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Rosu LM, Prodan-Bărbulescu C, Maghiari AL, Bernad ES, Bernad RL, Iacob R, Stoicescu ER, Borozan F, Ghenciu LA. Current Trends in Diagnosis and Treatment Approach of Diabetic Retinopathy during Pregnancy: A Narrative Review. Diagnostics (Basel) 2024; 14:369. [PMID: 38396408 PMCID: PMC10887682 DOI: 10.3390/diagnostics14040369] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2024] [Revised: 02/05/2024] [Accepted: 02/06/2024] [Indexed: 02/25/2024] Open
Abstract
Diabetes mellitus during pregnancy and gestational diabetes are major concerns worldwide. These conditions may lead to the development of severe diabetic retinopathy during pregnancy or worsen pre-existing cases. Gestational diabetes also increases the risk of diabetes for both the mother and the fetus in the future. Understanding the prevalence, evaluating risk factors contributing to pathogenesis, and identifying treatment challenges related to diabetic retinopathy in expectant mothers are all of utmost importance. Pregnancy-related physiological changes, including those in metabolism, blood flow, immunity, and hormones, can contribute to the development or worsening of diabetic retinopathy. If left untreated, this condition may eventually result in irreversible vision loss. Treatment options such as laser therapy, intravitreal anti-vascular endothelial growth factor drugs, and intravitreal steroids pose challenges in managing these patients without endangering the developing baby and mother. This narrative review describes the management of diabetic retinopathy during pregnancy, highlights its risk factors, pathophysiology, and diagnostic methods, and offers recommendations based on findings from previous literature.
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Affiliation(s)
- Luminioara M. Rosu
- Department of Anatomy and Embryology, Victor Babeș University of Medicine and Pharmacy, E. Murgu Square, No. 2, 300041 Timisoara, Romania; (L.M.R.); (A.L.M.); (R.I.); (F.B.)
| | - Cătălin Prodan-Bărbulescu
- Department of Anatomy and Embryology, Victor Babeș University of Medicine and Pharmacy, E. Murgu Square, No. 2, 300041 Timisoara, Romania; (L.M.R.); (A.L.M.); (R.I.); (F.B.)
| | - Anca Laura Maghiari
- Department of Anatomy and Embryology, Victor Babeș University of Medicine and Pharmacy, E. Murgu Square, No. 2, 300041 Timisoara, Romania; (L.M.R.); (A.L.M.); (R.I.); (F.B.)
| | - Elena S. Bernad
- Department of Obstetrics and Gynecology, Victor Babeș University of Medicine and Pharmacy, 300041 Timisoara, Romania;
- Clinic of Obstetrics and Gynecology, “Pius Brinzeu” County Clinical Emergency Hospital, 300723 Timisoara, Romania
- Center for Laparoscopy, Laparoscopic Surgery and In Vitro Fertilization, Victor Babeș University of Medicine and Pharmacy, 300041 Timisoara, Romania
- Department of Automatic Control and Applied Informatics, Politehnica University, 300223 Timisoara, Romania;
| | - Robert L. Bernad
- Department of Automatic Control and Applied Informatics, Politehnica University, 300223 Timisoara, Romania;
| | - Roxana Iacob
- Department of Anatomy and Embryology, Victor Babeș University of Medicine and Pharmacy, E. Murgu Square, No. 2, 300041 Timisoara, Romania; (L.M.R.); (A.L.M.); (R.I.); (F.B.)
- Discipline of Radiology and Medical Imaging, Victor Babeș University of Medicine and Pharmacy, E. Murgu Square, No. 2, 300041 Timisoara, Romania;
| | - Emil Robert Stoicescu
- Discipline of Radiology and Medical Imaging, Victor Babeș University of Medicine and Pharmacy, E. Murgu Square, No. 2, 300041 Timisoara, Romania;
- Research Center for Pharmaco-Toxicological Evaluations, Victor Babeș University of Medicine and Pharmacy, E. Murgu Square, No. 2, 300041 Timisoara, Romania
| | - Florina Borozan
- Department of Anatomy and Embryology, Victor Babeș University of Medicine and Pharmacy, E. Murgu Square, No. 2, 300041 Timisoara, Romania; (L.M.R.); (A.L.M.); (R.I.); (F.B.)
| | - Laura Andreea Ghenciu
- Department of Functional Sciences, Victor Babeș University of Medicine and Pharmacy, E. Murgu Square, No. 2, 300041 Timisoara, Romania;
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Pappot N, Do NC, Vestgaard M, Ásbjörnsdóttir B, Hajari JN, Lund‐Andersen H, Holmager P, Damm P, Ringholm L, Mathiesen ER. Prevalence and severity of diabetic retinopathy in pregnant women with diabetes-time to individualize photo screening frequency. Diabet Med 2022; 39:e14819. [PMID: 35188688 PMCID: PMC9303564 DOI: 10.1111/dme.14819] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/21/2021] [Revised: 01/21/2022] [Accepted: 02/18/2022] [Indexed: 11/29/2022]
Abstract
AIMS To evaluate the prevalence and severity of diabetic retinopathy including macular oedema in pregnant women with diabetes and to identify women in whom the frequency of retinal screening can be reduced to minimize the burden of health care visits. METHODS A cohort study of 348 women with pre-existing diabetes were routinely screened with retinal photo in early (12 weeks) and late pregnancy (27 weeks). Diabetic retinopathy was classified in five stages in accordance with National Danish Guidelines based on the eye with the highest retinopathy level. Sight-threatening retinopathy was defined as the presence of proliferative retinopathy and/or clinically significant macular oedema (CSMO). RESULTS Retinopathy was present in 52% (116/223) vs. 14% (17/125), with sight-threatening retinopathy in 16% (35/223) vs. 6% (7/125) of women with type 1 and type 2, respectively. Women without retinopathy in early and late pregnancy were characterized by shorter diabetes duration (p < 0.0001 and p = 0.008) and predominance of type 2 diabetes. Amongst the 50% (175/348) of the cohort having no retinopathy in early pregnancy and HbA1c<53 mmol/mol (7.0%), none developed sight-threatening retinopathy and 94% (165/175) remained without any retinopathy during pregnancy. Development of sight-threatening retinopathy was mainly observed in women with retinopathy in early pregnancy. Treatment for sight-threatening retinopathy was given to a minority (2.7 and 2.4%, respectively). CONCLUSION Good glycaemic control and no retinopathy was seen in a large proportion of women in early pregnancy and none of these women developed sight-threatening retinopathy. The frequency of retinal screening can probably be safely reduced during pregnancy in these women.
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Affiliation(s)
- Nina Pappot
- Center for Pregnant Women with DiabetesRigshospitaletCopenhagenDenmark
- Department of Endocrinology and MetabolismRigshospitaletCopenhagenDenmark
| | - Nicoline Callesen Do
- Center for Pregnant Women with DiabetesRigshospitaletCopenhagenDenmark
- Department of Endocrinology and MetabolismRigshospitaletCopenhagenDenmark
- Department of Clinical MedicineUniversity of CopenhagenCopenhagenDenmark
| | | | | | - Javad Nouri Hajari
- Department of OphthalmologyRigshospitalet‐Glostrup HospitalCopenhagenDenmark
| | | | - Pernille Holmager
- Center for Pregnant Women with DiabetesRigshospitaletCopenhagenDenmark
- Department of Endocrinology and MetabolismRigshospitaletCopenhagenDenmark
| | - Peter Damm
- Center for Pregnant Women with DiabetesRigshospitaletCopenhagenDenmark
- Department of Clinical MedicineUniversity of CopenhagenCopenhagenDenmark
- Department of ObstetricsRigshospitaletCopenhagenDenmark
| | - Lene Ringholm
- Center for Pregnant Women with DiabetesRigshospitaletCopenhagenDenmark
- Department of Endocrinology and MetabolismRigshospitaletCopenhagenDenmark
| | - Elisabeth Reinhardt Mathiesen
- Center for Pregnant Women with DiabetesRigshospitaletCopenhagenDenmark
- Department of Endocrinology and MetabolismRigshospitaletCopenhagenDenmark
- Department of Clinical MedicineUniversity of CopenhagenCopenhagenDenmark
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Freimane KZ, Kerrigan L, Eastwood KA, Watson CJ. Pre-Eclampsia Biomarkers for Women With Type 1 Diabetes Mellitus: A Comprehensive Review of Recent Literature. Front Bioeng Biotechnol 2022; 10:809528. [PMID: 35721866 PMCID: PMC9198830 DOI: 10.3389/fbioe.2022.809528] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2021] [Accepted: 04/21/2022] [Indexed: 12/26/2022] Open
Abstract
Background: Pre-eclampsia is a serious consideration for women with type 1 diabetes mellitus (T1DM) planning pregnancy. Risk stratification strategies, such as biomarkers measured in the first trimester of pregnancy, could help identify high-risk women. The literature on T1DM-specific pre-eclampsia biomarkers is expanding. We aimed to provide a narrative review of recently published evidence to identify the most promising biomarker candidates that could be targeted for clinical implementation in existing PE models. Methods: A search using MeSH terms was carried out of Medline, EMBASE, Maternity and Infant Care, Web of Science, and Scopus for relevant papers published since 2015 inclusive and in English. The time limit was applied from the publication of the preceding systematic review in this field. Included studies had pre-eclampsia as a primary outcome, measured one or more serum, plasma or urine biomarkers at any time during pregnancy, and had a distinct group of women with T1DM who developed pre-eclampsia. Studies with pre-eclampsia as a composite outcome were not considered. No restrictions on study types were applied. A narrative synthesis approach was adopted for analysis. Results: A total of 510 records were screened yielding 18 eligible studies relating to 32 different biomarkers. Higher first-trimester levels of HbA1c and urinary albumin were associated with an increased risk of pre-eclampsia development in women with T1DM. Urinary neutrophil gelatinase-associated lipocalin and adipokines were novel biomarkers showing moderate predictive ability before 15 gestational weeks. Two T1DM-specific pre-eclampsia prediction models were proposed, measuring adipokines or urinary neutrophil gelatinase-associated lipocalin together with easily attainable maternal clinical characteristics. Contradicting previous literature, pre-eclampsia risk in women with T1DM was correlated with vitamin D levels and atherogenic lipid profile in the context of haptoglobin phenotype 2-2. Pregnancy-associated plasma protein-A and soluble endoglin did not predict pre-eclampsia in women with T1DM, and soluble Fms-like tyrosine kinase 1 only predicted pre-eclampsia from the third trimester. Conclusion: Maternally derived biomarkers reflecting glycemic control, insulin resistance and renal dysfunction performed better as PE predictors among women with T1DM than those derived from the placenta. These biomarkers could be trialed in current PE prediction algorithms to tailor them for women with T1DM.
