Impact of pregnancy on the progression of diabetic retinopathy in Type 1 diabetes

Determinants of progression of diabetic retinopathy in pregnancy

AIMS

To assess the rate of diabetic retinopathy (DR) progression in an Australian cohort and to identify the determinants of DR progression in pregnancy.

METHODS

A total of 367 pregnancies of women with Type 1 or 2 diabetes mellitus attending King Edward Memorial Hospital, Western Australia, between June 2020 and July 2023 were included. These women were screened for the presence and severity of DR in the first trimester and/or at 28-32 weeks gestation via retinal imaging with a DRS camera.

RESULTS

DR was seen in 121 (33 %) pregnancies at baseline and DR progression was seen in 62 (17 %) pregnancies. Only 11 (4 %) women with no baseline DR developed DR and none of these progressed to more than moderate non-proliferative DR. A total of 51 (42 %) women with baseline DR had DR progression. The presence of baseline DR was the only significant predictor for DR progression on multivariate analysis (OR 9.88 (4.43-22.07), p < 0.001).

CONCLUSIONS

Women without DR at baseline are unlikely to progress to more severe forms of DR and usually do not require treatment. The presence of DR at baseline screening during pregnancy is a strong predictor of DR progression during pregnancy.

Risk for fetal malformations and unfavorable neonatal outcomes in early-onset gestational diabetes mellitus

BACKGROUND

Early-onset gestational diabetes mellitus (GDM) is diagnosed before the 24th gestational week. Since early GDM is associated with first trimester hyperglycemia, many clinicians treat these women as having pre-GDM. However, whether early GDM increases the risk for unfavorable pregnancy outcomes and particularly for fetal malformations to a greater extent than late-onset GDM were not studied sufficiently. We aimed to examine the effect of early-onset GDM on unfavorable pregnancy outcomes.

METHODS

A retrospective cohort study of women with GDM delivering singletons during 2005-2018 was conducted. Women were divided into GDM diagnosed at the first (Trimester1; up to 13.6 weeks; N = 117), the second (Trimester2; up to 23.6 weeks; N = 126), and the third trimester (Trimester3; N = 2334). The primary outcomes were neonatal malformations and a composite of large-for-age newborns, hypoglycemia and hyperbilirubinemia treated with phototherapy. Comparisons were made between early- (Trimester1 + Trimester2-groups) and late-onset GDM (Trimester3-group), and between the three trimesters.

RESULTS

Fetal malformations were low and comparable between the trimester1, trimester2, trimester3 groups (2 (1.7%), 3 (2.4%), and 110 (4.7%), respectively). The composite neonatal complications was similar between the groups (68 (58%), 58 (46%), and 1087 (47%), respectively). In early-onset, the rates of neonatal hypoglycemia and shoulder dystocia were higher than in the late-onset GDM group (OR 95% CI 3.5 [2.0-6.1] and 10.3 [2.4-44.6], respectively). Macrosomia was higher in trimester1 compared with trimester2 and trimester3 cohorts (OR 95% CI 5.3 [1.7-16.9] and 2.8 [1.5-5.2], respectively).

CONCLUSIONS

The risk for fetal malformations was low and comparable between the first, second and third trimester GDM. Since the risks for macrosomia, shoulder dystocia, and neonatal hypoglycemia are higher in early-onset GDM, these women should undergo strict glycemic control, intensive monitoring, and careful neonatal evaluation.

Current Trends in Diagnosis and Treatment Approach of Diabetic Retinopathy during Pregnancy: A Narrative Review

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.

The risk of development and progression of diabetic retinopathy in a group of ethnically diverse pregnant women with diabetes attending three regional Diabetic Eye Screening Programs in the UK

BACKGROUND/OBJECTIVES

Currently, all pregnant women with diabetes are asked to attend screening at least twice during pregnancy, even if no retinopathy is detected in early pregnancy. We hypothesise that for women with no diabetic retinopathy in early pregnancy, the frequency of retinal screening may be safely reduced.

SUBJECTS/METHODS

In this retrospective cohort study, data for 4718 pregnant women attending one of three UK Diabetic Eye Screening (DES) Programmes between July 2011 and October 2019 was extracted. The women's UK DES grades at 13 weeks gestation (early pregnancy) and 28 weeks gestation (late pregnancy) were recorded. Descriptive statistics were used to report baseline data. Ordered logistic regression was used to control for covariates, such as age, ethnicity, diabetes duration, and diabetes type.

