sign in sign up
<<
Home , Gestational diabetes

9/24/19

Congratulations, you’re Disclosures What to Expect When pregnant!.... Your Patients Expecting • None

Cecelia Koetting, OD FAAO Virginia Eye Consultants Norfolk, VA Heart of America Conference 2020

Now, here’s a list of all the New FDA and But why are we worried things to worry about . . . . . Lactation Categories

• Spontaneous of the pregnancy • 8.1 Pregnancy includes labor and delivery

• Transference of medication both during pregnancy • 8.2 Lactation including nursing mothers and during • Causing complications during pregnancy for both • 8.3 Females and males of reproductive Potential mother and child • rates from medication use • Topical vs Oral

Old FDA Pregnancy and Lactation Categories Optometrist Prescribing • Category A • Category D • The safest drugs to take during pregnancy. Controlled studies • There is positive evidence of potential fetal risk, but the for Pregnant Patients show no risk or find no evidence of harm benefits from use in pregnant women may be acceptable despite the risk (i.e. life threatening • Category B condition to mother). • Animal Studies show no risks but there are no controlled studies on pregnant women • Category X • Category C • Studies in animals or human beings have demonstrated fetal abnormalities, or there is evidence of fetal risk. • Animal studies have shown risk to the , there are no The drug is contraindicated in women who are or may controlled studies in women, or studies in women and become pregnant. animals are not available.

1 9/24/19

When in doubt….. Oral Medication Oral Medication

• Can NOT be prescribed • CAN be prescribed • Antibiotic • Antivirals Contact the patients OB/GYN • Oral Acyclovir, Valcyclovir and Famcyclovir • Chloramphenicol, neomycin, ciprofloxacin, doxycycline, • Category B tetracycline, sulfonamides, trimethoprim • Oral Acyclovir is OK for lactating women • Systemic tobramycin is category D • Antibiotics • Pain relief • Often needed for skin and soft tissue infections • Augmentin, erythromycin, azithromycin, amoxicillin • Codeine, ibuprofen/Motrin • Category B • Steroids • Pain relief • Category C • Tylenol • Contraindicated due to their teratogenic effect and role in CSR • Tylenol #3 (short term) • Call OB/GYN • In breastfeeding patients Hydrocodone is preferred • Alternative therapy: meditation and acupuncture during certain trimesters

Topical Medications Topical Medications Topical Medications

• Dilation drops • Allergy drops • Antibiotics drops • Occasional is acceptable: risk vs benefit • All except Lastacaft are category C • Similar to oral • Alternative: consider shorter acting agents and not recommended • Fluoroquinolones used when benefits>risk, consult OB/ • Tropicamide 0.5% GYN • Category C • SE shown in studies to fetus • Anesthetic • NO phenylephrine • Tobramycin category B, safe for use • Proparicaine is Category C • May cause fetus heart to beat to slowly or cause birth • Less severe bacterial infection defects • Erythromycin, polymyxin B, topical azithromycin • Minor fetal malformations reported with use of systemic phenylephrine, atropine and homatropine • Severe ulcers or bacterial keratitis • Fortified cephalosporin's category B

Topical Medications Misc

• Glaucoma drops • Steroids • Anti-VEGF • Most are category C • Unlike oral, no known teratogenic effect however is • Systemic absorption is low • Prostaglandins have concern for induction of labor and category C • Bevacizumab can’t cross the barrier but is • Beta blockers caution in first trimester and discontinued • Restasis category C shortly before birth to prevent neonatal beta blockade • Could still affect placental vasculature • Category C • CAI has teratogenic and hepatorenal effects • Ranibizumab is category C • Miotic appear to be safe but are still category C • Decrease systemic absorption • pegaptanib (Macugen) is category B • Alphagan is category B • • DO NOT use in lactation, can cause sleep apnea and CNS Punctal occlusion? depression in infant • Punctal plugs? • No oral diamox

