Call for Better Diabetic Retinopathy Screening in Pregnancy

Marlene Busko

September 19, 2014

VIENNA — Many pregnant diabetic women do not receive appropriate retinal eye exams, new research from Ireland indicates.

Specifically, in a cohort of more than 300 pregnant women with type 1 or type 2 diabetes, only 60% received recommended screening, defined as having at least 2 retinal exams in 2 trimesters. In addition, the study showed that there was significant variation in whether eye exams were conducted appropriately in pregnancy across the 5 participating centers.

"We have concerns about missing [diabetic] patients who were not fully evaluated" and had only 1 or, worse, no retinal exams during their pregnancies, Aoife Egan, MD, from the National University of Ireland, in Dublin said when presenting the study in an oral session here at the European Association for the Study of Diabetes 2014 Meeting.

In just over a quarter (26%) of the women who were correctly screened, retinopathy worsened during pregnancy, which emphasizes the "urgent need" for adequate screening, said Dr. Egan.

Women who had higher systolic blood-pressure levels at their first prenatal doctor visit and those who had the biggest drops in HbA1c from the start to the end of pregnancy were the most likely to have diabetic retinopathy that progressed.

"We advocate an automatic recall system for retinal screening in pregnancy," which does not yet exist in Ireland, Dr. Egan said. She added that they also strongly encourage women to attend prenatal classes, as those who did were the most likely to have adequate retinal exams.

"All of us have to focus on really getting our women screened, because we still see sight-threatening retinopathy development during pregnancy," session cochair Elisabeth R. Mathiesen, MD, from the University of Copenhagen, in Denmark told Medscape Medical News. Her group found similar results in a study in Denmark a few years, she said.

Moreover, almost every year, "a woman comes into my clinic with good vision in early pregnancy and within the next few months she cannot read her own glucose measurements…and she's [extremely] scared," Dr. Mathiesen added.

The sight problems developing in diabetic pregnancies are mostly cases of macular edema as opposed to proliferative retinopathy, she explained. The patients are offered experimental treatment with an intraocular injection of steroids, which has an excellent effect on vision and is less risky for the developing fetus.

Almost 30% of Pregnant Diabetics Had No Retinal Eye Exam at All

Pregnancy is a risk factor for the development of diabetic retinopathy and for worsening disease, so it is important to provide frequent screening to detect and treat this, Dr. Egan said. However, there have been few studies investigating this issue in large sample sizes in the modern era, she noted.

She and her team aimed to determine the number of patients who were receiving appropriate retinal screening during pregnancy, the number who had progression of diabetic retinopathy, and the factors that influenced screening and progression, in women who participated in the Atlantic Diabetes in Pregnancy (DIP) study.

They identified 233 women with type 1 diabetes and 108 women with type 2 diabetes who were seen at 5 antenatal centers in Ireland from 2006 to 2012.

The rate of diabetic retinopathy screening varied widely in the 5 centers — from 21% to 71% of patients. Appropriate screening took place in 191 (56%) pregnancies, more commonly in women with type 1 diabetes.

Overall, 6 in 10 women had at least 2 retinal exams in 2 trimesters, but 29% had no evaluation at all, and 11% had only 1 retinal eye exam.

On average, compared with other women, women who were adequately screened were slightly older (32.9 vs 31.5 years) and were more likely to be white (94.1% vs 85.2%) and have had diabetes for a longer time (11.28 vs 9.25 years); notably, they were much more likely to attend prenatal classes (58.4% vs 17.2%).

Among the 48 women who had worsening retinopathy during pregnancy, in most cases (26 patients; 54.2%), the disease progressed from R0 (no retinopathy) to R1 (background retinopathy). In other cases it progressed to more advanced stages.

In the group of women with adequate retinal eye exams, compared with the other women, those with retinopathy progression had a higher systolic blood pressure at their initial prenatal visit (128.6 mm Hg vs 122.1 mm Hg) and a greater drop in HbA1c levels from the first to the third trimester (1.38% vs 0.74%).

"We demonstrate inadequate screening for diabetic retinopathy during pregnancy and significant variation across participating centers," Dr. Egan and colleagues reiterate.

"Our study highlights the importance of participation in prepregnancy care, as this is associated with appropriate screening in the ensuing pregnancy." And as 26% of women continued to demonstrate progression of retinopathy during pregnancy, "there is an urgent need to ensure adherence to screening protocols," they conclude.

The authors have reported no relevant financial relationships.

European Association for the Study of Diabetes 2014; September 17, 2014; Vienna, Austria. Abstract 153

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