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DIABETICMedicine

Letters
DOI: 10.1111/dme.12152

The utility of retinal screening in


gestational diabetes
Diabet. Med. 30, 10091010 (2013)
Gestational diabetes is defined as glucose intolerance that
develops or is first diagnosed in pregnancy [1]. Therefore, by
definition, a proportion of individuals with gestational
diabetes will have pre-existing Type 2 diabetes, latent
Type 1 diabetes, or indeed other forms of diabetes, for
example, maturity-onset diabetes of the young (MODY).
With changing population demographics it is likely that
more patients with undiagnosed pre-gestational Type 2
diabetes will be seen in antenatal clinics. Up to 20% of
individuals with classical Type 2 diabetes will have retinopathy at diagnosis [2]. However, retinal screening is not
currently recommended in gestational diabetes [3]. It has
been our local practice to offer retinal screening to all
patients attending our combined diabetes antenatal clinic
and, given that there are only limited data evaluating retinal
screening in gestational diabetes, we sought to investigate its
utility in our clinic population.
Following Caldicott Guardian approval, we identified 222
women with gestational diabetes attending our combined
diabetes antenatal clinic in Tayside, Scotland between
January 2008 and May 2012 by manually searching our
clinic records. The clinic serves a predominantly Caucasian
mixed urban and rural population of ~400 000, with a
general fertility rate of ~56/1000 women/year. Pregnant
women are invited to attend for a 75-g oral glucose tolerance
test, depending on results of urinalysis and timed plasma
glucose results at booking and 28-week visits [4]. Prior to
2011, diagnostic criteria for gestational diabetes were a
fasting and 2-h plasma glucose of 5.5 mmol/l and
9.1 mmol/l, respectively [5], whilst, from 2011 onwards,
the International Association of Diabetes and Pregnancy
Study Groups (IADPSG) criteria of 5.1 mmol/l and
8.5 mmol/l were used [1]. All women are offered an oral
glucose tolerance test at 6 weeks post-partum.
Retinal screening is usually performed at the first attendance at the combined antenatal clinic. A quality-assured
system of retinal grading is undertaken by trained graders
using the Scottish diabetic retinopathy grading scheme
following single-field digital retinal photography performed
on each eye [6]. Retinopathy grading results were obtained
from the regional eye screening database using the patientspecific community health index number.
Patient characteristics of all women with gestational
diabetes are shown in Table 1, with 17% of women also
2013 The Authors.
Diabetic Medicine 2013 Diabetes UK

meeting the classical World Health Organziation criteria for


Type 2 diabetes [7] following intra-partum oral glucose
tolerance test. Retinal screening data were available for 154
out of 222 (70%) patients and were abnormal in only two
patients (1.3% of those screened), with both individuals
identified as having a single microaneurysm. The remaining
98.7% were graded as normal. Eighty-five per cent of our
cohort attended for post-partum oral glucose tolerance test,
with 4.2% of patients (n = 8) meeting the criteria for Type 2
diabetes. Seven of these eight individuals had undergone
retinal screening, but only one patient had an abnormal
retinal screening result, suggesting that retinal screening is
unlikely to help predict pre-existing or progression to Type 2
diabetes (P = 0.099 by Fishers exact test).
Our results confirm that the vast majority of patients with
gestational diabetes in our local population have normal
retinal screening results, in keeping with results from a
limited number of previous studies [810]. Reassuringly,
there was no clinically significant retinopathy in our population. This is compared with 4.2% of women diagnosed
with gestational diabetes having proliferative retinopathy at
diagnosis in a Japanese series, and 5% having unspecified
retinopathy in a predominantly Mexican-American population [9].
The lack of retinopathy is perhaps not unsurprising in our
population, in keeping with the short duration of hyperglycaemia that women with gestational diabetes will have
been exposed to at this stage in pregnancy (~29 weeks
gestation), the lower diagnostic thresholds compared with
classical diabetes and our relatively low incidence of Type 2
diabetes on post-partum testing (4.2%). The data set was
also incomplete and it is possible that clinical bias may have
influenced those without retinal screening results. Strengths
include the use of a quality-assured retinal grading system in
a relatively homogeneous patient population, with graders

Table 1 Demographics of 222 patients attending our combined


diabetes antenatal clinic between January 2008 and May 2012
Age at first visit (years)
Gestation at first visit (weeks)
Body weight at first visit (kg)
Previous gestational diabetes (%)
Parity
Fasting plasma glucose (mmol/l)
2-h plasma glucose (mmol/l)
HbA1c at first visit (mmol/mol)
% treated with lifestyle measures alone
% attending for post-partum oral
glucose tolerance test
Results are mean 

31.6 
29.2 
93.1 
12.7
1.2 
5.6 
8.8 
40 
61
85

5.6
6.3
20.7
1.5
1.1
2.4
12 (5.8  1.1%)

SD.

