Pregnancy as a human model of ocular hemodynamic remodeling: A systematic review of retinal, choroidal, and ocular blood flow adaptations
Wiku Andonotopo, Muhammad Adrianes Bachnas, Mochammad Besari Adi Pramono, Julian Dewantiningrum, Efendi Lukas, I. Nyoman Hariyasa Sanjaya, Anak Agung Gede Putra Wiradnyana, Anak Agung Ngurah Jaya Kusuma, Khanisyah Erza Gumilar, Ernawati Darmawan, Dovy Djanas, Dudy Aldiansyah, Arief Setiawan, Aloysius Suryawan, Ridwan Abdullah Putra, Theresia Monica Rahardjo, Rizna Tyrani Rumanti, Roland Frederik Lengkey, Anita Deborah Anwar, Cut Meurah Yeni, Aryani Aziz, Nuswil Bernolian, Donel Suhaimi, Agus Rusdhy Hamid, Dhika Prabu Armadhanu, Laksmana Adi Krista Nugraha, Wibisana Andika Krista Dharma, Waskita Ekamaheswara Kasumba AndanaputraABSTRACT
Pregnancy represents one of the few naturally occurring physiological states characterized by rapid cardiovascular and systemic vascular remodeling. Because the retina and choroid comprise highly regulated microvascular tissues that can be evaluated non-invasively, ocular imaging offers a unique opportunity to investigate maternal vascular adaptation in vivo. However, published studies have variably focused on retinal circulation, choroidal thickness, ocular blood flow, and optical coherence tomography angiography (OCTA)-derived microvascular parameters, resulting in heterogeneous findings and uncertain physiological interpretation. We conducted a systematic review in accordance with PRISMA guidelines to synthesize the available evidence regarding pregnancy-associated ocular hemodynamic remodeling in both physiological and pathological gestational states. Electronic databases and supplementary sources were systematically searched using predefined eligibility criteria. Twenty-nine studies published between 2002 and 2025 were included in the qualitative synthesis. Across the included studies, ocular remodeling was consistently demonstrated by alterations in retinal perfusion, choroidal structure, and ocular blood-flow dynamics, although the magnitude and direction of reported changes varied according to gestational stage, disease status, imaging modality, and measurement protocol. Subfoveal choroidal thickness was the most frequently investigated biomarker, whereas hypertensive disorders of pregnancy, particularly preeclampsia, demonstrated more pronounced retinal–choroidal structural abnormalities and ocular perfusion disturbances than uncomplicated pregnancy. Gestational diabetes mellitus (GDM) and pregnancy-induced hypertension (PIH) were also associated with measurable retinal and choroidal alterations, although reported structural changes were generally less consistent across studies. Current evidence supports pregnancy as a clinically relevant human model of systemic vascular remodeling rather than a purely transient physiological state. Ocular hemodynamic assessment may provide complementary insights into maternal vascular adaptation and pregnancy-related disease processes; however, substantial heterogeneity in imaging devices, acquisition protocols, segmentation methods, and limited longitudinal follow-up currently restrict direct quantitative comparison across studies and highlight the need for standardized imaging methodologies and prospective validation.