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Lyerly AD, Faden RR, Mello MM. Beneath the Sword of Damocles: Moral Obligations of Physicians in a Post-Dobbs Landscape. Hastings Cent Rep 2024; 54:15-27. [PMID: 38842894 DOI: 10.1002/hast.1589] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/07/2024]
Abstract
Since the U.S. Supreme Court's decision in Dobbs vs. Jackson Women's Health Organization, a growing web of state laws restricts access to abortion. Here we consider how, ethically, doctors should respond when terminating a pregnancy is clinically indicated but state law imposes restrictions on doing so. We offer a typology of cases in which the dilemma emerges and a brief sketch of the current state of legal prohibitions against providing such care. We examine the issue from the standpoints of conscience, professional ethics, and civil disobedience and conclude that it is almost always morally permissible and praiseworthy to break the law and that, in a subset of cases, it is morally obligatory to do so. We further argue that health care institutions that employ or credential physicians to provide reproductive health care have an ethical duty to provide a basic suite of practical supports for them as they work to ethically resolve the dilemmas before them.
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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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Do NC, Vestgaard M, Nørgaard SK, Damm P, Mathiesen ER, Ringholm L. Prediction and prevention of preeclampsia in women with preexisting diabetes: the role of home blood pressure, physical activity, and aspirin. Front Endocrinol (Lausanne) 2023; 14:1166884. [PMID: 37614711 PMCID: PMC10443220 DOI: 10.3389/fendo.2023.1166884] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/15/2023] [Accepted: 06/13/2023] [Indexed: 08/25/2023] Open
Abstract
Women with type 1 or type 2 (preexisting) diabetes are four times more likely to develop preeclampsia compared with women without diabetes. Preeclampsia affects 9%-20% of pregnant women with type 1 diabetes and 7%-14% of pregnant women with type 2 diabetes. The aim of this narrative review is to investigate the role of blood pressure (BP) monitoring, physical activity, and prophylactic aspirin to reduce the prevalence of preeclampsia and to improve pregnancy outcome in women with preexisting diabetes. Home BP and office BP in early pregnancy are positively associated with development of preeclampsia, and home BP and office BP are comparable for the prediction of preeclampsia in women with preexisting diabetes. However, home BP is lower than office BP, and the difference is greater with increasing office BP. Daily physical activity is recommended during pregnancy, and limiting sedentary behavior may be beneficial to prevent preeclampsia. White coat hypertension in early pregnancy is not a clinically benign condition but is associated with an elevated risk of developing preeclampsia. This renders the current strategy of leaving white coat hypertension untreated debatable. A beneficial preventive effect of initiating low-dose aspirin (150 mg/day) for all in early pregnancy has not been demonstrated in women with preexisting diabetes.
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Affiliation(s)
- Nicoline Callesen Do
- Center for Pregnant Women with Diabetes, Rigshospitalet, Copenhagen, Denmark
- Department of Endocrinology and Metabolism, Rigshospitalet, Copenhagen, Denmark
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Marianne Vestgaard
- Center for Pregnant Women with Diabetes, Rigshospitalet, Copenhagen, Denmark
- Department of Endocrinology and Metabolism, Rigshospitalet, Copenhagen, Denmark
| | - Sidse Kjærhus Nørgaard
- Center for Pregnant Women with Diabetes, Rigshospitalet, Copenhagen, Denmark
- Department of Endocrinology and Metabolism, Rigshospitalet, Copenhagen, Denmark
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Peter Damm
- Center for Pregnant Women with Diabetes, Rigshospitalet, Copenhagen, Denmark
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
- Department of Obstetrics, Rigshospitalet, Copenhagen, Denmark
| | - Elisabeth R. Mathiesen
- Center for Pregnant Women with Diabetes, Rigshospitalet, Copenhagen, Denmark
- Department of Endocrinology and Metabolism, Rigshospitalet, Copenhagen, Denmark
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Lene Ringholm
- Center for Pregnant Women with Diabetes, Rigshospitalet, Copenhagen, Denmark
- Department of Endocrinology and Metabolism, Rigshospitalet, Copenhagen, Denmark
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Pomytkina NV, Sorokin EL. [Investigation of diabetic retinopathy progression in women with diabetes mellitus during pregnancy]. Vestn Oftalmol 2023; 139:30-40. [PMID: 37379107 DOI: 10.17116/oftalma202313903130] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/30/2023]
Abstract
PURPOSE The study evaluates the transient and stationary diabetic retinal changes in pregnant women with diabetes mellitus (DM) based on the analysis of individual clinical cases of diabetic retinopathy (DR) progression. MATERIAL AND METHODS The study examined 24 pregnant women with DM. The examination was carried out in each trimester of pregnancy and 6 months after delivery. In 10 pregnant women DR was not detected, and 14 (58%) were diagnosed with DR. RESULTS Progression of DR during pregnancy was observed in 9 patients with pre-proliferative and proliferative DR (PPDR and PDR) and uncompensated glycemia, 3 patients developed macular edema (ME) in both eyes. Panretinal laser coagulation (PRLC) was performed in patients with ongoing DR progression. In the postpartum period, the manifestations of DR did not regress. ME turned out to be transient in one patient with PPDR. Three clinical cases of DR manifesting in the first trimester of pregnancy are presented: PPDR with transient ME, PDR with ME, non-proliferative DR with a stable course. CONCLUSION 1. DR detected at the beginning of gestation in women with decompensated glycemic status progressed in 64% of cases. 2. Progression of DR during pregnancy was noted in patients with PPDR and PDR. 3. Progression of DR during pregnancy is more often true than transient. 4. Detection of PPDR and PDR during pregnancy is a direct indication for laser coagulation of the retina.
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Affiliation(s)
- N V Pomytkina
- Khabarovsk branch of S.N. Fedorov National Medical Research Center "MNTK "Eye Microsurgery", Khabarovsk, Russia
- Far-Eastern State Medical University, Khabarovsk, Russia
| | - E L Sorokin
- Khabarovsk branch of S.N. Fedorov National Medical Research Center "MNTK "Eye Microsurgery", Khabarovsk, Russia
- Far-Eastern State Medical University, Khabarovsk, Russia
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Alnoman A, Peeva M, Badeghiesh AM, Baghlaf HA, Dahan MH. Pregnancy, delivery and neonatal outcomes among women with diabetic retinopathy. J Matern Fetal Neonatal Med 2022; 35:10621-10628. [PMID: 36404423 DOI: 10.1080/14767058.2022.2148095] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
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.
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Affiliation(s)
- Abdullah Alnoman
- Division of Maternal-Fetal Medicine, Obstetrics and Gynaecology, McGill University, Montreal, Canada.,Department of Obstetrics and Gynecology, King Abdulaziz University, Jeddah, Saudi Arabia
| | | | - Ahmad M Badeghiesh
- Department of Obstetrics and Gynecology, King Abdulaziz University, Jeddah, Saudi Arabia.,Division of Reproductive Endocrinology and Infertility, Obstetrics and Gynaecology, Western University, London, Canada
| | - Haitham A Baghlaf
- Division of Maternal-Fetal Medicine, Obstetrics and Gynaecology, McGill University, Montreal, Canada.,Division of Maternal-Fetal Medicine, Obstetrics and Gynaecology, University of Tabuk, Tabuk, Saudi Arabia
| | - Michael H Dahan
- Division of Reproductive Endocrinology and Infertility, MUHC Reproductive Center, McGill University, Montreal, Canada
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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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Widyaputri F, Rogers SL, Khong EWC, Nankervis AJ, Conn JJ, Sasongko MB, Shub A, Fagan XJ, Guest D, Symons RCA, Lim LL. Prevalence of diabetic retinopathy in women with pregestational diabetes during pregnancy and the postpartum. Clin Exp Ophthalmol 2022; 50:757-767. [PMID: 35603356 PMCID: PMC9796512 DOI: 10.1111/ceo.14111] [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: 09/29/2021] [Revised: 04/27/2022] [Accepted: 05/14/2022] [Indexed: 01/01/2023]
Abstract
BACKGROUND Diabetic retinopathy (DR) may be affected by pregnancy. The majority of prevalence data regarding DR in pregnancy predate the advent of contemporary guidelines for diabetes management during pregnancy. This study reports DR prevalence and associated risk factors in women with pregestational diabetes during pregnancy and the postpartum in Australia. METHODS A total of 172 pregnant women with type 1 (T1DM) or type 2 diabetes diagnosed pre-pregnancy were prospectively recruited from two obstetrics hospitals in Melbourne (November 2017-March 2020). Eye examinations were scheduled in each trimester, at 3-, 6-, and 12-months postpartum. DR severity was graded from two-field fundus photographs by an independent grader utilising the Airlie House Classification. Sight-threatening DR (STDR) was defined as the presence of diabetic macular oedema or proliferative DR. RESULTS Overall, 146 (84.9%) women had at least one eye examination during pregnancy. The mean age was 33.8 years (range 19-51), median diabetes duration was 7.0 years (IQR 3.0-17.0), 71 women (48.6%) had T1DM. DR and STDR prevalence during pregnancy per 100 eyes was 24.3 (95% CI 19.7-29.6) and 9.0 (95% CI 6.1-12.9); while prevalence in the postpartum was 22.2 (95% CI 16.5-29.3) and 10.0 (95% CI 5.4-17.9), respectively. T1DM, longer diabetes duration, higher HbA1c in early pregnancy, and pre-existing nephropathy were significant risk factors. CONCLUSIONS The prevalence of DR in pregnant women was similar to the non-pregnant diabetic population in Australia. One in nine participants had STDR during pregnancy and the postpartum, highlighting the need to optimise DR management guidelines in pregnancy given the significant risk of vision loss.