RESULTS

Of the women with grades recorded for both early and late pregnancy, a total of 3085 (65.39%) women had no retinopathy in early pregnancy, and 2306 (74.7%) of these women did not develop any retinopathy by 28 weeks. The number of women without retinopathy in early pregnancy who developed referable retinopathy was 14 (0.45%), none of whom required treatment. Diabetic Retinopathy in early pregnancy remained a significant predictor of DES grade in late pregnancy when covariates of Age, Ethnicity, and Diabetes Type were controlled for (P < 0.001).

CONCLUSIONS

In summary, this study has demonstrated that the burden of managing diabetes for pregnant mothers may be safely reduced by limiting the number of diabetic eye screening appointments in women who have no retinal changes in early pregnancy. Screening of women with retinopathy in early pregnancy should continue in line with current UK guidance.

The role of technology in the care of diabetes mellitus in pregnancy: an expert review

Diabetes mellitus is one of the most commonly encountered pregnancy complications and is associated with multiple adverse perinatal outcomes. Technology has progressed to address the unique challenges patients face in managing diabetes mellitus in pregnancy. Technology has bolstered diabetes mellitus education with smartphone applications focused on nutrition counseling and carbohydrate intake advice. Continuous glucose monitors and insulin infusion systems have shown benefit by simplifying glycemic monitoring and insulin administration. Improvements in glycemic control and perinatal outcomes have been seen with continuous glucose monitor use when compared with intermittent blood glucose monitoring, and more pregnant people are using insulin pumps instead of multiple daily insulin injections. Hybrid closed-loop systems are emerging and are able to integrate continuous glucose monitoring and insulin pump technologies while maximizing automated features in the nonpregnant population, but these have not been endorsed for use in pregnancy yet. Applying telehealth practices has been associated with high patient satisfaction among those with diabetes mellitus in pregnancy, and leveraging remote patient monitoring through telehealth platforms and short-range wireless technologies can reduce the burden of patient visits. As technology becomes more integrated into routine management of diabetes mellitus in pregnancy, practitioners should emphasize individualized counseling and device selection to ensure patient autonomy and safety.

Association of community walkability and glycemic control among pregnant individuals with pregestational diabetes mellitus

BACKGROUND

Neighborhood walkability is a community-level social determinant of health that measures whether people who live in a neighborhood walk as a mode of transportation. Whether neighborhood walkability is associated with glycemic control among pregnant individuals with pregestational diabetes remains to be defined.

OBJECTIVE

This study aimed to evaluate the association between community-level neighborhood walkability and glycemic control as measured by hemoglobin A1c (A1C) among pregnant individuals with pregestational diabetes.

STUDY DESIGN

This was a retrospective analysis of pregnant individuals with pregestational diabetes enrolled in an integrated prenatal and diabetes care program from 2012 to 2016. Participant addresses were geocoded and linked at the census-tract level. The exposure was community walkability, defined by the US Environmental Protection Agency National Walkability Index (score range 1-20), which incorporates intersection density (design), proximity to transit stops (distance), and a mix of employment and household types (diversity). Individuals from neighborhoods that were the most walkable (score, 15.26-20.0) were compared with those from neighborhoods that were less walkable (score <15.26), as defined per national Environmental Protection Agency recommendations. The outcomes were glycemic control, including A1C <6.0% and <6.5%, measured both in early and late pregnancy, and mean change in A1C across pregnancy. Modified Poisson regression and linear regression were used, respectively, and adjusted for maternal age, body mass index at delivery, parity, race and ethnicity as a social determinant of health, insurance status, baseline A1C, gestational age at A1C measurement in early and late pregnancy, and diabetes type.

