Retinopathy: antiangiogenics, when and how?

Abstract

Pregnancy is an important risk factor for the development of diabetic retinopathy (DR) in women with diabetes given that, added to the metabolic disorders of diabetes, are those of pregnancy.

The risk of DR progression increases with poor glycaemic control during pregnancy among other risk factors  and progression may occur until one year after delivery. There is not enough evidence to confirm the safety or harm of using intravitreal injections of anti-vascular endothelial growth factor (anti-VEGF) for diabetic macular edema or proliferative diabetic retinopathy during pregnancy. Possible side effects include hypertension, proteinuria, defective embryogenesis and fetal loss. It is unknown if it crosses placenta or if it is secreted in breast milk. The evidence for the use of anti-VEGF in pregnancy is based solely on case reports or case series. Therefore, it is not possible to correlate anti-VEGF with feto-maternal complications.

Different guides consider the following in the preconception stage: guarantee a negative pregnancy test and use of contraceptives during intravitreal anti-VEGF therapy and consider delaying conception for 3 months after the last intravitreal injection. Intravitreal anti-VEGF therapy in pregnancy should be avoided, especially during the first trimester.

Current anti-VEGF medications have been assigned to Pregnancy category C by FDA (Animal studies have revealed evidence of embryo-fetal toxicity, but there is no controlled data in human pregnancy),and caution should be taken in pregnant women with diabetes due to the potential risks on the vasculature of the developing fetus.