Metabolic control and progression of retinopathy. The Diabetes in Early Pregnancy Study. National Institute of Child Health and Human Development Diabetes in Early Pregnancy Study

Managing type 1 diabetes mellitus in pregnancy--from planning to breastfeeding

Type 1 diabetes mellitus in pregnant women increases the risk of adverse outcomes for mother and offspring. Careful preconception counselling and screening is important, with particular focus on glycaemic control, indications for antihypertensive therapy, screening for diabetic nephropathy, diabetic retinopathy and thyroid dysfunction, as well as review of other medications. Supplementation with folic acid should be initiated before conception in order to minimize the risk of fetal malformations. Obtaining and maintaining tight control of blood glucose and blood pressure before and during pregnancy is crucial for optimizing outcomes; however, the risk of severe hypoglycaemia during pregnancy is a major obstacle. Although pregnancy does not result in deterioration of kidney function in women with diabetic nephropathy and normal serum creatinine levels, pregnancy complications such as pre-eclampsia and preterm delivery are more frequent in these women than in women with T1DM and normal kidney function. Rapid-acting insulin analogues are considered safe to use in pregnancy and studies on long-acting insulin analogues have provided reassuring results. Immediately after delivery the insulin requirement declines to approximately 60% of the prepregnancy dose, and remains 10% lower than before pregnancy during breastfeeding.

Current epidemiology of diabetic retinopathy and diabetic macular edema

With increasing global prevalence of diabetes, diabetic retinopathy (DR) is set to be the principle cause of vision impairment in many countries. DR affects a third of people with diabetes and the prevalence increases with duration of diabetes, hyperglycemia, and hypertension-the major risk factors for the onset and progression of DR. There are now increasing data on the epidemiology of diabetic macular edema (DME), an advanced complication of DR, with studies suggesting DME may affect up to 7 % of people with diabetes. The risk factors for DME are largely similar to DR, but dyslipidemia appears to play a more significant role. Early detection of DR and DME through screening programs and appropriate referral for therapy is important to preserve vision in individuals with diabetes. Future research is necessary to better understand the potential role of other risk factors such as apolipoproteins and genetic predisposition to shape public health programs.

[Management of patients with ocular diseases during pregnancy. Diabetes, glaucoma and uveitis]

Many ocular diseases require treatment even during pregnancy. Some conditions, such as diabetic retinopathy tend to worsen during pregnancy but others, such as uveitis may benefit from the physiological changes occurring during pregnancy. But generally even a favorable development is not sufficient to obtain a steady state without treatment. Each medication applied during pregnancy should only be given after thorough consideration of the pros and cons and discussion of these with the patient. There are sufficient medications for ocular diseases that can be given when indicated following published guidelines and experiences. This review focuses on the course and therapy of glaucoma, diabetic retinopathy and uveitis during pregnancy.

Pregnancy management of women with pregestational diabetes

Optimal glycemic control is pivotal to the successful outcome of diabetic pregnancy. The goals for glycemic control include levels for preprandial and postprandial glucose and HbA1c as well as avoidance of severe hypoglycemia. These goals are best obtained with diet, exercise, and insulin treatment, often a multiple-dose insulin regimen or insulin pump. A focus on blood pressure, microalbuminuria, diabetic nephropathy, and diabetic retinopathy is needed.

Microalbuminuria and low hemoglobin as risk factors for the occurrence and increasing severity of diabetic retinopathy

AIM

To assess the influence of urinary microalbuminuria and hemoglobin concentration on the occurrence and severity of diabetic retinopathy (DR), clinically significant macular edema (CSME) and hard exudate formation.

MATERIALS AND METHODS

In this prospective cross-sectional study carried out over a period of 2 years, type 2 diabetic patients seeking ocular evaluation for DR were assessed for presence and severity of DR, presence of hard exudates and CSME. Retinal findings were correlated to severity of microalbuminuria, hemoglobin concentration and other systemic risk factors using linear regression analysis.

