What women with diabetes need to know about retinopathy, macular oedema, screening and treatment
Pregnancy can temporarily increase the risk that diabetic retinopathy will develop or worsen. This does not mean that every woman with diabetes will have eye problems. With the recommended retinal assessments, careful management of diabetes and timely treatment when needed, most women can be monitored safely through pregnancy and after birth.
| Seek urgent eye advice if you develop sudden loss of vision, a new dark curtain or shadow, a sudden increase in floaters, flashing lights, or rapidly worsening distortion or blur. |
What are Diabetic Retinopathy and Diabetic Macular Oedema?
糖尿病视网膜病变 is damage to the small blood vessels in the retina, the light-sensitive tissue at the back of the eye. Early stages may cause no symptoms. More advanced disease can lead to abnormal new blood vessels, bleeding into the eye or, less commonly, retinal detachment.
Diabetic macular oedema (DMO) occurs when damaged retinal blood vessels leak fluid into the macula, the central part of the retina used for reading, recognising faces and seeing fine detail. DMO may cause blurred or distorted central vision, although it can also be found on imaging before a person notices symptoms.
How Common Is It?
Diabetic retinopathy is a common complication of diabetes. Broad population estimates suggest that about one in three people with diabetes has some degree of retinopathy. DMO affects a smaller proportion, often quoted at around 7% of people with diabetes, but estimates vary with the population and the definition used.
There is no reliable UK figure for the exact number of pregnant women affected by DMO. Pregnancy-related DMO is mainly a concern in women who already had type 1 or type 2 diabetes before conception. Gestational diabetes, which is first diagnosed during pregnancy, does not usually cause retinopathy during that pregnancy because retinal damage generally develops over a longer period. An eye assessment may still be appropriate if previously unrecognised diabetes is suspected.
How Can Pregnancy Affect Diabetic Eye Disease?
Pregnancy produces hormonal, circulatory and metabolic changes that can accelerate diabetic retinal disease. Existing retinopathy may become more severe, and DMO may appear or worsen. The risk is greatest during pregnancy and can continue for a period after delivery.
Improving blood glucose control remains important for the health of both mother and baby. A rapid, substantial fall in HbA1c can sometimes be accompanied by short-term worsening of retinopathy, so the diabetes and eye teams should coordinate care when major treatment changes are expected. Retinopathy is not a reason to withhold necessary optimisation of blood glucose in early pregnancy.
Which is More Likely to Worsen?
The likelihood of progression varies between individuals. Risk is higher in women with:
- Retinopathy already present at conception, especially severe non-proliferative or proliferative disease
- A longer duration of diabetes
- Higher HbA1c or major fluctuations in glucose control
- High blood pressure or pre-eclampsia
- Diabetic kidney disease
- Type 1 diabetes, although significant progression can also occur with type 2 diabetes
Planning Pregnancy
If possible, arrange a pre-conception review with your diabetes and eye teams. NICE recommends a retinal assessment at the first pre-conception appointment unless one has been performed within the previous 6 months. Significant proliferative retinopathy should ideally be treated before conception. If you are receiving eye injections, tell your retinal specialist that you are planning a pregnancy so that the treatment plan can be reviewed.
Recommended Retinal Assessment During Pregnancy
For women with pre-existing type 1 or type 2 diabetes, the current NICE schedule is:
- After the first antenatal clinic appointment: 数字成像的视网膜 after pupil dilation with tropicamide, unless a retinal assessment was performed within the previous 3 months.
- At 16 to 20 weeks: an additional retinal assessment if diabetic retinopathy was present at the first antenatal assessment.
- At 28 weeks: a further retinal assessment for all women with pre-existing diabetes.
This is the minimum national schedule. Women with severe disease, PDR, DMO, recent treatment or rapidly changing findings may need more frequent hospital eye review. The interval should be individualised according to retinal findings, vision, HbA1c, blood pressure and kidney function.
How is Proliferative Diabetic Retinopathy Treated?
Proliferative diabetic retinopathy (PDR) means that abnormal new blood vessels have developed because parts of the retina are not receiving enough oxygen. These vessels are fragile and can bleed; associated scar tissue can pull on the retina.
Pan-retinal photocoagulation (PRP) laser is usually the first treatment for PDR and can be performed during pregnancy. It treats the peripheral retina to reduce the drive for abnormal blood vessel growth. NICE recommends offering PRP when PDR is first diagnosed. During pregnancy, prompt treatment is particularly important because disease can progress quickly. If bleeding prevents laser or tractional retinal detachment is suspected, specialist vitreoretinal assessment may be required.
