Pregnancy offers window of opportunity to assess bodily/ocular health

Ophthalmologists, neuro-ophthalmologists, and optometrists should understand the impact pregnancy can have on the eye, according to Kathleen B. Digre, MD.

“Pregnancy is really a window of opportunity during which 2 people are cared for simultaneously, as well as a window into the patient’s future health. The latter began to become apparent during the past 20 years,” she commented. Digre, a neuro-ophthalmologist, is Distinguished Professor of Neurology Emerita, professor of ophthalmology, adjunct professor of obstetrics and gynecology, Moran Eye Center, University of Utah, Salt Lake City.

Previously, she noted, clinicians paid attention to a pregnant patient’s eyes only when something went wrong. More recent studies have focused on the ocular effects of pregnancy, and understanding these potential effects is important for clinicians seeing patients in the chair.

Physiologic effects of pregnancy

Digre described pregnancy as a stress test on a woman’s cardiovascular, immune, and coagulation systems, the major ones affected during a normal pregnancy.^1-3

“Basic physiologic changes occur. Blood volume, cardiac output, and coagulation factors change during pregnancy. The immune system changes to avoid expelling the fetus. These are the important adjustments that make pregnancy especially important for all women and for women’s ocular health,” she said.

Specifically, according to Digre, the blood volume and cardiac output can increase by 30% to 50% by term. Cardiac output can increase even further during labor. Hypercoagulability is characterized by elevated plasminogen and fibrinogen levels; elevated levels of factors I, V, VII, IX, and X; and decreased fibrinolytic activity. Hyperplasia of smooth muscle and fragmentation of the reticular fibers within the blood vessel walls are seen. Extracellular fluid can increase by 2 L by term, Digre reported.

Ocular changes during normal pregnancy

Benign physiologic changes generally resolve shortly after delivery or nursing. These include refractive changes resulting from increased blood volume and fluid retention that cause progesterone-mediated fluid buildup in or behind the eye, resulting in corneal thickness and curvature changes toward myopia.^4,5

Microvascular changes can develop in the retina of women with obesity,⁶ and the macula’s vascular density can increase.⁷ Hormonal changes can reduce tear production, resulting in dry eye and making contact lens wear uncomfortable during the third trimester. Dry eye affects almost 80% of patients during the third trimester,^8,9 Digre related.

IOP can decrease by approximately 10% during the second half of pregnancy, but the retina and optic nerve generally are spared from alterations.^5,10-12

Physiologic changes also can occur in the brain. Studies have documented slight decreases in brain size, generally related to hormones or fluid changes.^13,14 Numerous biochemical/hormonal changes in the brain in pregnancy and post partum prepare women for motherhood.¹⁵ The pituitary gland increases in size, and sleep is dysregulated late in pregnancy.^16-18

Migraine develops often in pregnancy and more often in women who are and are not pregnant, compared with men; 20% of all women have migraines.¹⁰ During pregnancy, women can experience their first migraine aura, which must be differentiated from preeclampsia or other disorders by measuring blood pressure. Aura will be a self-limiting event that resolves with time; in contrast, preeclampsia and eclampsia are characterized by consistent headache and elevated blood pressure. “Ophthalmologists will see migraine in clinic every day, but pregnant women seen in ophthalmology with headache and visual changes can benefit from a blood pressure check,” Digre stated.

Changes during a complicated pregnancy

Gestational diabetes is a major concern because retinopathy can worsen during pregnancy, depending on hypertension and diabetes control; affected patients require frequent examinations.

Retinopathy occurs when high glucose levels damage the blood vessels in the retina, potentially leading to background hemorrhaging, microaneurysms, and rapid loss of visual clarity.¹⁹

Also of concern are preeclampsia, eclampsia, and HELLP syndrome (characterized by Hemolysis [destruction of red blood cells], Elevated Liver enzymes [liver damage], and Low Platelet count [clotting problems], often associated with preeclampsia).^19,20 “These are related to a whole host of visual problems, such as blurry vision, photopsias in the visual field, seizures, and even stroke,” Digre emphasized.

When a patient presents with blurred vision or headache, the eye care clinician must measure the blood pressure to identify preeclampsia, a pregnancy-specific condition, she advised.

Ocular complications affect approximately 25% to 33% of women with preeclampsia and up to 50% of those with eclampsia, Digre said. The resulting high blood pressure can cause severe vascular changes in the eye: HELLP syndrome is characterized by hemolysis, elevated liver enzymes, and low platelet counts.

Other ocular complications include preeclamptic retinopathy characterized by arteriolar narrowing, retinal hemorrhages, swelling, and cotton-wool spots; serous retinal detachment, in which fluid accumulates under the retina, and resultant localized visual field defects or blurred vision (in up to 10% of patients with eclampsia); and associated neurologic changes, such as ischemic optic neuropathy, papilledema, and occipital cortex involvement (which can cause temporary cortical blindness).²¹

Pregnant women, particularly those experiencing stress or elevated blood pressure, are at a higher risk for central serous chorioretinopathy. Fluid leakage occurs under the central retina, causing a gray or blurred spot in the central vision, distorted shapes (metamorphopsia), or reduced color vibrancy.²²

Generally, Digre advised, when examining pregnant patients, eye care clinicians should perform every test they would on a nonpregnant patient. For example, patients can be dilated safely while pregnant, and noninvasive imaging such as optical coherence tomography is readily available.

Stroke in pregnancy has been reported to occur during 9 to 34 per 100,000 deliveries, and stroke accounts for 4.7% to 7.6% of maternal mortality (mainly from hemorrhagic stroke),^23,24 Digre related.

Case reports

Case 1. A 31-year-old woman experienced severe nausea during the first trimester. She reported feeling a “pop” behind her right eye, a droopy lid, and minimal pain. Results of the physical examination were normal except for ptosis and proptosis. The Hertel measurement was 16 mm in the right eye and 14.5 mm in the left eye.²⁵

She was diagnosed based on the findings of MRI, CT, and ultrasound with a spontaneous orbital hemorrhage, which is rare but occurs most often during the first trimester, with nausea and vomiting, and during labor with the Valsalva maneuver. The symptoms include sudden diplopia, proptosis, and pain.

In cases such as this, treatment is usually not necessary and the hemorrhage resolves spontaneously.

Case 2. A 24-year-old woman who was 30 weeks pregnant presented with increasing headache and dimming of vision. Neurologic examination results and the blood pressure were normal. She presented to the emergency department 3 times without a diagnosis being established.

Digre emphasized that viewing the fundus for papilledema would have led to a brain MRI in pregnancy and would have ruled out a mass lesion or venous thrombosis. Increased primary and secondary intracranial pressure results from idiopathic intracranial hypertension and cerebral venous thrombosis, respectively.²⁶

Kathleen B. Digre, MD

E: [email protected]

Digre is Distinguished Professor of Neurology Emerita, professor of ophthalmology, adjunct professor of obstetrics and gynecology, Moran Eye Center, University of Utah, Salt Lake City. Digre has no financial interest in any aspect of this report.

References

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