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Affiliation(s)
- Felicia Widyaputri
- Centre for Eye Research AustraliaRoyal Victorian Eye and Ear HospitalMelbourneVictoriaAustralia,Ophthalmology, Department of SurgeryUniversity of MelbourneMelbourneVictoriaAustralia,Department of Ophthalmology, Faculty of Medicine, Public Health, and NursingUniversitas Gadjah MadaYogyakartaIndonesia
| | - Sophie L. Rogers
- Centre for Eye Research AustraliaRoyal Victorian Eye and Ear HospitalMelbourneVictoriaAustralia
| | - Edmund W. C. Khong
- Centre for Eye Research AustraliaRoyal Victorian Eye and Ear HospitalMelbourneVictoriaAustralia
| | - Alison J. Nankervis
- Department of Diabetes and EndocrinologyRoyal Melbourne HospitalMelbourneVictoriaAustralia,Diabetes and Endocrine ServiceRoyal Women's HospitalMelbourneVictoriaAustralia
| | - Jennifer J. Conn
- Department of Diabetes and EndocrinologyRoyal Melbourne HospitalMelbourneVictoriaAustralia,Diabetes and Endocrine ServiceRoyal Women's HospitalMelbourneVictoriaAustralia
| | - Muhammad B. Sasongko
- Department of Ophthalmology, Faculty of Medicine, Public Health, and NursingUniversitas Gadjah MadaYogyakartaIndonesia
| | - Alexis Shub
- Perinatal DepartmentMercy Hospital for WomenHeidelbergVictoriaAustralia,Department of Obstetrics and GynaecologyUniversity of MelbourneMelbourneVictoriaAustralia
| | - Xavier J. Fagan
- Department of OphthalmologyAustin HospitalHeidelbergVictoriaAustralia,Medical Retina UnitRoyal Victorian Eye and Ear HospitalMelbourneVictoriaAustralia
| | - Daryl Guest
- Department of Optometry and Vision SciencesUniversity of MelbourneMelbourneVictoriaAustralia
| | - Robert C. A. Symons
- Centre for Eye Research AustraliaRoyal Victorian Eye and Ear HospitalMelbourneVictoriaAustralia,Ophthalmology, Department of SurgeryUniversity of MelbourneMelbourneVictoriaAustralia,Department of Optometry and Vision SciencesUniversity of MelbourneMelbourneVictoriaAustralia,Department of SurgeryAlfred Hospital, Monash UniversityClaytonVictoriaAustralia
| | - Lyndell L. Lim
- Centre for Eye Research AustraliaRoyal Victorian Eye and Ear HospitalMelbourneVictoriaAustralia,Ophthalmology, Department of SurgeryUniversity of MelbourneMelbourneVictoriaAustralia,Medical Retina UnitRoyal Victorian Eye and Ear HospitalMelbourneVictoriaAustralia
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Trends in the Prevalence and Progression of Diabetic Retinopathy Associated with Hyperglycemic Disorders during Pregnancy in Japan. J Clin Med 2021; 11:jcm11010165. [PMID: 35011906 PMCID: PMC8745209 DOI: 10.3390/jcm11010165] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2021] [Revised: 12/03/2021] [Accepted: 12/20/2021] [Indexed: 11/20/2022] Open
Abstract
The aim of this study was to determine the prevalence and progression of diabetic retinopathy (DR) with hyperglycemic disorders during pregnancy (HDPs) in Japan between 2013 and 2018 using two cohorts. The patients with HDPs were classified as those with pre-existing DM (pexD), gestational DM (GDM), and overt DM (ODM). Cohort 1 was obtained from the health claims database whose diseases were classified by the International Classification of Diseases-10. Cohort 2 was derived from a retrospective, multicenter analysis of the medical records of 225 patients from 10 ophthalmological institutions. In Cohort 1, there were 5268 patients with an HDP prevalence of 8.4%. Among them, 73 of 1139 patients had pexD (6.4%) and 61 of 4129 patients with GDM (1.5%) had DR; the overall prevalence of DR was 2.5%. In Cohort 2, 36 of 225 patients (16.0%) had DR, and 149 patients were followed at the early and late stages of pregnancy. Moreover, 10 of the 102 patients with pexD (9.8%) and two of five patients with ODM (40.0%) had a progression of DR. In conclusion, the prevalence and progression of DR in patients with pexD is lower than previously reported. More attention should be given to pexD and ODM.
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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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10
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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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11
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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: 01/28/2021] [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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12
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Anton N, Doroftei B, Ilie OD, Ciuntu RE, Bogdănici CM, Nechita-Dumitriu I. A Narrative Review of the Complex Relationship between Pregnancy and Eye Changes. Diagnostics (Basel) 2021; 11:1329. [PMID: 34441264 PMCID: PMC8394444 DOI: 10.3390/diagnostics11081329] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2021] [Revised: 07/14/2021] [Accepted: 07/21/2021] [Indexed: 12/14/2022] Open
Abstract
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.
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Affiliation(s)
- Nicoleta Anton
- Department of Ophthalmology, Faculty of Medicine, University of Medicine and Pharmacy “Grigore T. Popa”, University Street, No. 16, 700115 Iasi, Romania; (N.A.); (R.-E.C.); (C.M.B.); (I.N.-D.)
- Ophthalmology Clinic, “Saint Spiridon” Emergency Clinic Hospital, Independence Avenue, No. 1, 700111 Iasi, Romania
| | - Bogdan Doroftei
- Department of Mother and Child Medicine, Faculty of Medicine, University of Medicine and Pharmacy “Grigore T. Popa”, University Street, No. 16, 700115 Iasi, Romania
- Origyn Fertility Center, Palace Street, No. 3C, 700032 Iasi, Romania
| | - Ovidiu-Dumitru Ilie
- Department of Biology, Faculty of Biology, “Alexandru Ioan Cuza” University, Carol I Avenue, No. 20A, 700505 Iasi, Romania;
| | - Roxana-Elena Ciuntu
- Department of Ophthalmology, Faculty of Medicine, University of Medicine and Pharmacy “Grigore T. Popa”, University Street, No. 16, 700115 Iasi, Romania; (N.A.); (R.-E.C.); (C.M.B.); (I.N.-D.)
- Ophthalmology Clinic, “Saint Spiridon” Emergency Clinic Hospital, Independence Avenue, No. 1, 700111 Iasi, Romania
| | - Camelia Margareta Bogdănici
- Department of Ophthalmology, Faculty of Medicine, University of Medicine and Pharmacy “Grigore T. Popa”, University Street, No. 16, 700115 Iasi, Romania; (N.A.); (R.-E.C.); (C.M.B.); (I.N.-D.)
- Ophthalmology Clinic, “Saint Spiridon” Emergency Clinic Hospital, Independence Avenue, No. 1, 700111 Iasi, Romania
| | - Ionela Nechita-Dumitriu
- Department of Ophthalmology, Faculty of Medicine, University of Medicine and Pharmacy “Grigore T. Popa”, University Street, No. 16, 700115 Iasi, Romania; (N.A.); (R.-E.C.); (C.M.B.); (I.N.-D.)
- Ophthalmology Clinic, “Saint Spiridon” Emergency Clinic Hospital, Independence Avenue, No. 1, 700111 Iasi, Romania
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13
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Kgosidialwa O, Bogdanet D, Egan AM, O'Shea PM, Newman C, Griffin TP, McDonagh C, O'Shea C, Carmody L, Cooray SD, Anastasiou E, Wender-Ozegowska E, Clarson C, Spadola A, Alvarado F, Noctor E, Dempsey E, Napoli A, Crowther C, Galjaard S, Loeken MR, Maresh M, Gillespie P, de Valk H, Agostini A, Biesty L, Devane D, Dunne F. A core outcome set for the treatment of pregnant women with pregestational diabetes: an international consensus study. BJOG 2021; 128:1855-1868. [PMID: 34218508 PMCID: PMC9311326 DOI: 10.1111/1471-0528.16825] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/18/2021] [Indexed: 12/21/2022]
Abstract
Objective To develop a core outcome set (COS) for randomised controlled trials (RCTs) evaluating the effectiveness of interventions for the treatment of pregnant women with pregestational diabetes mellitus (PGDM). Design A consensus developmental study. Setting International. Population Two hundred and five stakeholders completed the first round. Methods The study consisted of three components. (1) A systematic review of the literature to produce a list of outcomes reported in RCTs assessing the effectiveness of interventions for the treatment of pregnant women with PGDM. (2) A three-round, online eDelphi survey to prioritise these outcomes by international stakeholders (including healthcare professionals, researchers and women with PGDM). (3) A consensus meeting where stakeholders from each group decided on the final COS. Main outcome measures All outcomes were extracted from the literature. Results We extracted 131 unique outcomes from 67 records meeting the full inclusion criteria. Of the 205 stakeholders who completed the first round, 174/205 (85%) and 165/174 (95%) completed rounds 2 and 3, respectively. Participants at the subsequent consensus meeting chose 19 outcomes for inclusion into the COS: trimester-specific haemoglobin A1c, maternal weight gain during pregnancy, severe maternal hypoglycaemia, diabetic ketoacidosis, miscarriage, pregnancy-induced hypertension, pre-eclampsia, maternal death, birthweight, large for gestational age, small for gestational age, gestational age at birth, preterm birth, mode of birth, shoulder dystocia, neonatal hypoglycaemia, congenital malformations, stillbirth and neonatal death. Conclusions This COS will enable better comparison between RCTs to produce robust evidence synthesis, improve trial reporting and optimise research efficiency in studies assessing treatment of pregnant women with PGDM. 165 key stakeholders have developed #Treatment #CoreOutcomes in pregnant women with #diabetes existing before pregnancy.
