Quality statement 4: Referral for retinal assessment

Quality statement

Pregnant women with pre‑existing diabetes are referred at their booking appointment for retinal assessment.

Rationale

Pregnant women with pre‑existing diabetes can have an increased risk of progression of diabetic retinopathy. Women should therefore be screened for diabetic retinopathy regularly during pregnancy. Early assessment ensures that treatment can start as soon as possible, and can act as a baseline to observe any further deterioration. A referral for retinal assessment should be offered at the booking appointment unless the woman has had an assessment in the last 3 months.

Quality measures

Structure

Evidence of local arrangements and written clinical protocols to ensure that pregnant women with pre‑existing diabetes are referred at their booking appointment for retinal assessment.

Data source: Local data collection.

Process

a) Proportion of pregnant women with pre‑existing diabetes who are referred at their booking appointment for retinal assessment.

Numerator – the number in the denominator who are referred at their booking appointment for retinal assessment.

Denominator – the number of pregnant women with pre‑existing diabetes attending a booking appointment who have not had retinal assessment in the last 3 months.

Data source: Local data collection.

b) Proportion of pregnant women with pre‑existing diabetes who have a retinal assessment in the first 3 months of pregnancy.

Numerator – the number in the denominator who have a retinal assessment in the first 3 months of pregnancy.

Denominator – the number of pregnant women with pre‑existing diabetes referred at their booking appointment for a retinal assessment.

Data source: National Pregnancy in Diabetes Audit and local data collection.

Outcome

a) Rates of diabetic retinopathy during pregnancy.

Data source: Local data collection.

b) Diabetic retinopathy progression during pregnancy.

Data source: Local data collection.

What the quality statement means for service providers, healthcare professionals and commissioners

Service providers (in primary and secondary care) ensure that pregnant women with pre‑existing diabetes are referred at their booking appointment for a retinal assessment if they have not had a retinal assessment in the last 3 months.

Healthcare professionals (in joint diabetes and antenatal care teams) ensure that they refer pregnant women with pre‑existing diabetes at their booking appointment for a retinal assessment, unless the woman has had a retinal assessment in the last 3 months.

Commissioners (clinical commissioning groups) ensure that they commission services in which pregnant women with pre‑existing diabetes are referred at their booking appointment for a retinal assessment if they have not had a retinal assessment in the last 3 months. Commissioners also ensure that services communicate the results of retinal assessments to the joint diabetes and antenatal care team.

What the quality statement means for patients

Pregnant women who had diabetes before they became pregnant are referred at their booking appointment for a screening check for eye damage (retinopathy) if they have not had this type of check in the last 3 months.

Source guidance

Definitions of terms used in this quality statement

Retinal assessment

A retinal assessment should be done by digital imaging with mydriasis (dilation of the pupils) using tropicamide, in accordance with the National Screening Committee's diabetic retinopathy screening programme.

[Diabetes in pregnancy (NICE guideline NG3) recommendation 1.3.24]

Booking appointment

A woman with diabetes will usually have a booking appointment with the joint diabetes and antenatal care team by 10 weeks of pregnancy. In some cases this appointment may take place earlier in the pregnancy.

[Diabetes in pregnancy (NICE guideline NG3) and expert opinion]

Equality and diversity considerations

Pregnant women with diabetes and complex social needs may be less likely to access or maintain contact with antenatal care services, and may present to a service later than 10 weeks. Services should give special consideration to these groups of women and ensure that they are referred for a retinal assessment at the earliest opportunity.