Diabetic retinopathy in pregnancy

Diabetes and pregnancy

• women with diabetes who become pregnant require special care as there are risks to both the mother, the developing foetus and the newborn child
• approximately 650,000 women give birth in England and Wales each year, and 2-5% of pregnancies involve women with diabetes
• approximately 87.5% of pregnancies complicated by diabetes are estimated to be due to gestational diabetes (which may or may not resolve after pregnancy), with 7.5% being due to type 1 diabetes and the remaining 5% being due to type 2 diabetes
  • the prevalence of type 1 and type 2 diabetes is increasing. In particular, type 2 diabetes is increasing in certain minority ethnic groups (including people of African, black Caribbean, South Asian, Middle Eastern and Chinese family origin)

Diabetic retinopathy in pregnancy

• Progression of diabetic retinopathy may occur during pregnancy. The worsening of retinopathy during pregnancy can be quite significant and may require photocoagulation during pregnancy, more frequently in those patients with preexisting diabetic retinopathy.
• The known risk factors for progression of diabetic retinopathy in pregnancy include:
  
  • 1. pregnancy is independently associated with progression of diabetic retinopathy
  • 2. baseline severity of retinopathy
  • 3. poor metabolic control at conception
  • 4. rapid improvement of glycaemic control
  • 5. poor metabolic control during pregnancy or the early post partum period
  • 6. duration of diabetes
  • 7. chronic hypertension and pregnancy induced hypertension.
    
• Retinal assessment should be carried out by digital imaging with mydriasis using tropicamide.
  
• The recommendations of the English National Screening Programme are (1):
  • 1. annual screening for diabetic retinopathy is recommended in the preconception period using two-field mydriatic digital photography using tropicamide (1,2)
    
  • 2. women with type 1 and type 2 diabetes should be offered two-field mydriatic digital photography to National Standards at (or soon after) their first antenatal clinic visit and again at 28 weeks' gestation
    
  • 3. if background diabetic retinopathy is found to be present, an additional screen should be performed at 16-20 weeks
    
  • 4. if referable diabetic retinopathy is found to be present in early pregnancy, careful ophthalmological supervision is required depending on the level of retinopathy both during pregnancy and for at least 6 months post-partum
    
  • 5. because, like many drugs that are used in pregnancy, Tropicamide is only licensed for use in pregnancy under the direction of a registered medical practitioner, care pathways should be set up in such a way as to enable this to be undertaken.
• For women with diabetes who are seeking preconception care, offer a retinal assessment at their first appointment (unless they have had a retinal assessment in the last 6 months).
• Advise women with diabetes who are planning a pregnancy to defer rapid optimisation of blood glucose control until after they have had retinal assessment and treatment.

Reference:

1. Ghanchi F; Diabetic Retinopathy Guidelines Working Group. The Royal College of Ophthalmologists' clinical guidelines for diabetic retinopathy: a summary. Eye (Lond). 2013 Feb;27(2):285-7. doi: 10.1038/eye.2012.287.
2. NICE (2015). Diabetes in pregnancy: management from preconception to the postnatal period. Available at https://www.nice.org.uk/guidance/ng3. (Accessed on 15 August 2022).