Graefe's Arch Clin Exp Ophthalmol (1995)

233:598-600 © Springer-Verlag 1995

David Landau The effect of normal childbirth on eyes

Morton H. Seelenfreund
Ofer Tadmor with abnormalities predisposing
Ben-Zion Silverstone
Yoram Diamant
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
Abstract • 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 o f 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.

contraindicated even in patients with high-risk retinal

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
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 o f developing rhegmatogenous reti-
nal detachment from the third trimester of pregnancy
through labor, delivery and the postpartum period, look-
ing for changes in the retinal status in Order to confirm
the understanding that a normal delivery is not con-
traindicated even in patients with high-risk retinal
pathology.

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 w o m e n were included in this study with an average
age at delivery of 32 years (range 2 3 - 4 4 years).
Five w o m e n were primiparas 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 multipara w o m e n giving a total of 19 deliver-
ies studied.
Delivery r o o m parameters
All pregnancies (prospective and retrospective) were un-
eventful, and all were full term. None of the w o m e n 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 - 8 0 min), and the average birth weight
was 3022 g (range 2 5 6 0 - 4 2 5 0 g).
Ocular findings
Refraction
One w o m a n 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).
599
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 treatment 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 w o m a n had a retinal detachment
repair during the first trimester 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, p o s t p a r t u m reexamination showed
no signs of retinal change in either eye c o m p a r e d 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 postpartum 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 m a n a g e m e n t of pregnant w o m a n who
have high-risk retinal pathology predisposing them to
rhegmatogenous retinal detachment. Over the years,
general practitioners, obstetricians and ophthalmologists
have encouraged w o m e n 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. reported 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 m e c h a n i s m 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 w o m e n 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 c o n f i r m s 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

woman had extensive bilateral lattice changes. Eight
eyes h a d tears l a r g e e n o u g h to r e q u i r e l a s e r t r e a t m e n t or
c r y o p e x y , and six eyes h a d u n d e r g o n e r e p a i r o f r e t i n a l
d e t a c h m e n t p r i o r to the p r e g n a n c y .
In all o f the eyes in our study, the p o s t - d e l i v e r y f o l l o w -
up e x a m i n a t i o n o f the r e t i n a f a i l e d to s h o w a n y s i g n i f i -
c a n t c h a n g e s c o m p a r e d to the p r e - d e l i v e r y f i n d i n g s .
B a s e d on our f i n d i n g s and o t h e r r e p o r t s in the l i t e r a t u r e
[6, 9 - 1 1 ] , we t h e r e f o r e b e l i e v e that s p o n t a n e o u s v a g i n a l
d e l i v e r y is not c o n t r a i n d i c a t e d in w o m e n w i t h h i g h - r i s k
retinal pathology.
A n o t h e r question that has b e e n r a i s e d b y o b s t e t r i c i a n s
is w h e t h e r p r o p h y l a c t i c l a s e r t r e a t m e n t o r c r y o p e x y d u r -
ing p r e g n a n c y is i n d i c a t e d in p a t i e n t s w h o s e eyes have a
p r e d i s p o s i t i o n to r e t i n a l d e t a c h m e n t . We f o u n d no evi-
d e n c e that s p o n t a n e o u s v a g i n a l d e l i v e r y i n c r e a s e s the
r i s k for r e t i n a l d e t a c h m e n t . T h e r e f o r e we see no n e e d for
prophylaxis of asymptomatic retinal degenerative prob-
lems during pregnancy.

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