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Affiliation(s)
- Katrina Z. Freimane
- Wellcome-Wolfson Institute for Experimental Medicine, Queen’s University Belfast, Belfast, United Kingdom
| | - Lauren Kerrigan
- Wellcome-Wolfson Institute for Experimental Medicine, Queen’s University Belfast, Belfast, United Kingdom
| | - Kelly-Ann Eastwood
- School of Medicine, Dentistry and Biomedical Sciences, Centre for Public Health, Queen’s University Belfast, Belfast, United Kingdom
- Department of Fetal Medicine, St. Michael’s Hospital, University Hospitals Bristol and Weston NHS Foundation Trust, Bristol, United Kingdom
| | - Chris J. Watson
- Wellcome-Wolfson Institute for Experimental Medicine, Queen’s University Belfast, Belfast, United Kingdom
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Widyaputri F, Rogers SL, Kandasamy R, Shub A, Symons RCA, Lim LL. Global Estimates of Diabetic Retinopathy Prevalence and Progression in Pregnant Women With Preexisting Diabetes: A Systematic Review and Meta-analysis. JAMA Ophthalmol 2022; 140:486-494. [PMID: 35357410 PMCID: PMC8972153 DOI: 10.1001/jamaophthalmol.2022.0050] [Citation(s) in RCA: 15] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2021] [Accepted: 01/01/2022] [Indexed: 12/15/2022]
Abstract
Importance Diabetic retinopathy (DR) may be worsened by pregnancy in pregnant women with preexisting type 1 diabetes (T1D) or type 2 diabetes (T2D). Conflicting findings from previous studies have resulted in inconsistencies in guidelines regarding DR management in pregnancy. Global estimates of DR prevalence and progression in pregnancy are therefore required to provide clearer information about the overall true burden of DR in this population. Objective To estimate the prevalence of DR and its progression rate in pregnant women with preexisting T1D or T2D diagnosed before pregnancy. Data Sources For this systematic review and meta-analysis, conducted from November 27, 2018, to June 29, 2021, a systematic literature search was conducted in MEDLINE/Ovid, Embase/Ovid, and Scopus databases to identify English-language articles that were published from inception through October 2020. Study Selection Observational studies that reported on DR and its changes in pregnant women with preexisting T1D and T2D. Data Extraction and Synthesis Two independent reviewers extracted relevant data from each included study. Data were pooled using a random-effects model with the Freeman-Tukey double arcsine transformation. This study followed the Meta-analysis of Observational Studies in Epidemiology (MOOSE) reporting guidelines. Main Outcomes and Measures Prevalence of any DR, proliferative DR (PDR), and DR progression rates. Results A total of 18 observational studies involving 1464 pregnant women with T1D and 262 pregnant women with T2D were included in the analysis. The pooled prevalence of any DR and PDR in early pregnancy was 52.3 (95% CI, 41.9-62.6) and 6.1 (95% CI, 3.1-9.8) per 100 pregnancies, respectively. The pooled progression rate per 100 pregnancies for new DR development was 15.0 (95% CI, 9.9-20.8), worsened nonproliferative DR was 31.0 (95% CI, 23.2-39.2), progression from nonproliferative DR to PDR was 6.3 (95% CI, 3.3-10.0), and worsened PDR was 37.0 (95% CI, 21.2-54.0). DR progression rates per 100 pregnancies were similar between the T1D and T2D groups, except for the development of new DR (T1D groups: 15.8; 95% CI, 10.5-21.9; T2D groups: 9.0; 95% CI, 4.9-14.8). A global trend toward a lower DR progression rate was observed after the 1989 St Vincent Declaration. Conclusions and Relevance Results of this systematic review and meta-analysis suggest that women with T1D and T2D had a similar risk of DR progression during pregnancy. Despite improvements in the management of diabetes and diabetes during pregnancy, DR prevalence and progression in pregnant women with diabetes remains higher than the nonpregnant population with diabetes, highlighting the need to improve DR management in pregnancy.
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Affiliation(s)
- Felicia Widyaputri
- Ophthalmology, Department of Surgery, University of Melbourne, Melbourne, Australia
- Centre for Eye Research Australia, Melbourne, Australia
- Department of Ophthalmology, Faculty of Medicine, Public Health and Nursing, Universitas Gadjah Mada, Yogyakarta, Indonesia
| | | | | | - Alexis Shub
- Department of Obstetrics and Gynecology, University of Melbourne, Melbourne, Australia
- Department of Obstetrics and Gynecology, Mercy Hospital for Women, Melbourne, Australia
| | - Robert C. A. Symons
- Ophthalmology, Department of Surgery, University of Melbourne, Melbourne, Australia
- Centre for Eye Research Australia, Melbourne, Australia
- Department of Optometry and Vision Sciences, University of Melbourne, Melbourne, Australia
| | - Lyndell L. Lim
- Ophthalmology, Department of Surgery, University of Melbourne, Melbourne, Australia
- Centre for Eye Research Australia, Melbourne, Australia
- Royal Victorian Eye and Ear Hospital, Melbourne, Australia
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Scanlon PH. Improving the screening of risk factors in diabetic retinopathy. Expert Rev Endocrinol Metab 2022; 17:235-243. [PMID: 35730170 DOI: 10.1080/17446651.2022.2078305] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/05/2022] [Accepted: 05/12/2022] [Indexed: 10/17/2022]
Abstract
INTRODUCTION In 2002, Diabetic Retinopathy was reported as the leading cause of blindness in the working age group. The introduction of systematic screening programs in the UK has reduced visual loss and blindness due to diabetic retinopathy, but it does still occur with catastrophic consequences for the individual. AREAS COVERED The author conducted an ongoing search for articles relating to diabetic retinopathy since 2000 utilizing Zetoc Alert with keywords and contents page lists from relevant journals. This review covers the risk factors for loss of vision due to diabetic retinopathy and discusses ways in which the awareness of these risk factors can be used to further reduce visual loss. Some risk factors such as glycemic and B/P control are well known from landmark trials. This review has included these factors but concentrated more on the evidence behind those risk factors that are not so clearly defined or so well known. EXPERT OPINION The major risk factors are well known, but one continues to find that people with diabetes lose vision in situations in which a better awareness of the risks by both the individual with diabetes and the health workers involved may have prevented the visual loss.
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Affiliation(s)
- Peter H Scanlon
- Consultant Ophthalmologist, Department of Ophthalmologist, Gloucestershire Hospitals NHS Foundation Trust Cheltenham, UK
- National Clinical Lead, NHS Diabetic Eye Screening Programme (Ophthalmology), Public Health Commissioning and Operations, England
- Associate Professor, Nuffield Department of Clinical Neuroscience, University of Oxford, UK
- Visiting Professor, School of Health and Social Care, University of Gloucestershire, UK
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Kruit H, Mertsalmi S, Rahkonen L. Planned vaginal and planned cesarean delivery outcomes in pregnancies complicated with pregestational type 1 diabetes - A three-year academic tertiary hospital cohort study. BMC Pregnancy Childbirth 2022; 22:173. [PMID: 35236314 PMCID: PMC8892757 DOI: 10.1186/s12884-022-04510-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2021] [Accepted: 02/23/2022] [Indexed: 11/29/2022] Open
Abstract
Background Finland has the world’s highest incidence of 62.5/100000 of diabetes mellitus type 1 (DM1) with approximately 400 (1%) DM1 pregnancies annually. Pregnancies complicated by DM1 are accompanied with increased risk for perinatal morbidity and mortality. Timing and mode of delivery are based on the risk of complications, yet the data on labor induction is limited. The aim of this study was to compare delivery outcomes in planned vaginal (VD) and planned cesarean deliveries (CD) in late preterm and term DM1 pregnancies, and to evaluate the feasibility of labor induction. Materials and Methods Pregnant women with DM1, live singleton fetus in cephalic presentation ≥34 gestational weeks delivering in Helsinki University Hospital between January 1st 2017 and December 31st 2019 were included. The primary outcome were the rates of adverse maternal and perinatal outcome. The study population was classified according to the 1980-revised White’s classification. Statistical analyses were performed by IBM SPSS Statistics for Windows. Results Two hundred four women were included, 59.8% (n = 122) had planned VD. The rate of adverse maternal outcome was 27.5% (n = 56), similar between the planned modes of delivery and White classes. The rate of perinatal adverse outcome was 38.7% (n = 79), higher in planned CD (52.4% vs. 29.5%;p = 0.001). The most common adverse perinatal event was respiratory distress (48.8% vs. 23.0%;p < 0.001). The rate of adverse perinatal outcome was higher in White class D + Vascular compared to B + C (45.0% vs. 25.0%, OR after adjustment by gestational age 2.34 [95% CI 1.20–4.50];p = 0.01). The total rate of CD was 63.7% (n = 130), and 39.3% (n = 48) in planned VD. Women with White class D + Vascular more often had emergency CD compared to White Class B + C (48.6% vs. 25.0%;p = 0.009). The rate of labor induction was 51%, being 85.2% in planned VD. The rate of VD in induced labor was 58.7% (n = 61) and the rate of failed induction was 14.1% (n = 15). Conclusion Planned VD was associated with lower rate of adverse perinatal outcome compared to planned CS, with no difference in the rates of adverse maternal outcome. Induction of labor may be feasible option but should be carefully considered in this high-risk population.
