Elsevier

Seminars in Perinatology

Volume 43, Issue 6, October 2019, Pages 323-332
Seminars in Perinatology

The role of the obstetrician in the prevention of retinopathy of prematurity

https://doi.org/10.1053/j.semperi.2019.05.003Get rights and content

Abstract

This review underlines the important role that obstetricians play in the prevention of retinopathy of prematurity. Efforts predominately focus on predicting which pregnant women are at highest risk of preterm birth, instigating treatments to prevent pre-eclampsia, fetal growth restriction and maternal infection which could lead to iatrogenic or spontaneous preterm birth, and optimizing care when preterm birth is inevitable. More broadly, optimizing maternal health pre-conception through stopping smoking, improving diet, reducing obesity with its associated gestational diabetes, and treating hypertension may reduce preterm birth and other pregnancy complications. This is a message that all healthcare professionals including obstetricians, neonatologists and GPs, nursing and midwifery staff need to communicate all women and men who are contemplating having a baby.

Introduction

The obstetrician's role in preventing retinopathy of prematurity (ROP) centers around the accurate prediction and prevention of preterm birth (PTB). Defined as delivery before 37 completed weeks of gestation, PTB affects 7–15% of pregnancies worldwide.1 Despite a significant increase in prematurity focused research over the last 20 years, the incidence of PTB remains largely unchanged, and persists as a global health concern. Given the linear correlation with early gestation age (GA) at birth and severity of ROP, prevention of PTB and low birth weight (LBW) is key. This review highlights the important pre-conception and antenatal measures that are important to optimise obstetric and neonatal outcome. We review the screening tools available for PTB prediction, including identification of maternal risk factors, antenatal sonographic assessment of the cervix and detection of biomarkers in the cervicovaginal fluid. We discuss the current measures available for spontaneous PTB prevention, such as cervical cerclage, vaginal progesterone and the cervical pessary, and iatrogenic PTB such as aspirin. Finally we consider the role the obstetrician plays in ameliorating additional modifiable risk factors for ROP, including LBW, antenatal infection, preterm prelabour rupture of membranes (PPROM) and multiple pregnancy.2, 3

Section snippets

Preconception care

An emerging area of intervention relevant for both women and men is pre-conception care, and the importance of ‘getting fit for pregnancy’. Health before conception is strongly linked to pregnancy outcome and is crucial for health across generations.4 A pre-conception diet high in fruit, vegetables, legumes, nuts and fish, and low in red and processed meat, up to 3 years pre-pregnancy, in addition to weight loss among obese women, appears to reduce the risk of PTB, hypertensive disease,

Antenatal risk factors

Maternal and obstetric histories are central to estimating subsequent PTB risk. It is important that the following risk factors are highlighted early during antenatal care so that women may be monitored accordingly (Table 1).

Prediction of preterm birth

Predictive tests for PTB are important, given the huge personal, economic, and health impacts of prematurity. The results may provide reassurance for women who are unlikely to deliver preterm. Women identified at higher risk of PTB can be offered timely interventions to prolong pregnancy, thereby reducing the risk of ROP. Predictive tests for PTB are frequently used in clinical practice to screen 1) asymptomatic women with established risk factors for PTB and 2) women presenting with symptoms

Prevention of PTB

Interventions such as progesterone, cervical cerclage or an Arabin cervical pessary may be beneficial for asymptomatic women identified to be at risk of PTB. Immediate treatments for those symptomatic of PTB include tocolysis, antenatal corticosteroids and in-utero transfer to tertiary centers.

Optimising delivery

Identification of pregnancies most likely to deliver preterm allows for timely and targeted antenatal preparation to optimize neonatal outcome.

Discussion

This review underlines the important role of obstetrician in the prevention of ROP. Efforts predominately focus on predicting and preventing spontaneous PTB, as well as preventing fetal growth restriction, LBW and maternal infection. ROP is an infrequently reported outcome in obstetric trials, and so proxy outcomes described within this review included rates of spontaneous PTB and alternate neonatal morbidity. We have described how accurate prediction of pregnancies at highest risk of PTB is a

Conclusion

The impact of obstetric practice on the prevention of retinopathy of prematurity is largely surmised through alternative outcomes and focuses predominantly the prediction and prevention of spontaneous PTB, its primary culprit. Measurement of CL and fFN helps to identify those at risk of PTB, while cerclage, progesterone, the cervical pessary and aspirin may be used to ameliorate this risk in specific populations. Diet and lifestyle modifications are important in the pre-conception period in

Disclosure

LK reports no proprietary or commercial interest in any product mentioned or concept discussed in this article. ALD is an unpaid member of the Hologic Inc. European Perinatal Advisory Board and has received an honorarium from Hologic Inc. to cover registration fees to speak at the British Maternal Fetal Medicine Conference in 2017.

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