2 9/24/19

Ocular and Systemic Refractive Shifts Refractive Shifts

Changes During • Studies show approximately 40-75% of pregnant women • Hormonal changes during first trimester causes changes in experience a change in their distance vision Pregnancy thickness of the cornea • Mehdizadehkashi et al. • Water retention • Second trimester • 51% DVA OU affected • Increase in lens curvature • 11% NVA OU affected • Third trimester • Accommodation loss and insufficiency • 74.7% DVA OU affected • Resolve shortly after breastfeeding discontinued • 20..2% NVA OU affected

• Other less common causes • Postnatal 8.2% DVA and 4% NVA still affected at • Shifts in cataracts, DM, accommodative spasm • Most studies found women's vision returned to pre- • Usually a myopic shift but hyperopic can also occur pregnancy refractive error shortly after birth and cessation of breast feeding

Dry Eye Disease Dry Eye Disease

• Changes to cornea and lacrimal system can lead to • Safe treatments during pregnancy DED or worsening of pre-existing DED • Punctal Plugs Bells palsy • Changes have been noted in tear film physiology • Artificial tears • Possible immune reaction to the lacrimal duct cells and • Omega 3 and 6 Fatty Acids destruction of acinar cells by prolactine • Steroids? • Physical dehydration from and • Category C • Restasis? • Secondary contact lens intolerance • Category C • Xiidra? • Decrease in corneal sensitivity in third trimester • No category assigned, data not available

Bell’s Palsy Risk Factors

• Facial palsy caused by compression or inflammation and swelling of the facial nerve

• Usually only one side of the face • Rarely both sides • Are pregnant, especially during the third trimester, or who are in the first week after giving birth • Can occur at any age • Rapid onset of mild weakness to total paralysis on one side of the face • Have an upper respiratory infection, such as the flu • Within hours to days or a cold • Facial droop • Have • Drooling

• Pain around jaw or behind ear on affected side

• Decreased taste

• Changes in amount of tears and saliva produced

3 9/24/19

Causes of Bell’s Palsy Causes of Bell’s Palsy

• Often related to viral infection • Less often • Herpes Simplex • Tumor • Chickenpox and shingles (herpes zoster) • Skull fracture • Infectious mononucleosis (Epstein-Barr) • Cytomegalovirus infections • Respiratory illnesses (adenovirus) • Ordering an MRI or CT to help rule out • German measles (rubella) these causes • Mumps (mumps virus) • Flu (influenza B) • Hand-foot-and-mouth disease (coxsackievirus)

Treatment IOP Variations Adnexa Changes

• Most people will recover with or without treatment • Studies have found IOP tends to decrease during pressure • • Will start to improve within a few weeks with Increased pigmentation around the eyes may occur • 19.6% reduction in patients with normal IOP • “pregnancy mask”, Cloasma, or complete recovery within about 6 months • 24.4% reduction for OHTN patients • Caused by increased estrogen, and • Occasionally permanent symptoms for life • Possible Explanation: melanocyte stimulating • Can reoccur • Increased aqueous outflow • Lower episcleral venous pressure due to decreased systemic • Occasional unilateral ptosis occurs • Oral corticosteroids vascular resistance • Returns to prior position after delivery • Helps decrease swelling of facial nerve • Lower scleral rigidity resultant of increased tissue elasticity • Thought to be result of fluid and hormonal effects on • General acidosis during pregnancy the levator aponeurosis • Antiviral drugs • Returns to normal approx 2 months post partum • Although studies have shown no benefit compared with placebo