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Affiliation(s)
- Heidi Kruit
- Department of Obstetrics and Gynecology, University of Helsinki and Helsinki University Hospital, Haartmaninkatu 2, 00029 HUS, Helsinki, Finland.
| | - Saara Mertsalmi
- Department of Internal Medicine, Hyvinkää Hospital Sairaalankatu 1, 05850, Hyvinkää, Finland
| | - Leena Rahkonen
- Department of Obstetrics and Gynecology, University of Helsinki and Helsinki University Hospital, Haartmaninkatu 2, 00029 HUS, Helsinki, Finland
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Relph S, Patel T, Delaney L, Sobhy S, Thangaratinam S. Adverse pregnancy outcomes in women with diabetes-related microvascular disease and risks of disease progression in pregnancy: A systematic review and meta-analysis. PLoS Med 2021; 18:e1003856. [PMID: 34807920 PMCID: PMC8654151 DOI: 10.1371/journal.pmed.1003856] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/24/2021] [Revised: 12/08/2021] [Accepted: 10/26/2021] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND The rise in the global prevalence of diabetes, particularly among younger people, has led to an increase in the number of pregnant women with preexisting diabetes, many of whom have diabetes-related microvascular complications. We aimed to estimate the magnitude of the risks of adverse pregnancy outcomes or disease progression in this population. METHODS AND FINDINGS We undertook a systematic review and meta-analysis on maternal and perinatal complications in women with type 1 or 2 diabetic microvascular disease and the risk factors for worsening of microvascular disease in pregnancy using a prospective protocol (PROSPERO CRD42017076647). We searched major databases (January 1990 to July 2021) for relevant cohort studies. Study quality was assessed using the Newcastle-Ottawa Scale. We summarized the findings as odds ratios (ORs) with 95% confidence intervals (CIs) using random effects meta-analysis. We included 56 cohort studies involving 12,819 pregnant women with diabetes; including 40 from Europe and 9 from North America. Pregnant women with diabetic nephropathy were at greater risk of preeclampsia (OR 10.76, CI 6.43 to 17.99, p < 0.001), early (<34 weeks) (OR 6.90, 95% CI 3.38 to 14.06, p < 0.001) and any preterm birth (OR 4.48, CI 3.40 to 5.92, p < 0.001), and cesarean section (OR 3.04, CI 1.24 to 7.47, p = 0.015); their babies were at higher risk of perinatal death (OR 2.26, CI 1.07 to 4.75, p = 0.032), congenital abnormality (OR 2.71, CI 1.58 to 4.66, p < 0.001), small for gestational age (OR 16.89, CI 7.07 to 40.37, p < 0.001), and admission to neonatal unit (OR 2.59, CI 1.72 to 3.90, p < 0.001) compared to those without nephropathy. Diabetic retinopathy was associated with any preterm birth (OR 1.67, CI 1.27 to 2.20, p < 0.001) and preeclampsia (OR 2.20, CI 1.57 to 3.10, p < 0.001) but not other complications. The risks of onset or worsening of retinopathy were increased in women who were nulliparous (OR 1.75, 95% CI 1.28 to 2.40, p < 0.001), smokers (OR 2.31, 95% CI 1.25 to 4.27, p = 0.008), with existing proliferative disease (OR 2.12, 95% CI 1.11 to 4.04, p = 0.022), and longer duration of diabetes (weighted mean difference: 4.51 years, 95% CI 2.26 to 6.76, p < 0.001) compared to those without the risk factors. The main limitations of this analysis are the heterogeneity of definition of retinopathy and nephropathy and the inclusion of women both with type 1 and type 2 diabetes. CONCLUSIONS In pregnant women with diabetes, presence of nephropathy and/or retinopathy appear to further increase the risks of maternal complications.
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Affiliation(s)
- Sophie Relph
- Department of Women & Children’s Health, King’s College London, London, United Kingdom
| | - Trusha Patel
- Department of Women’s Health, Barnet Hospital, Royal Free NHS Foundation Trust, London, United Kingdom
| | - Louisa Delaney
- Department of Women & Children’s Health, King’s College London, London, United Kingdom
| | - Soha Sobhy
- Barts Research Centre for Women’s Health (BARC), Barts and the London School of Medicine and Dentistry, London, United Kingdom
| | - Shakila Thangaratinam
- WHO Collaborating Centre for Global Women’s Health, Institute of Metabolism and Systems Research, University of Birmingham, Birmingham, United Kingdom
- Birmingham Women’s and Children’s NHS Foundation Trust, Birmingham, United Kingdom
- * E-mail:
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Abstract
PURPOSE OF REVIEW The aim of this study was to summarize common eye changes that may occur during pregnancy, and how pregnancy may affect preexisting eye conditions such as glaucoma and diabetic retinopathy. Challenges and complexities surrounding the treatment of these eye conditions during pregnancy are also highlighted. RECENT FINDINGS Refractive changes are common and may persist in the postpartum in patients with keratoconus. Although new medical and surgical glaucoma treatments are available, their safety in pregnancy is unknown. Limited use of topical and systemic glaucoma therapies is recommended, with a preference for selective laser trabeculoplasty as first line treatment in appropriate cases. The impact of pregnancy on diabetic retinopathy remains unclear. Although anti-vascular endothelial growth factor agents are first-line treatment for sight-threatening diabetic retinopathy, their effect on the developing foetus remains unknown and are therefore best avoided in the first and second trimesters. Noninfectious uveitis tends to become less active during pregnancy, allowing the potential tapering of systemic therapy and the use of local topical or injected corticosteroid treatment for active disease as required. SUMMARY Significant changes can occur to the eye during pregnancy, wherein the optimal treatment for many ocular conditions remains uncertain, highlighting the need for further research to develop clear recommendations that best balance the need to preserve the mother's sight, and the health of the developing foetus. The need for preconception planning, and collaborative multidisciplinary care between the obstetrician, physician, ophthalmologist and paediatrician is paramount.
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Affiliation(s)
- Edmund W C Khong
- Department of Surgery, Central Clinical School, Monash University
- Centre for Eye Research Australia, University of Melbourne
| | - Helen H L Chan
- Royal Victorian Eye and Ear Hospital
- Department of Ophthalmology, Royal Melbourne Hospital, Melbourne, Victoria
| | - Stephanie L Watson
- Save Sight Institute, Sydney Medical School, University of Sydney
- Corneal Unit, Sydney Eye Hospital, Sydney, New South Wales, Australia
| | - Lyndell L Lim
- Centre for Eye Research Australia, University of Melbourne
- Royal Victorian Eye and Ear Hospital
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9
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Chandrasekaran PR, Madanagopalan VG, Narayanan R. Diabetic retinopathy in pregnancy - A review. Indian J Ophthalmol 2021; 69:3015-3025. [PMID: 34708737 PMCID: PMC8725079 DOI: 10.4103/ijo.ijo_1377_21] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Diabetes and gestational diabetes (GD) are areas of concern worldwide. GD can eventually lead to serious development of diabetic retinopathy (DR) during pregnancy or worsening of an already existing DR. GD confers future risk of diabetes, both in the mother and fetus, further complicating their lives. DR in pregnant women has been intriguing in terms of understanding the prevalence, assessing risk factors causing pathogenesis, and problems associated with treating them. Pregnancy itself is a risk factor for progression of DR. Physiological changes such as metabolic, vascular, immunologic, and hormonal changes that occur during pregnancy can cause development as well as worsening of DR. This can eventually lead to permanent visual loss if not addressed on time. Timing of laser, choice of treatment for diabetic macular edema with laser, intravitreal anti-vascular endothelial growth factor agents (VEGF), and intravitreal steroids pose a serious challenge in managing these patients without causing damage to the mother and fetus. This review article showcases the prevalence, risk factors, and pathogenesis, outlines the management of DR in pregnancy, and recommends guidelines based on the available evidence. PubMed and MEDLINE searches were performed pertaining to the prevalence of GD in India, DR in pregnancy, risk factors for progression of DR, role of vasoactive mediators in DR, role of angiopoietic factors in DR, hormonal influence of DR, role of growth factors in DR, use of fluorescein and indocyanine green angiography, retinal lasers, anti-VEGF agents, intravitreal steroids, anesthesia, and retinal surgery, all pertaining to pregnancy and guidelines and recommendations for managing DR in pregnancy.
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Affiliation(s)
| | - V G Madanagopalan
- Cataract and Vitreoretinal Services, JB Eye Hospital, Salem, Tamil Nadu, India
| | - Raja Narayanan
- Director-The Retina Institute and Suven Clinical Research Centre, Consultant Ophthalmologist, Vitreo Retinal Diseases, Kallam Anji Reddy Campus, L V Prasad Eye Institute, Hyderabad, Telangana, India
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Choo PP, Md Din N, Azmi N, Bastion MLC. Review of the management of sight-threatening diabetic retinopathy during pregnancy. World J Diabetes 2021; 12:1386-1400. [PMID: 34630896 PMCID: PMC8472492 DOI: 10.4239/wjd.v12.i9.1386] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/25/2021] [Revised: 06/25/2021] [Accepted: 08/12/2021] [Indexed: 02/06/2023] Open
Abstract
Diabetes mellitus (DM) is a noncommunicable disease reaching epidemic proportions around the world. It affects younger individuals, including women of childbearing age. Diabetes can cause diabetic retinopathy (DR), which is potentially sight threatening when severe nonproliferative DR (NPDR), proliferative DR (PDR), or sight-threatening diabetic macular oedema (STDME) develops. Pregnancy is an independent risk factor for the progression of DR. Baseline DR at the onset of pregnancy is an important indicator of progression, with up to 10% of women with baseline NPDR progressing to PDR. Progression to sight-threatening DR (STDR) during pregnancy causes distress to the patient and often necessitates ocular treatment, which may have a systemic effect. Management includes prepregnancy counselling and, when possible, conventional treatment prior to pregnancy. During pregnancy, closer follow-up is required for those with a long duration of DM, poor baseline control of blood sugar and blood pressure, and worse DR, as these are risk factors for progression to STDR. Conventional treatment with anti-vascular endothelial growth factor agents for STDME can potentially lead to foetal loss. Treatment with laser photocoagulation may be preferred, and surgery under general anaesthesia should be avoided. This review provides a management plan for STDR from the perspective of practising ophthalmologists. A review of strategies for maintaining the eyesight of diabetic women with STDR with emphasis on prepregnancy counselling and planning, monitoring and safe treatment during pregnancy, and management of complications is presented.
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Affiliation(s)
- Priscilla Peixi Choo
- Department of Ophthalmology, Universiti Kebangsaan Malaysia Medical Centre, Kuala Lumpur 56000, Wilayah Persekutuan, Malaysia
| | - Norshamsiah Md Din
- Department of Ophthalmology, Universiti Kebangsaan Malaysia Medical Centre, Kuala Lumpur 56000, Wilayah Persekutuan, Malaysia
| | - Nooraniah Azmi
- Department of Ophthalmology, Universiti Kebangsaan Malaysia Medical Centre, Kuala Lumpur 56000, Wilayah Persekutuan, Malaysia
- Department of Ophthalmology, Universiti Putra Malaysia, Serdang 43400, Selangor, Malaysia
| | - Mae-Lynn Catherine Bastion
- Department of Ophthalmology, Universiti Kebangsaan Malaysia Medical Centre, Kuala Lumpur 56000, Wilayah Persekutuan, Malaysia
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Diabetic retinopathy and diabetic macular oedema pathways and management: UK Consensus Working Group. Eye (Lond) 2021; 34:1-51. [PMID: 32504038 DOI: 10.1038/s41433-020-0961-6] [Citation(s) in RCA: 82] [Impact Index Per Article: 27.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
The management of diabetic retinopathy (DR) has evolved considerably over the past decade, with the availability of new technologies (diagnostic and therapeutic). As such, the existing Royal College of Ophthalmologists DR Guidelines (2013) are outdated, and to the best of our knowledge are not under revision at present. Furthermore, there are no other UK guidelines covering all available treatments, and there seems to be significant variation around the UK in the management of diabetic macular oedema (DMO). This manuscript provides a summary of reviews the pathogenesis of DR and DMO, including role of vascular endothelial growth factor (VEGF) and non-VEGF cytokines, clinical grading/classification of DMO vis a vis current terminology (of centre-involving [CI-DMO], or non-centre involving [nCI-DMO], systemic risks and their management). The excellent UK DR Screening (DRS) service has continued to evolve and remains world-leading. However, challenges remain, as there are significant variations in equipment used, and reproducible standards of DMO screening nationally. The interphase between DRS and the hospital eye service can only be strengthened with further improvements. The role of modern technology including optical coherence tomography (OCT) and wide-field imaging, and working practices including virtual clinics and their potential in increasing clinic capacity and improving patient experiences and outcomes are discussed. Similarly, potential roles of home monitoring in diabetic eyes in the future are explored. The role of pharmacological (intravitreal injections [IVT] of anti-VEGFs and steroids) and laser therapies are summarised. Generally, IVT anti-VEGF are offered as first line pharmacologic therapy. As requirements of diabetic patients in particular patient groups may vary, including pregnant women, children, and persons with learning difficulties, it is important that DR management is personalised in such particular patient groups. First choice therapy needs to be individualised in these cases and may be intravitreal steroids rather than the standard choice of anti-VEGF agents. Some of these, but not all, are discussed in this document.