RESULTS

Three hundred and six patients were included in the study. DR of any grade was seen in 132 (43%) patients, hard exudate formation in 93/306 (30.4%) patients, CSME in 50/306 (16.3%) patients and proliferative DR in 26/306 (8.5%) patients. Duration of diabetes (P < 0.001), microalbuminuria (P < 0.001) and low hemoglobin (P = 0.001) were found to be highly significant risk factors for the development and increasing severity of DR as well as for CSME and hard exudate formation.

CONCLUSION

Microalbuminuria and low hemoglobin are strong predictors for DR, CSME and hard exudate formation in type 2 diabetics even after correcting for duration of diabetes and other systemic risk factors. Although not directly involved in the pathogenesis, microalbuminuria can help in identifying patients at risk for more severe diabetic eye disease. Microalbuminuria warrants intensive monitoring of both retinal and renal status. The hemoglobin levels should be monitored regularly in diabetic patients to detect and treat anemia, thereby reducing one risk factor for DR.

Basal insulin analogues in diabetic pregnancy: a literature review and baseline results of a randomised, controlled trial in type 1 diabetes

As basal insulin analogues are being used off-label, there is a need to evaluate their safety (maternal hypoglycaemia and fetal and perinatal outcomes) and efficacy [haemoglobin A1c(HbA1c), fasting plasma glucose, and maternal weight gain]. The aim of this review is to provide an overview of the current literature concerning basal insulin analogue use in diabetic pregnancy, and to present the design and preliminary, non-validated baseline characteristics of a currently ongoing randomized, controlled, open-label, multicentre, multinational trial comparing insulin detemir with neutral protamine hagedorn insulin, both with insulin aspart, in women with type 1 diabetes planning a pregnancy (n = 306) or are already pregnant (n = 164). Inclusion criteria include type 1 diabetes > 12 months' duration; screening HbA1c ≤ 9.0% (women recruited prepregnancy), or pregnant with gestational age 8-12 weeks and HbA1c ≤ 8.0% at randomization. At confirmation of pregnancy all subjects must have HbA1c ≤ 8.0%. Exclusion criteria include impaired hepatic function, cardiac problems, and uncontrolled hypertension. Subjects are randomized to either insulin detemir or neutral protamine hagedorn insulin, both with prandial insulin aspart. The results are expected mid-2011 with full publications expected later this year. Baseline characteristics show that basal insulin analogues are already frequently used in pregnant women with type 1 diabetes. This study will hopefully elucidate the safety and efficacy of the basal insulin analogue detemir in diabetic pregnancy.

Current and future approaches in the prevention and treatment of diabetic retinopathy

Diabetic retinopathy (DR) is a major cause of blindness worldwide and is the number one cause of blindness in working-age individuals in developed countries. We review the current literature and discuss the pathogenesis, modifying risk factors, genetics, and treatment of DR. Special focus is placed on the rationale and effectiveness of therapeutic modalities, both current and future.

Managing diabetes during pregnancy with insulin lispro: a safe alternative to human insulin

OBJECTIVE

To assess the safety of the use of insulin lispro during pregnancy on the basis of published literature and to report on any related efficacy findings.

METHODS

The National Center for Biotechnology Information Entrez Database PubMed (http://www.ncbi. nlm.nih.gov/pubmed/) was used to search for citations from MEDLINE in the November 2009 time frame that contained safety data and efficacy results on the use of insulin lispro during pregnancy.

RESULTS

From the MEDLINE search, we identified a total of 27 publications (with 1,265 pregnancies) with relevant information, which were included in this report. No statistically significant differences in the rates of occurrence of congenital anomalies or spontaneous abortions associated with the use of insulin lispro during pregnancy, in comparison with the use of human insulin, were reported. Moreover, in comparison with human insulin, insulin lispro was reported to result in improved glycemic control, as demonstrated by lower postprandial glucose concentrations and hemoglobin A1c levels.

CONCLUSION

The current review of the published literature indicates that insulin lispro is a safe alternative to human insulin with similar perinatal outcomes and potentially improved glycemic control in the management of diabetes during pregnancy.

Pregnancy-induced increase in circulating IGF-I is associated with progression of diabetic retinopathy in women with type 1 diabetes

OBJECTIVE

To evaluate the influence of Insulin-like Growth factor-I (IGF-I) and Placental Growth Hormone (GH) on progression of diabetic retinopathy during pregnancy in women with type 1 diabetes.

