Diabetic retinopathy in pregnancy - A review

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.

Keywords: Diabetic retinopathy in pregnancy; gestational diabetes; investigations; management in pregnancy; pathogenesis and risk factors.

Figure 1

Pathway for pathogenesis of DR in pregnancy with diabetes (AGE – advanced glycosylated end products, RAS – renin–angiotensin system, ROS – reactive oxygen species, PGI2 – prostacyclin, NO – nitric oxide)

Figure 2

Role of various growth factors and inflammatory mediators in causing progression of DR in pregnancy with diabetes. (TNF-α – tumor necrosis factor, IL-6 and 10 – interleukin-6 and 10, CRP – C-reactive protein, VCAM-1 – vascular endothelial adhesion molecule-1, ICAM-1 – intercellular adhesion molecule-1, ELAM – endothelial leucocyte adhesion molecule, IGF-1 – insulin growth factor-1, IGFBP – insulin growth factor binding protein, FGF – fibroblast growth factor, TGF α and β – transforming growth factor α and β, PEDF – pigment epithelial derived factor)