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12
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Bourry J, Courteville H, Ramdane N, Drumez E, Duhamel A, Subtil D, Deruelle P, Vambergue A. Progression of Diabetic Retinopathy and Predictors of Its Development and Progression During Pregnancy in Patients With Type 1 Diabetes: A Report of 499 Pregnancies. Diabetes Care 2021; 44:181-187. [PMID: 33177172 DOI: 10.2337/dc20-0904] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/21/2020] [Accepted: 10/19/2020] [Indexed: 02/03/2023]
Abstract
OBJECTIVE Pregnancy has been associated with development and progression of diabetic retinopathy (DR), but incidence of DR remains unclear. We assessed DR progression rate and its predictors during pregnancies in patients with type 1 diabetes. RESEARCH DESIGN AND METHODS We report the retrospective data from pregnancies in patients with type 1 diabetes followed in Lille, France (1997-2015). Eye examination was performed every 3 months or every month in case of severe nonproliferative retinopathy or progression. Progression was defined by DR degradation (≥1 stage of the Early Treatment Diabetic Retinopathy Study [ETDRS] classification); it included DR development and worsening in patients without and with prepregnancy DR, respectively. RESULTS A total of 499 pregnancies in 375 patients were included; prepregnancy retinopathy was present in 30.3%. Progression, development, and worsening rates were 21.8%, 24.4% of those without retinopathy, and 15.9% of those with retinopathy, respectively. Development of sight-threatening retinopathy was rare. Progression mainly occurred in early or midpregnancy. Elevated prepregnancy HbA1c and duration of diabetes ≥10 years were predictors of DR progression. Among pregnancies with prepregnancy DR, continuous subcutaneous insulin infusion (CSII) tended to decrease the risk of DR progression. Among CSII-treated patients, those with prepregnancy DR had a significantly decreased risk of DR progression. Among the 270 pregnancies of women with any DR during pregnancy who returned for a postpartum ophthalmologic examination, the rate of progression was only 4.1% and the rate of regression was 9.3%. CONCLUSIONS This study provides epidemiologic data on progression of retinopathy during pregnancy and will be useful for future guidelines for retinopathy screening.
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Affiliation(s)
- Julien Bourry
- Department of Diabetology, Endocrinology and Metabolism, Lille University Hospital, Lille, France
| | | | - Nassima Ramdane
- EA 2694 - Santé publique: épidémiologie et qualité des soins, CHU Lille, University Lille, Lille, France
| | - Elodie Drumez
- EA 2694 - Santé publique: épidémiologie et qualité des soins, CHU Lille, University Lille, Lille, France
| | - Alain Duhamel
- EA 2694 - Santé publique: épidémiologie et qualité des soins, CHU Lille, University Lille, Lille, France.,European Genomic Institute for Diabetes, University School of Medicine, Lille, France
| | - Damien Subtil
- European Genomic Institute for Diabetes, University School of Medicine, Lille, France.,Department of Gynecology and Obstetrics, Lille University Hospital, Lille, France
| | - Philippe Deruelle
- European Genomic Institute for Diabetes, University School of Medicine, Lille, France.,Department of Gynecology and Obstetrics, Lille University Hospital, Lille, France
| | - Anne Vambergue
- Department of Diabetology, Endocrinology and Metabolism, Lille University Hospital, Lille, France .,European Genomic Institute for Diabetes, University School of Medicine, Lille, France.,Department of Gynecology and Obstetrics, Lille University Hospital, Lille, France
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13
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Battarbee AN, Cavallini M, Keller C, Boggess KA. Missed Opportunities for Early Diabetes Screening in Pregnancy. Am J Perinatol 2021; 38:23-27. [PMID: 31421638 DOI: 10.1055/s-0039-1694727] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
OBJECTIVE This study aimed to identify characteristics of women at risk of undiagnosed type 2 diabetes mellitus (T2DM) that fail to receive early pregnancy screening. STUDY DESIGN This was a retrospective case-control study of at-risk women who initiated care at the University of North Carolina at Chapel Hill at <21 weeks from January 2015 to December 2015. In 2013, the American College of Obstetricians and Gynecologists and the American Diabetes Association recommended women with prior GDM, glucose intolerance, or body mass index (BMI) ≥ 30 kg/m2 receive early pregnancy screening for undiagnosed T2DM. We defined early screening as 1-hour 50-g glucose challenge test or hemoglobin A1c at <21 weeks' gestation. Cases were women who did not have early screening, and controls were women who did. Modified Poisson regression with robust error variance estimated relative risks of factors associated with missed early screening. RESULTS Of the 1,932 women who initiated care at <21 weeks, 257 (13%) women were at risk of undiagnosed T2DM and, thus, candidates for early screening. However, 129 (50.2%) women were not screened. Higher BMI and prior GDM were associated with a lower relative risk of missed screening. CONCLUSION Higher BMI and prior GDM increased the likelihood of early diabetes screening, but only half of at-risk women were screened. Provider education and best practice alert systems are needed to increase screening for undiagnosed T2DM.
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Affiliation(s)
- Ashley N Battarbee
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, University of North Carolina School of Medicine, Chapel Hill, North Carolina
| | - Maximiliano Cavallini
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, University of North Carolina School of Medicine, Chapel Hill, North Carolina
| | - Catherine Keller
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, University of North Carolina School of Medicine, Chapel Hill, North Carolina
| | - Kim A Boggess
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, University of North Carolina School of Medicine, Chapel Hill, North Carolina
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14
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Whittington JR, Cummings KF, Ounpraseuth ST, Aughenbaugh AL, Quick CM, Dajani NK. Placental changes in diabetic pregnancies and the contribution of hypertension. J Matern Fetal Neonatal Med 2020; 35:486-494. [PMID: 32075455 DOI: 10.1080/14767058.2020.1724944] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Objective: To evaluate placental abnormalities in pregnancies affected by diabetes compared to unaffected pregnancies from a single academic center.Methods: This is a retrospective cohort study of women with singleton gestations delivered at the University of Arkansas for Medical Sciences from 2007 to 2016. Pathologic examination of placentas from pregestational and gestational diabetic pregnancies were compared to placentas from patients without diabetes using 12 histologic elements. Maternal and neonatal outcomes were extracted from the medical record and compared between groups. Findings were adjusted for hypertensive disorders of pregnancy. Placental lesions were also correlated with diabetic control.Results: Pathology reports of 590 placentas along with corresponding medical records were reviewed. The diabetic group (N = 484) consisted of 188 patients with pregestational diabetes and 296 patients with gestational diabetes. The nondiabetic group consisted of 106 patients. The diabetic group was older, had a higher average BMI, and more hypertensive disorders (p < .0001). Out of the 12 histologic elements investigated, accelerated villous maturation (aOR = 8.45, 95%CI (1.13-62.95)) and increased placental weight (aOR = 3.131, 95% CI (1.558-6.293)) were noted to be significantly increased in placentas from diabetic pregnancies after controlling for hypertension. Intervillous thrombi were not significantly increased in pregnancies affected by diabetes. Neonates of the diabetic group were more likely to be large for gestational age (p < .0001) and had a higher rate of preterm delivery (p < .0001).Conclusions: Accelerated villous maturation was found to be more frequent in pregnancies complicated by pregestational diabetes, even after controlling for hypertension. In pregnancies complicated by gestational diabetes, the placental findings were not significant after controlling for hypertension. In contrast with prior studies, there was no increase in thrombotic lesions of the placenta in patients with diabetes.
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Affiliation(s)
- Julie R Whittington
- Department of Obstetrics and Gynecology, University of Arkansas for Medical Sciences, Little Rock, AR, USA
| | - Kelly F Cummings
- Department of Obstetrics and Gynecology, Marshall Health, Huntington, WV
| | - Songthip T Ounpraseuth
- Department of Biostatistics, University of Arkansas for Medical Sciences, Little Rock, AR, USA
| | - Ashley L Aughenbaugh
- Department of Obstetrics and Gynecology, Louisiana State University Health, Shreveport, LA, USA
| | - Charles M Quick
- Department of Pathology, University of Arkansas for Medical Sciences, Little Rock, AR, USA
| | - Nafisa K Dajani
- Department of Obstetrics and Gynecology, University of Arkansas for Medical Sciences, Little Rock, AR, USA
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Abstract
INTRODUCTION Pregnancy is a risk factor for progression of diabetic retinopathy (DR). Despite the common opinion about the regression of DR after childbirth, it is possible for the disease to progress aggressively, which can cause loss of visual functions when treated untimely. PURPOSE To present clinical cases with different course of development of DR in pregnant women with type 1 diabetes mellitus (DM1). MATERIAL AND METHODS Five pregnant women with DM1 lasting more than 8 years were examined. Glycemic level of all patients was higher than normal (glycated hemoglobin (HbA1c) of more than 6.1%). Ophthalmologic examination was carried out including fundus photography, optical coherence tomography (OCT) of the macular area, Angio-OCT. RESULTS The most significant factors in the progression of DR in pregnant women are DR1 compensation, severity and stabilization of DR during the preconception period, presence of a concomitant pathology. Timely detection of signs of progression of DR and therapeutic measures taken during pregnancy, in particular laser coagulation, were shown to stabilize the course of the disease and prevent loss of vision in pregnant women with DM1. CONCLUSION Clinical course of DR in pregnancy can vary between absence of manifestation, stabilization, and progression. Progression of DR during pregnancy is determined by a number of factors including compensation of DM during the preconception period and throughout pregnancy, severity and stabilization of retinopathy during the preconception period, and presence of a concomitant pathology. Timely detection of the signs of DR progression and its treatment, in particular laser coagulation of the retina, can help stabilize the course of the disease during pregnancy. The course of DR may be aggressive in some pregnant women involving progression in the postpartum period, which warrants active monitoring of patients with retinopathy after childbirth.