RESULTS

Among 417 pregnant individuals (33% type 1, 67% type 2 diabetes mellitus), 10% were living in the most walkable communities. All 417 individuals underwent A1C assessment in early pregnancy (median gestational age, 9.7 weeks; interquartile range, 7.4-14.1), and 376 underwent another A1C assessment in late pregnancy (median gestational age, 30.4 weeks; interquartile range, 27.8-33.6). Pregnant individuals living in the most walkable communities were more likely to have an A1C <6.0% in early pregnancy (15% vs 8%; adjusted relative risk, 1.46; 95% confidence interval, 1.00-2.16), and an A1C <6.5% in late pregnancy compared with those living in less walkable communities (13% vs 9%; adjusted relative risk, 1.33; 95% confidence interval, 1.08-1.63). For individuals living in the most walkable communities, the median A1C was 7.5 (interquartile range, 6.0-9.4) in early pregnancy and 5.9 (interquartile range, 5.4-6.4) in late pregnancy. For those living in less walkable communities, the median A1C was 7.3 (interquartile range, 6.2-9.2) in early pregnancy and 6.2 (interquartile range, 5.6-7.1) in late pregnancy. Change in A1C across pregnancy was not associated with walkability.

CONCLUSION

Pregnant individuals with pregestational diabetes mellitus living in more walkable communities had better glycemic control in both early and late pregnancy. Whether community-level interventions to enhance neighborhood walkability can improve glycemic control in pregnancy requires further study.

Pregnancy, delivery and neonatal outcomes among women with diabetic retinopathy

OBJECTIVES

Diabetic retinopathy is a common microvascular complication of diabetes. Despite that, there are few studies in the literature to address pregnancy, delivery, or neonatal outcomes among women with diabetic retinopathy.

METHODS

We conducted a retrospective study using the Health Care Cost and Utilization Project-Nationwide Inpatient Sample Database over 11 years from 2004 to 2014. A delivery cohort was created using ICD-9 codes. ICD-9 code 250 or 249 was used to extract the cases of maternal diabetic retinopathy. A multivariant logistic regression model was used to adjust for statistically significant variables (p-value ≤ .05).

RESULTS

There were a total of 9,096,788 deliveries during the study period. Of those, 86 615 pregnant women were found to have Diabetes Mellites (DM). Diabetic retinopathy was present in 1233 of the patients with DM. Diabetic retinopathy increased the likelihood of developing pregnancy-induced HTN (p < .0001), Preeclampsia (p < .0001), and Preeclampsia and eclampsia superimposed on preexisting HTN (p < .0001). In addition, in women with DM, the presence of diabetic retinopathy increased the risk of Preterm delivery (p = .002), cesarean section (p < .0001), requiring transfusion (p < .0001), and undergoing hysterectomy (p = .001), and were less likely to have a spontaneous vaginal delivery (p < .0001). However, the presence of diabetic retinopathy in women with DM did not increase the risk of the fetus being small at delivery, having intrauterine fetal demise, or congenital anomalies.

CONCLUSION

Women with diabetic retinopathy should be counseled about their increased risk of pregnancy-induced HTN, preeclampsia, premature delivery, cesarean section, transfusion, and hysterectomy.

Studies of the retinal microcirculation using human donor eyes and high-resolution clinical imaging: Insights gained to guide future research in diabetic retinopathy

The microcirculation plays a key role in delivering oxygen to and removing metabolic wastes from energy-intensive retinal neurons. Microvascular changes are a hallmark feature of diabetic retinopathy (DR), a major cause of irreversible vision loss globally. Early investigators have performed landmark studies characterising the pathologic manifestations of DR. Previous works have collectively informed us of the clinical stages of DR and the retinal manifestations associated with devastating vision loss. Since these reports, major advancements in histologic techniques coupled with three-dimensional image processing has facilitated a deeper understanding of the structural characteristics in the healthy and diseased retinal circulation. Furthermore, breakthroughs in high-resolution retinal imaging have facilitated clinical translation of histologic knowledge to detect and monitor progression of microcirculatory disturbances with greater precision. Isolated perfusion techniques have been applied to human donor eyes to further our understanding of the cytoarchitectural characteristics of the normal human retinal circulation as well as provide novel insights into the pathophysiology of DR. Histology has been used to validate emerging in vivo retinal imaging techniques such as optical coherence tomography angiography. This report provides an overview of our research on the human retinal microcirculation in the context of the current ophthalmic literature. We commence by proposing a standardised histologic lexicon for characterising the human retinal microcirculation and subsequently discuss the pathophysiologic mechanisms underlying key manifestations of DR, with a focus on microaneurysms and retinal ischaemia. The advantages and limitations of current retinal imaging modalities as determined using histologic validation are also presented. We conclude with an overview of the implications of our research and provide a perspective on future directions in DR research.

