Varicose veins during pregnancyis an ectasia of the venous vessels that occurred during the gestational period and is pathogenetically associated with it. It manifests itself with severity, paraesthesia, pain in the lower limbs and external genitalia, swelling, muscle contractions, trophic skin lesions. It is diagnosed by examination, ultrasound angiography methods. During pregnancy, treatment is usually limited to compression therapy with sleep and rest correction, physical activity and nutrition. Perhaps the appointment of phlebotonics, phleboprotectors, anticoagulants, antiplatelet agents. Surgical treatments are usually used after delivery.
General information
Varicose veins (varicose veins) are one of the most common vascular diseases associated with the gestational period. According to studies, up to 15-20% of people 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. In more than two thirds of cases, the varicose vein clinic debuts after the 20th week of the first pregnancy. The relevance 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
Taking into account the statistical data on the incidence 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 venous sheath, 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 facilitated by:
- Increase in the volume of circulating blood. The increase in BCC in pregnant women ranges from 30-50% (when carrying 1 baby) to 45-70% (if there are 2 or more fetuses in the womb). This compensatory mechanism makes it possible to ensure an adequate blood supply to the baby, the woman's vital organs and the fetal-placental system.
- Hormonal changes 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 and structural reconstruction of the connective tissue occurs. As a result, the vascular wall copes with the increase in 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 limbs is impaired, intravascular pressure increases, which causes the venous walls to stretch. 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 labor approaches, the fibrinolytic activity of the blood decreases and the number of clotting factors increases. This adaptation mechanism aims to reduce the volume of physiological blood loss during labor. This increases the likelihood of thrombosis of the pathologically altered veins.
An additional etiofactor contributing to the onset of varicose veins in pregnant women is a decrease in physical activity. With insufficient work of the skeletal muscles, blood stagnation in the legs and pelvis increases. The situation worsens in the presence of overweight, in which there is an even greater increase in the volume of blood circulating in the patient's vascular bed.
Pathogenesis
The starting point in the development of varicose veins during pregnancy is the disruption of the compensatory capacities of the valvular apparatus of the venous network. Due to an increase in BCC and mechanical obstruction to the outflow from the lower limbs, when the main veins are squeezed, the blood exerts greater pressure on the vascular wall. Genetically inherited insufficiency of connective tissue fibers is increased by relaxation of vascular smooth muscle under the action of progesterone. As a result, the lumen of the vein expands, the valves stop closing, blood settles in the vascular system of the lower extremities. As the disease progresses, the pathological process can spread to the vessels of the vulvar ring, vagina and small pelvis.
Classification
The main criteria for systematizing the forms of varicose veins are the anatomical prevalence of venous stasis and the severity of the disease. This approach allows for a 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, varicose veins of the pelvic organs are distinguished. Based on the severity of clinical symptoms, the following phases of expansion of the venous vessels of the lower limbs 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 exercise and brisk walking.
- Subcompensated varicose veins. A vascular pattern ("stars") appears on the skin. In the evening, the legs swell, at night there are cramps, numbness, pain. Bruises and scratches heal longer than usual.
- Decompensated varicose veins. The patient is constantly worried about pain in the legs, swelling is increasing. The veins are markedly enlarged, gnarled. 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. In the first stage, the diameter of the affected vessels in any venous plexus of the pelvis does not exceed 5. 0 mm. With the second, 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 ectasia of veins of more than 10 mm with total involvement of all the pelvic venous plexuses.
Symptoms of varicose veins
In 80-82% of patients, the disease begins with a feeling of heaviness, tension, "buzz" in the legs, which increases in the evening and during physical exertion. The symptomatology of varicose veins gradually increases. As the disease progresses in some areas of the muscles, pain arises, which first develops with a prolonged standing, performing physical work. In severe cases, the pain becomes constant, and its intensity can be so pronounced that the pregnant woman has difficulty in independent movement. Up to 60% of patients note cramps in the calf muscles, up to 40-50% - loss of sensation, numbness in the legs, up to 30% - itching.
In the subcompensated stage of varicose veins, external signs of expansion of the superficial veins appear. First, areas of reticular vessels and telangiectasias ("lattices" and "stars") form on the skin. Subsequently, the venous pattern becomes distinct. The veins appear dilated, twisted, eventually nodular. The spread of ectasia to deep vessels is evidenced by the appearance of edema in the ankle joints and lower legs. With the decompensation of varicose veins, the skin of the legs looks hyperpigmented, eczema develops. If the pathology manifested itself long before pregnancy, then dystrophy of the subcutaneous fatty tissue, trophic ulcers is possible.