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Affiliation(s)
- N V Pomytkina
- Khabarovsk branch of S. Fyodorov Eye Microsurgery Federal State Institution, 211 Tikhookeanskaia St., Khabarovsk, Russian Federation, 680033
| | - E L Sorokin
- Khabarovsk branch of S. Fyodorov Eye Microsurgery Federal State Institution, 211 Tikhookeanskaia St., Khabarovsk, Russian Federation, 680033; Far-Eastern State Medical University, 35 Muravyov-Amursky St., Khabarovsk, Russian Federation, 680000
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16
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Zurawska-Klis M, Cypryk K. The Impact of Pregnancy and Parity on Type 1 Diabetes Complications. Curr Diabetes Rev 2019; 15:429-434. [PMID: 30648512 DOI: 10.2174/1573399815666190115143538] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/26/2018] [Revised: 09/11/2018] [Accepted: 01/08/2019] [Indexed: 11/22/2022]
Abstract
BACKGROUND The potential influence of pregnancy and parity on the risk of chronic diabetic complications is a matter of great concern and constant discussion. This aspect seems relevant and should be the subject of thorough discussion with the woman planning childbirth. INTRODUCTION Current data concerning the impact of pregnancy and parity covers primarily retinopathy and nephropathy, while the aspects of neuropathy and macrovascular complications are unsatisfactorily documented. Majority of studies focus on single complication only, while the number of papers assessing this problem in a complex setting is limited. The available body of evidence concerns mainly the short-term impact of pregnancy on diabetic chronic complications while the data concerning the longer perspective are scarce. Moreover, the results found in the available literature are conflicting. The aim of the study was to summarize all available data concerning the longer impact of parity on the chronic complications in the women with type 1 diabetes. METHODS PubMed database has been searched between October 2013 and September 2018 and all relevant papers were selected. This review summarizes data on the impact of pregnancy and parity on chronic complications in type 1 diabetic women. RESULTS Current data assessing this matter in a complex way are limited, and the available results are controversial. It seems however that pregnancy itself may rather influence pre-existing diabetic complication than affect risk of its development. Additionally, evidence suggests that any deleterious changes appearing during pregnancy are transient and tend to remit after delivery. CONCLUSION It seems that neither pregnancy nor parity affects the risk of diabetic chronic complications in the longer perspective.
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Affiliation(s)
- Monika Zurawska-Klis
- Department of Internal Diseases and Diabetology, Medical University of Lodz, Pomorska Str. 251, 92-213 Lodz, Poland
| | - Katarzyna Cypryk
- Department of Internal Diseases and Diabetology, Medical University of Lodz, Pomorska Str. 251, 92-213 Lodz, Poland
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18
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Benfica CZ, Zanella T, Farias LB, Oppermann MLR, Canani LHS, Lavinsky D. Macular choroidal thickness in pregnant women with type 1, type 2 and gestational diabetes mellitus measured by spectral-domain optical coherence tomography. Clin Ophthalmol 2018; 12:1259-1265. [PMID: 30050277 PMCID: PMC6055625 DOI: 10.2147/opth.s166620] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023] Open
Abstract
Purpose To analyze choroidal thickness (CT) of pregnant women with type 1 diabetes mellitus (DM), type 2 DM and gestational diabetes mellitus (GDM) using spectral-domain optical coherence tomography. Patients and methods This cross-sectional study included 144 eyes of 72 pregnant women in the third trimester divided into four groups: 27 non-diabetic pregnant women; 15 pregnant women with GDM; 16 with type 2 DM and 14 with type 1 DM. CT was measured using optical coherence tomography at ten different locations. We also analyzed possible confounding factors, such as gestational age, glycosylated hemoglobin, time from DM diagnosis, hypertension and severity of diabetic retinopathy. Results The comparison between the four groups showed a thinner choroid in patients with type 1 DM in all locations, with statistical significance in subfoveal and temporal measurements. When comparing only patients with type 1 and type 2 DM, adjusting for confounding factors, the choroid of patients with type 1 DM remained thinner at all macular points, also with statistical significance in subfoveal and temporal measurements. Conclusion Pregnant women with type 1 DM had significantly thinner CT measurements on subfoveal and temporal locations. No differences were found in CT between the control group and pregnant women with GDM and type 2 DM.
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Affiliation(s)
- Camila Zanella Benfica
- Universidade Federal do Rio Grande do Sul (UFRGS), Porto Alegre, Brazil, .,Department of Ophthalmology, Hospital de Clínicas de Porto Alegre, Porto Alegre, Brazil,
| | - Teresinha Zanella
- Department of Gynecology and Obstetrics, Hospital de Clínicas de Porto Alegre, Porto Alegre, Brazil
| | - Lucas Brandolt Farias
- Universidade Federal do Rio Grande do Sul (UFRGS), Porto Alegre, Brazil, .,Department of Ophthalmology, Hospital de Clínicas de Porto Alegre, Porto Alegre, Brazil,
| | - Maria Lúcia Rocha Oppermann
- Universidade Federal do Rio Grande do Sul (UFRGS), Porto Alegre, Brazil, .,Department of Gynecology and Obstetrics, Hospital de Clínicas de Porto Alegre, Porto Alegre, Brazil
| | - Luis Henrique Santos Canani
- Universidade Federal do Rio Grande do Sul (UFRGS), Porto Alegre, Brazil, .,Department of Endocrinology, Hospital de Clínicas de Porto Alegre, Porto Alegre, Brazil
| | - Daniel Lavinsky
- Universidade Federal do Rio Grande do Sul (UFRGS), Porto Alegre, Brazil, .,Department of Ophthalmology, Hospital de Clínicas de Porto Alegre, Porto Alegre, Brazil,
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Makwana T, Takkar B, Venkatesh P, Sharma JB, Gupta Y, Chawla R, Vohra R, Kriplani A, Tandon N. Prevalence, progression, and outcomes of diabetic retinopathy during pregnancy in Indian scenario. Indian J Ophthalmol 2018; 66:541-546. [PMID: 29582816 PMCID: PMC5892058 DOI: 10.4103/ijo.ijo_1062_17] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023] Open
Abstract
Purpose The objective of this study is to evaluate pattern of diabetic retinopathy (DR) during pregnancy in females with pregestational diabetes mellitus (DM). Methods This is an ambispective observational cohort study conducted at an Indian tertiary care centre. A total of 50 pregnant females with pregestational DM were included while those with gestational DM were excluded from the study. Ocular examination (inclusive of fundus photography) was conducted and systemic parameters (inclusive of Glycated hemoglobin) were assessed during each of the 3 trimesters and 3 months postpartum. The prevalence and progression of DR during pregnancy in the study cohort were the main outcome measures. Results Three of the 50 patients had type 1 DM while 47 had type II DM. All the patients with type I DM were insulin dependent while 19 patients with type II DM were insulin dependent. Overall prevalence of DR was 8% (4/50); 2 cases had nonproliferative DR (NPDR), and 2 had proliferative DR (PDR). During the study period, worsening was seen in both the patients with PDR and one required vitrectomy. Mean visual acuity in patients with PDR decreased from 0.77 logMAR units at presentation to 1.23 logMAR at final follow-up. There was no change in the mean visual acuity of patients with NPDR. None of the patients with NPDR converted to PDR. There was no new onset DR in the patients without DR at presentation. Assessment of risk factors for DR revealed significantly higher duration of DM (14 ± 6.32 years vs. 3.43 ± 1.43 years, P = 0.0008). The median age was also higher in the DR patients (31 years vs. 29 years, P = 0.32). Conclusion No new onset cases were seen during the course of pregnancy and no conversion from NPDR to PDR was seen; however, a worsening of the two PDR cases was observed. No cases of DR were seen in noninsulin-dependent DM. None of the four participants with DR showed a spontaneous resolution of DR postpartum. Patients with PDR and long-standing DM require careful observation during pregnancy. A registry of diabetic mothers should be set up for development of guidelines for managing such cases.
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Affiliation(s)
- Tarjani Makwana
- Dr R P Centre for Ophthalmic Sciences, All India Institute of Medical Sciences, New Delhi, India
| | - Brijesh Takkar
- Dr R P Centre for Ophthalmic Sciences, All India Institute of Medical Sciences, New Delhi, India
| | - Pradeep Venkatesh
- Dr R P Centre for Ophthalmic Sciences, All India Institute of Medical Sciences, New Delhi, India
| | - Jai Bhagwan Sharma
- Department of Obstetrics and Gynaecology, All India Institute of Medical Sciences, New Delhi, India
| | - Yashdeep Gupta
- Department of Endocrinology, All India Institute of Medical Sciences, New Delhi, India
| | - Rohan Chawla
- Dr R P Centre for Ophthalmic Sciences, All India Institute of Medical Sciences, New Delhi, India
| | - Rajpal Vohra
- Dr R P Centre for Ophthalmic Sciences, All India Institute of Medical Sciences, New Delhi, India
| | - Alka Kriplani
- Department of Obstetrics and Gynaecology, All India Institute of Medical Sciences, New Delhi, India
| | - Nikhil Tandon
- Department of Endocrinology, All India Institute of Medical Sciences, New Delhi, India
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Feig DS, Berger H, Donovan L, Godbout A, Kader T, Keely E, Sanghera R. Diabetes and Pregnancy. Can J Diabetes 2018; 42 Suppl 1:S255-S282. [DOI: 10.1016/j.jcjd.2017.10.038] [Citation(s) in RCA: 108] [Impact Index Per Article: 18.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
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Wang LZ, Cheung CY, Tapp RJ, Hamzah H, Tan G, Ting D, Lamoureux E, Wong TY. Availability and variability in guidelines on diabetic retinopathy screening in Asian countries. Br J Ophthalmol 2017; 101:1352-1360. [PMID: 28292772 DOI: 10.1136/bjophthalmol-2016-310002] [Citation(s) in RCA: 48] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2016] [Revised: 01/10/2017] [Accepted: 02/10/2017] [Indexed: 01/18/2023]
Abstract
BACKGROUND Diabetic retinopathy (DR) is a blinding yet treatable complication of diabetes. DR screening is highly cost-effective at reducing blindness. Amidst the rapidly growing diabetic population in Asia, the prevalence of DR in the region is relatively less well known. AIMS To review existing national DR screening guidelines of 50 countries in Asia, compare them against the International Council of Ophthalmology (ICO) guideline, and summarise the prevalence rates of DR and sight-threatening DR (STDR) in these countries. METHODS We systematically searched for published guidelines from the National Guideline Clearinghouse and other databases, and contacted local diabetic and ophthalmological associations of all 50 Asian countries. RESULTS Eleven Asian countries have published relevant guidelines, nine of which pertain to general diabetes care and two are DR-specific, covering less than half of Asia's population. The median DR prevalence among patients with diabetes is 30.5% (IQR: 23.2%-36.8%), similar to the USA and the UK. However, rates of STDR are consistently higher. All guidelines from the 11 Asian countries fulfil the ICO standard on when to start and repeat screening, except for screening interval for pregnant patients. However, only 2 of the 11 guidelines fulfil the ICO referral criteria and 6 partially fulfil. A third of the recommendations on screening process, equipment and personnel is either unavailable or incomplete. CONCLUSIONS Countries in Asia need to establish more comprehensive and evidence-based DR screening guidelines to facilitate the execution of robust screening programmes that could help reduce DR-related blindness, improve patient outcomes and reduce healthcare costs.