Gestational Diabetes Diabetic AOA Practice Guidelines

• Like other types of diabetes, gestational affects how • Patients who already have DM and diabetic • Gestational Diabetes your body uses retinopathy may note quick progression • Occurs in second to third trimester and glucose • Pt with NPDR show 50% progression during tolerance usually returns to normal within 6 weeks after • Gestational DM has a small risk of developing pregnancy pregnancy ends retinopathy • 5-20% pts with serve NPDR progress to PDR • Since it is relatively short and temporary it does not • 10% pt without DR prior to pregnancy develop NPDR • Up to 45% progression can be seen in pts who already have a high likelihood they will develop retinopathy during pregnancy have PDR • Retinal evaluation for in these • Baseline examination in first trimester is usually patients is not indicated sufficient when pt is absent of visual symptoms

4 9/24/19

AOA Practice Guideline Preeclampsia/ Preeclampsia/Eclampsia

• Diabetes Mellitus Type I and II • Preeclampsia triad in a normotensive pregnant • Preeclampsia incidence is 5% woman • Ocular sequelae in 1 out of 3 • Women with pre-existing diabetes who are planning on • BP > 140/90mmHg • being pregnant or become pregnant • • Photopsia • Scotoma • Should have a comprehensive eye exam prior to planned • after week 20 of pregnancy pregnancy or during first trimester • Diplopia • Should have a follow-up each trimester of pregnancy • This triad plus contractions without any other cause • Signs of retinopathy mimic HTN retinopathy is eclampsia • Most common finding retinal arteriolar narrowing • Will return to normal after patient is post partum

Idiopathic Intracranial Multiple Sclerosis Hypertension

• Patients with MS may note a decrease in attacks • Increased intracranial pressure with no known cause during pregnancy causing bilateral edematous ONH • Visual field defects, OCTG elevation • Will possibly increase the first 3 months postpartum • Diplopia and photopsia less often • Optic Neuritis may occur as a result of immune • Headaches and tinitis medicated changes • Caused by increase in weight during pregnancy that triggers and overproduction of CSF

IIH Treatment What’s causing this?

• Diagnosis with MRI without contrast of brain and orbit followed by LP to confirm diagnosis • Based on exclusion • Pts are usually monitored with no treatement given the possible side effects to the fetus from Diamox and Topamax • Serial LP throughout pregnancy and sometimes a tube shunt or OHN fenestration if vision is at high risk

5 9/24/19

Pituitary Adenoma Pituitary Gland Graves disease

• Previously asymptomatic PA or microadenomas • Patients without a pituitary adenoma can also • Most common cause of hyperthyroidism during may grow during pregnancy experience visual field defects when the pituitary pregnancy • Headaches, gland grows during pregnancy • May exacerbate during first trimester • visual field changes (bitemporal) • Can mimic PA VF defects with a bitemporal defect • Then subside during the rest of pregnancy • Decreased VA • Re-exacerbate during • After pregnancy will usually shrink

• If patient is known to have this prior to pregnancy, • Usually treat with propylthiouracil should monitor with visual fields for tumor growth

Central Serous Retinopathy Toxoplasmosis Toxoplasmosis

• Noted decreased vision with unilateral or bilateral metamorphopsia • Parasitic disease by Toxoplasma gondii • First trimester infection can severely effect the fetus • Eating undercooked contaminated meat • Believed to be caused by increased levels of endogenous • More commonly occurs in third trimester • Infected cat feces • Maternal and fetal circulation in greatest contact • Mother to child transmission during pregnancy • Most frequently occurs in the third trimester • Latent infection in mother may become active • Will resolve a few months after delivery • Congenital infection occurs when primary infection • Retinochoroditis findings • Increased risk for reoccurrence in future during pregnancy

• transplacental transmission • Study by Perkins et al. • 90% of pregnant CSR patients had fibrous subretinal exudate • Only 20% of non-pregnant CSR patients had this

Toxo Treatment Wrap Up

• Mother can be treated with oral macrolide antibiotic • Remember what's ok to use and when in doubt ask spiramycin the patients OB/GYN Questions? • Avoid sulfamethazole/trimethoprim combo • Knowing what your pregnant patient may be • Causes neonatal kericterus experiencing or is at risk for is important • OB/GYN involvement

6 9/24/19

Thank you!

7