VIENNA – A concerning number of women with gestational diabetes may not be getting optimal retinal care during their pregnancy.
About 11% of women in an Irish observational cohort study received just one retinal exam of the two that are recommended during pregnancy and 29% received no exam, Dr. Aoife Maria Egan said at the annual meeting of the European Association for the Study of Diabetes.
Women who attended prepregnancy care clinics were most likely to get appropriate screening. “This is probably because they had been made aware of what would be expected for them during pregnancy,” said Dr. Egan of the University Hospital Galway (Ireland).
Michele G. Sullivan/Frontline Medical News
Women who attended prepregnancy care clinics were most likely to get appropriate screening, said Dr. Aoife Maria Egan.
The study was an offshoot of the ongoing Atlantic Diabetes in Pregnancy (DIP) project, which examines the outcomes of pregnancy for women with type 1 and type 2 diabetes and the factors influencing these outcomes. It was created in 2005 and provides universal screening for gestational diabetes as part of its outcomes research. The retinopathy study covered 2006-2012.
Adequate retinopathy evaluation was considered to be at least two retinal exams conducted in separate trimesters. Each exam consisted of tests of visual acuity, dilation, and opthalmologic exams and retinal images that were reviewed by an accredited retinal grader.
DIP considered four grades of retinopathy, which have been defined by the National Screening Committee in the United Kingdom: none (R0), background (R1), preproliferative (R2), and proliferative (R3). Additionally, macular edema is graded as present or absent. Progression was considered to be a change from one retinopathy grade to the next or the development of new macular edema.
The study group consisted of 341 women with gestational diabetes (68% type 1). Most of these (90%) were white. They averaged 31 years of age, with a history of two pregnancies. There were 296 live births (87%). The final analysis included 307 women who delivered after 22 weeks.
Most of the women (60%) did have an adequate evaluation. However, 11% had only one exam and 29% had no exam, Dr. Egan said.
There were a few significant differences between those who had adequate retinal exams and those who did not. Women who had two exams were more likely to have type 1 diabetes (72% vs. 61% without adequate exams) and white (94% vs. 85%). They had a longer duration of diabetics (11 vs. 9 years). More of them had attended a prepregnancy center (56% vs. 17%) and were taking folic acid (70% vs. 54%), she reported.
A multivariate analysis determined that attending the prepregnancy clinic was the strongest predictive factor, increasing the likelihood of adequate screening by more than six times.
Of those who had an adequate exam, 74% did not progress during their pregnancy and 26% did. Of those 48 who progressed, the largest portion (26) went from R0 to R1. R1 to R2 progression occurred in seven patients, and R1/R2 to R3 in six. Six patients developed a new maculopathy and three had worsening maculopathy.
Several significant differences emerged when comparing those who progressed with those who did not. The women with worsening retinopathy had a longer duration of diabetes (14 vs. 10 years) and higher systolic blood pressure at baseline (129 vs. 122 mm Hg).
They also had higher baseline hemoglobin A1c (7.7% vs. 7%) and a greater change in HbA1cduring the pregnancy (1.38% vs. 0.74%). An HbA1creduction between the first and third trimester was associated with a doubling in the risk of progression. Those who had a higher reduction of HbA1cbetween trimesters one and three were more than twice as likely to have retinopathy progression.
This highlights the dilemma clinicians face when trying to balance maternal and fetal risks of glycemic control, Dr. Egan said. Women who present with poor glycemic control should moderate that to optimize fetal health, but lowering HbA1ccan predispose the mother to retinopathic changes.
“We try and target tight control and monitor the ones we know are at risk for retinopathy progression very closely,” she said.
Whether that makes any long-term difference is still an unknown. “Some studies have shown that, while pregnancy might accelerate retinopathy, in the long run women end up even in that regard. Six or seven years down the road, everyone looks the same,” she noted.
The DIP program is funded by the Health Research Board of Ireland. Dr. Egan had no financial disclosures.
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