DESIGN

Observational study of 88 consecutive pregnant women with type 1 diabetes for median 16.5 years (range 1-36) and HbA(1c) 6.6% (5.2-10.5) in early pregnancy. At 8, 14, 21, 27 and 33 weeks blood samples were drawn for measurement of IGF-I, placental GH and Hemoglobin A(1c) (HbA(1c)) and blood pressure was recorded. Fundus photography was performed at 8 and 27 weeks. Diabetic retinopathy was classified in five stages. Progression was defined as deterioration of at least one stage of diabetic retinopathy and/or development of macular edema on at least one eye.

RESULTS

Placental GH and IGF-I levels increased throughout pregnancy and new onset or progression of diabetic retinopathy occurred in 22 (25%). A steeper increase in women with progression of diabetic retinopathy resulted in higher IGF-I levels at 27 weeks (p=0.01) and 16% higher IGF-I levels throughout pregnancy (p=0.02) compared with women without progression while similar levels of placental GH (p=0.58) and HbA(1c) (p=0.85) were observed throughout pregnancy. In a multivariate logistic regression analysis, progression of diabetic retinopathy was associated with higher IGF-I levels at 33 weeks (odds ratio 2.0 [95% confidence interval 1.1-3.6], p=0.02) and higher systolic blood pressure at 8 weeks (1.9 [1.1-3.2], p=0.02) independent of placental GH and HbA(1c) levels.

CONCLUSIONS

Pregnancy-induced increase in IGF-I levels is associated with progression of diabetic retinopathy in women with type 1 diabetes.

Pregestational diabetes

The prevalence of preexisting diabetes in pregnancy is increasing largely because of an increase in type 2 diabetes. Outcomes of diabetic pregnancies for mother and newborn have improved greatly in recent decades from advances in understanding the disease process, improved education, and new treatment modalities delivered in a team approach. Nausea and vomiting from pregnancy and pregnancy-associated insulin resistance can make glycemic control a challenge. Care of women with preexisting diabetes demands careful monitoring in the preconception, prenatal, and peripartum periods.

Maternal immune system adaptation to pregnancy--a potential influence on the course of diabetic retinopathy

BACKGROUND

Progression of diabetic retinopathy occurs at least temporarily during pregnancy. Although the cause of this progression is not entirely understood, the immune phenomenon and chronic inflammation may play a significant role. During pregnancy in order to avoid fetus rejection, certain components of the immune system that are knowingly implicated in the pathogenesis of diabetic retinopathy are activated including generalized leukocyte activation and an increase in certain cytokine plasma levels. Activated leukocytes with up regulated adhesion molecules have an increased potential to bind to the endothelium cells of blood vessels. Leukocyte-endothelial interaction and the consequent leukostasis with capillary occlusion, ischemia and vascular leakage have a substantial role in the development of diabetic retinopathy. Furthermore, certain increased cytokines are known to cause blood-retinal-barrier breakdown whilst others promote angiogenic and fibrovascular proliferation and thereby can also be implicated in the pathogenesis of this diabetic complication.

PRESENTATION OF THE HYPOTHESIS

We hypothesized that the activation of the immune system during gestation may have an influence on the course of retinopathy in pregnant diabetic women.

TESTING THE HYPOTHESIS

We suggest two prospective follow up studies conducted on women with type 1 diabetes mellitus. The first study would include a group of non-pregnant women and a group of diabetic women undergoing normal pregnancy matched for age and duration of diabetes. In the second study pregnant women would be divided into two groups: one with normal pregnancy and the other with preeclampsia. The procedure and data collection in both studies will be identical: a complete ophthalmological examination, glycaemic control, blood pressure measurement and venous blood samples for the determination of plasma levels of cytokines (TNF-alpha, IL-1beta, IL-6, IL-8) and adhesion molecules (ICAM-1, VCAM-1).