Cardio-Obstetrics: the Next Frontier in Cardiovascular Disease Prevention

PURPOSE OF REVIEW

Internationally, cardiovascular disease (CVD) is the leading cause of death in women. With risk factors for CVD continuing to rise, early identification and management of chronic diseases such as hypertension, diabetes, and obstructive sleep apnea is necessary for prevention. Pregnancy is a natural stress test for women with risk factors who may be predisposed to CVD and offers a unique opportunity to not only recognize disease but also implement effective and long-lasting strategies for prevention.

RECENT FINDINGS

Prevention begins before pregnancy, as preconception screening, counseling, and optimization of chronic diseases can improve maternal and fetal outcomes. Throughout pregnancy, women should maintain close follow-up, continued reevaluation of risk factors, with counseling when necessary. Continued healthcare engagement during the "fourth trimester," 3 months following delivery, allows clinicians to continue monitoring the evolution of chronic diseases, encourage ongoing lifestyle counseling, and connect women with primary care and appropriate specialists if needed. Unfortunately, this postpartum period represents a major care gap, as a significant proportion of most women do not attend their scheduled visits. Social determinants of health including decreased access to care and economic instability lead to increased risk factors throughout pregnancy but particularly play a role in poor compliance with postpartum follow-up. The use of telemedicine clinics and remote monitoring may prove to be effective interventions, bridging the gap between physicians and patients and improving follow-up for at-risk women. While many clinicians are beginning to understand the impact of CVD on women, screening and prevention strategies are not often implemented until much later in life. Pregnancy creates an opportunity to begin engaging women in cardiovascular protective strategies before the development of the disease.

Prevalence and severity of diabetic retinopathy in pregnant women with diabetes-time to individualize photo screening frequency

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.

Global Estimates of Diabetic Retinopathy Prevalence and Progression in Pregnant Women With Preexisting Diabetes: A Systematic Review and Meta-analysis

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.

Improving the screening of risk factors in diabetic retinopathy

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.

Type 1 Diabetes in Pregnancy: A Review of Complications and Management

BACKGROUND

Pre-gestational diabetes can pose significant risk to the mother and infant, thus requiring careful counselling and management. Since Saint Vincent's declaration in 1989, adverse maternal and fetal outcomes, such as preeclampsia, perinatal mortality, congenital anomalies, and macrosomia, continue to be associated with type 1 diabetes. Although pregnancy is not considered an independent risk factor for the development of new onset microvascular complications, it is known to exacerbate pre-existing microvascular disease. Strict glycaemic control is the optimal management for pre-existing type 1 diabetes in pregnancy, as raised HbA1C is associated with increased risk of maternal and fetal complications. More recently, time in range on Continuous Glucose Monitoring glucose profiles has emerged as another useful evidence-based marker of fetal outcomes.

OBJECTIVES

This review summarises the complications associated with pre-gestational type 1 diabetes, appropriate evidence-based management, including preparing for pregnancy, intrapartum and postpartum care.

METHODS

A structured search of the PubMed and Cochrane databases was conducted. Peer-reviewed articles about complications and management guidelines on pre-gestational type 1 diabetes were selected and critically appraised.

RESULTS

One hundred and twenty-three manuscripts were referenced and appraised in this review, and international guidelines were summarised.

CONCLUSION

This review provides a comprehensive overview of the recurring themes in the literature pertaining to type 1 diabetes in pregnancy: maternal and fetal complications, microvascular disease progression, and an overview of current guideline-specific management.

Adverse pregnancy outcomes in women with diabetes-related microvascular disease and risks of disease progression in pregnancy: A systematic review and meta-analysis

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.

Pregnancy and the eye

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.

Diabetic retinopathy in pregnancy - A review

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.

Review of the management of sight-threatening diabetic retinopathy during pregnancy

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.

A Narrative Review of the Complex Relationship between Pregnancy and Eye Changes

Pregnancy is a condition often characterized by changes that occur in different parts of the body. Generally, the eyes suffer several changes during pregnancy that are usually transient but may become permanent at times. This may occur due to the release of placental hormones and those of maternal endocrine glands and fetal adrenal glands. Due to hormonal influences, physiological ocular changes during pregnancy have been shown in Caucasian women, so corneal sensitivity, refractive status, intraocular pressure, and visual acuity may change during pregnancy. Within this review, all studies that referred to physiological aspects and to changes of ocular pathology of pregnancy, the effect of the pregnancy on pre-existing (diabetic retinopathy, neuro-ophthalmic disorders) eye disorders, postpartum ocular changes, the intraocular pressure and the effect of hypotensive ophthalmic medicine during pregnancy, the connection between pregnancy and the neuro-ophthalmic pathology, as well as the role of anesthesia were analyzed.

