Varicose veins during pregnancyis an ectasia of the venous vessels that arose in the gestational period and is pathogenically associated with it. It is manifested by severity, paresthesia, pain in the lower extremities and external genitalia, swelling, muscle spasms, trophic skin lesions. It is diagnosed by examination, ultrasound angiography methods. During pregnancy, treatment is generally limited to compression therapy with correction of sleep and rest, physical activity, and nutrition. Perhaps the appointment of phlebotonics, phleboprotectors, anticoagulants, antiplatelet agents. Surgical treatments are often 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 the early 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 pregnancy, most specialists in the field of obstetrics and gynecology consider the disease as a complication of pregnancy. The predisposing factor that causes vascular ectasia in 91% of patients is a genetically determined failure of the middle vein sheath, in which the amount of collagen is reduced and the polysaccharide content is increased. The development of varicose veins in women with constitutional predisposition during pregnancy is facilitated by:
- Increase in circulating blood volume. The increase in BCC in pregnant women ranges from 30-50% (when pregnant with 1 child) to 45-70% (if there are 2 or more fetuses in the uterus). This compensatory mechanism ensures adequate blood supply to the child, the vital organs of the woman, and the fetoplacental 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 worse with increased intravenous pressure.
- Compression of vessels by the pregnant uterus. The growing uterus compresses the inferior vena cava and the iliac veins. The outflow of blood from the pelvis and lower extremities is affected, intravascular pressure increases, which causes 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 labor approaches, the fibrinolytic activity of the blood decreases and the number of clotting factors increases. This adaptive mechanism aims to reduce the volume of physiological blood loss during labor. This increases the probability of pathologically altered vein thrombosis.
An additional etiofactor that contributes to varicose veins in pregnant women is decreased physical activity. With insufficient work of skeletal muscles, 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 patient's vascular bed.
Pathogenesis
The starting point in the development of varicose veins during pregnancy is the interruption of the compensatory capacities of the valvular apparatus of the venous network. Due to the increased BCC and mechanical obstruction of the lower extremity outflow, when the main veins are squeezed, the blood exerts greater pressure on the vascular wall. Genetically inherited connective tissue fiber failure is enhanced 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 is deposited in the vascular system of the lower extremities. As the disease develops, the disease 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 a differentiated selection of treatment regimens for different variants of the disorder. Taking into account the participation of various organs in the process, varicose veins of the lower extremities, vulvar varicose veins and varicose veins of the pelvic organs are distinguished. Depending on the severity of the clinical symptoms, the following stages of expansion of the venous vessels of the lower extremities are distinguished:
- Compensated varicose veins. There are no outward signs of vascular ectasia, the pregnant woman notices leg fatigue at 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. At night, the legs swell, at night there are cramps, numbness, pain. Bruises and scratches heal more than usual.
- Decompensated varicose veins. The patient is constantly worried about pain in the legs, the swelling is increasing. The veins are markedly enlarged, knotty. 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 greater 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, "buzzing" in the legs, which increases at night and during physical exertion. The symptomatology of varicose veins gradually increases. As the disease progresses, pain occurs in some areas of the muscles, which first develops when standing for a long time, doing physical work. In the most severe cases, the pain becomes constant and its intensity can be so pronounced that the pregnant woman experiences difficulty moving independently. Up to 60% of patients notice cramps in the calf muscles, up to 40-50% - loss of sensation, numbness of the legs, up to 30% - itching.
In the undercompensated stage of varicose veins, external signs of expansion of the superficial veins appear. First, areas of reticular vessels and telangiectasias ("mesh" and "stars") form on the skin. Later, the venous pattern becomes different. Veins appear dilated, contoured, and nodular over time. The spread of the ectasia process to the deep vessels is evidenced by the appearance of edema in the ankle and lower leg joints. With decompensation of varicose veins, the skin on the legs becomes hyperpigmented and eczema develops. If the pathology arose long before pregnancy, it is possible subcutaneous fatty tissue dystrophy, trophic ulcers.
In 4% of patients, the disease affects the veins of the vulva, vagina, and small pelvis. With vulvar and vaginal varicose veins, discomfort, bloating, 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 intercourse. Pelvic plethora syndrome is manifested by painful pulling or aching 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 the superficial and deep veins, thromboembolism of the pulmonary artery and other large vessels during laborBirth. In 40-45% of cases, placental insufficiency occurs with acute and chronic fetal hypoxia. In 25% of patients, labor abnormalities (weakness of work forces, incoordination of myometrial contractile activity) are observed. With vaginal varicose veins, a massive traumatic course of the postpartum period is possible. Almost one third of women in labor have defects in placental separation and placental discharge. The long-term consequences of varicose veins that arise during pregnancy are hemorrhoids, disabling chronic venous insufficiency, and pelvic pain.
