Women with type 1 diabetes (T1DM) are at increased risk of new or progressive retinopathy during pregnancy; the risk increases with longer duration of diabetes (over 15 years) and severity of pre-existing diabetic retinopathy¹ (DR). Treatment options are limited, with intravitreal anti-VEGF injections being contraindicated in the first and second trimester². After observing a case of progressive DR necessitating bilateral vitrectomy in pregnancy we set out to explore the characteristics and treatment of similar patients in our centre.    

In this series we retrospectively reviewed three cases of proliferative diabetic retinopathy in pregnancy managed at a tertiary referral centre.  All cases surpassed 20-year duration of T1DM and two cases had pre-existing retinopathy. Progression was detected at routine eye screening in all three cases.      

Treatment during pregnancy included blood pressure management, optimisation of glycaemic control, panretinal photocoagulation (PRP) and in one case bilateral vitrectomy due to sight-threatening disease. Multiple additional pregnancy complications were observed, including polyhydramnios, macrosomia and pre-eclampsia. Vaginal delivery due to valsalva maeuver was contraindicated in one patient due to the presence of vitreous haemorrhage, and preterm delivery by 36 weeks gestation occurred in all three cases.  Reduced visual acuity persisted in the postpartum period in one case.     

This series highlights the need for appropriate pre-conception counselling regarding the risk of progression, pregnancy complications including pre-eclampsia, prematurity and increased rates of caesarean section^1,3. Preconception care should include ensuring women are screened for DR as (1) treatment prior to pregnancy reduces the risk of progression¹; (2) DR is an independent risk factor for PET³; and (3) vaginal delivery may be contraindicated in some due to severe proliferative disease⁴.  

References: 

1. Chandrasekaran PR, Madanagopalan VG, Narayanan R. Diabetic retinopathy in pregnancy - A review. Indian J Ophthalmol. 2021;69(11):3015-3025. doi:10.4103/ijo.IJO_1377_21 
2. Khong EWC, Chan HHL, Watson SL, Lim LL. Pregnancy and the eye. Curr Opin Ophthalmol. 2021;32(6):527-535. doi:10.1097/ICU.0000000000000778 
3. 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(26):10621-10628. doi:10.1080/14767058.2022.2148095 
4. Abdelaal AM, Alqahtani AS. Mode of Delivery in the Setting of Repeated Vitreous Hemorrhages in Proliferative Diabetic Retinopathy: A Case Report and Review of the Literature. Cureus. 2020;12(10):e11239. Published 2020 Oct 29. doi:10.7759/cureus.11239