What are the risks and management options for retinal thinning in pregnant women?

Retinal Thinning and Pregnancy Management

Pregnant women with preexisting retinal thinning or diabetic retinopathy require comprehensive ophthalmologic examination in the first trimester and close monitoring throughout pregnancy, as pregnancy significantly accelerates retinopathy progression and threatens vision. 1, 2

Risk Assessment and Baseline Evaluation

For women with preexisting diabetes (Type 1 or Type 2):

• Obtain comprehensive dilated eye examination before conception or in the first trimester to establish baseline retinal status 1, 2
• Counsel all women of childbearing potential about the substantial risk of retinopathy development and progression during pregnancy 1
• The prevalence of any diabetic retinopathy in early pregnancy is 52.3%, with proliferative diabetic retinopathy (PDR) present in 6.1% 1

Progression rates during pregnancy are significant:

• New diabetic retinopathy develops in 15% of pregnancies 1
• Existing nonproliferative retinopathy worsens in 31% of cases 1
• Progression from nonproliferative to sight-threatening PDR occurs in 6.3% 1
• Existing PDR worsens in 37% of cases 1

Important caveat: Women who develop gestational diabetes mellitus do NOT require eye examinations during pregnancy, as they are not at increased risk of diabetic retinopathy 1, 2

Monitoring Schedule During Pregnancy

Frequency of examinations depends on baseline retinal status:

• Women with any level of diabetic retinopathy: monitor every trimester throughout pregnancy 2
• Continue ophthalmologic monitoring for one year postpartum 2
• More frequent examinations are required if retinopathy is progressing or sight-threatening 1

Critical warning: Rapid implementation of intensive glycemic management in women with existing retinopathy is associated with early worsening of retinal status, necessitating more frequent monitoring 1, 2

Treatment Interventions

Immediate ophthalmology referral is mandatory for: 1, 2

• Any level of diabetic macular edema
• Moderate or worse nonproliferative diabetic retinopathy
• Any proliferative diabetic retinopathy

Treatment options during pregnancy:

• Panretinal laser photocoagulation is indicated to reduce vision loss risk in high-risk PDR and may be used during pregnancy 1, 2
• Anti-VEGF agents (intravitreal injections) should NOT be used in pregnant women due to theoretical risks to the developing fetus 2
• This represents a critical departure from non-pregnant management, where anti-VEGF is often first-line therapy 1

Mode of Delivery Considerations

Retinal thinning or high-risk retinal pathology is NOT a contraindication to vaginal delivery:

• A prospective study of women with retinal detachment history, extensive lattice degeneration, or symptomatic retinal holes found no changes in retinal status after spontaneous vaginal delivery 3
• Prenatal treatment of asymptomatic retinal pathology is not indicated 3
• Cesarean section is not required solely for retinal concerns 3

Additional Management Considerations

Monitor for preeclampsia-related visual symptoms: 2

• Visual disturbances (blurred vision, double vision, transient vision loss) require immediate evaluation
• These may indicate preeclampsia-associated retinopathy, which is a separate pregnancy-specific condition 4, 5

Aspirin use: The presence of retinopathy is not a contraindication to aspirin for cardioprotective purposes, as aspirin does not increase retinal hemorrhage risk 2

Optimize systemic control: 1

• Maintain glycemic control (while avoiding rapid intensive changes in women with existing retinopathy)
• Control blood pressure
• Manage serum lipids