Intravitreal vascular endothelial growth factor (VEGF) inhibitor injection in unrecognised early pregnancy

Abstract

The use of intravitreal vascular endothelial growth factor (VEGF) inhibitor medications has widened considerably to include indications affecting females of reproductive age. Our patient was inadvertently exposed to bevacizumab within the first trimester when placental growth and fetal organogenesis take place and patient suffered pregnancy loss. There is insufficient information to suggest that such use is safe, nor is there definitive evidence to suggest that it causes harm. We advise that ophthalmologists discuss pregnancy with women of childbearing age undergoing intraocular anti-VEGF injections and in pregnant woman counselling is needed to explain the potential risks and benefits.

Review of the management of sight-threatening diabetic retinopathy during pregnancy

“…The injection was given between a few days before or after the LMP and during the third trimester. There were 5 cases of abortion[ 76 , 79 , 82 , 83 ] and one case of pre-eclampsia[ 80 ] after the use of intravitreal bevacizumab. Petrou et al [ 76 ] described 2 women who received intravitreal bevacizumab at approximately 4 and 3 wk of gestation, respectively, followed by spontaneous miscarriage 7 and 10 d, respectively, after administration of the drug[ 76 ].…”

“…Gómez Ledesma et al [ 79 ] also reported a 41-year-old woman who received intravitreal bevacizumab a few days before or after the LMP and suffered a miscarriage approximately 7 wk after the injection[ 79 ]. Kianersi et al [ 82 , 83 ] reported pregnancy loss within 18 to 24 h in two patients who received intravitreal bevacizumab injection while they were between 10 and 12 wk pregnant[ 82 , 83 ]. Intravitreal bevacizumab given preconception and continued after 29 wk of gestation was associated with preeclampsia requiring urgent caesarean section[ 80 ].…”

Intravitreal vascular endothelial growth factor (VEGF) inhibitor injection in patient during pregnancy

“…Silvio Polizzi et al 5 and Ambreen Sarmad 6 in their studies have provided promising information on the fetal and maternal security profile of intravitreal hostile to VEGF agents A c c e p t e d M a n u s c r i p t in pregnant patients. There have been described cases of abortion following IVB treatment 2,[7][8] . Petrou et al described spontaneous miscarriage 7 and 10 days following administration of IVB at approximately 4 and 3 weeks of gestation 7 .…”

“…Intravitreal injection of the anti-vascular endothelial growth factor (anti-VEGF) agents is currently the first-line treatment in exudative age-related macular degeneration (AMD) 1 . It is also efficacious in many ocular diseases such as diabetic retinopathy, retinal vein occlusion, and choroidal neovascularization by other causes like high myopia 2 , and uveitisassociated cystoid macular edema 1 Intravitreal bevacizumab is injected at a much lower concentration within the eye, and the systemic exposure of IVB is much lower than the systemic use of intravenous bevacizumab. We report the clinical course of pregnancy in a woman treated with a single intravitreal injection of bevacizumab during the first trimester of pregnancy.…”

Ocular manifestations of pregnancy and labour: from the innocuous to the sight threatening

“…18 For pregnant women who develop signficant macular oedema and are at risk of irreversible vision loss, ophthalmology review and counselling regarding the potential risks versus benefits is mandated. 19,20 If anti-VEGF drugs are to be used, then ranibizumab may be preferable to bevacizumab or aflibercept because it suppresses plasma VEGF levels to a lesser degree. 21 Alternatively, an intravitreal steroid implant (0.7 mg dexamethasone) may be considered.…”