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Affiliation(s)
- O Kgosidialwa
- College of Medicine, Nursing and Health Sciences, National University of Ireland Galway, Galway, Ireland
| | - D Bogdanet
- College of Medicine, Nursing and Health Sciences, National University of Ireland Galway, Galway, Ireland
| | - A M Egan
- Division of Endocrinology, Mayo Clinic, Rochester, MN, USA
| | - P M O'Shea
- College of Medicine, Nursing and Health Sciences, National University of Ireland Galway, Galway, Ireland
| | - C Newman
- College of Medicine, Nursing and Health Sciences, National University of Ireland Galway, Galway, Ireland
| | - T P Griffin
- College of Medicine, Nursing and Health Sciences, National University of Ireland Galway, Galway, Ireland
| | - C McDonagh
- College of Medicine, Nursing and Health Sciences, National University of Ireland Galway, Galway, Ireland
| | - C O'Shea
- College of Medicine, Nursing and Health Sciences, National University of Ireland Galway, Galway, Ireland
| | - L Carmody
- College of Medicine, Nursing and Health Sciences, National University of Ireland Galway, Galway, Ireland
| | - S D Cooray
- Diabetes and Endocrinology Units, Monash Health, Clayton, Vic., Australia.,Monash Centre for Health Research and Implementation, Monash University, Clayton, Vic., Australia
| | - E Anastasiou
- Department Diabetes & Pregnancy Outpatients, Mitera Hospital, Athens, Greece
| | - E Wender-Ozegowska
- Department of Reproduction, Poznan University of Medical Sciences, Poznan, Poland
| | - C Clarson
- Department of Paediatrics, University of Western Ontario, London, ON, Canada.,Lawson Health Research Institute, London, ON, Canada
| | - A Spadola
- Mother Infant Research Institute, Tufts Medical Center, Boston, MA, USA
| | - F Alvarado
- Mother Infant Research Institute, Tufts Medical Center, Boston, MA, USA
| | - E Noctor
- Division of Endocrinology, University Hospital Limerick, Limerick, Ireland
| | - E Dempsey
- INFANT Centre and Department of Paediatrics & Child Health, University College Cork, Cork, Ireland
| | - A Napoli
- Department of Clinical and Molecular Medicine, Sant'Andrea University Hospital, Sapienza, University of Rome, Rome, Italy
| | - C Crowther
- Liggins Institute, The University of Auckland, Auckland, New Zealand
| | - S Galjaard
- Department of Obstetrics and Gynaecology, Division of Obstetrics and Prenatal Medicine, Erasmus MC, University Medical Centre Rotterdam, Rotterdam, The Netherlands
| | - M R Loeken
- Section of Islet Cell and Regenerative Biology, Joslin Diabetes Center, Boston, MA, USA.,Department of Medicine, Harvard Medical School, Boston, MA, USA
| | - Mja Maresh
- Department of Obstetrics, St Mary's Hospital, Manchester University Hospitals NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester, UK
| | - P Gillespie
- Health Economics and Policy Analysis Centre (HEPAC), National University of Ireland, Galway, Ireland
| | - H de Valk
- Department of Internal Medicine, University Medical Centre Utrecht, Utrecht, The Netherlands
| | - A Agostini
- A.S.LViterbo Distretto A, Consultorio Montefiascone, Rome, Italy
| | - L Biesty
- School of Nursing & Midwifery, National University of Ireland Galway, Galway, Ireland
| | - D Devane
- School of Nursing & Midwifery, National University of Ireland Galway, Galway, Ireland.,HRB-Trials Methodology Research Network, National University of Ireland Galway, Galway, Ireland
| | - F Dunne
- College of Medicine, Nursing and Health Sciences, National University of Ireland Galway, Galway, Ireland
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14
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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: 81] [Impact Index Per Article: 27.0] [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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15
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Nørgaard SK, Mathiesen ER, Nørgaard K, Clausen TD, Damm P, Ringholm L. CopenFast trial: Faster-acting insulin Fiasp versus insulin NovoRapid in the treatment of women with type 1 or type 2 diabetes during pregnancy and lactation - a randomised controlled trial. BMJ Open 2021; 11:e045650. [PMID: 33837106 PMCID: PMC8043014 DOI: 10.1136/bmjopen-2020-045650] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
INTRODUCTION Faster-acting insulin aspart (Fiasp) is approved for use in pregnancy and lactation, but no clinical study has evaluated its effects during this life stage in women with pre-existing diabetes. The aim of the CopenFast trial is to evaluate the effect of Fiasp compared with insulin aspart (NovoRapid) on maternal glycaemic control during pregnancy, delivery and lactation and on fetal growth and infant health. METHODS AND ANALYSIS An open-label randomised controlled trial of pregnant women with type 1 or type 2 diabetes including women on multiple daily injection (MDI) therapy or insulin pump therapy. During a 2-year inclusion period, approximately 220 women will be randomised 1:1 to Fiasp or NovoRapid in early pregnancy and followed until 3 months after delivery. At 9, 21 and 33 gestational weeks and during planned induction of labour or caesarean section, women are offered blinded continuous glucose monitoring (CGM) for 7 days. Randomisation will stratify for type of diabetes and insulin treatment modality (MDI or insulin pump therapy, respectively). Health status of the infants will be followed until 3 months of age. The primary outcome is birth weight SD score adjusted for gestational age and gender. Secondary outcomes include maternal glycaemic control including glycated haemoglobin, preprandial and postprandial self-monitored plasma glucose levels, episodes of mild and severe hypoglycaemia, maternal gestational weight gain and weight retention, CGM time spent in, above and below target ranges as well as pregnancy outcomes including pre-eclampsia, preterm delivery, perinatal mortality and neonatal morbidity. Data analysis will be performed according to the intention-to-treat principle. ETHICS AND DISSEMINATION The trial has been approved by the Regional Ethics Committee (H-19029966) on 7 August 2019. Results will be sought disseminated in peer-reviewed journals and at scientific meetings. TRIAL REGISTRATION NUMBER NCT03770767.
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Affiliation(s)
- Sidse Kjærhus Nørgaard
- Center for Pregnant Women with Diabetes, Rigshospitalet, Copenhagen, Denmark
- Department of Endocrinology, Rigshospitalet, Copenhagen, Denmark
| | - Elisabeth Reinhardt Mathiesen
- Center for Pregnant Women with Diabetes, Rigshospitalet, Copenhagen, Denmark
- Department of Endocrinology, Rigshospitalet, Copenhagen, Denmark
- Department of Clinical Medicine, University of Copenhagen Faculty of Health and Medical Sciences, Copenhagen, Denmark
| | | | - Tine Dalsgaard Clausen
- Department of Clinical Medicine, University of Copenhagen Faculty of Health and Medical Sciences, Copenhagen, Denmark
- Department of Gynaecology and Obstetrics, Nordsjaellands Hospital, Hillerod, Denmark
| | - Peter Damm
- Center for Pregnant Women with Diabetes, Rigshospitalet, Copenhagen, Denmark
- Department of Clinical Medicine, University of Copenhagen Faculty of Health and Medical Sciences, Copenhagen, Denmark
- Department of Obstetrics, Rigshospitalet, Copenhagen, Denmark
| | - Lene Ringholm
- Center for Pregnant Women with Diabetes, Rigshospitalet, Copenhagen, Denmark
- Department of Endocrinology, Rigshospitalet, Copenhagen, Denmark
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16
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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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17
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Kgosidialwa O, Bogdanet D, Egan A, O'Shea PM, Biesty L, Devane D, Dunne F. Developing a core outcome set for the treatment of pregnant women with pregestational diabetes-a study protocol. Trials 2020; 21:1017. [PMID: 33308263 PMCID: PMC7730783 DOI: 10.1186/s13063-020-04910-1] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2020] [Accepted: 11/16/2020] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND Pregestational diabetes mellitus (PGDM) is associated with adverse pregnancy outcomes including increased rates of caesarean section birth, macrosomia, congenital malformation, prematurity, admission to the neonatal intensive care unit and stillbirth. As a result, there has been an increase in interventions to improve outcomes in both mother and infant. To date, meaningful comparisons between these studies are limited due to heterogeneity in outcome selection and reporting. The aim of this study is to develop a core outcome set (COS) for randomised controlled trials evaluating the effectiveness of interventions for the treatment of pregnant women with PGDM. METHODS The study consists of three steps. The first step is a systematic review of the literature to assess outcomes reported in randomised controlled trials assessing the effectiveness of interventions for the treatment of pregnant women with PGDM. The second step is a three round, online Delphi survey to prioritise these outcomes. In this step, stakeholders (including women with PGDM, healthcare workers, researchers and policymakers) will be asked to rank the importance of outcomes for inclusion in the COS using a 9-point Likert type scale. Outcomes that meet the inclusion criteria after completion of the Delphi surveys will be brought to the consensus meeting. The consensus meeting will be the third and final step, where the COS will be finalised. The consensus meeting will include members from each stakeholder group. DISCUSSION This paper describes the process used to develop a COS for the reporting of studies evaluating the effectiveness of interventions in pregnant women with PGDM. The COS will enable greater comparison between and information synthesis across RCTs in the treatment of PGDM. In addition, this COS will also help improve trial reporting and minimise research waste by prioritising the collection and reporting of outcomes that matter to all relevant stakeholder groups. TRIAL REGISTRATION This COS has been registered with the Core Outcome Measures in Effectiveness Trials (COMET) initiative ( http://www.comet-initiative.org/studies/details/1425 ) on the 4th of November 2019. The systematic review component of this study has also been registered with the International Prospective Register of Systematic Reviews (PROSPERO) ( https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42020173549 ).
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Affiliation(s)
| | - Delia Bogdanet
- School of Medicine, National University of Ireland Galway, Galway, Ireland
| | - Aoife Egan
- Department of Endocrinology, Mayo Clinic Rochester, Rochester, MN, USA
| | - Paula M O'Shea
- School of Medicine, National University of Ireland Galway, Galway, Ireland
| | - Linda Biesty
- School of Nursing and Midwifery, National University of Ireland Galway, Galway, Ireland.,Ireland HRB-Trials Methodology Research Network, National University of Ireland Galway, Galway, Ireland
| | - Declan Devane
- School of Nursing and Midwifery, National University of Ireland Galway, Galway, Ireland.,Ireland HRB-Trials Methodology Research Network, National University of Ireland Galway, Galway, Ireland
| | - Fidelma Dunne
- School of Medicine, National University of Ireland Galway, Galway, Ireland
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18
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Rudland VL, Price SAL, Hughes R, Barrett HL, Lagstrom J, Porter C, Britten FL, Glastras S, Fulcher I, Wein P, Simmons D, McIntyre HD, Callaway L. ADIPS 2020 guideline for pre-existing diabetes and pregnancy. Aust N Z J Obstet Gynaecol 2020; 60:E18-E52. [PMID: 33200400 DOI: 10.1111/ajo.13265] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2020] [Accepted: 09/14/2020] [Indexed: 02/07/2023]
Abstract
This is the full version of the Australasian Diabetes in Pregnancy Society (ADIPS) 2020 guideline for pre-existing diabetes and pregnancy. The guideline encompasses the management of women with pre-existing type 1 diabetes and type 2 diabetes in relation to pregnancy, including preconception, antepartum, intrapartum and postpartum care. The management of women with monogenic diabetes or cystic fibrosis-related diabetes in relation to pregnancy is also discussed.
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Affiliation(s)
- Victoria L Rudland
- Department of Diabetes and Endocrinology, Westmead Hospital, Sydney, New South Wales, Australia.,Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales, Australia
| | - Sarah A L Price
- Department of Diabetes and Endocrinology, Royal Melbourne Hospital, Melbourne, Victoria, Australia.,Department of Diabetes, Royal Women's Hospital, Melbourne, Victoria, Australia.,Mercy Hospital for Women, Melbourne, Victoria, Australia.,Faculty of Medicine, University of Melbourne, Melbourne, Victoria, Australia
| | - Ruth Hughes
- Department of Obstetrics and Gynaecology, University of Otago, Christchurch, New Zealand
| | - Helen L Barrett
- Department of Endocrinology, Mater Health, Brisbane, Queensland, Australia.,Mater Research, The University of Queensland, Brisbane, Queensland, Australia
| | - Janet Lagstrom
- Green St Specialists Wangaratta, Wangaratta, Victoria, Australia.,Denis Medical Yarrawonga, Yarrawonga, Victoria, Australia.,Corowa Medical Clinic, Corowa, New South Wales, Australia.,NCN Health, Numurkah, Victoria, Australia
| | - Cynthia Porter
- Geraldton Diabetes Clinic, Geraldton, Western Australia, Australia
| | - Fiona L Britten
- Department of Obstetric Medicine, Royal Brisbane and Women's Hospital, Brisbane, Queensland, Australia.,Mater Private Hospital and Mater Mother's Private Hospital, Brisbane, Queensland, Australia.,Faculty of Medicine, University of Queensland, Brisbane, Queensland, Australia
| | - Sarah Glastras
- Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales, Australia.,Department of Diabetes, Endocrinology and Metabolism, Royal North Shore Hospital, Sydney, New South Wales, Australia
| | - Ian Fulcher
- Liverpool Hospital, Sydney, New South Wales, Australia
| | - Peter Wein
- Mercy Hospital for Women, Melbourne, Victoria, Australia.,Department of Obstetrics and Gynaecology, University of Melbourne, Melbourne, Victoria, Australia
| | - David Simmons
- Western Sydney University, Sydney, New South Wales, Australia.,Campbelltown Hospital, Sydney, New South Wales, Australia
| | - H David McIntyre
- Faculty of Medicine, University of Queensland, Brisbane, Queensland, Australia.,Mater Health, Brisbane, Queensland, Australia
| | - Leonie Callaway
- Faculty of Medicine, University of Queensland, Brisbane, Queensland, Australia.,Women's and Children's Services, Metro North Hospital and Health Service District, Brisbane, Queensland, Australia.,Women's and Newborn Services, Royal Brisbane and Women's Hospital, Brisbane, Queensland, Australia
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19
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Rudland VL, Price SAL, Callaway L. ADIPS position paper on pre-existing diabetes and pregnancy. Aust N Z J Obstet Gynaecol 2020; 60:831-839. [PMID: 33135798 DOI: 10.1111/ajo.13266] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2020] [Accepted: 09/14/2020] [Indexed: 01/17/2023]
Abstract
This is an executive summary of the Australasian Diabetes in Pregnancy Society (ADIPS) 2020 guideline for pre-existing diabetes and pregnancy. The summary focuses on the main clinical practice points for the management of women with type 1 diabetes and type 2 diabetes in relation to pregnancy, including preconception, antepartum, intrapartum and postpartum care. The full guideline is available at https://doi.org/10.1111/ajo.13265.