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Affiliation(s)
- Louis Zizhao Wang
- Singapore Eye Research Institute, Singapore National Eye Centre, Singapore, Singapore.,Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | - Carol Y Cheung
- Singapore Eye Research Institute, Singapore National Eye Centre, Singapore, Singapore.,Department of Ophthalmology and Visual Sciences, The Chinese University of Hong Kong, Hong Kong, Hong Kong
| | - Robyn J Tapp
- Singapore Eye Research Institute, Singapore National Eye Centre, Singapore, Singapore.,Department of Optometry and Vision Sciences, The University of Melbourne, Melbourne, Victoria, Australia.,School of Clinical and Applied Sciences, Leeds Beckett University, Leeds, UK
| | - Haslina Hamzah
- Singapore Eye Research Institute, Singapore National Eye Centre, Singapore, Singapore
| | - Gavin Tan
- Singapore Eye Research Institute, Singapore National Eye Centre, Singapore, Singapore
| | - Daniel Ting
- Singapore Eye Research Institute, Singapore National Eye Centre, Singapore, Singapore
| | - Ecosse Lamoureux
- Singapore Eye Research Institute, Singapore National Eye Centre, Singapore, Singapore.,Duke-NUS Medical School, National University of Singapore, Singapore, Singapore
| | - Tien Yin Wong
- Singapore Eye Research Institute, Singapore National Eye Centre, Singapore, Singapore.,Duke-NUS Medical School, National University of Singapore, Singapore, Singapore
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22
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Morrison JL, Hodgson LA, Lim LL, Al-Qureshi S. Diabetic retinopathy in pregnancy: a review. Clin Exp Ophthalmol 2016; 44:321-34. [PMID: 27062093 DOI: 10.1111/ceo.12760] [Citation(s) in RCA: 51] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2015] [Revised: 03/24/2016] [Accepted: 04/02/2016] [Indexed: 12/15/2022]
Abstract
The prevalence of diabetes in pregnancy is increasing. Pre-existing diabetes is present in 1 in 167 pregnancies in Australia, divided equally between type 1 and type 2 diabetes. Diabetic retinopathy is a leading cause of blindness in women during their childbearing years, and pregnancy increases the short-term risk of diabetic retinopathy progression. We examine the risk factors for progression of diabetic retinopathy during pregnancy including duration of diabetes, baseline level of retinopathy, level of glycaemic control and hypertension. We also examine current screening and management guidelines and their levels of evidence, current treatment options for diabetic retinopathy and avenues for further research.
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Affiliation(s)
- Julie L Morrison
- Centre for Eye Research Australia, Royal Victorian Eye and Ear Hospital, Melbourne, Victoria, Australia.,Division of Ophthalmology, Department of Surgery, University of Melbourne, Melbourne, Victoria, Australia
| | - Lauren Ab Hodgson
- Centre for Eye Research Australia, Royal Victorian Eye and Ear Hospital, Melbourne, Victoria, Australia.,Division of Ophthalmology, Department of Surgery, University of Melbourne, Melbourne, Victoria, Australia
| | - Lyndell L Lim
- Centre for Eye Research Australia, Royal Victorian Eye and Ear Hospital, Melbourne, Victoria, Australia.,Division of Ophthalmology, Department of Surgery, University of Melbourne, Melbourne, Victoria, Australia.,Medical Retina Clinic, Royal Victorian Eye and Ear Hospital, Melbourne, Victoria, Australia
| | - Salmaan Al-Qureshi
- Centre for Eye Research Australia, Royal Victorian Eye and Ear Hospital, Melbourne, Victoria, Australia.,Division of Ophthalmology, Department of Surgery, University of Melbourne, Melbourne, Victoria, Australia.,Medical Retina Clinic, Royal Victorian Eye and Ear Hospital, Melbourne, Victoria, Australia
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Abstract
Long-standing hyperglycemia frequently leads to vasculopathy. Microvascular disease is characterized by retinopathy and nephropathy, while macrovascular involvement can affect coronary arteries. Diabetic autonomic neuropathy, when present, is generally associated with retinal and/or renal involvement. Early identification of these diabetic complications allows appropriate counseling and early treatment. Among women with diabetic vasculopathy, nephropathy, chronic hypertension, preeclampsia, preterm delivery, and fetal growth restriction are frequently observed. Furthermore, women with impaired renal function in early pregnancy have increased risk of long-term deterioration of glomerular filtration rate. Proliferative retinopathy can progress during pregnancy and 1 year after delivery, but long-term effects are not likely to occur. When coronary artery disease or gastroparesis diabeticorum are present, excessive maternal and fetal morbidity is observed. When modern management is synchronized with early medical care, favorable maternal and perinatal outcomes can be expected.
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Affiliation(s)
- Gustavo Leguizamón
- Department of Obstetrics and Gynecology, High Risk Pregnancy Unit, Center for Medical Education and Clinical Research (C.E.M.I.C.), C.E.M.I.C. University, Av. Galvan 4089, CABA., CP1431, Buenos Aires, Argentina,
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S. Mukherjee M, Coppenrath VA, Dallinga BA. Pharmacologic Management of Types 1 and 2 Diabetes Mellitus and Their Complications in Women of Childbearing Age. Pharmacotherapy 2015; 35:158-74. [DOI: 10.1002/phar.1535] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Affiliation(s)
| | | | - Bree A. Dallinga
- Edward M. Kennedy Community Health Center; Framingham Massachusetts
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Egan AM, McVicker L, Heerey A, Carmody L, Harney F, Dunne FP. Diabetic retinopathy in pregnancy: a population-based study of women with pregestational diabetes. J Diabetes Res 2015; 2015:310239. [PMID: 25945354 PMCID: PMC4402566 DOI: 10.1155/2015/310239] [Citation(s) in RCA: 39] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/17/2015] [Revised: 03/25/2015] [Accepted: 03/26/2015] [Indexed: 11/17/2022] Open
Abstract
The aim of this observational study was to evaluate screening and progression of diabetic retinopathy during pregnancy in women with pregestational diabetes attending five antenatal centres along the Irish Atlantic seaboard. An adequate frequency of screening was defined as at least two retinal evaluations in separate trimesters. Progression was defined as at least one stage of deterioration of diabetic retinopathy and/or development of diabetic macular edema on at least one eye. Women with pregestational diabetes who delivered after 22 gestational weeks (n = 307) were included. In total, 185 (60.3%) had an adequate number of retinal examinations. Attendance at prepregnancy care was associated with receiving adequate screening (odds ratio 6.23; CI 3.39-11.46 (P < 0.001)). Among those who received adequate evaluations (n = 185), 48 (25.9%) had retinopathy progression. Increasing booking systolic blood pressure (OR 1.03, CI 1.01-1.06, P = 0.02) and greater drop in HbA1c between first and third trimesters of pregnancy (OR 2.05, CI 1.09-3.87, P = 0.03) significantly increased the odds of progression. A significant proportion of women continue to demonstrate retinopathy progression during pregnancy. This study highlights the role of prepregnancy care and the importance of close monitoring during pregnancy and identifies those patients at the highest risk for retinopathy progression.
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Affiliation(s)
- Aoife M. Egan
- Galway Diabetes Research Centre, National University of Ireland Galway and University Hospital Galway, Newcastle, Galway, Ireland
- *Aoife M. Egan:
| | - Lyle McVicker
- Galway Diabetes Research Centre, National University of Ireland Galway and University Hospital Galway, Newcastle, Galway, Ireland
| | - Adrienne Heerey
- Galway Diabetes Research Centre, National University of Ireland Galway and University Hospital Galway, Newcastle, Galway, Ireland
| | - Louise Carmody
- Galway Diabetes Research Centre, National University of Ireland Galway and University Hospital Galway, Newcastle, Galway, Ireland
| | - Fiona Harney
- Department of Ophthalmology, National University of Ireland Galway and University Hospital Galway, Newcastle, Galway, Ireland
| | - Fidelma P. Dunne
- Galway Diabetes Research Centre, National University of Ireland Galway and University Hospital Galway, Newcastle, Galway, Ireland
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Blumer I, Hadar E, Hadden DR, Jovanovič L, Mestman JH, Murad MH, Yogev Y. Diabetes and pregnancy: an endocrine society clinical practice guideline. J Clin Endocrinol Metab 2013; 98:4227-49. [PMID: 24194617 PMCID: PMC8998095 DOI: 10.1210/jc.2013-2465] [Citation(s) in RCA: 322] [Impact Index Per Article: 29.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/06/2013] [Accepted: 09/16/2013] [Indexed: 12/13/2022]
Abstract
OBJECTIVE Our objective was to formulate a clinical practice guideline for the management of the pregnant woman with diabetes. PARTICIPANTS The Task Force was composed of a chair, selected by the Clinical Guidelines Subcommittee of The Endocrine Society, 5 additional experts, a methodologist, and a medical writer. EVIDENCE This evidence-based guideline was developed using the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) system to describe both the strength of recommendations and the quality of evidence. CONSENSUS PROCESS One group meeting, several conference calls, and innumerable e-mail communications enabled consensus for all recommendations save one with a majority decision being employed for this single exception. CONCLUSIONS Using an evidence-based approach, this Diabetes and Pregnancy Clinical Practice Guideline addresses important clinical issues in the contemporary management of women with type 1 or type 2 diabetes preconceptionally, during pregnancy, and in the postpartum setting and in the diagnosis and management of women with gestational diabetes during and after pregnancy.
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Affiliation(s)
- Ian Blumer
- 8401 Connecticut Avenue, Suite 900, Chevy Chase, Maryland 20815.
