© 2003 Diabetes UK. Diabetic Medicine, 20, 683–685 683 Case report A 31-year-old with Type 1 diabetes of 26 years’ duration was referred to the eye clinic at 6 weeks gestational age having just presented for her first antenatal clinic. She had a previous his- tory of silent miscarriage at 12 weeks gestational age associ- ated with hypertension, nephropathy and poor diabetic control (Table 1). At presentation she was taking Enalapril 5 mg /day, Actrapid 10 U in the morning, 10 U at lunch and 8 U in the evening and Insulatard 28 U at night. On examina- tion she had early background diabetic retinopathy and a vis- ual acuity of 6/6 in both eyes. She was under the combined care of a diabetologist, a renal physician, an ophthalmologist and an obstetrician. The HbA 1c , blood glucose, blood pressure, weight, proteinuria and retin- opathy were monitored (Table 1). The HbA 1c was 8.6% at booking falling to 6.3% in week 20 of gestation. She devel- oped proliferative diabetic retinopathy in week 20 of gestation and was treated with panretinal photocoagulation. In week 26 of gestation she developed unstable blood pressure, and worsen- ing proteinuria. At this time bed rest and low-molecular-weight heparin (subcutaneous Fragmin 5000 U /day) was initiated. Two further sessions of bilateral panretinal photocoagulation were also performed but the retinopathy failed to regress. An elective caesarean section at 34 weeks was planned, but in week 32 of gestation, while on low-molecular-weight heparin (subcutaneous Fragmin reduced to 2500 U/day), she developed massive intravitreal, subretinal and intraretinal haemorrhages in the right eye. The right visual acuity dropped to hand move- ments. An ocular ultrasonogram excluded a detached retina. The low-molecular-weight heparin was temporarily stopped, the patient advised to remain mobile and prenatal dexameth- asone administered to aid fetal lung maturation. At 34 weeks a combined elective caesarean section and tubal ligation was performed under anticoagulant cover. A healthy baby of 2.5 kg, appropriate in size for gestational age, was delivered. The per- inatal and neonatal period was uneventful. Four months post- partum she had a vitrectomy to the right eye for the persistent vitreous haemorrhage. Two years postpartum, the retinopathy in the right eye is stable with a vision of 6/6. She is awaiting a vitrectomy in her second eye. Her nephropathy is stable with protein excretion at prepregnancy values, her blood pressure is in the low normal range but HbA 1c remains high at 9.7%. Discussion It is well established that pregnancy can cause worsening of retinopathy in Type 1 diabetes [1], inducing a transient increase during pregnancy and in the first year postpartum [2]. A recent prospective study of pregestational Type 1 diabetes found progression of retinopathy in 5% of pregnancies [3]. Risk factors for progression include duration of diabetes, degree of retinopathy at the beginning of the pregnancy [3], poor glycae- mic control at booking, rapid normalization of blood glucose Correspondence to: S. Chatterjee, Department of Ophthalmology, Musgrove Park Hospital, Taunton, Somerset TA1 5DA, UK. E-mail: eshnac@aol.com Abstract Deterioration of retinopathy is a recognized complication of pregnancy in Type 1 diabetes. We discuss management issues relating to a case of rapid sight-threatening progression of retinopathy in pregnancy complicated by pre- gestational diabetes. Diabet. Med. 20, 683 – 685 (2003) Keywords pregestational diabetes, retinopathy, sight-threatening, pregnancy Blackwell Publishing Ltd. Oxford, UK DME Diabetic Medicine 0742-3071 Blackwell Science Ltd, 2003 20 Case Report Case report Pregestational diabetes and pregnancy S. Chatterjee et al. From minimal background diabetic retinopathy to profuse sight threatening vitreoretinal haemorrhage: management issues in a case of pregestational diabetes and pregnancy S. Chatterjee, M. D. Tsaloumas*, H. Gee†, G. Lipkin‡ and F. P. Dunne* Department of Ophthalmology, Musgrove Park Hospital, Taunton, UK,*University Hospital, Birmingham, UK, †Birmingham Women’s Hospital, Birmingham, UK and ‡Queen Elizabeth Medical Centre, Birmingham, UK Accepted 21 March 2003