Varicose veins during pregnancy is an ectasia of venous vessels that occurred during the gestational period and is pathogenetically associated with it. It is manifested by heaviness, paresthesia, pain in the lower extremities and external genitals, swelling, convulsive twitching of muscles, trophic skin lesions. It is diagnosed by examination, ultrasound angioscanning methods. During pregnancy, treatment is usually limited to compression therapy with correction of sleep and rest, physical activity, nutrition. It is possible to prescribe phlebotonics, phleboprotectors, anticoagulants, antiplatelet agents. Surgical methods of treatment are usually used after childbirth.
ICD 10
O22.0 Varicose veins of the lower extremities during pregnancy
General information
Varicose veins (varicose veins) is one of the most common vascular diseases associated with the gestational period. According to research, up to 15-20% of US residents suffer from venous pathology, while 2/3 of them are women, and 60-80% of cases of venous ectasia have arisen due to pregnancy. The disease is usually first diagnosed in young patients, 75% of whom are under the age of 30 years. In more than two thirds of cases, the varicose veins clinic debuts after the 20th week of the first pregnancy. The urgency of timely diagnosis of varicose veins is associated with a high probability of fetoplacental insufficiency and the risk of fatal thromboembolic complications in the absence of adequate therapy.
Reasons of varicose veins during pregnancy
Taking into account statistical data on the frequency of varicose veins during gestation, most specialists in the field of obstetrics and gynecology consider the disease as a complication of pregnancy. The predisposing factor causing vascular ectasia in 91% of patients is a genetically determined failure of the middle vein lining, in which the amount of collagen substance is reduced and the content of polysaccharides is increased. The development of varicose veins in constitutionally predisposed women during pregnancy is promoted by:
- An increase in the volume of circulating blood. The increase in CBV in pregnant women ranges from 30-50% (when carrying 1 child) to 45-70% (if there are 2 or more fetuses in the uterus). This compensatory mechanism makes it possible to ensure adequate blood supply to the child, the vital organs of the woman and the fetoplacental system.
- Hormonal restructuring during pregnancy. During gestation, the ovaries and placenta intensively secrete progesterone and relaxin. Under the influence of these hormones, the smooth muscle fibers of the veins relax, a structural restructuring of the connective tissue occurs. As a result, the vascular wall copes worse with increased intravenous pressure.
- Compression of vessels by the pregnant uterus. The growing uterus compresses the inferior vena cava and iliac veins. The outflow of blood from the pelvis and lower extremities is disrupted, intravascular pressure increases, which provokes stretching of the venous walls. The influence of this factor plays a key role in the formation of varicose veins after the 25th week of pregnancy.
- Changes in the hemostasis system. As the birth approaches, the fibrinolytic activity of the blood decreases, the number of coagulation factors increases. This adaptation mechanism is aimed at reducing the volume of physiological blood loss in childbirth. At the same time, the probability of thrombosis of pathologically altered veins increases.
An additional etiofactor contributing to the occurrence of varicose veins in pregnant women is a decrease in motor activity. With insufficient skeletal muscle work, blood stagnation in the legs and pelvis increases. The situation is aggravated by the presence of excess body weight, in which there is an even greater increase in the volume of blood circulating in the vascular bed of the patient.
Pathogenesis
The starting point in the development of varicose veins during pregnancy is the disruption of the compensatory capabilities of the valve apparatus of the venous network. Due to an increase in the CBV and a mechanical obstacle to the outflow from the lower extremities when the main veins are squeezed, the blood exerts increased pressure on the vascular wall. The genetically inherited failure of connective tissue fibers is enhanced by the relaxation of vascular smooth muscles under the action of progesterone. As a result, the lumen of the vein expands, the valves stop closing, blood is deposited in the vascular system of the lower extremities. As the disease develops, the pathological process can spread to the vessels of the vulvar ring, vagina, and pelvis.
Classification
The main criteria for the systematization of varicose veins are the anatomical prevalence of venous congestion and the severity of the disease. This approach allows for differentiated selection of treatment regimens for different variants of the disorder. Taking into account the involvement of various organs in the process, varicose veins of the lower extremities, vulvar varicose veins, and pelvic varicose veins are distinguished. According to the severity of clinical symptoms , the following stages of dilation of the venous vessels of the lower extremities are distinguished:
- Compensated varicose veins. There are no external signs of vascular ectasia, the pregnant woman notes leg fatigue by the end of the day, discomfort in the calf muscles during physical exertion and fast walking.