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Pregnancy-associated retinal diseases and their management. Surv Ophthalmol 2013; 58:127-42. [PMID: 23410822 DOI: 10.1016/j.survophthal.2012.08.001] [Citation(s) in RCA: 79] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2011] [Revised: 08/05/2012] [Accepted: 08/07/2012] [Indexed: 01/20/2023]
Abstract
Pregnancy-associated retinal diseases are conditions that may occur uniquely in pregnancy or, more commonly, general conditions that may worsen or alter during pregnancy as a result of hematologic, hormonal, metabolic, cardiovascular, and immunologic changes. Diabetic retinopathy (DR) is by far the most common retinal condition that is altered by pregnancy. However, there are currently no widely accepted, precise clinical guidelines regarding its management during pregnancy. At present it is not possible to predict who will regress and who will progress without treatment. Some of the variation in progression of DR in pregnancy may be a result of well-known risk factors such as hypertension or inadequate glycemic control prior to pregnancy. Other pregnancy-associated retinal diseases are relatively uncommon, and their treatments are poorly characterized. Pre-existing conditions include the white dot syndromes, such as punctuate inner choroidopathy and ocular histoplasmosis syndrome, as well as chorioretinal neovascularization from many other etiologies. Retinal and chorioretinal disorders that can arise during pregnancy include central serous chorioretinopathy and occlusive vasculopathy such as retinal artery occlusion (Purtschers-like retinopathy) and retinal vein occlusion. There remains a small group that appear to be unique to pregnancy, with pre-eclampsia- and eclampsia-associated retinopathy, disseminated intravascular coagulopathy, or amniotic fluid embolism being the best described. In angiogenic retinal diseases outside of pregnancy, the use of anti-vascular endothelial growth factor (anti-VEGF agents) has proven helpful. There are no safety data about the use of anti-VEGF agents during pregnancy, and conventionally the proposed interventions have been laser photocoagulation and systemic or intravitreal injections of steroids. Most of the literature on the treatment of pregnancy associated-chorioretinal neovascularization is anecdotal.
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Diep TM, Tsui I. Risk factors associated with diabetic macular edema. Diabetes Res Clin Pract 2013; 100:298-305. [PMID: 23380134 DOI: 10.1016/j.diabres.2013.01.011] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/23/2012] [Revised: 12/11/2012] [Accepted: 01/07/2013] [Indexed: 01/19/2023]
Abstract
Diabetic macular edema (DME) is the most common cause of vision loss in patients with type 1 and type 2 diabetes. Glycemic control, hypertension, and dyslipidemia are known to be important risks factors for DME. In addition, nephropathy, anemia, sleep apnea, glitazone usage, and pregnancy are also important modifiable risk factors. It is important for physicians of different subspecialties to work together and understand multiple aspects of DME and diabetic healthcare.
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Affiliation(s)
- Thuan M Diep
- David Geffen School of Medicine, Jules Stein Eye Institute, University of California, Los Angeles (UCLA), Los Angeles, CA, USA
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Thompson D, Berger H, Feig D, Gagnon R, Kader T, Keely E, Kozak S, Ryan E, Sermer M, Vinokuroff C. Diabetes and pregnancy. Can J Diabetes 2013; 37 Suppl 1:S168-83. [PMID: 24070943 DOI: 10.1016/j.jcjd.2013.01.044] [Citation(s) in RCA: 136] [Impact Index Per Article: 12.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
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Klein R, Klein BE. The Epidemiology of Diabetic Retinopathy. Retina 2013. [DOI: 10.1016/b978-1-4557-0737-9.00045-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/31/2023]
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Magon N, Chauhan M. Pregnancy in Type 1 Diabetes Mellitus: How Special are Special Issues? NORTH AMERICAN JOURNAL OF MEDICAL SCIENCES 2012; 4:250-6. [PMID: 22754875 PMCID: PMC3385360 DOI: 10.4103/1947-2714.97202] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
India leads the world with largest number of diabetics earning the dubious distinction of "the diabetes capital of the world." Diabetes is associated with maternal and perinatal morbidity and mortality. The number of pregnant women with pre-existing diabetes is increasing, mainly from an increase in type 2 diabetes, but also an increase in type 1 diabetes. Overall, type 1 diabetes accounts for approximately 5% to 10% of all diabetes outside of pregnancy, and in pregnancy put together with type 2 account for 10% of diabetic pregnancies. Management of the pregnant diabetic woman is a complex task that ideally begins before conception. Specific attention is required for diabetic pregnancies in different trimesters of pregnancy. Diabetes, especially type 1 diabetes, can be a challenge in pregnancy, but with education, close monitoring, and latest therapeutic modalities, these women can have healthy newborns. Close attention to diet, glycemic control, metabolic stresses, and early diagnosis and monitoring of complications can make pregnancy a successful experience for women with diabetes. A MedLine search was done to review relevant articles in English literature on diabetes and pregnancy, and specific issues related to pregnancy in type 1 diabetes were reviewed.
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Affiliation(s)
- Navneet Magon
- Department of Obstetrics and Gynaecology, Air Force Hospital, Nathu Singh Road, Kanpur Cantt, Uttar Pradesh, India
| | - Monica Chauhan
- Department of Obstetrics and Gynaecology, Netaji Subhash Chandra Bose Government Medical College, Jabalpur, Madhya Pradesh, India
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Feghali M, Khoury JC, Shveiky D, Miodovnik M. Association of vaginal delivery efforts with retinal disease in women with type I diabetes. J Matern Fetal Neonatal Med 2011; 25:27-31. [DOI: 10.3109/14767058.2012.626924] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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Knight KM, Pressman EK, Hackney DN, Thornburg LL. Perinatal outcomes in type 2 diabetic patients compared with non-diabetic patients matched by body mass index. J Matern Fetal Neonatal Med 2011; 25:611-5. [PMID: 21728737 DOI: 10.3109/14767058.2011.587059] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
OBJECTIVE Given that both type 2 diabetes and obesity are associated with adverse pregnancy outcomes and often coexist, we sought to determine if outcomes in type 2 diabetic patients are related to the presence of diabetes or to maternal obesity. METHODS This retrospective cohort study examined perinatal outcomes of type 2 diabetic and nondiabetic patients matched by prepregnancy body mass index January 2000 to July 2008. Chi-square, Fisher's exact test, Mann-Whitney U and t-tests were used to compare groups. The association between type 2 diabetes and adverse perinatal outcomes was evaluated through logistic regression with adjustment for potential confounders. RESULTS 213 pairs of type 2 and non-diabetic patients were compared. Diabetic patients had overall worse composite pregnancy, delivery, fetal, and neonatal outcomes. Specifically, diabetic patients had higher rates of preeclampsia, poly- and oligohydramnios, cesarean delivery, shoulder dystocia, postpartum hemorrhage, preterm delivery, LGA infant, fetal anomaly, and neonatal hypoglycemia, hyperbilirubinemia, RDS, sepsis, intubation, and admission to the NICU. Diabetes remained a significant predictor of adverse delivery, fetal and neonatal composite outcomes when adjusted for confounders in logistic regression. CONCLUSIONS Type 2 diabetic patients have a higher incidence of adverse perinatal outcomes than nondiabetic patients independent of obesity.
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Affiliation(s)
- Kristin M Knight
- University of Rochester Strong Memorial Hospital, Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, Rochester, New York, USA.
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Abstract
The prevalence of preexisting diabetes in pregnancy is increasing largely because of an increase in type 2 diabetes. Outcomes of diabetic pregnancies for mother and newborn have improved greatly in recent decades from advances in understanding the disease process, improved education, and new treatment modalities delivered in a team approach. Nausea and vomiting from pregnancy and pregnancy-associated insulin resistance can make glycemic control a challenge. Care of women with preexisting diabetes demands careful monitoring in the preconception, prenatal, and peripartum periods.
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Affiliation(s)
- Gabriella Pridjian
- Division of Maternal-Fetal Medicine, Department of Obstetrics & Gynecology, SL11, Tulane University Medical School, 1430 Tulane Avenue, New Orleans, LA 70112, USA.
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Stalnikiewicz L, Floriot M, Guerci B, Angioi K. Progression de la rétinopathie diabétique chez les femmes enceintes : étude rétrospective monocentrique d’une série de 77 patientes consécutives. J Fr Ophtalmol 2010; 33:481-6. [DOI: 10.1016/j.jfo.2010.06.005] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2010] [Accepted: 05/18/2010] [Indexed: 10/19/2022]
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Rasmussen KL, Laugesen CS, Ringholm L, Vestgaard M, Damm P, Mathiesen ER. Progression of diabetic retinopathy during pregnancy in women with type 2 diabetes. Diabetologia 2010; 53:1076-83. [PMID: 20225131 DOI: 10.1007/s00125-010-1697-9] [Citation(s) in RCA: 77] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/01/2009] [Accepted: 01/22/2010] [Indexed: 11/25/2022]
Abstract
AIMS/HYPOTHESIS We studied the progression of diabetic retinopathy during pregnancy in women with type 2 diabetes. METHODS Fundus photography was performed at median 10 (range 6-21) and 28 (27-37) gestational weeks in 80 of 110 (73%) consecutively referred pregnant women with type 2 diabetes. Diabetic retinopathy was classified in five stages. Progression was defined as at least one stage of deterioration of diabetic retinopathy and/or development of macular oedema on at least one eye between the two examinations. Macular oedema was defined as retinal thickening and/or hard exudates within a diameter of 1,500 microm in the macula area. RESULTS Diabetic retinopathy, mainly mild, was present in 11 (14%) women in early pregnancy. Median duration of diabetes was 3 years (range 0-16 years). At baseline, HbA(1c) was 6.4% (1.0) (mean [SD]), systolic BP 121 (13) and diastolic BP 72 (9) mmHg. Prior to pregnancy, 22 (28%) women had been on insulin treatment. During pregnancy 74 women (93%) were treated with insulin and 11 (14%) with antihypertensive medication. Progression of diabetic retinopathy was observed in 11 (14%) women. Progression was mainly mild, but one woman with poor glycaemic control and uncontrolled hypertension progressed from mild retinopathy to sight-threatening retinopathy with proliferations, clinically significant macular oedema and impaired vision in both eyes. Progression of diabetic retinopathy was associated with a longer duration of diabetes (p = 0.03) and insulin treatment before pregnancy (p = 0.004). CONCLUSIONS/INTERPRETATION Despite a low risk of progression of retinopathy in pregnant women with type 2 diabetes, sight-threatening deterioration did occur.
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Affiliation(s)
- K L Rasmussen
- Department of Endocrinology, Rigshospitalet, Copenhagen University Hospital, Blegdamsvej 9, 2100 København Ø, Denmark.
