NIGHT BLINDNESS IN PREGNANCY

by

G. S. MANDAL, * M.B., D.G.O. (Cal.), M.R.C.O.G. (Lond.)

K. N. NANDA ,* * B.Sc., M.B.B.S. (Cal.), D.G.O. (Cal.)
and
J. BosE,* ** M.B ., D.C .M.S. (Cal.)

Night blindness is a defect in dark- It is perhaps mainly with the third

adaptation and may occur as a sub- and partly with the fifth conditions
jective symptom in the following mentioned above that we are most
conditions: (Duke-Elder, 1942). concerned and pregnancy may al-
1. As an incidental result of dis- ways aggravate a latent or manifest
eases of the eye, e.g. peripheral cor- condition of malnutrition in a
neal or lens-opacities (cataract), mother.
pigmentary degeneration of the re- Admittedly, multivitamin defici-
tina, advanced myopia and chorio- ency disorders, with or without anae-
retinitis. mia and protein deficiency, are quite
2. As a congenital or hereditary common in pregnant women iq tro-
condition. pical countries. The incidence may
. 3. As a symptom in conditions of be significantly increased during
malnutrition, associated with defi- periods of famines or famine-like
ciency of vitamin A. conditions, sometimes precipitated
4. In patholog·ical conditions of the by droughts, but perhaps the pro-·
liver. blem needs more attention than it
5. In over-exposure to light (spe- has as yet received.
cially strong tropical sunlight). . In the department of Gynaecology
6. In neurasthenics (e.g. shell- and Obstetrics, B.S. Medical College
shocked soldiers) . & Hospitals, Bankura, night-blind-
The aetiology may be either - a ness in pregnancy has been observed
structural deficiency of the rods or a sporadically. But the year 1967
functional deficiency of the visual showed a significantly increased inci-·
purple. dence of the symptom. (17 compared
-- ----
':'Asst. Prof. Dept. of Obst. & Gyne~ . to 3 in the corresponding period of
**Medical Officer, Dept. of Obst. & the year 1966).
Gynec. Mate?,ial (During the period
***Asso c. Pmf. & Head Dept . of Oph- 29.1.67 to 2.8.69).
thalmology. All the patients reported here
B . S. Medical College & Hospital, were admitted in the Dept. of Obste-
Bankura (West Bengal) . trics, except one (No. 17) who was
-~- Received fm· publication on 12-12-1968. admitted in the Dept. of Ophthal-

