We read with great interest the excellent article by Madanat and Sheshah titled “Preconception care of Saudi women with diabetes mellitus.” We applaud the authors' description of the challenges, but would like to make some contribution to the maternal outcomes of this disease, especially as the ocular aspect needs much attention and should have been a part of the introduction/discussion.
One of the most common complications of diabetes mellitus is the ocular condition that pregnancy modifies. Gestational diabetes poses a very low risk for the development of retinopathy. In patients who have nonproliferative diabetic retinopathy (DR), studies have demonstrated that as many as 50% may show an increase in their nonproliferative retinopathy. Approximately 5–20% of these patients develop proliferative changes. An ophthalmologic examination at least once every trimester is recommended. Studies on patients with proliferative DR have shown that there could be a progression of the disease in as many as 45%. In patients with proliferative DR, monthly ophthalmic examinations are warranted. Proliferative DR may regress at the end of the third trimester or postpartum. A cesarean section should be considered for patients with proliferative DR to prevent vitreous hemorrhage resulting from Valsalva maneuver used during labor. Diabetic macular edema may develop or worsen during pregnancy.
Factors that have been shown to influence the progression of DR in pregnancy include the pregnant state itself, duration of diabetes, degree of retinopathy at the time of conception, metabolic control of diabetes, and the presence of coexisting hypertension. The exact pathogenesis for the progression of DR during pregnancy remains controversial. Some studies have demonstrated a decrease in retinal venous diameter and volumetric blood flow in diabetic patients during pregnancy and hypothesized that this may exacerbate retinal ischemia and hypoxia.
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