Other risk factors that have been associated with progression of retinopathy include hypertension, higher levels of insulin-like growth factor-I, placental growth factor, and macular edema identiied in early pregnancy (Bargiota, 2011; Huang, 2015; Mathiesen, 2012; Ringholm, 2011; Vestgaard, 2010). The American Academy of Ophthalmology (2016) recommends that pregnant women with preexisting diabetes should routinely be ofered retinal assessment after the first prenatal visit. Subsequent eye examinations depend on severity of retinopathy and level of diabetes control. Currently, most agree that laser photocoagulation and good glycemic control during pregnancy minimize the potential for deleterious efects of pregnancy.
Ironically, "acute" rigorous metabolic control during pregnancy has been linked to acute worsening of retinopathy. In a study of 201 women with retinopathy, almost 30 percent suffered eye disease progression during pregnancy despite intensive glucose control (11cElvy, 2001). That said, Wang and coworkers (1993) observed that although retinopathy worsened during the critical months of rigorous glucose control, long-term progression of eye disease actually slowed. Arun and Taylor (2008) found that only four women required laser photocoagulation during pregnancy, and none required laser in the next 5 years.
Diabetic Neuropathy. Peripheral symmetrical sensorimotor diabetic neuropathy is uncommon in pregnant women. But, a form of this, known as diabetic gastropathy, can be troublesome during pregnancy. It causes nausea and vomiting, nutritional problems, and diiculty with glucose control. Women with gastroparesis are advised that this complication is associated with a high risk of morbidity and poor perinatal outcome (Kitzmiller, 2008). Treatment with metoclopramide and D2-receptor antagonists is sometimes successful. Gastric neurostimulators have also been successfully used during pregnancy (Fuglsang, 2015). Treatment of hyperemesis gravidarum can be challenging, and we routinely provide insulin by continuous infusion for women who are admitted with this condition (Chap. 54, p. 1044).
Diabetic Ketoacidosis. his serious complication develops in approximately 1 percent of diabetic pregnancies and is most often encountered in women with type 1 diabetes (Hawthorne, 201r1). It is increasingly being reported in women with type 2 or even those with gestational diabetes (Bryant, 2017; Sibai, 2014). Diabetic ketoacidosis (DKA) may develop with hyperemesis gravidarum, infection, insulin noncompliance, 3-mimetic drugs given for tocolysis, and corticosteroids given to induce fetal lung maturation. DKA results from an insulin deiciency combined with an excess in counter-regulatory hormones such as glucagon. his leads to gluconeogenesis and ketone body formation. The ketone body 3-hydroxybutyrate is synthesized at a much greater rate than acetoacetate, which is preferentially detected by commonly used ketosis-detection methods. herefore, serum or plasma assays for 3-hydroxybutyrate more accurately reflect true ketone body levels.