section), except 1 patient (8.3%, 1/12) who did not show improvement in visual acuity within 1-year follow-up after the onset. The mechanism of SRD onset is not clearly understood. The underlying pathophysiology is proposed to involve accumulating endothelial damage, due to hypertension, eventually leading to generalized endothelial dysfunction and vasospasm [29]. SRD is secondary to ischemia in retinal pigment epithelium (RPE) and choroid from intense arteriolar vasospasm [30]. Choroidal vascular perfusion and permeability changes result in increased choroidal interstitial fluid with further extension into the subretinal space.
Interestingly, contrary to previous reports suggesting a therapeutic role of corticosteroids in HELLP-associated retinal detachment [31, 32], a potential association between corticosteroid use and SRD has been found in our study. In gestational ages between 24 and 34 weeks, obstetricians prefer a single course of corticosteroid therapy for foetal lung maturation [33]. Corticosteroids can impact the activities of sympathetic nerves of choroid, and leads to the decreased synthesis of nitric oxide, which, a regulator of choroidal blood flow [34], and further causing the spasm of choroidal vessels, altering the choroidal vascular perfusion and permeability [35]. It is also important to note that patients who received corticosteroids might have presented with greater disease severity, such as higher blood pressure. This underlying severity, rather than the corticosteroid use itself, could predispose them to a higher likelihood of developing SRD, thereby introducing a potential confounding bias. Given the association between corticosteroids and SRD, the practice of consulting ophthalmologists are indeed worthy of attention, even when visual symptoms are negative.
There are some limitations to our study. First, this retrospective study included a relatively small number of patients and is therefore subject to some selection bias. Second, the relatively small sample size precluded multivariate regression analysis to adjust for potential confounders, which limits the ability to identify independent associations and may introduce confounding bias. Finally, although the ophthalmology consultation records in this study were reconfirmed by senior ophthalmologist, the retinal assessments were performed solely by ophthalmic consultants using a bilateral direct ophthalmoscopy, which was significantly influenced by the experience level of the consultants.
Notwithstanding these shortcomings, the clinical data from this study represent real-world results, and this study seems to be the first study analyzing the proportion of ophthalmology consultation and retinal changes among pregnant women with HELLP syndrome. Ophthalmology consultation was obtained in more than two-third of patients with HELLP syndrome. Among those who received consultation, overall proportion of retinal changes were 55.1%. High DBP was found to be associated risk factor for developing retinal change, and there is a potential association between corticosteroid use and SRD, may provide a basis for future prospective investigations. Future studies with larger cohorts are needed to confirm these associations and to establish causality.
Abbreviations
- SRD
Serous retinal detachment
- LDH
Lactate dehydrogenase
- ALT
Alanine aminotransferase
- AST
Aspartate aminotransferase
- GW
Gestational week
- SBP
Systolic blood pressure
- DBP
Diastolic blood pressure
Authors' contributions
LSW and WYC contributes to the investigation, data collection, data curation, formal analysis and the original draft writing. MY and TZ contributes to the investigation, data collection and the draft revising. DL contributes to the supervision and methodology. HHZ and LYW contributes to the supervision, methodology, and reviewing. HSL contributes to the supervision, conceptualization, methodology, funding acquisition, reviewing and the draft revising.
Funding
This study was supported by the Initial Foundation for Doctoral Scientific Research of the Second Affiliated Hospital of Wenzhou Medical University.
Data availability
Data is provided within the manuscript or supplementary information files.
Declarations
Ethics approval and consent to participate
The study was approved by the Ethics committee of the Second Affiliated Hospital of Wenzhou Medical University (Approval number: 2024-K-132-01). Informed consent of patients was not required in this retrospective study. This study was done in accordance with the tenets set forth in the Declaration of Helsinki.
Consent for publication
Not applicable.
Competing interests
The authors declare no competing interests.
Footnotes
Publisher’s note
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
Lasi Wu and Wenyao Chen contributed equally to this article.
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Data Availability Statement
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