Malignant Hypertension and Acute Loss of Vision In A Patient With History of Pre-eclampsia

Abstract

Pre-eclampsia may have an impact on women’s health beyond their pregnancies and has been associated with increased risks for future hypertension and cardiovascular disease. We report a case of a patient with history of pre-eclampsia and emergency caesarean section at 31 weeks of gestation due to impending eclampsia who defaulted follow up and presented with malignant hypertension and acute loss of vision 10 years later. A 34-year-old Malay female,  presented with generalized painless reduced vision of 5 days duration which was preceded by an intermittent headache for 1 months duration. She had a history of pre-eclampsia during her last childbirth 10 years ago and was not started on any antihypertensive medication as her blood pressure normalized 2 weeks post-delivery. Subsequently, she defaulted on her follow up. Visual acuity was counting finger at 1 meter in both eyes with no relative afferent pupillary defect. Funduscopy revealed bilateral grade IV hypertensive retinopathy with the presence of optic disc swelling and macular star. Optical coherence tomography showed bilateral sub-retinal fluid at the macula. Her blood pressure was 255/168 mmHg with other systemic examinations being normal. Ultrasonography of the kidneys showed the presence of bilateral renal parenchymal disease with elevation of serum urea and creatinine levels. Her blood pressure was controlled with triple oral antihypertensive agents. Her vision improved to 6/36 and 6/6 with a pinhole in both eyes and resolution of papilloedema and sub-retinal fluid at three  months follow-up. Patients with a history of pre-eclampsia must be closely monitored during the postpartum period. Even though her blood pressure was normalized, careful monitoring and long-term medical follow up plan must be clearly explained to the patient as she might develop chronic or essential hypertension afterward. Our patient most likely had essential hypertension superimposed with pre-eclampsia during her last pregnancy and currently presented with malignant hypertension due to undiagnosed chronic hypertension as she defaulted her medical follow up.