1009

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masked to the patients diagnosis. It is also, to the best of our


knowledge, the largest study to date of retinal screening in
gestational diabetes and the first study to investigate the
utility of routine retinal screening in gestational diabetes in
the UK, including individuals diagnosed using the new
diagnostic criteria [1].
Ultimately, a number of factors have to be considered
when deciding on the utility of any screening test; for
example, prevalence of the condition, cost and available
treatment, hence routine retinal screening in gestational
diabetes cannot be recommended, and we no longer offer
routine retinal screening to all women with gestational
diabetes. Our practice has changed and we now only offer
retinal screening to patients with gestational diabetes who
also fit the criteria for Type 2 diabetes on oral glucose
tolerance test.
In summary, routine use of retinal screening in gestational diabetes cannot be recommended as significant
retinopathy is rare and the presence of retinopathy does
not help predict the diagnosis of Type 2 diabetes on postpartum testing.

Funding sources

None.

Competing interests

None declared.
D. P. Macfarlane1, E. P. OSullivan1, S. Dorman1
J. Allison1, A. Ellingford1, E. R. Pearson1
G. J. Mires2 and G. P. Leese1
1
Department of Diabetes, Ninewells Hospital and
Medical School, Dundee, UK, and 2Department of
Obstetrics, Ninewells Hospital and Medical School,
Dundee, UK

References
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Damm P et al. International association of diabetes and pregnancy study groups recommendations on the diagnosis and
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2 Fong DS, Aiello L, Gardner TW, King GL, Blankenship G,
Cavallerano JD et al. Retinopathy in diabetes. Diabetes Care
2004; 27: S84S87.
3 NICE. Diabetes in Pregnancy. Management of Diabetes and its
Complications from Pre-Conception to the Postnatal Period.
Clinical guideline 63. London: National Institute for Health and
Clinical Excellence, 2008.
4 NHS Tayside Diabetes MCN. Screening for Gestational Diabetes.
Available at http://www.diabetes-healthnet.ac.uk/Default.aspx?pageid=26 Last accessed 31 January 2013.
5 SIGN. Managment of Diabetes: A National Clinical Guideline.
Edinburgh: Scottish Intercollegiate Guidelines Network, 2001.

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Letters
6 Vallance JH, Wilson PJ, Leese GP, McAlpine R, MacEwen CJ, Ellis
JD. Diabetic retinopathy: more patients, less laser: a longitudinal
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DOI: 10.1111/dme.12178

Reply to Morton. Heart-rate responses to


exercise in patients with diabetes with
acute or chronic autonomic dysfunction
Diabet. Med. 30, 10101011 (2013)
We thank Dr Morton for his interest in our paper on the
utility of post-exercise heart-rate recovery for cardiac autonomic neuropathy assessment [1] and for elucidating this
interesting case study highlighting the related issue of
chronotropism. Slower heart-rate recovery in patients with
vs. without cardiac autonomic neuropathy in our study
coincided with (but was still independent of) a blunted heartrate response to exercise. The significance of this relative
chronotropic incompetence is highlighted by its associations
with adverse outcomes [2] and exercise intolerance [3].
Mortons case provides a compelling argument that
hypoglycaemia triggers acute chronotropic incompetence in
patients with diabetes. Unfortunately, our data cannot
provide substantiating evidence as no patients in either
group were found to be hypoglycaemic on exercise testing
(conducted in the postprandial state and following a blood
sample confirming normo- or hyperglycaemia). This is not
surprising considering all patients had Type 2, rather than
Type 1 diabetes. We therefore interpret our finding of
chronotropic incompetence in cardiac autonomic neuropathy
(previously recognized [4,5]) to reflect this complications
chronic sequelae rather than a transient abnormality. Importantly, assessment of chronotropism may provide mechanistic insights into cardiac autonomic neuropathy incremental
to heart-rate recovery. Whereas abnormal findings on the
latter parasympathetic marker intuitively reflect a cardiovagal neuropathy (on which cardiac autonomic neuropathy
diagnoses are predominantly based), the key arbiter of
chronotropism is sympathetic activation [6]. Indeed, the
flattened heart-rate/exercise intensity slope (with parallel

2013 The Authors.


Diabetic Medicine 2013 Diabetes UK