Diagnosis
With the appearance of characteristic cutaneous signs, the diagnosis of varicose veins during pregnancy does not usually present any difficulty. The tasks of the diagnostic stage are to determine the stage and location of the venous ectasia, to exclude other causes that may cause stagnation in the vasculature of the lower extremities. The most informative survey methods are:
- Inspection of the chair. The study reveals characteristic changes in the venous vessels in the vulvar region and in the inner part of the thighs: ectasia, tortuosity, knotty. Swelling of the lips and perineum is possible. When looking in the mirrors, the vaginal mucosa looks hypertrophied, cyanotic. Vaginal vaults with bimanual palpation are softened, often painful.
- USDG of the venous system. During ultrasound, the shape and diameter of the vessels, their length, anatomical position, and the condition of the wall are evaluated. The method makes it possible to determine the branching zones, the consistency of the valve apparatus, the permeability of the veins, the presence and direction of the reflux. It can scan both the vessels of the lower extremities and the inferior vena cava (IVC ultrasound).
- Duplex scan of leg vessels. The advantage of the non-invasive method, which combines traditional ultrasound and Doppler studies, is not only obtaining detailed information on blood flow parameters, but also visualization of the venous network. Duplex angioscanning is used for a comprehensive assessment of the condition of superficial, perforating, and deep vessels.
Radiodiagnostic methods (varicography, selective ovariocography, ascending limb venography, pelvic venography, CT venography, phleboscintigraphy, etc. ) are used to a limited extent during pregnancy due to possible negative effects on the fetus. In difficult cases, with suspected 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 must be differentiated from genital endometriosis, chronic inflammatory pathology of the pelvic organs, submucosal 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 and oncologist.
Treatment of varicose veins during pregnancy
The main objectives of treating 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-pharmacological methods are considered preferable, if necessary supplemented with drug therapy in safe periods of pregnancy:
- Compression therapy. It is recommended that a woman with a confirmed diagnosis of varicose veins wear it every day during pregnancy, wear elastic bandages, special compression stockings or compression class 1-2 stockings during childbirth and the postpartum period. Compression treatment by mechanically reducing the diameter of the superficial veins accelerates blood flow, reduces swelling and congestion.
- Herbal phlebotonics and phleboprotectors. 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, an improvement in microcirculation, rheological properties of blood and lymphatic flow. The advantage of most bioflavonoids is that they can be used during pregnancy and breastfeeding. 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 developing DIC, drugs with antithrombotic activity are used with caution. To improve blood rheology and vascular microcirculation, pharmaceutical agents are shown to prevent platelet aggregation and have an angioprotective effect.
Pregnant women with varicose veins are recommended special complexes of physical therapy exercises, lymphatic drainage massage, metered walking, daily ascending contrast shower. The correction of the diet involves the consumption of foods rich in fiber and vegetable fats. Injection sclerotherapy, miniflebectomy, crossectomy, endovascular laser coagulation, and other surgical methods of treatment are used in rare cases with severe forms of the disease, severe pain syndrome, and the presence of complications. Most of the time, surgical correction is done at the end of the breastfeeding period.
Delivery Tactics
The preferred method of delivery for varicose veins is natural delivery, at the beginning of which elastic bandages or compression garments are applied to the lower extremities 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, as indicated. When the ecstatic veins rupture, the damaged vessels are carefully ligated with repeated sutures from the node cluster. Cesarean section is recommended in patients at high risk for thromboembolic complications and severe vulvar varicose veins.
Forecast and prevention
With early detection and adequate therapy, the prognosis is favorable. For prophylactic purposes, it is recommended to get enough sleep at night and to rest periodically during the day in a supine position with the legs resting on a firm surface at an angle of 30 °. Pregnant women with a hereditary burden should refuse to wear shoes with heels greater than 5 cm, limit the duration of sitting or standing, and monitor weight gain.
To prevent varicose veins, walking every day, reducing salt intake, taking vitamin preparations that strengthen the vascular wall are effective. Patients with varicose veins who are planning a pregnancy, as directed, undergo surgery to correct the disease.