Diabetic retinopathy and diabetic macular oedema pathways and management: UK Consensus Working Group

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.

Progression of Diabetic Retinopathy and Predictors of Its Development and Progression During Pregnancy in Patients With Type 1 Diabetes: A Report of 499 Pregnancies

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 HbA_1c 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.

Postpartum Readmissions Among Women With Diabetes

OBJECTIVE

To estimate whether women with diabetes are at risk for 60-day postpartum readmissions and associated complications.

METHODS

The Nationwide Readmissions Database from 2010 to 2014 was analyzed to determine risk for 60-day postpartum readmissions among women with type 1 diabetes mellitus (DM), type 2 DM, gestational diabetes mellitus (GDM), and unspecified DM compared with women with no diabetes. Secondary outcomes included evaluating risk for overall severe maternal morbidity during readmissions, as well as wound complications, acute diabetic complications such as diabetic ketoacidosis, venous thromboembolism, and hypertensive diseases of pregnancy. Billing data were used to ascertain both exposures and outcomes. Adjusted log-linear regression models including demographic, hospital, medical and obstetric, and hospital factors were performed with adjusted risk ratios (aRRs) and with 95% Cis as measures of association.

RESULTS

Of an estimated 15.7 million delivery hospitalizations, 1.1 million occurred among women with diabetes, of whom 3.2% had type 1 DM, 9.1% type 2 DM, 86.6% GDM, and 1.1% unspecified diabetes. Compared with women without diabetes (1.5% risk for readmission), risk for readmission was significantly higher for women with type 1 DM (4.4%), unspecified diabetes (4.0%), type 2 DM (3.9%), and GDM (2.0%) (P<.01). After adjusting for hospital, demographic, medical, and obstetric risk factors, type 1 DM (aRR 1.77, 95% CI 1.69-1.87), type 2 DM (aRR 1.46, 95% CI 1.42-1.51), unspecified (aRR 1.73, 95% CI 1.59-1.89) and gestational diabetes (aRR 1.16, 95% CI 1.14-1.17) retained increased risk. Among women with diabetes public insurance, lower ZIP code income quartiles, and hospitals with high safety net burdens were associated with higher risk for readmission. In both unadjusted and adjusted analyses, all diabetes diagnoses were associated with readmissions for wound complications, hypertensive diseases of pregnancy, and severe maternal morbidity.

CONCLUSION

Although overall risk for readmission is low, pregnancies complicated by pregestational diabetes in particular are at increased risk. Women in this high-risk group should receive coordinated care and be monitored closely in the postpartum period.

Management of pregestational diabetes mellitus: a comparison of guidelines

Background: Pregestational diabetes is associated with adverse maternal and neonatal outcomes. The aim of this study was to summarize and compare evidence-based recommendations on pregestational diabetes and to focus especially on issues related to the management of this entity.Materials and methods: A descriptive review of three recently published national guidelines on pregestational diabetes was conducted: the American Diabetes Association on "Diabetes in Pregnancy: Standards of Medical Care in Diabetes - 2019," the National Institute for Health and Care Excellence on "Diabetes in pregnancy: management from preconception to the postnatal period" and the American College of Obstetricians and Gynecologists on "Pregestational Diabetes Mellitus." These guidelines were compared according to recommendations on management, during the preconception, antenatal, intrapartum and postpartum period.Results: There were many similar recommendations regarding the preconception counseling, the antepartum assessment by specialists, the glycemic control target levels, the pharmacologic treatment and the postpartum period among the three guidelines. On the other hand, the American Diabetes Association makes no recommendations regarding fetal monitoring and obstetric management during pregnancy and the intrapartum period, while there are several similarities between the other two guidelines.Conclusions: The adoption of an international consensus based on evidence - based guidelines will increase the awareness of the healthcare professionals on the management of pregestational diabetes, leading that way to more favorable perinatal outcomes.