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Gaucher D, Saleh M, Sauer A, Averous L, Bourcier T, Speeg-Schatz C. [Progression of diabetic retinopathy during pregnancy]. J Fr Ophtalmol 2010; 33:355-61. [PMID: 20452094 DOI: 10.1016/j.jfo.2010.03.003] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2009] [Accepted: 03/15/2010] [Indexed: 10/19/2022]
Abstract
Diabetic retinopathy should be carefully monitored during certain risk situations. Indeed, diabetic retinopathy in pregnant type 1 diabetic patients can rapidly progress and threaten vision, as in other situations such as puberty, glycemic equilibration, or ocular surgery. During pregnancy, five major risk factors for progression have been identified: pregnancy itself, diabetic retinopathy grade at baseline, duration of diabetes, important glycated hemoglobin reduction, and high blood pressure. These factors must be taken into account when planning pregnancy in diabetic patients and during the follow-up of their diabetic retinopathy. Diabetic women should be counseled about the risks of progression of their disease before planning pregnancy. Careful eye examination before and during the first trimester should be done in these patients, in order to detect severe non-proliferative diabetic retinopathy and/or high-risk diabetic retinopathy and perform rapid laser treatment if needed. Follow-up visit frequency should be adapted to the severity of the diabetic retinopathy. Very few authors have studied diabetic macular edema during pregnancy. This complication can spontaneously regress postpartum and should not be treated too rapidly.
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Affiliation(s)
- D Gaucher
- Service d'ophtalmologie des hôpitaux universitaires de Strasbourg, nouvel hôpital civil, université Louis-Pasteur, 1, place de l'Hôpital, BP 426, 67091 Strasbourg cedex, France.
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Vestgaard M, Ringholm L, Laugesen CS, Rasmussen KL, Damm P, Mathiesen ER. Pregnancy-induced sight-threatening diabetic retinopathy in women with Type 1 diabetes. Diabet Med 2010; 27:431-5. [PMID: 20536515 DOI: 10.1111/j.1464-5491.2010.02958.x] [Citation(s) in RCA: 82] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
AIMS To determine the progression of diabetic retinopathy in pregnant women with diabetes offered tight glycaemic and blood pressure control. METHODS A prospective study of 102 (87%) out of 117 consecutive pregnant women with Type 1 diabetes for median 16 years (range 1-36) and HbA(1c) 6.7% (4.9-10.8) in early pregnancy. Fundus photography was performed at 8 and 27 weeks. Retinopathy was classified in five stages. Diabetic macular oedema was classified as present in a mild form or as clinically significant macular oedema (CSMO). Progression was defined as at least one stage of deterioration of retinopathy and/or development of macular oedema in at least one eye. Sight-threatening progression was defined as loss of visual acuity>or=0.2 on Snellen's chart or laser treatment performed during pregnancy due to proliferative retinopathy or CSMO. RESULTS Diabetic retinopathy was present at inclusion in at least one eye in 64 (63%) women and proliferative retinopathy and macular oedema were present in nine and 16 women, respectively. Progression of retinopathy occurred in 28 (27%) women. Sight-threatening progression occurred in six women; in three, visual acuity deteriorated and four required laser treatment. Sight-threatening progression was associated with presence of macular oedema (P=0.007), impaired visual acuity (P=0.03) and higher blood pressure (P=0.016) in early pregnancy, but not with HbA1c, decline in HbA1c, or prevalence of severe hypoglycaemia. CONCLUSIONS Loss of visual acuity and the need for laser treatment during diabetic pregnancy remain clinical problems associated with presence of macular oedema, visual impairment and higher blood pressure in early pregnancy.
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Affiliation(s)
- M Vestgaard
- Copenhagen Centre for Pregnant Women with Diabetes, Department of Endocrinology, Rigshospitalet, Faculty of Health Sciences, Copenhagen, Denmark
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Vitreous vascular endothelial growth factor level during gestation. Arch Gynecol Obstet 2009; 281:417-21. [DOI: 10.1007/s00404-009-1144-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2009] [Accepted: 05/28/2009] [Indexed: 01/20/2023]
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Abstract
Type 1 diabetes complicates around 1 in 200 to 300 pregnancies in the United Kingdom. Historically maternal type 1 diabetes carried very high risks for mother and child. Introduction of insulin led to an immediate, marked decline in the previously very high rates of maternal mortality; in contrast an improvement in perinatal outcomes occurred more slowly but was nevertheless dramatic. This is strikingly demonstrated by the temporal decline in perinatal mortality in offspring of mothers with type 1 diabetes which was virtually universal before use of insulin in the 1920's, likely remained in excess of 20% even in the 1960's and fell to under 4% by the 1990's. The reasons for this more gradual improvement in perinatal outcomes cannot be defined with precision but will have been influenced by improved glycaemic management with use of intensive, multiple dose insulin treatment and home glucose monitoring; improvements in obstetric and neonatal management, and better management of complications of diabetes before and during pregnancy. In 1989 the St Vincent declaration proposed that pregnancy outcomes in women with type 1 diabetes should approximate those of the non-diabetic population. While the long term improvements in fetal outcomes have been dramatic, contemporary surveys confirm a persistent doubling or more of rates of congenital anomaly and a three to four fold increase in perinatal mortality in the UK and other European countries which will require further clinical innovation to overcome.
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Abstract
Pregnancy may be associated with several ocular changes, including the development of new ocular conditions or modifications of existing conditions. The most common ocular condition modified by pregnancy is diabetic retinopathy. Pregnancy is associated with an increased risk of development and progression of diabetic retinopathy. The factors associated with its progression include the pregnant state itself, duration of diabetes, amount of retinopathy at conception, blood glucose control, and the presence of coexisting hypertension. Although the rate of regression of diabetic retinopathy at the end of pregnancy or the postpartum period is high, careful monitoring of these patients is necessary to optimize the vision and pregnancy outcomes.
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Affiliation(s)
- Bhavna P Sheth
- Eye Institute, Medical College of Wisconsin, 8701 Watertown Plank Road, Milwaukee, WI 53226, USA.
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Leguizamón G, Igarzabal ML, Reece EA. Periconceptional care of women with diabetes mellitus. Obstet Gynecol Clin North Am 2007; 34:225-39, viii. [PMID: 17572269 DOI: 10.1016/j.ogc.2007.04.002] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Pregestational diabetes is a common complication of pregnancy that can be associated with severe maternal and fetal morbidity. In addition, some women could have progression of diabetic complications secondary to pregnancy. Preconception care can significantly reduce pregnancy complications with a dramatic impact on the diabetic mother and her infant. For those women whose condition could be hastened by conception education, better understanding and an improved decision should be available to them and their families. Because unplanned pregnancy is common among diabetic women, they should be counseled early for the importance of preconception care in the progression of this disease.
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Affiliation(s)
- Gustavo Leguizamón
- Department of Obstetrics and Gynecology, Center for Medical Education and Clinical Research (C.E.M.I.C.) University, Av. Galván 4102, Buenos Aires, Argentina
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Rahman W, Rahman FZ, Yassin S, Al-Suleiman SA, Rahman J. Progression of retinopathy during pregnancy in type 1 diabetes mellitus. Clin Exp Ophthalmol 2007; 35:231-6. [PMID: 17430509 DOI: 10.1111/j.1442-9071.2006.01413.x] [Citation(s) in RCA: 41] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
PURPOSE The incidence and risk factors for progression of retinopathy during pregnancy in women with type 1 diabetes mellitus were retrospectively evaluated. METHODS Fifty-four insulin-dependent diabetic patients at a teaching hospital in Saudi Arabia were followed throughout the pregnancy/puerperium with serial ophthalmic examination. Dilated fundus examination was performed in each trimester and puerperium. RESULTS Progression of diabetic retinopathy in the study occurred in 13/54 (24%) patients--2/22 (9.1%) patients had no diabetic retinopathy initially, 4/20 (20%) had non-proliferative diabetic retinopathy (NPDR) and 7/12 (58.3%) had proliferative diabetic retinopathy (PDR). Of the eight patients with PDR who had no laser treatment before pregnancy, six (75%) showed progression but only one of the four patients who had PDR and laser treatment prior to pregnancy experienced progression of retinopathy. Eight patients in total received panretinal photocoagulation to arrest the progression of retinal disease during pregnancy and only one of them had laser treatment prior to pregnancy. CONCLUSION Laser photocoagulation for severe NPDR or early PDR prior to pregnancy may protect against rapid progression of PDR. Visual impairment resulting from progression of PDR can be prevented by aggressive laser treatment during pregnancy. Duration of diabetes>15 years, poor glycaemic control and hypertension are high-risk factors in the progression of diabetic retinopathy in pregnancy.
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Luis Bartha J, José Cerqueira M, González González NL, Jáñez M, Mozas J, Ramírez García O, Acosta D, Javier Ampudia F, Corcoy R, Cortázar A, Hernández Mijares A, Herranz L, Antonio Lobón J, López López J, Reyes Luna M, del Pino Navarro M, Antonia Sancho M, Ginovart G. Diabetes y embarazo. Guía Asistencial 2006. ACTA ACUST UNITED AC 2007. [DOI: 10.1016/s0304-5013(07)73182-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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Abstract
Without strict glycemic control, diabetic pregnancies are frequently complicated by spontaneous abortion, stillbirth, or congenital malformation. Retrospective studies have been largely reassuring that pregnancy does not accelerate morbid outcomes in women with diabetic vascular disease. Improved outcomes of high-risk pregnancy in women with pregestational, type 1, or type 2 diabetes mellitus remain challenging, depending on a comprehensive and multidisciplinary team approach and extensive preconception counseling.
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Affiliation(s)
- Melton J Bond
- Women and Infant Services, Department of Obstetrics and Gynecology, Washington Hospital Center, Washington DC 20010, USA.
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Abstract
PURPOSE OF REVIEW Pregnancy may cause ocular changes, both physiologic and pathologic, and may be associated with the development of new disease or may alter the course of preexisting disease. This paper discusses these changes and reviews diabetic retinopathy, uveitis, preeclampsia, cortical blindness and central serous chorioretinopathy. RECENT FINDINGS Recent reports have contributed to our understanding of the pathophysiology of diabetic retinopathy and cortical blindness associated with preeclampsia, the impact of pregnancy on the course of inflammatory eye disease, and the use of optical coherence tomography in following central serous chorioretinopathy in pregnant women. SUMMARY This improved understanding of the pathophysiology of ocular disease in pregnancy and the impact of pregnancy on the course of preexisting ocular disease offers the opportunity for meaningful counseling of women who are pregnant or planning to become pregnant.
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Affiliation(s)
- Kara L Schultz
- Department of Ophthalmology and Visual Sciences, University of Illinois at Chicago, Illinois 60612, USA
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