- Subcompensated varicose veins. A vascular pattern (“asterisks”) appears on the skin. By the evening, the legs swell, cramps, numbness, pain occur at night. Bruises and scratches heal longer than usual.
- Decompensated varicose veins. The patient is constantly bothered by pain in her legs, swelling increases. The veins are noticeably dilated, knotted. The skin is hyperpigmented. There are signs of eczema and trophic disorders.
With pelvic varicose veins in pregnant women, the disease also develops in stages. At the first stage, the diameter of the affected vessels in any venous plexus of the pelvis does not exceed 5.0 mm. In the second case, the uterus or ovaries are involved in the process, the lumen of the vessels is 6.0-10.0 mm. The third is characterized by vein ectasia of more than 10 mm with a total lesion of all pelvic venous plexuses.
Symptoms of varicose veins during pregnancy
In 80-82% of patients, the disease debuts with a feeling of heaviness, tension, “buzzing” in the legs, which increases in the evening and during physical exertion. The symptoms of varicose veins increase gradually. As the disease progresses, pain occurs in some areas of the muscles, which first develops with prolonged standing, performing physical work. In the most severe cases, the pain becomes constant, and its intensity can be so pronounced that the pregnant woman experiences difficulties with independent movement. Up to 60% of patients report cramps of the calf muscles, up to 40-50% – loss of sensitivity, numbness of the legs, up to 30% – itching of the skin.
At the subcompensated stage of varicose veins, external signs of expansion of the superficial veins appear. First, areas of reticular vessels and telangiectasias (“meshes” and “stars”) form on the skin. Subsequently, the venous pattern becomes distinct. The veins look dilated, convoluted, and eventually knotted. The spread of the process of ectasia to deep vessels is evidenced by the occurrence of edema in the ankle joints and shins. With decompensation of varicose veins, the skin of the legs looks hyperpigmented, eczema develops. If the pathology occurred long before pregnancy, possible dystrophy of subcutaneous fat, trophic ulcers.
In 4% of patients, the disease affects the veins of the vulva, vagina, and pelvis. With vulvar and vaginal varicose veins, discomfort, swelling, heaviness, itching are observed in the area of the external genitals. There may be swelling of the perineum and labia, contact bleeding from the vagina after sex. The syndrome of fullness of the pelvic organs is manifested by pulling or aching pains in the lower abdomen, which radiate into the lower back, sacrum, groin, external genitalia. Dyspareunia (soreness during sexual intercourse) is characteristic. In severe cases, dysuric disorders are detected.
Complications
In the absence of adequate treatment, varicose veins in pregnant women can be complicated by the development of trophic ulcers, erysipelas, thrombophlebitis, thrombosis of superficial and deep veins, pulmonary embolism and other major vessels in childbirth. Fetoplacental insufficiency with acute and chronic fetal hypoxia occurs in 40-45% of cases. Anomalies of labor activity (weakness of labor forces, discoordination of contractile activity of the myometrium) are observed in 25% of patients. With vaginal varicose veins, massive traumatic currents of the postpartum period are possible. Almost a third of women in labor have defects in the separation of the placenta and the discharge of the afterbirth. The long-term consequences of varicose veins that occurred during pregnancy are hemorrhoids, disabling chronic venous insufficiency, pelvic pain.
Diagnostics
With the appearance of characteristic skin signs, the diagnosis of varicose veins during pregnancy usually does not present any difficulties. The tasks of the diagnostic stage are to determine the stage and localization of venous ectasia, to exclude other causes that can cause stagnation in the vascular network of the lower extremities. The most informative methods of examination are considered to be:
- Examination on the chair. The study reveals characteristic changes of venous vessels in the vulvar region and on the inner surface of the thighs — ectasia, tortuosity, nodularity. Swelling of the labia and perineum is possible. When viewed in mirrors, the vaginal mucosa looks hypertrophied, cyanotic. Vaginal arches with bimanual palpation are smoothed, often painful.
