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Risk of high refractive error greatest among children with diabetic mothers

24th August 2021

An increased risk of high refractive error has been observed in children born to diabetic mothers, highlighting the need for early screening.

A refractive error represents a common eye disorder that prevents the eye from being able to focus images properly leading to blurred vision. There are several types of high refractive errors (HRE) including myopia (near-sightedness), hyperopia (far-sightedness), astigmatism (distorted vision) and presbyopia (difficulty in reading at arm’s length). The World Health Organisation has estimated that 153 million people worldwide have a visual impairment due to HRE. In children, the most common error is astigmatism, with one study finding a global prevalence of 14.9%. The cause of HRE remains uncertain although refractive changes are known to be associated changes in blood glucose levels and hence can be present in those with diabetes. In fact, there is some evidence that gestational diabetes can result in a three-fold increased probability of refractive errors compared to mothers without diabetes. In contrast, another study of refractive errors among diabetic and non-diabetic mothers found no significant differences in astigmatism between the two groups.

With some uncertainty over the relationship between HRE errors and diabetes, a team led by researchers from the Department of Clinical Epidemiology, Aarhus University, Denmark, undertook a population-based cohort study using Danish national registers. Mothers were considered to have diabetes if they were diagnosed either before or during their pregnancy. Their primary outcome of interest was high refractive errors in offspring and secondary outcomes were the specific types of refractive errors that developed over a 25-year follow-up period. The team used regression analysis to model the association between prenatal diabetes exposure and high refractive errors, adjusting for several factors including maternal age, smoking status, calendar period of delivery.

Findings
During the 25-year follow-up, there were 553 children of mothers with diabetes and 19,695 children of mothers without diabetes, diagnosed with a HRE. The children exposed to maternal had a 39% increased risk of having a HRE compared to those without diabetes (adjusted hazard ratio, aHR = 1.39, 95% CI 1.28 – 1.51, p < 0.001). This risk was significantly increased, compared to mothers without diabetes, for all forms of pre-gestational diabetes e.g., type 1 (aHR = 1.32), type 2 (aHR = 1.68) and gestational diabetes (aHR = 1.37). The risks for each type of HRE were also increased, e.g., hypermetropia (HR = 1.37), myopia (HR = 1.34) and astigmatism (HR = 1.58). In addition, the risks of HRE were higher in children of mothers who had at least one diabetic complications (aHR = 1.76) and higher still, in the presence of two or more complications (aHR = 2.24).
In trying to account for these elevated risks, the authors suggested the among diabetic mothers, it was possible that increased plasma glucose levels could result in foetal hyperglycaemia or that an increased oxidative stress and inflammatory response from the ensuing hyperglycaemia could have damaged the optical nerves. They concluded that given these finding, early ophthalmological screening should be undertaken in the children of mothers with diabetes.

Citation
Du J et al. Association of maternal diabetes during pregnancy with high refractive error in offspring: a nationwide population-based cohort study. Diabetologia 2021

Increased rate pre-term births in mothers with COVID-19

16th August 2021

A comprehensive analysis has found an increase rate of pre-term births in those with COVID-19 but was otherwise reassuring.

Pregnant women have been deemed to be at a higher risk of severe illness from COVID-19. Moreover, in a systematic review in May 2020, it was concluded that mothers infected with COVID-19 were at an increased risk of pre-term birth although the authors urged caution, as their data were derived from a small number of cases and also included the SARS and MERS viruses. In order to provide as much information as possible on the pregnancy outcomes associated with COVID-19 infection, a team from the Department of Obstetrics and Gynaecology, St George’s University Hospitals NHS Foundation Trust, London, UK, undertook a systematic review of all available literature on COVID-19 and pregnancy in order to provide comprehensive data and to direct the course of ongoing research and studies. They searched all major databases and included a wide range of studies e.g., case reports, case series, and randomised trials, provided that studies reported on women with a PCR-confirmed diagnosis of COVID-19. Extracted information on maternal outcomes including clinical symptoms, laboratory findings, any obstetric complications and perinatal outcomes including death and vertical transmission were also collected.

Findings
A total of 86 studies were identified which included 2567 pregnancies. Nearly a third of mothers (30.6%) were older than 35 years and half of the cohort (50.8%) were of Black, Asian or other ethnic minority groups. Overall, antiviral therapy was given to a fifth (21.1%) of women though a much higher proportion (51.15%) received anticoagulation and 18.2% required nasal or non-invasive oxygen support.
COVID-19 symptoms were predominately cough (71.4%), fever (63.3%), dyspnoea (34.4%) and loss of taste or smell (22.9%). The most common laboratory abnormality was a raised D-dimer (84.6%), followed by a raised C-reactive protein or procalcitonin (54%). Fortunately, only 7% of women needed admission to an intensive care unit. Pre-term birth which was primarily iatrogenic was found to be common (21.8%) though this was medically indicated in 18.4% of all cases. The incidence of neonatal COVID-19 infection was low at 1.2%.

Commenting on their findings, the authors noted that generally, pregnancy outcomes were good. The incidence of admission to maternal intensive care was low and likely to be similar to the rates for other non-infected women. Furthermore, there was a very low incidence of maternal mortality. The authors did note how their analysis had several limitations including the retrospective nature of most studies and a lack of standardisation of care, given that studies came from several different countries. While the incidence of vertical transmission appeared to be low, the authors felt that more evidence was needed to confirm whether this represents a significant problem. However, there was a higher-than-average increase in pre-term births which was consistent with findings from other studies.

Citation
Khalil A et al. SARS-CoV-2 infection in pregnancy: A systematic review and meta- analysis of clinical features and pregnancy outcomes. EClinicalMedicine 2021