The Impact of Pregnancy and Parity on Type 1 Diabetes Complications

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.

Prevalence, progression, and outcomes of diabetic retinopathy during pregnancy in Indian scenario

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.

Preconception care in diabetes: Predisposing factors and barriers

BACKGROUND AND OBJECTIVE

Preconception care has been shown to decrease the risk of pregnancy-related complications in women with diabetes, but many women do not plan their pregnancies. Our aim was to identify the associated factors and barriers related to involvement of these women in preconception care.

MATERIAL AND METHODS

Fifty women with pregestational diabetes (28 with type 1 diabetes) and 50 non-diabetic pregnant women were consecutively enrolled at our hospital. They completed a questionnaire, and their medical histories were reviewed.

RESULTS

All 33 patients with diabetes who received preconception care had a similar current age (34.3±5.3 years) and age at diagnosis (20.3±11.3) than those with no preconception care (n=17) (31.8±5.3 and 19.1±10.6 years respectively; P>.1), but were more frequently living with their partners (97% vs. 70.6%; P=.014), employed (69.7% vs. 29.4%; P=.047), and monitored by an endocrinologist (80.6% vs. 50%; P=.034), had more commonly had previous miscarriages (78.6% vs. 10%; P=.001), and knew the impact of diabetes on pregnancy (87.5% vs. 58.8%; P=.029). The frequency of preconceptional folic acid intake was similar in pregnant women with and without diabetes (23.8% vs. 32%; P>.1).

CONCLUSIONS

Preconception care of diabetic patients is associated to living with a partner, being employed, knowing the risks of pregnancy-related complications, having previous miscarriages, and being monitored by an endocrinologist. Pregnancy planning is infrequent in both women with and without diabetes.

The effect of pregnancy on the progression of diabetic retinopathy

PURPOSE

To evaluate the progression and risk factors of diabetic retinopathy during and after pregnancy in patients with diabetes.

METHODS

We checked the medical records of the patients with diabetes who were referred to the Diabetes Center, Tokyo Women's Medical University Hospital (Tokyo, Japan), and were pregnant between August 2004 and September 2010. The patients whose ophthalmic examinations records could not be found (n = 15) were excluded, and thus 93 patients (type 1 = 68, type 2 = 25) were included in the analyses. Data were obtained from the medical record and evaluated.

RESULTS

The mean pre-pregnancy HbA1c was 7.1 ± 0.8 %. All patients were encouraged to maintain HbA1c level of under 7.4 % before pregnancy. At baseline, the percentage of patients with no retinopathy was 78 %, with nonproliferative retinopathy 14 %, and with proliferative retinopathy, 8 %. Progression of retinopathy occurred in 16 (17 %) patients. Two (2 %) had loss of visual acuity and 1 (1 %) underwent laser treatment due to progression of retinopathy. Compared with patients who did not show progression, the patients with progression were characterized by longer duration of diabetes (p < 0.00001), presence of diabetic retinopathy before pregnancy (p < 0.00001) and higher blood pressure in the second trimester (p < 0.05).

CONCLUSIONS

Frequent ophthalmic examination, especially in patients with a long history of diabetes, is recommended, as well as for patients with presence of diabetic retinopathy before pregnancy. In contrast to previous reports, the progression of retinopathy in this study was lower. This is probably due to our patients' pre-pregnancy tight glucose control and the high ratio of patients with no retinopathy at baseline.

Diabetic retinopathy in pregnancy: a review

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.

Vascular complications in the diabetic pregnancy

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.

Diabetic retinopathy in pregnancy: a population-based study of women with pregestational diabetes

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.

Pregnancy-associated retinal diseases and their management

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.

Maternal endothelial dysfunction and its association with abnormal fetal growth in diabetic pregnancy

AIMS

Some authors consider the vascular endothelium to be a target organ in diabetes. However, there have only been a few studies of the function of the maternal endothelium during pregnancy in women with diabetes. We analysed the relationship between maternal vascular endothelial dysfunction and fetal growth in such pregnancies.

METHODS

Markers of endothelial dysfunction (serum concentration of sE-selectin and sVCAM-1) were measured at admission (baseline) and before delivery in 97 women with pregestational diabetes and a singleton pregnancy,. After delivery, the group with pregestational diabetes was divided retrospectively according to neonatal birthweight into three groups-appropriate, small and large for gestational age- and the maternal variables were analysed in relation to birthweight.