IMPLICATIONS OF THE HYPOTHESIS

Considering the present assumption, the gestational immune activation could be suggested as a potential risk factor for the development and progression of retinopathy in diabetic women. A better understanding of immunomodulatory effects of pregnancy on diabetic retinopathy pave the way for further investigations of the mechanism of its pathogenesis and could be essential for novel approaches to the treatment of this serious sight threatening complication of diabetes mellitus.

[Eye and pregnancy.]

Pregnancy may cause ocular changes, for example refractive changes or contact lens intolerance. A number of ocular diseases may deteriorate. Especially preexisting diabetic retinopathy may worsen. Vaginal delivery is nearly always possible. Caesarean section is not required due to myopia, peripheral retinal degenerations or after retinal surgery. Most topically applied drugs usually used in ophthalmology are safe during pregnancy.

Progression of diabetic retinopathy during pregnancy in women with type 2 diabetes

AIMS/HYPOTHESIS

We studied the progression of diabetic retinopathy during pregnancy in women with type 2 diabetes.

METHODS

Fundus photography was performed at median 10 (range 6-21) and 28 (27-37) gestational weeks in 80 of 110 (73%) consecutively referred pregnant women with type 2 diabetes. Diabetic retinopathy was classified in five stages. Progression was defined as at least one stage of deterioration of diabetic retinopathy and/or development of macular oedema on at least one eye between the two examinations. Macular oedema was defined as retinal thickening and/or hard exudates within a diameter of 1,500 microm in the macula area.

RESULTS

Diabetic retinopathy, mainly mild, was present in 11 (14%) women in early pregnancy. Median duration of diabetes was 3 years (range 0-16 years). At baseline, HbA(1c) was 6.4% (1.0) (mean [SD]), systolic BP 121 (13) and diastolic BP 72 (9) mmHg. Prior to pregnancy, 22 (28%) women had been on insulin treatment. During pregnancy 74 women (93%) were treated with insulin and 11 (14%) with antihypertensive medication. Progression of diabetic retinopathy was observed in 11 (14%) women. Progression was mainly mild, but one woman with poor glycaemic control and uncontrolled hypertension progressed from mild retinopathy to sight-threatening retinopathy with proliferations, clinically significant macular oedema and impaired vision in both eyes. Progression of diabetic retinopathy was associated with a longer duration of diabetes (p = 0.03) and insulin treatment before pregnancy (p = 0.004).

CONCLUSIONS/INTERPRETATION

Despite a low risk of progression of retinopathy in pregnant women with type 2 diabetes, sight-threatening deterioration did occur.

[Progression of diabetic retinopathy during pregnancy]

Diabetic retinopathy should be carefully monitored during certain risk situations. Indeed, diabetic retinopathy in pregnant type 1 diabetic patients can rapidly progress and threaten vision, as in other situations such as puberty, glycemic equilibration, or ocular surgery. During pregnancy, five major risk factors for progression have been identified: pregnancy itself, diabetic retinopathy grade at baseline, duration of diabetes, important glycated hemoglobin reduction, and high blood pressure. These factors must be taken into account when planning pregnancy in diabetic patients and during the follow-up of their diabetic retinopathy. Diabetic women should be counseled about the risks of progression of their disease before planning pregnancy. Careful eye examination before and during the first trimester should be done in these patients, in order to detect severe non-proliferative diabetic retinopathy and/or high-risk diabetic retinopathy and perform rapid laser treatment if needed. Follow-up visit frequency should be adapted to the severity of the diabetic retinopathy. Very few authors have studied diabetic macular edema during pregnancy. This complication can spontaneously regress postpartum and should not be treated too rapidly.

Pregnancy-induced sight-threatening diabetic retinopathy in women with Type 1 diabetes

AIMS

To determine the progression of diabetic retinopathy in pregnant women with diabetes offered tight glycaemic and blood pressure control.

METHODS

A prospective study of 102 (87%) out of 117 consecutive pregnant women with Type 1 diabetes for median 16 years (range 1-36) and HbA(1c) 6.7% (4.9-10.8) in early pregnancy. Fundus photography was performed at 8 and 27 weeks. Retinopathy was classified in five stages. Diabetic macular oedema was classified as present in a mild form or as clinically significant macular oedema (CSMO). Progression was defined as at least one stage of deterioration of retinopathy and/or development of macular oedema in at least one eye. Sight-threatening progression was defined as loss of visual acuity>or=0.2 on Snellen's chart or laser treatment performed during pregnancy due to proliferative retinopathy or CSMO.

