Prognosis in diabetic pregnancy

Macular edema and pregnancy in insulin-dependent diabetes

Seven women with insulin-dependent diabetes (mean age, 26 years; mean duration of diabetes, 15.4 years) had minimal or no retinopathy before becoming pregnant but developed severe macular edema associated with preproliferative or proliferative retinopathy during the course of their pregnancies. The edema was associated with significant macular capillary nonperfusion, and often with significant proteinuria and mild hypertension. Although proliferation was controlled with panretinal photocoagulation, the macular edema continued to worsen until delivery in all cases and was often aggravated by the photocoagulation. Macular edema and retinopathy both regressed after delivery in some patients but persisted in others, causing significant visual loss. Pregnant women with retinopathy, nephropathy, or hypertension should undergo ophthalmoscopy at least once a month. If proliferative retinopathy develops, panretinal photocoagulation should be applied even if the macular edema is aggravated.

The effect of pregnancy on the natural course of diabetic retinopathy

To determine the influence of pregnancy on the retinas of insulin-dependent diabetics, we assessed 53 diabetic women by retinal photography every six weeks throughout pregnancy and for six months post partum. Thirty-nine nonpregnant insulin-dependent diabetics of childbearing age served as controls. Of the 39 controls, 18 (46.2%) had retinopathy. Of the 53 pregnant women, 33 (62%) had retinopathy at the first examination and eight others (15%) developed it as pregnancy advanced, significantly increasing the prevalence of retinopathy during pregnancy to 77.4%. Progressive changes occurred as pregnancy advanced; microaneurysms moderately increased, hemorrhages appeared in 30 (56.6%), and soft exudates in 15 (28.3%). Four patients (7.5%) had neovascularization, one for the first time. The condition of all four deteriorated during pregnancy. Six months after delivery the background changes had regressed to control levels. Neovascularization showed some regression. Duration of disease was related to the development and progression of retinopathy; every pregnant patient who had had diabetes for ten years had retinopathy. Retinal hemorrhages or neovascularization were associated with increased infant morbidity. Hemorrhages and exudates behaved independently and were associated with different risk factors, but increased insulin requirements and polyhydramnios were important risk factors in the development of retinal hemorrhages. Low fasting blood glucose levels late in pregnancy were significantly associated with soft exudates.

Diabetic retinopathy and pregnancy

Diabetic retinopathy was found to be present in 12 out of a group of 67 diabetic patients supervised by us during 92 pregnancies, and 3 further pregnant diabetics were referred to us because of retinopathy. The mean duration of diabetes was 13 years (range 3--25 years). Nine patients had minimal retinopathy, 2 had background retinopathy, and the remaining 4 proliferative retinopathy. The cases with minimal retinopathy showed no progression during pregnancy. In 1 patient with background retinopathy there was deterioration. Of the 4 patients with proliferative retinopathy 1 showed regression during the pregnancy, 2 showed advance and were treated with photocoagulation (these 2 patients now have normal vision), while the patient with extensive retinitis proliferans, with retinal detachment in both eyes and previous photocoagulation remained unchanged. The prognosis during pregnancy for patients with diabetic retinopathy is reasonable and has been improved by the advent of photocoagulation.

Hypoglycemia associated with symptoms in the newborn period

Hypoglycemia in the neonatal period is a well-recognized phenomenon, but many authors have commented upon the infrequent association of symptoms attributable to it. Six infants were seen who appeared normal at birth but who, between 24 and 72, hours of age, developed apnea, irritability, lethargy, muscular twitchings and convulsions. Blood sugar concentrations of 10 mg./100 ml. or less were found in each case. The mothers of four of the babies had toxemia of pregnancy. Three babies were premature. The hypoglycemia was self-limiting in all cases, and four of the babies recovered completely without sequelae. The other two showed evidence of permanent brain damage, but it is not known whether this was the cause of their symptoms or the result of the hypoglycemia. It is concluded that hypoglycemia may cause neurological symptoms in the newborn period and that treatment by glucose administration is necessary. Whether symptomless hypoglycemia requires treatment remains an open question.