Pregnancy is known to bring with it multiple hormonal, immunological, and hematological changes that increase the risk of bleeding and valsalva retinopathy. In addition, an enlarged uterus increases intra-abdominal pressure and compresses the veins, leading to increased pressure in the veins, further increasing the risk and the intensity of valsalva manoeuvers [2].

We identified only fifteen reported cases of valsalva retinopathy in pregnant women in the scientific literature. Five cases occurred due to vomiting [6,7,8], one case during defecation [9], two cases with a history of constipation [2,10], one case with a history of lifting heavy objects [10], one case after several coughs [11] and one case during yoga [12]. And only two cases of valsalva retinopathy occurred during labour [13,14]. All but two patients subsequently had natural vaginal delivery without ophthalmic complications [9,11]. Three authors report that they treated patients with Nd:YAG laser vitrectomy, which successfully resolved the bleeding [11,13,15]. One patient with bilateral valsalva retinopathy underwent pars vitrectomy [16]. All other patients received conservative treatment.

Treatment options for this condition include observation, neodymium:YAG (Nd:YAG) laser vitrectomy, and pars vitrectomy [2,13]. The choice depends on the size and the location and of the bleed. If the hemorrhage is smaller than the diameter of the disc, it resorbs spontaneously within a short period of time; therefore conservative treatment is generally recommended. In patients with major bleeding, spontaneous absorption of the bleeding may take longer, sometimes months. This may lead to permanent visual impairment due to changes in macular pigmentation, formation of the macular hole and epimacular membrane, or from toxic damage to the retina due to chronic exposure to hemoglobin or iron [17,18,19]. In these cases, it is recommended to use a Nd:YAG laser to direct the trapped blood through the focal opening into the vitreous cavity where it will be absorbed more quickly. It should be noted that laser therapy drainage is not possible in the case of coagulated premacular hemorrhage. Another point to be aware of is that being close to the retinal surface poses additional risks for laser treatments. This may include macular hole, retinal detachment, epiretinal membrane formation  [18,21]. In this situation, vitrectomy is more effective and safer than other treatments for dense premacular hemorrhage. El-Defrawy et al. reported a conservative approach to retinal hemorrhage in pregnant women [20].

There is still much debate about the ideal timing to recommend intervention in this situation. There is also no general consensus on the optimal obstetric and anesthetic management of these pregnancies. Whether natural vaginal delivery might exacerbate bleeding remains controversial [22]. Possible interventions may include elective caesarean section to prevent progression by limiting venous pressure. There is no evidence that caesarean section is necessary. Natural vaginal delivery probably does not increase the risk of recurrent bleeding. Another factor to consider is that general anesthesia increases intraocular venous pressure, as hypercapnia and hypoxia cause retinal vasodilation [9,23]. Extubation can also cause a marked increase in venous pressure, followed by coughing [9]. It has also been shown that epidural anesthesia can be associated with preretinal hemorrhage by increasing cerebrospinal fluid pressure, it can increase retinal vein pressure[9,23].Our patient had normal vaginal delivery as recommendation by her obstetrician.

The prognosis for patients with valsalva retinopathy is generally promising. This situation just requires careful observation [24]. Vision usually returns to normal over time [21,23,24,25]. Some of these patients may experience poor vision due to the toxic effects of premacular hemorrhage on retinal pigment epithelium or epiretinal membrane formation.