RESULTS

Diabetic retinopathy was present at inclusion in at least one eye in 64 (63%) women and proliferative retinopathy and macular oedema were present in nine and 16 women, respectively. Progression of retinopathy occurred in 28 (27%) women. Sight-threatening progression occurred in six women; in three, visual acuity deteriorated and four required laser treatment. Sight-threatening progression was associated with presence of macular oedema (P=0.007), impaired visual acuity (P=0.03) and higher blood pressure (P=0.016) in early pregnancy, but not with HbA1c, decline in HbA1c, or prevalence of severe hypoglycaemia.

CONCLUSIONS

Loss of visual acuity and the need for laser treatment during diabetic pregnancy remain clinical problems associated with presence of macular oedema, visual impairment and higher blood pressure in early pregnancy.

New modalities in the treatment of pregnancies complicated by diabetes: drugs and devices

The development of drugs and devices in the treatment of pregnancies complicated by diabetes is in constant forward progression to compensate for pancreatic beta cell insufficiency. Maternal hyperglycemia during pregnancy is of particular interest due to the severe consequences that surface when a fetus is in development. The drugs that are currently recommended for use during pregnancy include rapid-acting insulin analogs lispro and aspart for meal-related bolus insulin and intermediate-acting NPH for basal insulin. Oral anti-diabetic agents are not recommended for use during pregnancy. Better control may be achieved with the incorporation of real-time glucose sensors and new insulin pumps with hopes of improving pregnancy outcome.

Does pregnancy accelerate the rate of progression of diabetic retinopathy?: an update

Pregnancy may be associated with several ocular changes, including the development of new ocular conditions or modifications of existing conditions. The most common ocular condition modified by pregnancy is diabetic retinopathy. Pregnancy is associated with an increased risk of development and progression of diabetic retinopathy. The factors associated with its progression include the pregnant state itself, duration of diabetes, amount of retinopathy at conception, blood glucose control, and the presence of coexisting hypertension. Although the rate of regression of diabetic retinopathy at the end of pregnancy or the postpartum period is high, careful monitoring of these patients is necessary to optimize the vision and pregnancy outcomes.

Influence of pregnancy on long-term progression of retinopathy in patients with type 1 diabetes

AIMS/HYPOTHESIS

Pregnancy in type 1 diabetic women is associated with risk of worsening of retinopathy. It has been reported that deterioration continues in the months after delivery, but direct data are lacking. It is also unclear what impact pregnancy has on the long-term progression of retinopathy.

METHODS

We studied 59 women with type 1 diabetes who had retinal photographs before pregnancy and yearly for 5 years post pregnancy. These photographs were graded using the EURODIAB retinopathy grading system.

RESULTS

The mean duration of diabetes was 14.4+/-8.2 years and mean age at pregnancy was 29.8+/-5.5 years. Mean HbA(1c) was 8.2+/-2.0% before pregnancy with tighter control during pregnancy itself. This value was high despite efforts to improve take-up of pre-conception care. Mean HbA(1c) was 8.6+/-1.5 during the follow-up period. At baseline, 43 (72.9%) women were free of retinopathy, 15 had non-proliferative retinopathy and one woman had previously had laser therapy. During pregnancy four women required laser therapy. Over the next 5 years none required laser therapy, although retinopathy worsened in 14 women. Ten-year follow-up data were available on 22 women, one of whom required laser therapy 8 years after pregnancy. Baseline retinopathy status was the only independent risk factor which predicted progression of retinopathy.

CONCLUSIONS/INTERPRETATION

Pregnancy is not associated with post-partum worsening of retinopathy.