In 4% of patients, the disease affects the veins of the vulva, vagina and small pelvis. With vulvar and vaginal varicose veins, discomfort, distension, heaviness, itching are observed in the area of the external genitalia. There may be swelling of the perineum and labia, contact bleeding from the vagina after sex. Pelvic congestion syndrome manifests as pulling or aching pains in the lower abdomen, radiating to the lower back, sacrum, groin, and external genitalia. Dyspareunia (pain during 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, thromboembolism of the pulmonary artery and other large vessels during labor. In 40-45% of cases, placental insufficiency occurs with acute and chronic fetal hypoxia. In 25% of patients, abnormalities of labor are observed (weakness of the labor forces, discordance of the contractile activity of the myometrium). With vaginal varicose veins, a massive traumatic course of the postpartum period is possible. Nearly one third of women in labor have defects in placental separation and placental secretion. The long-term consequences of varicose veins that occur during pregnancy are hemorrhoids, chronic disabling venous insufficiency, and 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 phase 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 limbs. The most informative survey methods are:
- Inspection of the chair. The study reveals characteristic changes in the venous vessels in the vulvar region and inside the thighs: ectasia, tortuosity, nodularity. Swelling of the labia and perineum is possible. When viewed in the mirrors, the vaginal mucosa appears hypertrophic, cyanotic. Vaginal vaults with bimanual palpation are smooth, often painful.
- USDG of the venous system. During the ultrasound scan, the shape and diameter of the vessels, their length, anatomical position and wall condition are evaluated. The method allows to determine the areas of branching, the consistency of the valve apparatus, the patency of the veins, the presence and direction of reflux. Both lower limb vessels and inferior vena cava can be scanned (IVC ultrasound).
- Duplex scan of the vessels of the legs. The advantage of the non-invasive method, which combines traditional ultrasound and Doppler studies, is not only to obtain detailed information on blood flow parameters, but also to visualize the venous network. Duplex angioscanning is used for a comprehensive assessment of the state of superficial, perforating and deep vessels.
Radiodiagnostic methods (varicography, selective oviography, ascending limb venography, pelvic venography, CT venography, phleboscintigraphy, etc. ) during pregnancy are used to a limited extent due to a possible negative effect on the fetus. In difficult cases, with suspicion of pelvic varicose veins, 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. Varicose veins of the small pelvis need to be differentiated from genital endometriosis, chronic inflammatory pathology of the pelvic organs, submucosal and subserous uterine myomas, cysts and other ovarian tumors. In addition to the observation of an obstetrician-gynecologist, the patient is advised to consult a phlebologist, a cardiologist and an oncologist.
Treatment of varicose veins during pregnancy
The main objectives of therapy for varicose veins in pregnant women are to arrest the progression of the disorder, to mitigate the severity of the clinical picture and to prevent possible thromboembolic complications. Non-pharmacological methods are considered preferable, if necessary supplemented with pharmacotherapy in safe periods of pregnancy:
- Compression therapy. A woman with a confirmed diagnosis of varicose veins is recommended to wear it daily during pregnancy, to use elastic bandages, special compression tights or stockings of compression class 1-2 during childbirth and the postpartum period. The compression treatment, mechanically reducing the diameter of the superficial veins, accelerates blood flow, reduces swelling and congestion.
- Herbal phlebotonics and phlebotonics. The effect of the use of drugs of this group is associated with an increase in the tone of the venous wall, a decrease in its permeability, improvement in microcirculation, rheological properties of blood and lymphatic outflow. The advantage of most bioflavonoids is that they can be used during pregnancy and breastfeeding. Phlebotonic drugs are prescribed both in the form of tablets and externally.
- Anticoagulants and antiplatelet agents. In the presence of signs indicating a tendency to increase clotting and the threat of developing DIC, drugs with antithrombotic activity are used with caution. To improve blood rheology and vascular microcirculation, pharmaceutical agents are shown that prevent platelet aggregation and have an angioprotective effect.
For pregnant women with varicose veins, special complexes of physiotherapy exercises, lymphatic drainage massage, dosed walking, daily ascending contrast shower are recommended. Correcting the diet involves consuming foods rich in fiber and vegetable fats. Injection sclerotherapy, miniflebectomy, crossectomy, endovascular laser coagulation and other surgical methods of treatment are used in exceptional cases with severe forms of the disease, severe pain syndrome and the presence of complications. Most often, surgical correction is performed at the end of the lactation period.
Delivery tactics
The preferred method of birth for varicose veins is natural childbirth, at the beginning of which elastic bandages or compression garments are applied to the lower limbs of the woman in labor. Patients with vulvar-vaginal varicose veins require particularly careful maintenance of the persistent period with the performance of a protective perineotomy, according to indications. When ectasized veins rupture, the damaged vessels are carefully tied with repeated stitching of the conglomerate of knots. Cesarean section is recommended for patients at high risk of thromboembolic complications and severe vulvar varicose veins.
Prediction and prevention
With timely diagnosis and adequate therapy, the prognosis is favorable. For prophylactic purposes, it is recommended to have sufficient night sleep and periodic rest during the day in the supine position with the legs resting on a solid surface at an angle of 30 °. Pregnant women with a burdened inheritance should refuse to wear shoes with a heel greater than 5 cm, limit the duration of sitting or standing, and control weight gain.
To prevent varicose veins, daily walking, reducing salt intake, taking vitamin preparations that strengthen the vascular wall are effective. Patients with varicose veins planning pregnancy, according to indications, undergo surgical interventions to correct the disease.