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Affiliation(s)
- Victoria L Rudland
- Department of Diabetes and Endocrinology, Westmead Hospital, Sydney, NSW, Australia.,Faculty of Medicine and Health, The University of Sydney, Sydney, NSW, Australia
| | - Sarah A L Price
- Department of Diabetes and Endocrinology, Royal Melbourne Hospital, Melbourne, Vic., Australia.,Department of Diabetes, Royal Women's Hospital, Melbourne, Vic., Australia.,Mercy Hospital for Women, Melbourne, Vic., Australia.,Faculty of Medicine, University of Melbourne, Melbourne, Vic., Australia
| | - Leonie Callaway
- Women's and Children's Services, Metro North Hospital and Health Service District, Brisbane, Qld, Australia.,Women's and Newborn Services, Royal Brisbane and Women's Hospital, Brisbane, Qld, Australia.,Royal Brisbane and Women's Hospital, Brisbane, Qld, Australia.,Faculty of Medicine, The University of Queensland, Brisbane, Qld, Australia
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20
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Naderan M, Sabzevary M, Rezaii K, Banafshehafshan A, Hantoushzadeh S. Intravitreal anti-vascular endothelial growth factor medications during pregnancy: current perspective. Int Ophthalmol 2020; 41:743-751. [PMID: 33044671 DOI: 10.1007/s10792-020-01610-2] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2020] [Accepted: 10/01/2020] [Indexed: 12/20/2022]
Abstract
PURPOSE Anti-vascular endothelial growth factor (VEGF) medications are widely used for treatment of a number of vitreoretinal disorders. However, the evidence for their effect on fetal and maternal health during pregnancy is very limited. The goal of this article is to accumulate evidence for the indications of anti-VEGF medications during pregnancy and their effects on maternal and fetal health. METHODS Review of literature regarding anti-VEGF administration during pregnancy and using PubMed database without language or date limit. RESULTS The main indications for treatment with intravitreal anti-VEGF medications include choroidal neovascularization (CNV) followed by retinal vascular occlusion (RVO) and complications of diabetes such as neovascular glaucoma, diabetic retinopathy (DR) and diabetic macular edema (DME). Among anti-VEGF medications, only ranibizumab and bevacizumab have been used during pregnancy with latter by far more than the former. CONCLUSION Women of childbearing age should be consulted regarding the potential adverse effects of anti-VEGF medications on fetal health and the risk of early pregnancy loss. They should be strongly encouraged to use appropriate contraceptive methods during treatment. A timely obstetrics consultation may help in this situation. Attempt for pregnancy should be withheld for at least 3 months following last injection of ranibizumab and aflibercept, and for at least 6 months following last injection of bevacizumab.
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Affiliation(s)
- Morteza Naderan
- Department of Ophthalmology, Farabi Eye Hospital Research Center, Farabi Eye Hospital, Tehran University of Medical Sciences, Qazvin square, South Karegar street, Tehran, Iran.
| | - Masomeh Sabzevary
- Maternal, Fetal, and Neonatal Research Center, Yas Women's Hospital, Tehran University of Medical Sciences, Tehran, Iran
| | - Keivan Rezaii
- Department of Ophthalmology, Farabi Eye Hospital Research Center, Farabi Eye Hospital, Tehran University of Medical Sciences, Qazvin square, South Karegar street, Tehran, Iran
| | - Ali Banafshehafshan
- Department of Ophthalmology, Farabi Eye Hospital Research Center, Farabi Eye Hospital, Tehran University of Medical Sciences, Qazvin square, South Karegar street, Tehran, Iran
| | - Seddigheh Hantoushzadeh
- Maternal, Fetal, and Neonatal Research Center, Valiasr Hospital, Imam Khomeini Hospital Complexs, Tehran University of Medical Sciences, Tehran, Iran
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Vestgaard M, Ásbjörnsdóttir B, Ringholm L, Andersen LLT, Jensen DM, Damm P, Mathiesen ER. White coat hypertension in early pregnancy in women with pre-existing diabetes: prevalence and pregnancy outcomes. Diabetologia 2019; 62:2188-2199. [PMID: 31628489 DOI: 10.1007/s00125-019-05002-9] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/12/2019] [Accepted: 07/26/2019] [Indexed: 02/01/2023]
Abstract
AIMS/HYPOTHESIS Hypertensive disorders are prevalent among pregnant women with pre-existing diabetes, but the prevalence and impact of white coat hypertension are unknown. Measurement of home BP before initiation of antihypertensive treatment is necessary to identify white coat hypertension since international guidelines recommend that white coat hypertension is left untreated. The aim of this study, conducted among women with pre-existing diabetes, was therefore to examine the prevalence of white coat hypertension in early pregnancy, and pregnancy outcome in women with white coat hypertension in early pregnancy. METHODS A prospective cohort study was undertaken involving women with pre-existing diabetes from a geographically well-defined area. Based on office BP in early pregnancy and home BP measured for 3 days, women were categorised in three groups: (1) white coat hypertension, defined as office BP ≥ 135/85 mmHg and mean home BP < 130/80 mmHg; (2) chronic hypertension, defined as pre-pregnancy hypertension including newly detected office BP ≥ 135/85 mmHg with home BP ≥ 130/80 mmHg; and (3) normotension. Office BP was measured every 2 weeks and, if ≥ 135/85 mmHg, home BP measurements were performed. White coat hypertension was left untreated, and tight antihypertensive treatment was initiated when both office BP ≥ 135/85 mmHg and home BP ≥ 130/80 mmHg. Pregnancy-induced hypertensive disorders were defined as office BP ≥ 140/90 mmHg with home BP ≥ 130/80 mmHg when available, with onset after 20 weeks of gestation. RESULTS In total, 32 out of 222 women with pre-existing diabetes had newly detected office BP ≥ 135/85 mmHg in early pregnancy. White coat hypertension was present in 84% (27/32) of these women, representing 12% (95% CI 8%, 17%) of the whole cohort. Chronic hypertension was present in 14% (n = 32) and normotension in 74% (n = 163). Women with white coat hypertension were characterised by higher pre-pregnancy BMI (p = 0.011), higher home BP (p < 0.001) and higher prevalence of type 2 diabetes (p = 0.009), but similar HbA1c (p = 0.409) compared to women with normotension. Regarding pregnancy outcome, pregnancy-induced hypertensive disorders developed in 44% (12/27) of women with white coat hypertension in comparison with 22% (36/163) among initially normotensive women (p = 0.013), while the prevalence of preterm delivery was comparable (p = 0.143). The adjusted analysis, performed post hoc, suggested approximately double the risk of developing pregnancy-induced hypertensive disorders (OR 2.43 [CI 0.98, 6.05]) if white coat hypertension was present in early pregnancy, independently of pre-pregnancy BMI and parity. CONCLUSIONS/INTERPRETATION White coat hypertension is prevalent in women with pre-existing diabetes and may indicate a high risk of later development of pregnancy-induced hypertensive disorders. To distinguish between persistent white coat hypertension and onset of pregnancy-induced hypertension, repeated home BP monitoring is recommended when elevated office BP is detected. The study was registered at ClinicalTrials.gov (ID: NCT02890836).
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Affiliation(s)
- Marianne Vestgaard
- Center for Pregnant Women with Diabetes, Department of Endocrinology and Obstetrics, Rigshospitalet, University of Copenhagen, Blegdamsvej 9, 2100, Copenhagen, Denmark.
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark.
| | - Björg Ásbjörnsdóttir
- Center for Pregnant Women with Diabetes, Department of Endocrinology and Obstetrics, Rigshospitalet, University of Copenhagen, Blegdamsvej 9, 2100, Copenhagen, Denmark
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Lene Ringholm
- Center for Pregnant Women with Diabetes, Department of Endocrinology and Obstetrics, Rigshospitalet, University of Copenhagen, Blegdamsvej 9, 2100, Copenhagen, Denmark
- Steno Diabetes Center Copenhagen, Gentofte, Denmark
| | | | - Dorte M Jensen
- Department of Obstetrics, Odense University Hospital, Odense, Denmark
- Steno Diabetes Center Odense, Odense University Hospital, Odense, Denmark
| | - Peter Damm
- Center for Pregnant Women with Diabetes, Department of Endocrinology and Obstetrics, Rigshospitalet, University of Copenhagen, Blegdamsvej 9, 2100, Copenhagen, Denmark
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Elisabeth R Mathiesen
- Center for Pregnant Women with Diabetes, Department of Endocrinology and Obstetrics, Rigshospitalet, University of Copenhagen, Blegdamsvej 9, 2100, Copenhagen, Denmark
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
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Narayanan SP, Shosha E, D Palani C. Spermine oxidase: A promising therapeutic target for neurodegeneration in diabetic retinopathy. Pharmacol Res 2019; 147:104299. [PMID: 31207342 PMCID: PMC7011157 DOI: 10.1016/j.phrs.2019.104299] [Citation(s) in RCA: 29] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/31/2018] [Revised: 04/23/2019] [Accepted: 06/05/2019] [Indexed: 12/20/2022]
Abstract
Diabetic Retinopathy (DR), is a significant public health issue and the leading cause of blindness in working-aged adults worldwide. The vision loss associated with DR affects patients' quality of life and has negative social and psychological effects. In the past, diabetic retinopathy was considered as a vascular disease; however, it is now recognized to be a neuro-vascular disease of the retina. Current therapies for DR, such as laser photocoagulation and anti-VEGF therapy, treat advanced stages of the disease, particularly the vasculopathy and have adverse side effects. Unavailability of effective treatments to prevent the incidence or progression of DR is a major clinical problem. There is a great need for therapeutic interventions capable of preventing retinal damage in DR patients. A growing body of evidence shows that neurodegeneration is an early event in DR pathogenesis. Therefore, studies of the underlying mechanisms that lead to neurodegeneration are essential for identifying new therapeutic targets in the early stages of DR. Deregulation of the polyamine metabolism is implicated in various neurodegenerative diseases, cancer, renal failure, and diabetes. Spermine Oxidase (SMOX) is a highly inducible enzyme, and its dysregulation can alter polyamine homeostasis. The oxidative products of polyamine metabolism are capable of inducing cell damage and death. The current review provides insight into the SMOX-regulated molecular mechanisms of cellular damage and dysfunction, and its potential as a therapeutic target for diabetic retinopathy. Structural and functional changes in the diabetic retina and the mechanisms leading to neuronal damage (excitotoxicity, loss of neurotrophic factors, oxidative stress, mitochondrial dysfunction etc.) are also summarized in this review. Furthermore, existing therapies and new approaches to neuroprotection are discussed.