How is Diabetic Macular Oedema Treated?
Treatment depends on whether the centre of the macula is involved, the effect on vision, the pattern of leakage, the stage of pregnancy and the balance between maternal visual benefit and any potential fetal risk.
Observation and systemic management
Mild DMO that does not threaten central vision may be monitored with visual acuity testing and optical coherence tomography (OCT). Blood glucose, blood pressure and kidney disease should be managed with the diabetes and maternity teams. Some pregnancy-associated oedema improves after delivery, but observation is appropriate only when the ophthalmologist considers the risk to vision to be low.
黄斑激光
Focal or grid macular laser may be suitable for selected areas of leakage, particularly non-centre-involving clinically significant DMO. Laser avoids exposing the fetus to an intravitreal medicine, although it is not suitable for every pattern of oedema and does not usually produce rapid visual improvement.
Intravitreal corticosteroid
An intravitreal steroid may be considered for sight-threatening centre-involving DMO when observation or laser is unsuitable. The decision is individualised. Steroids can raise eye pressure and accelerate cataract, so follow-up is required. They should not be presented as automatically risk-free in pregnancy.
抗VEGF注射
Anti-VEGF medicines are standard treatments for DMO outside pregnancy, but pregnancy requires additional caution. VEGF is involved in placental and fetal blood-vessel development, and small amounts of an injected eye medicine can reach the circulation. Human pregnancy data are limited and largely come from case reports and small series, so they cannot establish that treatment is completely safe or quantify a specific risk to the baby.
A cautious approach is therefore recommended, especially in the first trimester. Anti-VEGF treatment may still be considered when maternal vision is at significant risk and safer or better-established options are unsuitable. The decision should be made with the patient, retinal specialist and obstetric or maternal-medicine team. Choice of drug and timing should be individualised; no anti-VEGF agent should be described as proven safe in pregnancy. Inadvertent exposure is not, by itself, usually considered a reason to end a pregnancy, but should be discussed promptly with the treating teams.
Will the Eye Disease Improve After Delivery?
Pregnancy-related worsening often stabilises after delivery, and some DMO or retinal changes may partially improve. However, improvement is not guaranteed and established retinal damage may persist. Retinopathy or DMO can remain active or recur after birth, so women who developed or had worsening disease should remain under ophthalmic follow-up. The exact schedule is determined by severity and treatment history.
Does Diabetic Retinopathy Affect How I Give Birth?
Diabetic retinopathy on its own is not considered a contraindication to vaginal birth. Decisions about labour and delivery should be based on the overall obstetric and medical situation. If there is active, complex eye disease, the ophthalmology and obstetric teams can discuss the individual circumstances together.
关键要点
- Tell your diabetes and eye teams if you are planning pregnancy or become pregnant.
- Attend retinal assessment early in pregnancy, at 28 weeks, and at 16 to 20 weeks if retinopathy is present at the first assessment.
- Do not wait for symptoms: early retinopathy and DMO may be asymptomatic.
- PRP laser is usually first-line treatment for PDR and should not be unnecessarily delayed during pregnancy.
- DMO treatment is individualised. Observation, laser, intravitreal steroids and, in selected sight-threatening cases, anti-VEGF therapy may be considered.
- Anti-VEGF safety data in pregnancy are limited. Treatment requires careful shared decision-making rather than a blanket statement that it is safe or unsafe.
- Continue eye follow-up after delivery because disease may not immediately resolve.
| Important: This information supports, but does not replace, advice from your ophthalmologist, diabetes team or maternity team. Treatment must be tailored to your retinal findings, vision, stage of pregnancy and wider health. |
Sources and Further Information
- National Institute for Health and Care Excellence (NICE). Diabetes in pregnancy: management from preconception to the postnatal period (NG3). Retinal assessment before and during pregnancy. View source
- National Institute for Health and Care Excellence (NICE). Diabetic retinopathy: management and monitoring (NG242), 2024. View source
- UK Teratology Information Service (UKTIS). Use of ocular antineovascularisation agents in pregnancy, version 1.0, March 2024. View source
- Ong AY et al. Intravitreal anti-VEGF injections in pregnancy: a case series and systematic review. Eye. 2024. View source