Diabetes melito tipo 1 e gestação

As gestações em mulheres com diabetes têm apresentado resultados que melhoraram dramaticamente nas últimas décadas, em razão dos progressos com a monitorização das glicemias e administração de insulina. A gravidez nas mulheres com diabetes tipo 1 está associada a aumento de risco tanto para o feto quanto para a mãe. Antes da concepção, a prioridade é normalizar a glicemia para prevenir malformações congênitas e abortamentos espontâneos. Com o progresso da gestação, a mãe tem um risco aumentado de hipoglicemias e cetoacidose. Mais tarde existe risco de piora na retinopatia, hipertensão induzida pela gestação, pré-eclâmpsia-eclâmpsia, infecções de trato urinário e poliidrâmnios. No final da gestação, existe o risco de macrossomia e morte súbita intra-uterina do feto. Todas essas complicações podem ser prevenidas ou, pelo menos, minimizadas pelo planejamento da gestação e pelo controle intensivo das oscilações das glicemias, mantendo-as próximo ao normal.

Insulin analogues in the treatment of diabetes in pregnancy

This review reports the literature on the safety and efficacy of insulin analogues in pregnancy and thereby enables the clinician to choose the optimal insulin treatment protocol to achieve and maintain normoglycemia throughout pregnancies complicated by diabetes. This article also reviews the literature on the insulin analog during pregnancy and presents the authors' opinion as to the safety and efficacy of insulin analog treatment for the pregnant diabetic woman.

Periconceptional care of women with diabetes mellitus

Pregestational diabetes is a common complication of pregnancy that can be associated with severe maternal and fetal morbidity. In addition, some women could have progression of diabetic complications secondary to pregnancy. Preconception care can significantly reduce pregnancy complications with a dramatic impact on the diabetic mother and her infant. For those women whose condition could be hastened by conception education, better understanding and an improved decision should be available to them and their families. Because unplanned pregnancy is common among diabetic women, they should be counseled early for the importance of preconception care in the progression of this disease.

The vicious cycle of diabetes and pregnancy

The offspring of women with diabetes during pregnancy are at high risk of developing diabetes before they reach childbearing age, resulting in a vicious cycle of diabetes and pregnancy. New cases of diabetes enter the cycle as a result of the effects of the increasing obesity among our youth. Solutions need to be found to break this cycle by preventing diabetes or delaying its onset until later in life and by normalizing glucose regulation during pregnancy.

Progression of retinopathy during pregnancy in type 1 diabetes mellitus

PURPOSE

The incidence and risk factors for progression of retinopathy during pregnancy in women with type 1 diabetes mellitus were retrospectively evaluated.

METHODS

Fifty-four insulin-dependent diabetic patients at a teaching hospital in Saudi Arabia were followed throughout the pregnancy/puerperium with serial ophthalmic examination. Dilated fundus examination was performed in each trimester and puerperium.

RESULTS

Progression of diabetic retinopathy in the study occurred in 13/54 (24%) patients--2/22 (9.1%) patients had no diabetic retinopathy initially, 4/20 (20%) had non-proliferative diabetic retinopathy (NPDR) and 7/12 (58.3%) had proliferative diabetic retinopathy (PDR). Of the eight patients with PDR who had no laser treatment before pregnancy, six (75%) showed progression but only one of the four patients who had PDR and laser treatment prior to pregnancy experienced progression of retinopathy. Eight patients in total received panretinal photocoagulation to arrest the progression of retinal disease during pregnancy and only one of them had laser treatment prior to pregnancy.

CONCLUSION

Laser photocoagulation for severe NPDR or early PDR prior to pregnancy may protect against rapid progression of PDR. Visual impairment resulting from progression of PDR can be prevented by aggressive laser treatment during pregnancy. Duration of diabetes>15 years, poor glycaemic control and hypertension are high-risk factors in the progression of diabetic retinopathy in pregnancy.

Microvascular complications and the diabetic pregnancy

Without strict glycemic control, diabetic pregnancies are frequently complicated by spontaneous abortion, stillbirth, or congenital malformation. Retrospective studies have been largely reassuring that pregnancy does not accelerate morbid outcomes in women with diabetic vascular disease. Improved outcomes of high-risk pregnancy in women with pregestational, type 1, or type 2 diabetes mellitus remain challenging, depending on a comprehensive and multidisciplinary team approach and extensive preconception counseling.