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Affiliation(s)
- S Priya Narayanan
- Clinical and Experimental Therapeutics, College of Pharmacy, University of Georgia, Augusta, GA, United States; Augusta University Culver Vision Discovery Institute, Augusta, GA, United States; Vascular Biology Center, Augusta University, Augusta, GA, United States; VA Medical Center, Augusta, GA, United States.
| | - Esraa Shosha
- Augusta University Culver Vision Discovery Institute, Augusta, GA, United States; Vascular Biology Center, Augusta University, Augusta, GA, United States; Clinical Pharmacy Department, Faculty of Pharmacy, Cairo University, Cairo, Egypt
| | - Chithra D Palani
- Clinical and Experimental Therapeutics, College of Pharmacy, University of Georgia, Augusta, GA, United States; Augusta University Culver Vision Discovery Institute, Augusta, GA, United States; Vascular Biology Center, Augusta University, Augusta, GA, United States
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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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Keller MF, Vestgaard M, Damm P, Mathiesen ER, Ringholm L. Treatment with the long-acting insulin analog degludec during pregnancy in women with type 1 diabetes: An observational study of 22 cases. Diabetes Res Clin Pract 2019; 152:58-64. [PMID: 31102682 DOI: 10.1016/j.diabres.2019.05.004] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/10/2019] [Revised: 04/30/2019] [Accepted: 05/08/2019] [Indexed: 01/20/2023]
Abstract
AIM To report glycemic control and pregnancy outcome in pregnant women with type 1 diabetes on insulin degludec. METHODS Twenty-two women with type 1 diabetes on degludec from conception to delivery between 2014 and 2018 were compared with 51 pregnant women with type 1 diabetes on glargine. RESULTS Baseline characteristics were comparable, however HbA1c was higher at median 9 (range 5-19) weeks in women on degludec compared to women on glargine (6.9% (5.7-8.7); (52 (39-72) mmol/mol) versus 6.4% (5.1-10.1); (46 (32-87) mmol/mol), p = 0.04). HbA1c was similar in late pregnancy (6.3% (5.6-7.1); (45 (38-54) mmol/mol) versus 6.1% (5.2-9.0); (43 (33-75) mmol/mol), p = 0.28). The prevalence of severe hypoglycemia was 3 (14%) versus 6 (12%), p = 1.00 during pregnancy and 0 versus 1, p = 1.00 during hospital admittance after delivery. Most women on degludec used one daily injection in early (20 (91%) versus 25 (49%), p = 0.001) and late pregnancy (21 (96%) versus 19 (37%), p < 0.001). No significant differences in obstetrical and neonatal outcomes were found between the groups. Maternal hospital admittance after delivery was 2 (1-5) versus 3 (2-11) days (p = 0.004). CONCLUSIONS Glycemic control in late pregnancy, severe hypoglycemia during and immediately after pregnancy as well as pregnancy outcome were comparable in women on degludec or glargine. Degludec initiated preconceptionally may be continued in pregnancy.
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Affiliation(s)
- Maria Fredsgaard Keller
- Center for Pregnant Women with Diabetes, Rigshospitalet, Blegdamsvej 9, DK-2100 Copenhagen, Denmark
| | - Marianne Vestgaard
- Center for Pregnant Women with Diabetes, Rigshospitalet, Blegdamsvej 9, DK-2100 Copenhagen, Denmark; Department of Endocrinology, Rigshospitalet, Blegdamsvej 9, DK-2100 Copenhagen, Denmark; The Institute of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Blegdamsvej 3b, DK-2200 Copenhagen, Denmark
| | - Peter Damm
- Center for Pregnant Women with Diabetes, Rigshospitalet, Blegdamsvej 9, DK-2100 Copenhagen, Denmark; The Institute of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Blegdamsvej 3b, DK-2200 Copenhagen, Denmark; Department of Obstetrics, Rigshospitalet, Blegdamsvej 9, DK-2100 Copenhagen, Denmark
| | - Elisabeth Reinhardt Mathiesen
- Center for Pregnant Women with Diabetes, Rigshospitalet, Blegdamsvej 9, DK-2100 Copenhagen, Denmark; Department of Endocrinology, Rigshospitalet, Blegdamsvej 9, DK-2100 Copenhagen, Denmark; The Institute of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Blegdamsvej 3b, DK-2200 Copenhagen, Denmark
| | - Lene Ringholm
- Center for Pregnant Women with Diabetes, Rigshospitalet, Blegdamsvej 9, DK-2100 Copenhagen, Denmark; Department of Endocrinology, Rigshospitalet, Blegdamsvej 9, DK-2100 Copenhagen, Denmark; Steno Diabetes Center Copenhagen, Niels Steensens Vej 2, DK-2820 Gentofte, Denmark.
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25
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Alakhrass H, Alenazi W. Diabetes and Technology: Continuous Glucose Monitoring among Pregnant Women in Real Time. Health (London) 2019. [DOI: 10.4236/health.2019.117068] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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27
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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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Vestgaard M, Secher AL, Ringholm L, Jensen JEB, Damm P, Mathiesen ER. Vitamin D insufficiency, preterm delivery and preeclampsia in women with type 1 diabetes - an observational study. Acta Obstet Gynecol Scand 2017; 96:1197-1204. [DOI: 10.1111/aogs.13180] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2016] [Accepted: 05/25/2017] [Indexed: 11/29/2022]
Affiliation(s)
- Marianne Vestgaard
- Center for Pregnant Women with Diabetes; Rigshospitalet, University of Copenhagen; Copenhagen Denmark
- Department of Endocrinology; Rigshospitalet, University of Copenhagen; Copenhagen Denmark
- Institute of Clinical Medicine; Faculty of Health and Medical Sciences; University of Copenhagen; Copenhagen Denmark
| | - Anna L. Secher
- Center for Pregnant Women with Diabetes; Rigshospitalet, University of Copenhagen; Copenhagen Denmark
- Department of Endocrinology; Rigshospitalet, University of Copenhagen; Copenhagen Denmark
| | - Lene Ringholm
- Center for Pregnant Women with Diabetes; Rigshospitalet, University of Copenhagen; Copenhagen Denmark
- Steno Diabetes Center Copenhagen; Gentofte Denmark
| | | | - Peter Damm
- Center for Pregnant Women with Diabetes; Rigshospitalet, University of Copenhagen; Copenhagen Denmark
- Institute of Clinical Medicine; Faculty of Health and Medical Sciences; University of Copenhagen; Copenhagen Denmark
- Department of Obstetrics; Rigshospitalet, University of Copenhagen; Copenhagen Denmark
| | - Elisabeth R. Mathiesen
- Center for Pregnant Women with Diabetes; Rigshospitalet, University of Copenhagen; Copenhagen Denmark
- Department of Endocrinology; Rigshospitalet, University of Copenhagen; Copenhagen Denmark
- Institute of Clinical Medicine; Faculty of Health and Medical Sciences; University of Copenhagen; Copenhagen Denmark
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29
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Parihar JKS, Kaushik J, Jain VK, Naredi N, Raina S. The effect of assisted reproductive technology on ocular assessments. Clin Exp Optom 2016; 99:575-579. [PMID: 27306565 DOI: 10.1111/cxo.12389] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2015] [Revised: 02/03/2016] [Accepted: 02/10/2016] [Indexed: 11/27/2022] Open
Abstract
PURPOSE The aim was to study the various ocular assessments in women undergoing assisted reproductive techniques (ART). METHODS A total of 117 women with infertility were enrolled for study and the ART protocol was followed. The outcome measures were intraocular pressure (IOP), central corneal thickness, corneal endothelial cell counts, Schirmer I test done at baseline (V0), post-oral contraceptive (V1), post-GnRH agonist induction phase (V2), post-conception (V3), third trimester of pregnancy (V4) and three months post-partum (V5). Schirmer I test (without topical anaesthesia) less than 10 mm in at least one eye was considered a criterion for dry eye. RESULTS Out of 117 women enrolled for in vitro fertilisation (IVF), only 48 patients conceived. Sixteen women had abortions and remaining 32 women, who had childbirth were followed until three months post-partum. Baseline mean IOP showed a slight decrement and corneal pachymetry and corneal endothelial cell counts showed slight increment from phases V1 to V4 of ART but statistically they were not significant (p > 0.05). At three months post-partum (V5) mean IOP, corneal pachymetry, corneal endothelial cell counts become closer to baseline in both eyes. The number of patients with at least one eye with dryness (Schirmer I less than 10 mm) significantly increased at the third trimester (p = 0.02) and three months post-partum (p = 0.035), whereas in the rest of the phases, it was comparable to baseline (p > 0.05). CONCLUSION The ocular physiological changes (IOP, corneal pachymetry and corneal endothelial cell counts) seen in various phases of ART were non-specific. The ART appears to reduce tear secretions as measured by Schirmer I; however, further research would be required to determine the impact of ART on the tear film and whether ART is associated with symptoms and signs of dry eye.
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Affiliation(s)
| | - Jaya Kaushik
- Department of Ophthalmology, Command Hospital (WC), Chandimandir Cantonment, India
| | - Vaibhav Kumar Jain
- Department of Ophthalmology, Uttar Pradesh Rural Institute of Medical Sciences and Research, Etawah, India
| | - Nikita Naredi
- Department of Obstetrics & Gynecology & Assisted Reproductive Treatment Centre, Command Hospital (SC), Pune, India
| | - Sapna Raina
- Department of Ophthalmology, Air Force Central Medical Establishment, New Delhi, India
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30
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The effect of pregnancy on the progression of diabetic retinopathy. Jpn J Ophthalmol 2016; 60:454-458. [PMID: 27456842 DOI: 10.1007/s10384-016-0464-y] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2015] [Accepted: 04/26/2016] [Indexed: 10/21/2022]
Abstract
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.