- Doppler ultrasound of the venous system. During ultrasound scanning, the shape and diameter of the vessels, their length, anatomical position, and the condition of the wall are evaluated. The method allows you to determine the branching zones, the consistency of the valve apparatus, the patency of the veins, the presence and direction of reflux. It is possible to scan both the vessels of the lower extremities and the inferior vena cava (UD IVC).
- Duplex scanning of leg vessels. The advantage of a non-invasive method combining traditional ultrasound and Doppler studies is not only obtaining detailed information about blood flow parameters, but also visualization of the venous network. Duplex angioscanning is used for a comprehensive assessment of the condition of surface, perforant and deep vessels.
Methods of radiodiagnostics (varicography, selective ovariography, ascending limb phlebography, pelvic phlebography, CT venography, phleboscintigraphy, etc.) are used only in pregnancy due to the possible negative effect on the fetus. In difficult cases, if pelvic varicose veins are suspected, diagnostic laparoscopy is performed with caution. Differential diagnosis of varicose veins of the legs is carried out with dropsy of pregnant women, heart failure, lymphedema, acute thrombosis of the venous system. Pelvic varicose veins should be differentiated from genital endometriosis, chronic inflammatory pathology of the pelvic organs, submucous and subserous uterine fibroids, cysts and other ovarian tumors. In addition to the observation of an obstetrician-gynecologist, the patient is recommended to consult a phlebologist, cardiologist, oncologist.
Treatment of varicose veins during pregnancy
The main objectives of therapy for varicose veins in pregnant women are to stop the progression of the disorder, mitigate the severity of the clinical picture and prevent possible thromboembolic complications. Non-drug methods are considered preferable, supplemented, if necessary, with pharmacotherapy in safe pregnancy:
- Compression therapy. A woman with a confirmed diagnosis of varicose veins is recommended to wear daily throughout pregnancy, use elastic bandages, special compression tights or stockings of 1-2 compression classes during childbirth and the postpartum period. Compression treatment due to mechanical reduction of the diameter of superficial veins can accelerate blood flow, reduce swelling and congestion.
- Plant phlebotonics and phleboprotectors. The effect of using drugs of this group is associated with an increase in the tone of the venous wall, a decrease in its permeability, an improvement in microcirculation, rheological properties of blood and lymph outflow. The advantage of most bioflavonoids is the possibility of their use during pregnancy and lactation. Phlebotonic drugs are prescribed both in tablet form and externally.
- Anticoagulants and antiplatelet agents. In the presence of signs indicating a tendency to increased coagulation and the threat of DIC syndrome, medications with antithrombotic activity (conventional and low-molecular-weight heparins) are used with caution. To improve the rheology of blood and vascular microcirculation, pharmaceutical agents that prevent platelet aggregation and have an angioprotective effect are shown.
Pregnant women with varicose veins are recommended special complexes of physical therapy, lymphatic drainage massage, dosed walking, daily ascending contrast shower. Diet correction involves eating foods rich in fiber and vegetable fats. Injection sclerotherapy, miniflebectomy, crossectomy, endovasal laser coagulation and other surgical methods of treatment are used in exceptional cases with severe forms of the disease, severe pain syndrome, the presence of complications. More often, surgical correction is performed at the end of the lactation period.
Delivery tactics
The preferred method of delivery for varicose veins is natural childbirth, at the beginning of which elastic bandages are applied to the lower extremities of the woman in labor or compression underwear is put on. Patients with vulvar-vaginal varicose veins require especially careful maintenance of the labor period with the performance of protective perineotomy according to the indications. In case of rupture of ectated veins, careful ligation of damaged vessels is performed with repeated stitching of the conglomerate of nodes. Cesarean section is recommended for patients with a high risk of thromboembolic complications and severe vulvar varicose veins.
Prognosis and prevention
With timely detection and adequate therapy, the prognosis is favorable. For preventive purposes, it is recommended to have a sufficient night’s sleep and periodic rest throughout the day in a lying position with legs laid on a dense surface at an angle of 30 °. Pregnant women with a burdened heredity should refuse to wear shoes with a heel of more than 5 cm, limit the duration of being in a sitting or standing position, control weight gain.
To prevent varicose veins, daily hiking, reducing salt intake, taking vitamin preparations that strengthen the vascular wall (ascorbic acid, rutin) are effective. Patients with varicose veins planning pregnancy, according to indications, surgical interventions are performed to correct the disease.