Preterm delivery in normoalbuminuric, diabetic women without preeclampsia: The role of metabolic control

OBJECTIVE

The aim of this study was to examine the importance of glycemic regulation on the risk of preterm delivery in women with normoalbuminuria and no preeclampsia later in pregnancy.

STUDY DESIGN AND METHODS

A prospective study of 71 women with type 1 diabetes mellitus where complete data were collected on HbA1c, insulin dose, and albumin excretion rate from week 12 and every second week hereafter. Fundus photography was performed and diurnal blood pressure measured three times during pregnancy.

RESULTS

The preterm rate was 23% and women delivering preterm showed higher HbA1c throughout pregnancy. At regression analysis HbA1c was the strongest predictor for preterm delivery from week 6 to 32, also when including insulin dose, BMI, age, duration of diabetes, and diurnal blood pressure. The risk of delivering preterm was more than 40% when HbA1c was above 7.7% in week 8. Diurnal blood pressure was not found associated with preterm delivery.

CONCLUSION

The quality of glycemic regulation in the early and mid-pregnancy is a major, independent risk factor for preterm delivery in normoalbuminuric diabetic women without preeclampsia.

Ocular disease in pregnancy

PURPOSE OF REVIEW

Pregnancy may cause ocular changes, both physiologic and pathologic, and may be associated with the development of new disease or may alter the course of preexisting disease. This paper discusses these changes and reviews diabetic retinopathy, uveitis, preeclampsia, cortical blindness and central serous chorioretinopathy.

RECENT FINDINGS

Recent reports have contributed to our understanding of the pathophysiology of diabetic retinopathy and cortical blindness associated with preeclampsia, the impact of pregnancy on the course of inflammatory eye disease, and the use of optical coherence tomography in following central serous chorioretinopathy in pregnant women.

SUMMARY

This improved understanding of the pathophysiology of ocular disease in pregnancy and the impact of pregnancy on the course of preexisting ocular disease offers the opportunity for meaningful counseling of women who are pregnant or planning to become pregnant.

Safety and side effects of the insulin analogues

The analogue insulins were developed to more clearly mimic the basal and prandial components of insulin secretion for subjects with diabetes mellitus. Analogues are now widely used and have largely taken over from the conventional human recombinant insulins. It is important that these insulins are not only as effective as their predecessors, but are also safe and well-tolerated. In this manuscript, the authors review the adverse effects reported with analogue insulins and make a comparison with standard insulin treatments.

Screening for retinopathy in the pediatric patient with type 1 diabetes mellitus

Diabetic retinopathy (DR) is the leading cause of blindness in young adults in the United States. Early identification and treatment of DR can decrease the risk of vision loss in affected patients. This clinical report reviews the risk factors for the development of DR and screening guidance for pediatric patients with type 1 diabetes mellitus.

Diabetes mellitus in pregnancy

This article reviews normal and abnormal carbohydrate metabolism in pregnancy, with an emphasis on the challenges that are faced by those who care for the pregnant woman who has hyperglycemia. The growing problem of type 2 diabetes in pregnancy, the controversial use of oral antihyperglycemic agents for the treatment of gestational diabetes, and the long-term issue of diabetes prevention in those whose hyperglycemia resolves postpartum are also addressed.

Contemporary management of type 1 diabetes mellitus in pregnancy

Type 1 diabetes in pregnancy can result in significant short- and long-term morbidity to both mother and offspring if management is suboptimal. This morbidity imposes a considerable financial and health burden on the individual and society at large. There is currently a significant body of knowledge to offer guidance on optimal obstetric management of the woman with type 1 diabetes. Utilization of appropriate management guidelines preconception and during pregnancy is an effective strategy to limit complications of type 1 diabetes and should therefore become the standard of care.

TARGET AUDIENCE

Obstetricians & Gynecologists, Family Physicians.

LEARNING OBJECTIVES

After completion of this article, the reader should be able to describe the features of a type I diabetic patient, to outline the goals of preconception care in this population of patients, to list the potential adverse effects of diabetes in pregnancy, and to summarize a potential strategy for the management of insulin administration in pregnancy.