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31
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Gomes MB, Negrato CA, Almeida A, de Leon AP. Does parity worsen diabetes-related chronic complications in women with type 1 diabetes? World J Diabetes 2016; 7:252-259. [PMID: 27350848 PMCID: PMC4914833 DOI: 10.4239/wjd.v7.i12.252] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/15/2015] [Accepted: 05/09/2016] [Indexed: 02/05/2023] Open
Abstract
AIM: To determine the relationship between parity, glycemic control, cardiovascular risk factors and diabetes-related chronic complications in women with type 1 diabetes.
METHODS: This was a multicenter cross-sectional study conducted between December 2008 and December 2010 in 28 public clinics in 20 cities from the 4 Brazilian geographic regions. Data were obtained from 1532 female patients, 59.2% Caucasians, and aged 25.2 ± 10.6 years. Diabetes duration was of 11.5 ± 8.2 years. Patient’s information was obtained through a questionnaire and a chart review. Parity was stratified in five groups: Group 0 (nulliparous), group 1 (1 pregnancy), group 2 (2 pregnancies), group 3 (3 pregnancies), group 4 (≥ 4 pregnancies). Test for trend and multivariate random intercept logistic and linear regression models were used to evaluate the effect of parity upon glycemic control, cardiovascular risk factors and diabetes-related complications.
RESULTS: Parity was not related with glycemic control and nephropathy. Moreover, the effect of parity upon hypertension, retinopathy and macrovascular disease did not persist after adjustments for demographic and clinical variables in multivariate analysis. For retinopathy, the duration of diabetes and hypertension were the most important independent variables and for macrovascular disease, these variables were age and hypertension. Overweight or obesity was noted in a total of 538 patients (35.1%). A linear association was found between the frequency of overweight or obesity and parity (P = 0.004). Using a random intercept multivariate linear regression model with body mass index (BMI) as dependent variable a borderline effect for parity (P = 0.06) was noted after adjustment for clinical and demographic data. The observed variability of BMI was not attributable to differences between centers.
CONCLUSION: Our results suggest that parity has a borderline effect on body mass index but does not have an important effect upon hypertension and micro or macrovascular chronic complications. Future prospective evaluations must be conducted to clarify the relationship between parity, appearance or worsening of diabetes-related chronic complications.
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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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Concillado M, Lund-Andersen H, Mathiesen ER, Larsen M. Dexamethasone Intravitreal Implant for Diabetic Macular Edema During Pregnancy. Am J Ophthalmol 2016; 165:7-15. [PMID: 26896557 DOI: 10.1016/j.ajo.2016.02.004] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2015] [Revised: 02/04/2016] [Accepted: 02/09/2016] [Indexed: 01/17/2023]
Abstract
PURPOSE To describe the management of diabetic macular edema during pregnancy with the use of a dexamethasone slow-release intravitreal implant. DESIGN Retrospective, observational, consecutive case series. METHODS The study included 5 pregnant women who presented with diabetic macular edema during pregnancy in the period from 2011 to 2014. Review of charts and photographs comprised best-corrected visual acuity (BCVA), foveal center field thickness assessed by optical coherence tomography, blood pressure, glycated hemoglobin, medications, and changes in such parameters after implant injection. RESULTS Diabetic macular edema involving the foveal center was observed between gestational weeks 9 and 23 in 10 eyes of 5 patients. Dexamethasone intravitreal implant injection was given 10 times in 9 eyes with a mean preinjection center field retinal thickness of 535 μm (range, 239-727 μm) and a mean preinjection best-corrected visual acuity (BCVA) of 63 approximated Early Treatment Diabetic Retinopathy Study (approxETDRS) letters (range, 50-77 letters). One eye was unavailable for follow-up. In 7 of 8 eyes injection was followed, within 3 weeks, by a greater than 145 μm reduction in foveal center field thickness and in 6 of 8 eyes by an increase in BCVA of 5 or more approxETDRS letters. A mild transient rise in intraocular pressure occurred in 3 out of 8 eyes. CONCLUSION Diabetic macular edema involving the foveal center that presented during pregnancy responded promptly to intravitreal dexamethasone therapy by foveal thickness reduction and visual acuity improvement without clinically significant intraocular pressure increases.
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Ting DSW, Cheung GCM, Wong TY. Diabetic retinopathy: global prevalence, major risk factors, screening practices and public health challenges: a review. Clin Exp Ophthalmol 2016; 44:260-77. [DOI: 10.1111/ceo.12696] [Citation(s) in RCA: 444] [Impact Index Per Article: 55.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2015] [Revised: 12/07/2015] [Accepted: 12/21/2015] [Indexed: 12/12/2022]
Affiliation(s)
- Daniel Shu Wei Ting
- Singapore National Eye Center, Singapore Health Service (SingHealth); Singapore Singapore
- Singapore Eye Research Institute; Singapore Singapore
| | - Gemmy Chui Ming Cheung
- Singapore National Eye Center, Singapore Health Service (SingHealth); Singapore Singapore
- Singapore Eye Research Institute; Singapore Singapore
- Duke-NUS Graduate Medical School; Singapore Singapore
| | - Tien Yin Wong
- Singapore National Eye Center, Singapore Health Service (SingHealth); Singapore Singapore
- Singapore Eye Research Institute; Singapore Singapore
- Duke-NUS Graduate Medical School; Singapore Singapore
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Ringholm L, Damm JA, Vestgaard M, Damm P, Mathiesen ER. Diabetic Nephropathy in Women With Preexisting Diabetes: From Pregnancy Planning to Breastfeeding. Curr Diab Rep 2016; 16:12. [PMID: 26803648 DOI: 10.1007/s11892-015-0705-3] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
In women with preexisting diabetes and nephropathy or microalbuminuria, it is important to deliver careful preconception counselling to assess the risk for the mother and the foetus, for optimizing glycaemic status and to adjust medical treatment. If serum creatinine is normal in early pregnancy, kidney function is often preserved during pregnancy, but complications such as severe preeclampsia and preterm delivery are still common. Perinatal mortality is now comparable with that in women with diabetes and normal kidney function. Besides strict glycaemic control before and during pregnancy, early and intensive antihypertensive treatment is important to optimize pregnancy outcomes. Methyldopa, labetalol, nifedipine and diltiazem are considered safe, whereas angiotensin-converting enzyme (ACE) inhibitors or angiotensin receptor blockers should be stopped before or at confirmation of pregnancy. Supplementation with folic acid in early pregnancy and low-dose aspirin from 10 to 12 weeks reduces the risk of adverse pregnancy outcomes. During breastfeeding, several ACE inhibitors are considered safe.
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Affiliation(s)
- Lene Ringholm
- Center for Pregnant Women with Diabetes, Rigshospitalet, Blegdamsvej 9, 2100, Copenhagen, Denmark.
- Department of Endocrinology PE7562, Rigshospitalet, Blegdamsvej 9, 2100, Copenhagen, Denmark.
- Steno Diabetes Center, Niels Steensens Vej 2, 2820, Gentofte, Denmark.
| | - Julie Agner Damm
- Center for Pregnant Women with Diabetes, Rigshospitalet, Blegdamsvej 9, 2100, Copenhagen, Denmark.
- Department of Endocrinology PE7562, Rigshospitalet, Blegdamsvej 9, 2100, Copenhagen, Denmark.
| | - Marianne Vestgaard
- Center for Pregnant Women with Diabetes, Rigshospitalet, Blegdamsvej 9, 2100, Copenhagen, Denmark.
- Department of Endocrinology PE7562, Rigshospitalet, Blegdamsvej 9, 2100, Copenhagen, Denmark.
- Faculty of Health and Medical Sciences, University of Copenhagen, København, Denmark.
| | - Peter Damm
- Center for Pregnant Women with Diabetes, Rigshospitalet, Blegdamsvej 9, 2100, Copenhagen, Denmark.
- Faculty of Health and Medical Sciences, University of Copenhagen, København, Denmark.
- Department of Obstetrics, Rigshospitalet, Blegdamsvej 9, 2100, Copenhagen, Denmark.
| | - Elisabeth R Mathiesen
- Center for Pregnant Women with Diabetes, Rigshospitalet, Blegdamsvej 9, 2100, Copenhagen, Denmark.
- Department of Endocrinology PE7562, Rigshospitalet, Blegdamsvej 9, 2100, Copenhagen, Denmark.
- Faculty of Health and Medical Sciences, University of Copenhagen, København, Denmark.
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Abstract
Pregestational diabetes is a common medical complication of pregnancy and preconception planning is an essential component of care for affected women of childbearing age. Once pregnant, structured care in a multidisciplinary team setting is necessary to ensure optimal outcomes. Although significant progress has been made, these women and their offspring remain to have a significantly elevated risk of multiple adverse complications. Structured programmes using information technology and enabling access to novel technologies may facilitate our goal of ensuring an outcome closer to that of a pregnancy unaffected by diabetes.
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Affiliation(s)
- A M Egan
- From the Galway Diabetes Research Centre, National University of Ireland Galway, Newcastle, Galway, Ireland and
| | - H R Murphy
- Level 4 Metabolic Research Laboratories and NIHR Cambridge Biomedical Research Centre, University of Cambridge Wellcome Trust - MRC Institute of Metabolic Science, Cambridge, UK
| | - F P Dunne
- From the Galway Diabetes Research Centre, National University of Ireland Galway, Newcastle, Galway, Ireland and
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Murphy R, Jiang Y, Booth M, Babor R, MacCormick A, Hammodat H, Beban G, Barnes RM, Vincent AL. Progression of diabetic retinopathy after bariatric surgery. Diabet Med 2015; 32:1212-20. [PMID: 25689226 DOI: 10.1111/dme.12727] [Citation(s) in RCA: 39] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/09/2015] [Indexed: 12/14/2022]
Abstract
AIM To assess the impact of bariatric surgery on the progression of diabetic retinopathy in patients with Type 2 diabetes. METHOD We conducted a retrospective, observational study of patients with Type 2 diabetes who underwent bariatric surgery between 1 January 2001 and 31 December 2012 and had hospital-based retinal screening records. Data were collected from four surgical centres. Those who had pre-operative retinal screening and at least one post-operative retinal screen were eligible for analysis. A generalized linear mixed model was used to explore significant clinical predictors on the post-operative grade severity over time, controlling for important baseline characteristics. RESULTS Three hundred and eighteen patients were eligible for analysis. Of these, 68.6% had no diabetic retinopathy pre-operatively compared with 18.9%, 8.5% and 4% with a diabetic retinopathy grade of minimal, mild or moderate and higher, respectively. First post-operative retinal screening results showed that after surgery 73% had no change in their diabetic retinopathy grade, 11% regressed and 16% progressed. The probability of having a diabetic retinopathy grade of moderate or higher over time post surgery was significantly associated with the magnitude of HbA1c reduction from pre-surgery HbA1c levels, a shorter post-operative retinal screening duration, more severe pre-operative retinal screening grade, male gender and non-Maori/Pacific ethnicity. CONCLUSIONS A higher pre-operative diabetic retinopathy grade, and a large decrease in HbA1c post surgery warrant closer monitoring of diabetic retinopathy after bariatric surgery. Further prospective, randomized studies are required to investigate the gender and ethnic differences found.
