Graefe's Arch Clin Exp Ophthalmol (1995) 233:598-600 © Springer-Verlag 1995

David Landau Morton H. Seelenfreund Ofer Tadmor Ben-Zion Silverstone Yoram Diamant

The effect of normal childbirth on eyes with abnormalities predisposing to rhegmatogenous retinal detachment

Received: 24 October 1994 Revised version received: 6 February 1995 Accepted: 24 February 1995

D. Landau (~) - M.H. Seelenfreund B.-Z. Silverstone Retina Service, Ophthalmology Department,

Shaare Zedek Medical Center, RO.B. 3235, Jerusalem 91031, Israel Tel.: +972-2-555111, Fax: +972-2-513946

O. Tadmor. Y. Diamant Obstetric and Gynecological Department, Shaare Zedek Medical Center, RO.B. 3235 Jerusalem 91031, Israel

Abst rac t • Background: Pregnant women who have high myopia, a history of retinal detachment or retinal holes, or have known lattice degeneration are frequently referred to an ophthalmologist for advice concerning the management of pregnancy and labor, i.e. whether a spontaneous vaginal delivery can be allowed and whether prophylaxis for high-risk retinal pathology is in- dicated. Many obstetricians still be- lieve that pregnant women with oc- ular abnormalities predisposing to rhegmatogenous retinal detachment should have an instrumental deliv- ery, and a few even advocate cesari- an section. Very little has been written about the management of pregnant women with high-risk retinal pathology, and opinions dif- fer considerably. Patient data on

this subject are scarce. • Methods: We studied 10 women who had 19 deliveries (10 prospective and 9 ret- rospective) and who had a history of retinal detachment, had been di- agnosed as having extensive lattice degeneration, or had been treated for symptomatic retinal holes or breaks. The women were followed from the third trimester of pregnan- cy through labor and delivery into the postpartum period, looking for changes in the retinal status. • Results: We found no changes in the retinal status in the postpartum examination. • Conclusion: We conclude that prenatal treatment of asymptomatic retinal pathology is not indicated and that spontaneous vaginal delivery may be allowed to take place in women with high-risk retinal pathology.

Introduction

Pregnant women who have high myopia, a history of reti- nal detachment or retinal holes or breaks, or have known lattice degeneration are frequently referred to an oph- thalmologist for advice concerning the management of pregnancy and labor.

In the past, large numbers of obstetricians and oph- thalmologists have believed that labor exerts increased pressure on the eye and may lead to retinal detachment. Therefore, many have encouraged patients with high-risk retinal pathology to have a cesarian section or an instru- mental delivery.

In recent years there has been increasing agreement among ophthalmologists that a normal delivery is not

contraindicated even in patients with high-risk retinal pathology. Obstetricians are still unsure and many con- tinue to advise instrumental delivery. In the vast litera- ture concerning retinal diseases there is very little infor- mation based on patient data.

In this study we prospectively followed pregnant women at high risk of developing rhegmatogenous reti- nal detachment from the third trimester of pregnancy through labor, delivery and the postpartum period, look- ing for changes in the ret inal status in Order to conf i rm the understanding that a normal delivery is not con- traindicated even in patients with high-risk retinal pathology.

599

Subjects and methods

Women examined in the Prenatal Clinic of Shaare Zedek Medical Center, Jerusalem, from 1988 to 1991 were given questionnaires about previous retinal problems.

Any woman with a history of retinal disease was referred to the Retina Service for examination during the last trimester of preg- nancy. Women who had a history of retinal detachment, or had previously been treated for retinal holes or breaks were included in the study. The fundus was examined through dilated pupils with an indirect ophthalmoscope using a +20-D lens. Retinal drawings were made. Spontaneous vaginal delivery was permitted if there were no obstetric contraindications. The duration of each stage of labor was recorded in the delivery room, as were comments on the difficulty of labor, the size of the newborn, medication and instru- mentation. The women were reexamined 7-14 days postpartum looking for new retinal breaks, holes or detachment. The retinal findings were compared to the prepartum findings. Hospital records concerning previous deliveries were also reviewed.

Results

Ten women were included in this study with an average age at delivery of 32 years (range 23-44 years).

Five women were pr imiparas and 5 were multiparous. In the latter group, all had had at least one previous deliv- ery after diagnosis and treatment of the retinal pathology, with documentation of retinal status before and after pre- vious deliveries. There were a total of 9 previous deliver- ies in the 5 mult ipara women giving a total of 19 deliver- ies studied.

Delivery room parameters

All pregnancies (prospective and retrospective) were un- eventful, and all were full term. None of the women had eclampsia or pre-eclampsia. In 8 deliveries (6 prospec- tive and 2 retrospective) epidural anesthesia was used. Eighteen deliveries (9 prospective and 9 retrospective) were spontaneous vaginal deliveries without any instru- mentation such as forceps or vacuum cup. In one delivery of twins, instrumentation was required.

The average duration of the second stage of labor was 28.6 min (range 8-80 min), and the average birth weight was 3022 g (range 2560-4250 g).

Ocular findings

Refraction

One woman was hyperopic, two were mildly myopic ( - 0 . 5 0 to - 2 . 0 D ) , three were moderately myopic ( - 2 . 5 0 to - 6 . 0 0 D) and four had high myopia (greater than - 6 . 0 0 D).

