NICE has produced a clinical guideline that recognises that worsening of diabetic retinopathy (DR) during pregnancy in type 1 and type 2 diabetes can be significant and may require laser treatment (NICE, 2008).
Known risk factors for progression of DR in pregnancy:✲ Pregnancy itself is associated with an increased risk in the progression of DR
✲ The baseline severity of DR at conception
✲ Poor control of a woman’s diabetes at conception
✲ Rapid improvement in glycaemic control may be a contributing factor in the worsening of DR. However, the benefits of good control outweigh any risks of progression
✲ Poor metabolic control during pregnancy or the early postnatal period
✲ The length of time the woman has had diabetes
✲ Chronic hypertension and also pregnancy-induced hypertension.
It is important that midwives are aware of the correct care pathway so they can advise and care for women accordingly. Recommendations for retinal assessment during pregnancy in diabetes: ✲ Annual screening for DR should be carried out in the preconception period
✲ Women with type 1 and type 2 diabetes should be offered two dilated digital photographs of each eye as recommended by the English national DR screening programme at (or soon after) their first antenatal visit and again at 28 weeks’ gestation
✲ If background DR is found to be present, an additional screen should be performed at 16 to 20 weeks’ gestation
✲ If referable DR is found in early pregnancy, then careful ophthalmological supervision is required, depending on the level of retinopathy, during pregnancy and for at least six months postnatally
✲ Because tropicamide (drops used to dilate the pupils during eye examination) is only licensed for use in pregnancy under the direction of a registered medical practitioner, care pathways should be set up in such a way as to enable this to be undertaken. Agreed policies and protocols specifically dealing with the administration of eye drops to pregnant women should always be in place
✲ It is the responsibility of local lead clinicians for obstetrics, diabetology, ophthalmology and DR screening to make sure there are local policies, protocols and care pathways for photographing the eyes of pregnant women with diabetes. Women with gestational diabetes are not part of the national screening programme.
The National Screening Committee’s timeline now supports these messages by including the ‘optimum times for testing for diabetic retinopathy’ alongside the NHS antenatal and newborn screening tests.
Peter Scanlon is programme director of the English National Screening Programme for Diabetic Retinopathy and Joanne Harcombe is education lead at the UK National Screening Committee.
For research, evidence, more information and further reading, please visit:
www.screening.nhs.uk/diabeticretinopathy-england and http://cpd.screening.nhs.uk/timeline
ReferencesNICE. (2008).
Diabetes in pregnancy: management of diabetes and its complications from pre-conception to the postnatal period. NICE: London.