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Affiliation(s)
- R Murphy
- Department of Medicine, University of Auckland, Auckland, New Zealand
| | - Y Jiang
- Department of Statistics, University of Auckland, Auckland, New Zealand
| | - M Booth
- Department of Surgery, North Shore Hospital, Auckland, New Zealand
| | - R Babor
- Department of Surgery, Middlemore Hospital, Auckland, New Zealand
| | - A MacCormick
- Department of Surgery, Middlemore Hospital, Auckland, New Zealand
- Department of Surgery, University of Auckland, Auckland, New Zealand
| | - H Hammodat
- Department of Surgery, North Shore Hospital, Auckland, New Zealand
| | - G Beban
- Department of Surgery, Auckland City Hospital, Auckland, New Zealand
| | - R M Barnes
- Eye Department, Auckland District Health Board, Auckland, New Zealand
| | - A L Vincent
- Eye Department, Auckland District Health Board, Auckland, New Zealand
- Department of Ophthalmology, New Zealand National Eye Centre, University of Auckland, Auckland, New Zealand
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Acmaz G, Atas M, Gulhan A, Acmaz B, Atas F, Aksoy H, Zararsiz G, Gokce G. Assessment of Macular Peripapillary Nerve Fiber Layer and Choroidal Thickness Changes in Pregnant Women with Gestational Diabetes Mellitus, Healthy Pregnant Women, and Healthy Non-Pregnant Women. Med Sci Monit 2015; 21:1759-64. [PMID: 26084958 PMCID: PMC4484614 DOI: 10.12659/msm.893221] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022] Open
Abstract
Background Gestational diabetes mellitus (GDM) is a risk factor for the development of type II diabetes and it causes maternal and child morbidity. Screening for diabetic retinopathy (DR) is important because patients who develop DR have no symptoms until macular edema and/or proliferative diabetic retinopathy (PDR) are already present. The aim of this study was to determine the early retinal findings of GDM. Material/Methods This study was conducted in a tertiary research center. We conducted a prospective cross-sectional study with 3 groups: Group 1 consisted of 36 pregnant women with GDM, Group 2 consisted of 24 healthy pregnant women, and Group 3 consisted of 38 healthy non-pregnant women of reproductive age. Spectralis optical coherence tomography (OCT) was used for the assessment. Macular, choroid, and retinal nerve fiber layer (RNFL) thicknesses were evaluated in patients with GDM and comparisons were made among pregnant women with GDM, healthy pregnant women, and healthy non-pregnant women for these parameters. Results The nasal part of the RNFL was significantly thinner in the GDM group than in the healthy pregnant group. None of the patients had retinopathy or macular edema at the time of examination. Conclusions Decreased nasal part of RNFL thickness may be the first retinal change in patients with GDM. Our study suggests that OCT should be performed for the patients with GDM for detection of early retinal changes associated with GDM.
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Affiliation(s)
- Gokhan Acmaz
- Department of Obstetrics and Gynecology, Kayseri Education and Research Hospital, Kayseri, Turkey
| | - Mustafa Atas
- Department of Ophthalmology, Kayseri Education and Research Hospital, Kayseri, Turkey
| | - Ahmet Gulhan
- Department of Ophthalmology, Kayseri Education and Research Hospital, Kayseri, Turkey
| | - Banu Acmaz
- Department of Internal Medicine, Erciyes University School of Medicine, Kayseri, Turkey
| | - Fatma Atas
- Department of Obstetrics and Gynecology, Kayseri Education and Research Hospital, Kayseri, Turkey
| | - Huseyin Aksoy
- Department of Obstetrics and Gynecology, Kayseri Military Hospital, Kayseri, Turkey
| | - Gokmen Zararsiz
- Department of Statistics, Erciyes University School of Medicine, Kayseri, Turkey
| | - Gokcen Gokce
- Department of Ophthalmology, Kayseri Military Hospital, Kayseri, Turkey
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Sadiq MA, Agarwal A, Soliman MK, Hanout M, Sarwar S, Do DV, Nguyen QD. Sustained-release fluocinolone acetonide intravitreal insert for macular edema: clinical pharmacology and safety evaluation. Expert Opin Drug Saf 2015; 14:1147-56. [PMID: 25994877 DOI: 10.1517/14740338.2015.1041916] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
INTRODUCTION Inflammation plays a key role in the pathological processes leading to macular edema. Sustained release, low-dose intraocular corticosteroid delivery devices provide long-term anti-inflammatory therapy. Recently, a novel fluocinolone acetonide intravitreal insert (FAi, Iluvien), has been introduced with promising long-term results in the treatment of macular edema. AREAS COVERED An extensive review of the literature in the English language was performed to provide comprehensive information on the pharmacological properties of FAi and its safety and efficacy data from various multi-center randomized clinical trials. EXPERT OPINION The FAc, Retisert is a sustained-release device that is surgically implanted in the vitreous and has been approved by the US FDA for the treatment of non-infectious intermediate, posterior or panuveitis. FAi was developed after FAc and is an intravitreal corticosteroid delivery system that allows controlled release of therapeutic levels of fluocinolone acetonide (FA). Initial efficacy and safety data suggest that this delivery system maintains clinical effectiveness for up to 3 years after a single delivery of the device. This second-generation fluocinolone delivery device has shown superior safety results in clinical trials compared to the previous version of the higher dose FAc (0.59 mg). Sustained delivery preparations may help to reduce the treatment burden and its associated risks by decreasing the frequency of intravitreal injections. However, much needs to be learnt from additional clinical trials, post-marketing surveillance and results of extension studies. Concerns of intravitreal corticosteroids, such as cataract and increase in intraocular pressure, remain major challenges for this therapeutic strategy.
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Affiliation(s)
- Mohammad Ali Sadiq
- University of Nebraska Medical Center, Stanley M. Truhlsen Eye Institute, Ocular Imaging Research and Reading Center (OIRRC) , Omaha, NE 68198-5540 , USA
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Callec R, Perdriolle-Galet E, Sery GA, Lamy C, Floriot M, Fresson J, Morel O. [Type 2 diabetes and pregnancy: epidemiology and obstetrical consequences. A 97 women continuous series]. J Gynecol Obstet Hum Reprod 2015; 44:41-46. [PMID: 24315525 DOI: 10.1016/j.jgyn.2013.10.012] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2013] [Revised: 10/21/2013] [Accepted: 10/30/2013] [Indexed: 06/02/2023]
Abstract
OBJECTIVES To update the epidemiologic data of pregnant women with type 2 diabetes and to assess obstetrical outcomes. PATIENTS AND METHODS The pregnant women with type 2 diabetes who delivered between 2002 and 2010 were systematically involved in an observational study. Maternal and fetal outcomes were reviewed, as well as the potential impact of preconceptional management. The presented data were compared with those from the 2010 French perinatal study. RESULTS A rise in the incidence of type 2 diabetes was observed during the study period (from 0.19% to 0.35% between 2002 and 2010). Women with diabetes (n=97) were older and had a higher BMI than the general population (>35years: 49% vs 19%, P<0.00001, BMI>25: 86% vs 27.2, P<0.00001). The delivery mode was, for half of these women with diabetes, a C-section. Pregnancy was scheduled in only 4% of cases. Compared to the general population, prematurity rate was multiplied by 6 (28.7% vs 4.7%, P<0.0001) and the malformation rate by 3.2 (7.22% vs 2.2%, P<0.00001). CONCLUSION Obstetrical complications were more frequent than in the general population. Preconception care was almost inexistent, despite its potential benefits for the mother and child.
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Affiliation(s)
- R Callec
- Unité d'obstétrique et de médecine fœtale, pôle de la femme, maternité régionale universitaire de Nancy, 10, rue du Dr-Heydenreich, 54000 Nancy, France; Unité Inserm 947, IADI, 54000 Nancy, France; Université de Lorraine, 54000 Nancy, France.
| | - E Perdriolle-Galet
- Unité d'obstétrique et de médecine fœtale, pôle de la femme, maternité régionale universitaire de Nancy, 10, rue du Dr-Heydenreich, 54000 Nancy, France; Unité Inserm 947, IADI, 54000 Nancy, France; Université de Lorraine, 54000 Nancy, France
| | - G-A Sery
- Unité d'obstétrique et de médecine fœtale, pôle de la femme, maternité régionale universitaire de Nancy, 10, rue du Dr-Heydenreich, 54000 Nancy, France
| | - C Lamy
- Unité d'obstétrique et de médecine fœtale, pôle de la femme, maternité régionale universitaire de Nancy, 10, rue du Dr-Heydenreich, 54000 Nancy, France
| | - M Floriot
- Unité d'obstétrique et de médecine fœtale, pôle de la femme, maternité régionale universitaire de Nancy, 10, rue du Dr-Heydenreich, 54000 Nancy, France
| | - J Fresson
- Département d'informatique médicale, maternité régionale universitaire de Nancy, 54000 Nancy, France
| | - O Morel
- Unité d'obstétrique et de médecine fœtale, pôle de la femme, maternité régionale universitaire de Nancy, 10, rue du Dr-Heydenreich, 54000 Nancy, France; Unité Inserm 947, IADI, 54000 Nancy, France; Université de Lorraine, 54000 Nancy, France
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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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Parellada CB, Asbjörnsdóttir B, Ringholm L, Damm P, Mathiesen ER. Fetal growth in relation to gestational weight gain in women with type 2 diabetes: an observational study. Diabet Med 2014; 31:1681-9. [PMID: 25081349 PMCID: PMC4257095 DOI: 10.1111/dme.12558] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/30/2014] [Indexed: 11/26/2022]
Abstract
AIMS To evaluate fetal growth in relation to gestational weight gain in women with Type 2 diabetes. METHODS A retrospective cohort study of 142 consecutive pregnancies in 28 women of normal weight, 39 overweight women and 75 obese women with Type 2 diabetes (pre-pregnancy BMI < 25, 25-29.9, ≥ 30 kg/m2, respectively). Gestational weight gain was categorized as excessive (exceeding the US Institute of Medicine recommendations) or as non-excessive (within or below the Institute of Medicine recommendations). RESULTS Excessive and non-excessive gestational weight gain were seen in 61 (43%) and 81 women (57%) with a median (range) gestational weight gain of 14.3 (9-32) vs. 7.0 (-5-16) kg (P < 0.001), respectively. Infants of women with excessive gestational weight gain were characterized by higher birth weight (3712 vs. 3258 g; P = 0.001), birth weight z-score (1.14 vs. -0.01, P = 0.001) and prevalence of large-for-gestational-age infants (48 vs. 20%; P < 0.001). In normal weight, overweight and obese women with non-excessive gestational weight gain, the median weight gain in the first half of pregnancy was 371, 114 and 81 g/week, and in the second half of pregnancy 483, 427 and 439 g/week, respectively. In multiple linear regression analysis, gestational weight gain was associated with a higher infant birth weight z-score independent of pre-pregnancy BMI, smoking, HbA1c and insulin dose at last visit, ethnicity and parity [β=0.1 (95% CI 0.06-0.14), P < 0.001]. CONCLUSIONS Infant birth weight was almost 0.5 kg higher in women with Type 2 diabetes and excessive gestational weight gain than in women with Type 2 diabetes and non-excessive weight gain.