•
154
1 JOURNAL OF OBSTETRICS AND GYNAECOLOGY OF INDIA
mology. The college is situated in the
district town of Bankura amid rural
surroundings in the south-west part
of West-Bengal. The population from
which our patients come consists of
different groups. of castes of Hindus,
like brahmin, non-brahmin, Bauris,
Tribals, Bheriwals (who rear sheep
and make woolen goods as a cottage
industry) with different educational,
religious, and social back-ground.
Economically, they belong to middle
and low status (according to M~l­
hotra and Pathania (1958) and
Mathur ( 1860), as quoted by Chatto-
padhaya et al 1968). Mostly, they
depend on agriculture, but perhaps a
few are wage earners, shop keepers
and artisans in cottage industries
(e.g. wool-makers). Most of these
patients came from an averag;e dis-
tance of 12~ miles. The low stand-
ard of health education and socio-
economic status is probably the most
important cause for their not seeking
ante-natal care, either from the local
health centre or from our hospital.
They attend hospital only when they
are practically compelled by some
severe subjective symptom or symp-
toms. The patients are admitted
to the respective units according to
the day of their first visit. Apart
from patients in labour, those suffer-
ing from severe anaemia, pre-eclam-
psia and night-blindness were g·~ven
priority in admissions.
Methods
On admission, detailed notes, e.g.
name, age, address of the patient,
distance in miles the patient had to
cover, occupation of the husband,
socio-economic status and cause of
admission, were made.
Later on, the results of clinical ex-
amination, blood pressure, parity,
past history, duration of night blind-
ness, hospital stay, natl..\re of preg-
nancy and labour, birth weight of
the baby or babies and presence of
any congenital abnormality were
carefully noted.
Patients with night blindness were
referred to the department of Oph-
thalmology as far as possible. In
every case, 100,000 International
units of vitamin A were injected
intramuscularly for three consequ-
tive day~ along with the treatment of
other conditions, like anaemia, pre-
eclampsia, etc. From the 4th day,
vitamin A & D capsules ( 6000 Inter-
national units of vitamin A and
1000 units of vitamin D) were given
orally. They were, as a routine, on
high protein diet, 1610 calories ap-
proximately with 340 gm. of fish and
chana (Pharmacopeae, 1963).
Obstetric management was carried
out according to the individual needs
of the patients. On discharge, pati-
ents were advised to attend post-
natal clinics, but few turned up. The
new born babies of these nyctalopic
mothers were given multivitamin
drops ( 1500 International units of
vitamin A daily) .
Observations
1. Incidence-During the per!od
from 29.1.1967 to 2.8.1967, 17 pati-
ents were seen with night blindness
in a total of 368, as compared to 3 in
635 r atients during the identical
period of the previous year, i.e. 1966.
The increase was almost 4 times.
2. Age: Out of 17 patients, 12 be-
longed to the 15 to 24 years age
group, 3 to the 25 to 34 years age _
 NIGHT BLINDNESS IN PREGNANCY
group and 2 to the 35 to 44 years
age group.
3. Relation of night blindness to
parity-The incidence of night blind-
ness was highest in third paras
(35 Vo ) and next highest in second
paras (30 % ).
4. Relation o'f period of pregnancy
to night blindness: All the cases deve-
loped night blindness in the last tri-
mester. ' (b) Angular stomatitis
5. Duration of night blindness:
This could be recorded in only 12
cases. In others no definite answers
were received. It varied from 4 days
to 5 months, average duration being
62 days before the patients sought
any medical advice.
6. Absence of spectacles in the pati-
ents may probably exclude high de-
grees of ametropia (including my-
opia), but not low refractive error.
In a rural female population this sur-
, mise may not be totally correct as
there is some sort of social and farni-·
lial antipathy of young women for
spectacles.
7. Distance of the hospital from
patients' horne may have complicated
our series, as perhaps a distance of
more than 40 miles from the hospital
is not only impractical and inconveni-
ent for the patient in the context of
confinement but may also be costly
for the patient. Most of our patients
carne from an average distance of
12! miles (shortest -} mile and long'-
est 37 miles) and carne either during
or shortly before labour. Only one
case was admitted 2 months befor~
delivery because she had been suf-
fering from severe cough and low
general condition. It seems signifi-
cant that the cause for seeking ad-
r-rnission in the majority of our pati-
455
ents was imminent labour and not
night blindness. The only case of
keratomalacia carne in the puerperi-