RESULTS

The baseline concentration of sE-selectin was significantly higher in the large-for-gestational-age group vs. the small-for-gestational-age group (median: 53.1 vs. 39.0 ng/ml, P<0.05). The concentration of sVCAM-1 at baseline was significantly higher in the small-for-gestational-age vs. the appropriate- and large-for-gestational-age groups (median: 846.2 vs. 576.8 and 524.1 ng/ml, respectively; P<0.01 and P<0.001, respectively). The concentration of sE-selectin at baseline and gestational changes in the concentration of sVCAM-1 were related to birthweight. The baseline concentrations of sE-selectin and sVCAM-1 and the gestational change in sVCAM-1 concentration were predictive factors for large for gestational age (cut-off values: 45.0, 644.6 and 38.4 ng/ml; sensitivity: 67.7, 89.3 and 34.4%; specificity: 65.5, 39.7 and 85.5%, respectively).

CONCLUSIONS

Our study showed a relationship between maternal endothelial dysfunction and fetal growth disturbances during pregnancy in women with diabetes that was not associated with maternal metabolic control. Higher levels of maternal sE-selectin in early pregnancy were associated with increased risk of the large-for-gestational-age condition. High levels of maternal sVCAM-1 in early pregnancy were characteristic of gestation complicated by the small-for-gestational-age condition. Further studies in larger groups are warranted to determine whether markers of maternal endothelial dysfunction are of use in the prediction of abnormal birthweight (large or small for gestational age) in pregnant women with diabetes.

Pregnancy-induced increase in circulating IGF-I is associated with progression of diabetic retinopathy in women with type 1 diabetes

OBJECTIVE

To evaluate the influence of Insulin-like Growth factor-I (IGF-I) and Placental Growth Hormone (GH) on progression of diabetic retinopathy during pregnancy in women with type 1 diabetes.

DESIGN

Observational study of 88 consecutive pregnant women with type 1 diabetes for median 16.5 years (range 1-36) and HbA(1c) 6.6% (5.2-10.5) in early pregnancy. At 8, 14, 21, 27 and 33 weeks blood samples were drawn for measurement of IGF-I, placental GH and Hemoglobin A(1c) (HbA(1c)) and blood pressure was recorded. Fundus photography was performed at 8 and 27 weeks. Diabetic retinopathy was classified in five stages. Progression was defined as deterioration of at least one stage of diabetic retinopathy and/or development of macular edema on at least one eye.

RESULTS

Placental GH and IGF-I levels increased throughout pregnancy and new onset or progression of diabetic retinopathy occurred in 22 (25%). A steeper increase in women with progression of diabetic retinopathy resulted in higher IGF-I levels at 27 weeks (p=0.01) and 16% higher IGF-I levels throughout pregnancy (p=0.02) compared with women without progression while similar levels of placental GH (p=0.58) and HbA(1c) (p=0.85) were observed throughout pregnancy. In a multivariate logistic regression analysis, progression of diabetic retinopathy was associated with higher IGF-I levels at 33 weeks (odds ratio 2.0 [95% confidence interval 1.1-3.6], p=0.02) and higher systolic blood pressure at 8 weeks (1.9 [1.1-3.2], p=0.02) independent of placental GH and HbA(1c) levels.

CONCLUSIONS

Pregnancy-induced increase in IGF-I levels is associated with progression of diabetic retinopathy in women with type 1 diabetes.

Effect of trandolapril on regression of retinopathy in hypertensive patients with type 2 diabetes: a prespecified analysis of the benedict trial

Background. The effect of angiotensin converting enzyme inhibitors (ACEi) on regression of retinopathy in type 2 diabetics is still ill defined. Methods. We compared the incidence of retinopathy regression in 90 hypertensive type 2 diabetics randomized to at least 3-year blinded ACEi with trandolapril (2 mg/day) or non-ACEi therapy who had preproliferative or proliferative retinopathy at baseline. Results. Over a median (interquartile range) follow-up period of 35.8 (12.4–60.7) months, retinopathy regressed in 27 patients (30.0%). Regression occurred in 18 of 42 patients (42.9%) on ACEi and in 9 of 48 (18.8%) on non-ACEi therapy (adjusted for predefined baseline covariates HR (95% CI): 2.75 (1.18–6.42), P = .0193). Concomitant treatment with or without Non-Dihydropyridine Calcium Channel Blockers (ndCCBs) did not appreciably affect the incidence of retinopathy regression. Conclusions. Unlike ndCCB, ACEi therapy may have an additional effect to that of intensified BP and metabolic control in promoting regression of diabetic retinopathy.

