How to manage retinal thinning during labor?

Management of Retinal Thinning During Labor

Women with retinal thinning or other high-risk retinal pathology should be allowed to undergo spontaneous vaginal delivery, as diabetic retinopathy should not be considered a contraindication to vaginal birth. 1

Key Recommendation

• Spontaneous vaginal delivery is safe and recommended for women with retinal thinning, high myopia, history of retinal detachment, lattice degeneration, or treated retinal breaks. 2, 3
• No prophylactic retinal treatment is indicated before delivery in asymptomatic patients with high-risk retinal pathology. 2
• Cesarean section or instrumental delivery should NOT be performed solely based on retinal concerns. 2, 4, 5

Evidence Supporting Vaginal Delivery

• Prospective studies of women with extensive lattice degeneration, history of retinal detachment, or treated symptomatic retinal holes showed no changes in retinal status after spontaneous vaginal delivery. 2
• High myopic patients (4.5 to 15.0 diopters) with various retinal degenerations and retinal breaks showed no deterioration of retinal defects after spontaneous delivery. 3
• The traditional concern about Valsalva maneuvers during pushing causing retinal detachment is not supported by evidence. 5

Special Considerations for Diabetic Retinopathy

• Women with pre-existing diabetes and diabetic retinopathy should have close ophthalmologic follow-up throughout pregnancy but can deliver vaginally. 1
• Eye examinations should occur in the first trimester with close follow-up throughout pregnancy and for 1 year postpartum, as diabetic retinopathy can progress rapidly during pregnancy. 1
• The presence of diabetic retinopathy, even proliferative disease, is not a contraindication to vaginal delivery. 1

Management of Active Retinal Detachment During Pregnancy

• If rhegmatogenous retinal detachment occurs during pregnancy, surgical repair can be safely performed with careful coordination between ophthalmology, anesthesia, and obstetrics. 6
• Scleral buckle procedures with monitored anesthesia care are safe during pregnancy. 6
• Following successful retinal detachment repair during pregnancy, spontaneous vaginal delivery at term remains appropriate. 6

Common Pitfalls to Avoid

• Do not recommend cesarean section or instrumental delivery based solely on retinal pathology - this represents unnecessary intervention in otherwise healthy women. 4, 5
• Do not perform prophylactic laser or cryotherapy to asymptomatic retinal lesions before delivery, as this is not indicated. 2
• Be aware that many obstetricians may still recommend operative delivery based on outdated beliefs rather than evidence - ophthalmologists should advocate for vaginal delivery when consulted. 4, 5

Clinical Algorithm

1. Antepartum assessment: Examine retina in first trimester and monitor throughout pregnancy for any diabetic retinopathy or high-risk lesions. 1

2. If asymptomatic retinal thinning/pathology present: Reassure patient that vaginal delivery is safe; no intervention needed. 2

3. If symptomatic changes occur: Treat retinal pathology as indicated (laser, surgery), but this does not change delivery recommendations. 2, 6

4. At term: Proceed with spontaneous vaginal delivery regardless of retinal status. 1, 2, 3

5. Postpartum: Continue ophthalmologic follow-up for 1 year, especially in diabetic patients. 1