um and was admitted, 'd ue to her
grave eye condition, in the depart-
ment of Ophthalmology.
8. Associated complications and
abnormalities:-
( a)Anaemia (clinical) 16
4
(c) Pre-eclarn psia 4
(d) Ante-partum haemor-
rhage 1
(e) Twin pregnancy 3
Majority of the patients had anae-
mia, another manifestation of mal-
nutrition. Incidence of twin preg-
nancy 1s apparently high (e.g.
( 18 % ), but this may be due to the
fallacy of small numbers.
9. Socio-economic status: Low,
i.e. below a monthly income of Rs.
100, except in 2 who belonged to
middle group, i.e. from Rs. 100-500
per month ( Chattopadhya 1968 Loc
cit).
10. Babies: Three out of 19 pati-
ents had twins. None of the babies
had any abnormality except prema-
turity in 13 (including 3 pairs of
twins). This high proportion of pre-
mature babies may partly be explain- I
ed by the presence of 3 pairs of twins.
R.er art of an interesting case
Mrs. K. D., Hindu, aged 35 years, was
admitted in the Ophthalmic department
under one of us (J. B.) with complaints of:
(i) Night blindness- 5 months.
(ii) Pain and discharge- both eyes- 5
months.
(ii) Lightning flashes and severe loss of
vision- 2 months.
Past history: Has five children, last child
birth- 2 mcnths before admission.
Patient had consecutive attacks of night
456 JOURNAL OF OBSTETRICS AND GYNAECOLOGY OF INDIA
blindness during her second, third and
fourth pregnancy, although the symptom
disappeared spontaneously every time after
labour. But, in her last (i.e. fifth) preg-
nancy, the night blindness gradually de-
teriorated into a severe condition o£
keratomalacia during the puerperium.
On examination: A middle-aged woman
showing signs of anaemia, malnutrition,
phrenoderma, short, lustreless scalp hair
(with patches of alopecia), angular stoma-
titis and glossitis (Fig. I)·
Local examination showed phthisis bulbi
with prolapse of iris in 'the temporal sector
and flatness of cornea and opacity in the
inferior and nasal sector of the cornea (Fig.
2). There was perception of light only in
the temporal field.
In the . left eye, adherent leucoma with
corneal vascularisation, peculiar dryness in
the skin adjacent to the orbit, but normal
bulbar conjunctivae, eye lashes and eye
brows (Fig. 3). z ed demand of the foetus in the late
Visual acuity was finger-counting at 3
metres .
Treatment ·
1. Local- Tetracycline (Terramycin)
eye ointment to both eyes, thrice daily.
The patient was given a pair of dark
goggles. ·
2. Oral vitamin A capsule- 6,000 units
daily, along with Fersolate 15 grains and 2
multi-vitamin capsules daily.
3. Injection vitamin A-1 lac units in~
tramuscularly, daily for 10 days.
4. Diet- As scheduled for all patients
(Diet No. 2).
With this treatment the patient's general
health improved appreciably and vision in
the left eye improved to some extent, i.e.,
finger counting at 6 metres. At the time of
discharge (after 4 weeks) tubectomy was
advised to prevent further pregnancies.
, ness of more than a month's dura-
Discussion
Deficiency diseases are quite
common in India, particularly in
Bankura. They are more common
during' pregnancy when some latent
deficiency may become manifest, e.g.
anaemia, vitamin · A deficiency, etc.
Deficiency of vitamin A, either due
to inadequate intake or improp.er ab-
sorption, is not very rare. Ocular
disturbances are the most charac-
teristic features of vitamin A defici-
ency and of these again, night blind-
h
ness is t e earliest symptom and is
due to the important role of vitamin
A in the functioning and regenera-
tion of pigments of the retinal rods
which are concerned with vision in
dim light. But, this also appears
only after a more or less lengthy
latent period (Clement 1967).
In our series, the patients might
have been in the latent state during
their pre-pregnant period but deve-
loped a manifest stage by the increas-
months of pregnancy. (All our pati-
ents developed night blindness in the
third trimester) .
The rise in the incidence of night
blindness during the year 1967 may"'
be explained by the delay in the on-
set of the monsoon and its shortness
of duration causing a condition of
drought and near famine in the dis-
trict during the period. The factor
of over-exposure to tropical sun may
have some importance.
It is. worth noting that all our pati-
ents except two, belonged to the low-
income group and had clinical anae-
mia. None of them attended ·an-
tenatal clinic before admission, al-
though most of them had night blind-
tion and at least m some of them
distance was no bar. This led us to
conclude that patients or their rela-
tives do not consider night blindness
during pregnancy as a serious condi-
tion. This is unfortunate as 80 % of
our patients . belonged to the age- •
 NIGHT BLINCNESS IN PHEGNANCY 157