Progression of diabetic retinopathy during pregnancy in women with type 2 diabetes

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.

[Progression of diabetic retinopathy during pregnancy]

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.

Microvascular complications are associated with low levels of maternal sE-selectin and sVCAM-1 in pregnancy complicated with pregestational diabetes mellitus

Pregestational diabetes with vasculopathy in pregnant women is still associated with increased risk for severe maternal and foetal complications and their pathomechanism remains unclear. We investigate endothelial function in diabetic pregnant women with and without vascular disease, measured as changes in concentrations of soluble E-selectin and VCAM-1 throughout pregnancy. 121 pregnant women with PGDM and singleton pregnancy (30 participants with vasculopathy, 91 without vasculopathy) were enrolled into the prospective study. Control group consisted of 20 nondiabetic pregnant women in uncomplicated gestation, sampled cross-sectionally in early pregnancy and at term. We demonstrated lower concentrations of circulating sE-selectin both in early and in late diabetic gestation, irrespective of a concomitant vasculopathy. We also found reduced concentrations of sVCAM-1 in late gestation in diabetic pregnancies both with and without vascular disease, and reduced increase in its levels with gestation. We report significantly elevated concentrations of sVCAM-1 in early pregnancy in diabetic participants with retinopathy and nephropathy comparing with patients with retinopathy only and nondiabetic pregnant controls. We noted a general pattern of pregestational diabetes associated with reduced levels of cell adhesion molecules in early pregnancy with a further reduction during gestation, except for participants with combined retino- and nephropathy.

Pregnancy-induced sight-threatening diabetic retinopathy in women with Type 1 diabetes

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.

Sex- and gender-based differences in healthy and diseased eyes

PURPOSE

The aim of this study was to identify sex- and gender-based differences in ocular anatomy, physiology, and disease susceptibility or manifestation.

METHODS

Review of current indexed literature was conducted.

RESULTS

Sex and sex hormones influence the lacrimal system, eyelids and blinking, corneal anatomy and disease, aqueous humor dynamics and glaucoma, crystalline lens and cataract, uveitis and retinal disease, ocular circulation, and optic nerve anatomy and disease. Systemic conditions, particularly autoimmune disease, and conditions that are unique to women, such as pregnancy and menopause, further illustrate the effects of sex hormones on the eye. Gender-based differences in ocular conditions and disease should be considered within the context of the underlying physical and social environment.

CONCLUSIONS

Many sex- and gender-based differences exist in healthy and diseased eyes.

Acute unilateral cataract in a postpartum adolescent with poorly-controlled type 1 diabetes

Acute cataract is recognized as a rare complication in adolescents with type 1 diabetes mellitus and may be associated with rapid improvement in glycaemia in patients with newly diagnosed diabetes. Transient cataracts, which resolve following improved metabolic control, and irreversible cataracts requiring surgery have also previously been documented. Development or progression of retinopathy may complicate pregnancy in women with diabetes. To our knowledge, we present the first case report of an acute cataract developing postpartum in a woman with type 1 diabetes. This rare case serves to demonstrate a possible association between acute cataract and altered glycaemic control in pregnancy. Acute cataract should be considered in any woman with diabetes who develops sudden visual loss following pregnancy.

Type 2 diabetes in pregnancy: importance of optimized care before, during and after pregnancy

Women with Type 2 diabetes (T2DM) are an increasingly important part of the practice of obstetric medicine. The rising rates of obesity and advanced maternal age have resulted in a surge in the number of pregnant women with T2DM. The hyperglycaemia and associated conditions of the metabolic syndrome lead to poor obstetric outcome and impact on the long-term health of the mother and offspring. It is essential that women and care-givers recognize the seriousness of T2DM in pregnancy and strive to improve prepregnancy care, obstetric outcome and the long-term health of both the mother and child.

Progression of retinopathy during pregnancy in type 1 diabetes mellitus

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.