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Affiliation(s)
- C B Parellada
- Center for Pregnant Women with Diabetes, University of Copenhagen, Copenhagen, Denmark; Department of Endocrinology, University of Copenhagen, Copenhagen, Denmark
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Secher AL, Parellada CB, Ringholm L, Asbjörnsdóttir B, Damm P, Mathiesen ER. Higher gestational weight gain is associated with increasing offspring birth weight independent of maternal glycemic control in women with type 1 diabetes. Diabetes Care 2014; 37:2677-84. [PMID: 25249669 DOI: 10.2337/dc14-0896] [Citation(s) in RCA: 50] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
OBJECTIVE We evaluate the association between gestational weight gain and offspring birth weight in singleton term pregnancies of women with type 1 diabetes. RESEARCH DESIGN AND METHODS One hundred fifteen consecutive women referred at <14 weeks were retrospectively classified as underweight (prepregnancy BMI <18.5 kg/m(2); n = 1), normal weight (18.5-24.9; n = 65), overweight (25.0-29.9; n = 39), or obese (≥30.0; n = 10). Gestational weight gain was categorized as excessive, appropriate, or insufficient according to the Institute of Medicine recommendations for each BMI class. Women with nephropathy, preeclampsia, and/or preterm delivery were excluded because of restrictive impact on fetal growth and limited time for total weight gain. RESULTS HbA1c was comparable at ∼6.6% (49 mmol/mol) at 8 weeks and ∼6.0% (42 mmol/mol) at 36 weeks between women with excessive (n = 62), appropriate (n = 37), and insufficient (n = 16) gestational weight gain. Diabetes duration was comparable, and median prepregnancy BMI was 25.3 (range 18-41) vs. 23.5 (18-31) vs. 22.7 (20-30) kg/m(2) (P = 0.05) in the three weight gain groups. Offspring birth weight and birth weight SD score decreased across the groups (3,681 [2,374-4,500] vs. 3,395 [2,910-4,322] vs. 3,295 [2,766-4,340] g [P = 0.02] and 1.08 [-1.90 to 3.25] vs. 0.45 [-0.83 to 3.18] vs. -0.02 [-1.51 to 2.96] [P = 0.009], respectively). In a multiple linear regression analysis, gestational weight gain (kg) was positively associated with offspring birth weight (g) (β = 19; P = 0.02) and birth weight SD score (β = 0.06; P = 0.008) when adjusted for prepregnancy BMI, HbA1c at 36 weeks, smoking, parity, and ethnicity. CONCLUSIONS Higher gestational weight gain in women with type 1 diabetes was associated with increasing offspring birth weight independent of glycemic control and prepregnancy BMI.
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Affiliation(s)
- Anna L Secher
- Center for Pregnant Women with Diabetes, Rigshospitalet, Copenhagen, Denmark Department of Endocrinology, Rigshospitalet, Copenhagen, Denmark
| | - Clara B Parellada
- Center for Pregnant Women with Diabetes, Rigshospitalet, Copenhagen, Denmark Department of Endocrinology, Rigshospitalet, Copenhagen, Denmark
| | - Lene Ringholm
- Center for Pregnant Women with Diabetes, Rigshospitalet, Copenhagen, Denmark Department of Endocrinology, Rigshospitalet, Copenhagen, Denmark
| | - Björg Asbjörnsdóttir
- Center for Pregnant Women with Diabetes, Rigshospitalet, Copenhagen, Denmark Department of Endocrinology, Rigshospitalet, Copenhagen, Denmark
| | - Peter Damm
- Center for Pregnant Women with Diabetes, Rigshospitalet, Copenhagen, Denmark Department of Obstetrics, Rigshospitalet, Copenhagen, Denmark Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Elisabeth R Mathiesen
- Center for Pregnant Women with Diabetes, Rigshospitalet, Copenhagen, Denmark Department of Endocrinology, Rigshospitalet, Copenhagen, Denmark Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
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Varadhan L, Humphreys T, Walker AB, Varughese GI. The impact of improved glycaemic control with GLP-1 receptor agonist therapy on diabetic retinopathy. Diabetes Res Clin Pract 2014; 103:e37-9. [PMID: 24456992 DOI: 10.1016/j.diabres.2013.12.041] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/28/2013] [Accepted: 12/26/2013] [Indexed: 11/23/2022]
Abstract
Rapid improvement in glycaemic control with GLP-1 receptor agonist (RA) therapy has been reported to be associated with significant progression of diabetic retinopathy. This deterioration is transient, and continuing GLP-1 RA treatment is associated with reversal of this phenomenon. Pre-existent maculopathy, higher grade of retinopathy and longer duration of diabetes may be risk factors for persistent deterioration.
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Affiliation(s)
- Lakshminarayanan Varadhan
- Department of Diabetes and Endocrinology, University Hospital of North Staffordshire NHS Trust, Trent Building, Stoke-on-Trent ST4 6QG, United Kingdom.
| | - Tracy Humphreys
- Department of Diabetes and Endocrinology, University Hospital of North Staffordshire NHS Trust, Trent Building, Stoke-on-Trent ST4 6QG, United Kingdom; Department of Ophthalmology, University Hospital of North Staffordshire NHS Trust, Trent Building, Stoke-on-Trent ST4 6QG, United Kingdom
| | - Adrian B Walker
- Department of Diabetes and Endocrinology, University Hospital of North Staffordshire NHS Trust, Trent Building, Stoke-on-Trent ST4 6QG, United Kingdom
| | - George I Varughese
- Department of Diabetes and Endocrinology, University Hospital of North Staffordshire NHS Trust, Trent Building, Stoke-on-Trent ST4 6QG, United Kingdom.
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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] [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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Secher AL, Ringholm L, Andersen HU, Damm P, Mathiesen ER. The effect of real-time continuous glucose monitoring in pregnant women with diabetes: a randomized controlled trial. Diabetes Care 2013; 36:1877-83. [PMID: 23349548 PMCID: PMC3687305 DOI: 10.2337/dc12-2360] [Citation(s) in RCA: 132] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
OBJECTIVE To assess whether intermittent real-time continuous glucose monitoring (CGM) improves glycemic control and pregnancy outcome in unselected women with pregestational diabetes. RESEARCH DESIGN AND METHODS A total of 123 women with type 1 diabetes and 31 women with type 2 diabetes were randomized to use real-time CGM for 6 days at 8, 12, 21, 27, and 33 weeks in addition to routine care, including self-monitored plasma glucose seven times daily, or routine care only. To optimize glycemic control, real-time CGM readings were evaluated by a diabetes caregiver. HbA1c, self-monitored plasma glucose, severe hypoglycemia, and pregnancy outcomes were recorded, with large-for-gestational-age infants as the primary outcome. RESULTS Women assigned to real-time CGM (n = 79) had baseline HbA1c similar to that of women in the control arm (n = 75) (median 6.6 [range 5.3-10.0] vs. 6.8% [5.3-10.7]; P = 0.67) (49 [34-86] vs. 51 mmol/mol [34-93]). Forty-nine (64%) women used real-time CGM per protocol. At 33 weeks, HbA1c (6.1 [5.1-7.8] vs. 6.1% [4.8-8.2]; P = 0.39) (43 [32-62] vs. 43 mmol/mol [29-66]) and self-monitored plasma glucose (6.2 [4.7-7.9] vs. 6.2 mmol/L [4.9-7.9]; P = 0.64) were comparable regardless of real-time CGM use, and a similar fraction of women had experienced severe hypoglycemia (16 vs. 16%; P = 0.91). The prevalence of large-for-gestational-age infants (45 vs. 34%; P = 0.19) and other perinatal outcomes were comparable between the arms. CONCLUSIONS In this randomized trial, intermittent use of real-time CGM in pregnancy, in addition to self-monitored plasma glucose seven times daily, did not improve glycemic control or pregnancy outcome in women with pregestational diabetes.
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Affiliation(s)
- Anna L Secher
- Center for Pregnant Women with Diabetes, Rigshospitalet, Copenhagen, Denmark.
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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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Hampshire R, Wharton H, Leigh R, Wright A, Dodson P. Screening for diabetic retinopathy in pregnancy using photographic review clinics. Diabet Med 2013; 30:475-7. [PMID: 23252726 DOI: 10.1111/dme.12077] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/12/2012] [Revised: 10/12/2012] [Accepted: 11/22/2012] [Indexed: 01/19/2023]
Abstract
AIMS To assess the efficacy and value of the National Institute for Health and Clinical Excellence guidelines for digital photographic screening for diabetic retinopathy in pregnancy using photographic review clinics. METHODS Pregnant patients (n = 186) with known diabetes were screened at first antenatal visit and at 28 weeks' gestation, if no retinopathy was noted at first visit, or at other intervals if retinopathy was present. Two 45° images (disc-centred and macula-centred views) were taken in both eyes and graded by trained graders and by an ophthalmologist. RESULTS Ninety-three patients (50%) remained free of diabetic retinopathy throughout pregnancy. Eighteen (10%) presented with sight-threatening retinopathy at their first antenatal screen and were referred to the hospital eye service. Fifty patients (27%) were shown to have relatively stable retinopathy throughout pregnancy, with only two patients deteriorating and requiring referral to hospital eye service. Twenty-three (12%) failed to complete the screening protocol after their first screen. CONCLUSIONS The study showed that pregnant patients screened for retinopathy in an ophthalmic photographic diabetic review clinic achieved National Institute for Health and Clinical Excellence guidelines in the majority and were clinically safe. Only 1% of patients required referral to ophthalmology after their initial screen, thus avoiding unnecessary hospital eye service appointments.
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Affiliation(s)
- R Hampshire
- Birmingham, Solihull and Black Country Diabetic Retinal Screening Programme, Heart of England Diabetic Retinopathy Screening Centre, Birmingham Heartlands Hospital, Birmingham, UK
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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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