group of 15 to 24 years and 65 j~ were medical care of the population in

either biparous or triparous mothers. general. As a short term plan, it is
Morbidity and mortality in this parti- suggested that provision of home
cular group of mothers would affect help and free conveyance, ~o and
their children and families and ulti- from the ante-natal clinics of the
mately the community most severely. rural area, would induce the patients
Admittedly, all the patients showed to attend ante-natal clinics in larger
normal reproductive performance numbers than has been hitherto
but it is difficult to explain the high . seen. More stress should be laid on
incidence of prematurity in our eliciting any history of night blind-
series except by the co-existent mal- ness during previous pregnancies or
--.mtrition of the mother, even after in the present pregnancy and the
allowing for the complicating factor nece~sary treatment should immedi-
of 3 pairs of twins. It is also diffi- ately be started. This would go a
cult to surmise what clinical data long way to prevent morbidity and
would be collected by prolonged mortality not only in mothers, but
paediatric follow-up of these babies also in their babies. Free supply of
born of deficiency state mothers, some nutritious composite food con-
but perhaps some of them would be taining proteins and vitamin A to
more prone to develop vitamin A poor mothers, e.g. milk, eggs etc.,
deficiency including keratomalacia should also be considered (Kuming
(Bose 1963), than those born of nor- and Politzer 1967).
mal mothers.
The sudden and spontaneous cure Summary
of night blindess in mothers by the Sixteen pregnant women with
termination of pregnancy is extreme- night blindness and one woman in
ly interesting and perhaps there is the puerperium with keratomalacia
some sort of exaggeration in the are reported. All had anaemia, but
descriptions of the symptoms by the normal deliveries. Three had twins.
patients. For restoring the deficit Most were of low income group and
store of vitamin A to normal in these were in the 15 to 24 ag·e group. Night
mothers, at least some prolonged blindness was seen in the third tri-
period should have been appropriate, mester, with an average duration of
- but there is no doubt that at least in 62 days. Average distance from
some of the cases the eye condition home in miles was 12t Thirteen out
might have further deteriorated lead- of 19 babies were premature. Home
ing to keratomalacia and consequent help, free conveyance, health insur-
adhe:rent leucoma and/ or phthisis ance, supply of composite food and
bulbi (as in the case 17) (Bose-Joe- a long term economic upliftment pro-
cit). gramme are suggested.
In conclusion, it may be said that
prevention of this condition on a Acl-cnowledgements
national scale lies in the improve- We are thankful to Dr. S. K. Upa-
ment of socio-economic conditions, dhaya, M.B., D.T.M., D.P.H. (C.U.)
l -better health education and better M.Sc. (Harvard), Principal cum
I 4

.
458 JOURNAL OF OBSTETRICS AND GYNAECOLOGY OF INDIA
Superintendent, B. S. Medical Col-
lege & Hospitals, Bankura, for his
kind permission to utilise the hospi-
tal records and for various helps. We
are grateful to the colleagues of the
departments of Gynaecology and
Obstetrics and Ophthalmology and
particularly to Dr. D. C. Mukherji,
M.B. (Cal.), D.G.O. (Rotunda)
Hony. Visiting Surgeon. Thanks
are also due to Sri B. C. Sinha, the
ambulance driver, who provided us
the distances in miles of the different
villages of Bankura district from
where our patients came.
Reje1·ences
1. Bose, J.: Bulletin of the Madras
See Figs. on ATt PapeT I
State Ophthalmic Association, •
November, 1963, p. 12.
2. Chattopadhaya, M. L., Mittal, lV:I.
M., Bhargava, S. P , and Sharma,
M. L.: J.I.M.A. 51: 1, 1968.
3. Chattopadhaya: ibid.
4. Duke-Elder, Sir Stewart: Text
Book of Ophthalmology. Vol. I,
London, 1942, Henry Kimpton, p.
982.
5. Government of West Bengal Phar-
macopea of the Medical Collegl....-
Hospitals, Cal. Revised Edition,
1963, p. 305.
G. Kuming, B. S. and Politzer, W. M.:
Brit. J. Oph. 51: 649, 1967.
7. Robert, Clement: LA Medecine
En France. 15: 2, 1967.
...