Retinal findings

Four eyes had extensive lattice degeneration only. Eight other eyes were treated for impending retinal detachment because of retinal holes; six had laser t reatment and two eyes had cryopexy for retinal holes. Six eyes had a histo- ry of operation for retinal detachment prior to delivery. Of these, five had retinal detachment repair before their first pregnancy. One woman had a retinal detachment repair during the first t r imester of her fourth pregnancy, but then had a spontaneous vaginal delivery without any ocular complications. She spontaneously delivered twice thereafter without any ocular problems.

In all 10 women, pos tpar tum reexamination showed no signs of retinal change in either eye compared to the examination in the third trimester. The hospital records of the nine retrospective deliveries made no mention of changes in retinal status in the postpar tum examinations.

Discussion

It is well established that complications of pregnancy, e.g. pre-eclampsia , eclampsia, disseminated intravascu- lar coagulation, and H.E.L.L.R syndrome, may cause serous retinal detachment [1-5]. However, in the vast literature concerning retinal diseases there is very little written about the management of pregnant woman who have high-risk retinal pathology predisposing them to rhegmatogenous retinal detachment. Over the years, general practitioners, obstetricians and ophthalmologists have encouraged women with high myopia, known reti- nal degeneration problems, or previous retinal detach- ment to deliver by cesarian section or instrumental deliv- ery (vacuum or forceps), in order not to "put pressure" on the eyes during a normal vaginal delivery [6-8]. In- glesby et al. repor ted in the British Medical Journal that three quarters of obstetricians surveyed felt that "a histo- ry of surgery for detachment of the retina was an indica- tion for obstetric intervention during labour" [11].

The reasoning was that during the second stage of labor, the Valsalva-like straining mechanism might cause serious intra-ocular pressure changes which would precipitate retinal tears or detachment in predisposed eyes. In a study by Neri et al. [6], 50 women with myopia of - 4 . 5 0 D or higher were examined by retina specialists 4 weeks before labor and again within 2 weeks after de- livery. In the pre-delivery exam, 17 eyes had lattice changes and 11 eyes had retinal breaks. The post-deliv- ery exam "did not reveal any change in the individual patients ' eye background" [6]. These authors and others [9-11] concluded that normal spontaneous delivery could be allowed to take place in highly myopic women.

Our study conf i rms these findings. In fact, our group of patients had even more serious retinal changes than those in the study by Neri et al. As stated above, eight

600

w o m a n had ex tens ive b i l a t e r a l l a t t i ce changes . E igh t eyes had tears l a rge enough to requ i re l ase r t r e a t m e n t or c ryopexy, and six eyes had u n d e r g o n e r epa i r o f r e t ina l d e t a c h m e n t p r io r to the p regnancy .

In all o f the eyes in our study, the p o s t - d e l i v e r y fo l low- up examina t i on o f the re t ina fa i led to show any s ign i f i - cant changes c o m p a r e d to the p r e - d e l i v e r y f ind ings . B a s e d on our f ind ings and o the r r epo r t s in the l i t e ra tu re [6, 9 - 1 1 ] , we the re fo re be l ieve that spon taneous vag ina l de l ive ry is not c o n t r a i n d i c a t e d in w o m e n wi th h i g h - r i s k re t ina l pa thology.

A n o t h e r ques t ion that has been ra i sed by obs t e t r i c i an s is w h e t h e r p r o p h y l a c t i c l a se r t r e a tmen t or c r y o p e x y dur- ing p r e g n a n c y is i n d i c a t e d in pa t ien ts w h o s e eyes have a p r e d i s p o s i t i o n to re t ina l de t achmen t . We found no evi- dence that spon taneous vag ina l d e l i v e r y i nc r ea se s the r i sk for r e t ina l de t achmen t . T h e r e f o r e we see no need for p r o p h y l a x i s o f a s y m p t o m a t i c r e t ina l degene ra t i ve p rob - lems d u r i n g p regnancy .

References

1. Dornan KJ, Mallek DR, Wittmann BK (1981) The sequel of serous retinal in preeclampsia. Obstet Gynecol 60:657-663

2. McEvoy M, Runciman J, Edmonds DK, Kerin JF (1981) Bilateral retinal detachment in association with preeclampsia. Aust N Z J Obstet Gy- naecol 21:246-247

3. Hoines J, Buettner H (1989) Ocular complications of disseminated in- travascular coagulation (DIC) in abruptio placentae. Retina 9:105-109 [erratum Retina (1989) 9:339]

4. Burke JR Whyte I, MacEwen CJ (1989) Bilateral serous retinal detach- ments in the H.E.L.L.R syndrome. Acta Ophthalmol (Copenh) 67:322- 324

5. Hemeter W (1988) Presumed throm- botic thrombocytopenic purpura asso- ciated with bilateral serous retinal de- tachments. Am J Ophthalmol 105:421-422

6. Neri A, Grausbord R, Kremer I, Ova- dia J, Treister G (1985) The manage- ment of labor in high myopic patients. Eur J Obstet Gynecol Reprod Biol 19:277-279

7. Ivanov IR Butskikh TR Kasiyanova NS (1978) Procedure for managing pregnancy and labor in certain forms of pathology of the organ of vision (in Russian). Akush Ginekol (Mosk) Feb: 32-35

8. Schenk H (1975) The effect of preg- nancy and labor on myopia and retinal detachment. Gynakol Rundsch 15:301-304

9. Legerlotz C (1971) Retinal detach- ment and interruption of pregnancy. Klin Monatsbl Augenheilkd 159:827- 832

10. Legerlotz C (1971) Obstetrical care following retinal detachment. Klin Monatsbl Augenheilkd 158:597-601

11. Inglesby DV, Little BC, Chignell AH (1990) Surgery for detachment of the retina should not affect a normal de- livery. Br Med J 300:980