Varicose veins during pregnancyis a venous ectasia that occurs during gestation and is pathogenetically related. Manifested by heaviness, paresthesia, pain in the lower extremities and external genitalia, swelling, muscle twitching, trophic skin lesions. Diagnosed by examination, ultrasound methods for angioscanning. During pregnancy, treatment is usually limited to compression therapy with correction of sleep and rest, physical activity and nutrition. Perhaps the appointment of phlebotonics, phleboprotectors, anticoagulants, antiplatelet agents. Surgical treatment is usually used after birth.
General information
Varicose veins (varicose veins) are one of the most common vascular diseases associated with gestation. 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 are due to pregnancy. The disease is usually diagnosed for the first time in young patients, 75% of whom are under 30 years of age. In more than two-thirds of cases, the varicose vein clinic debuts after the 20th week of the first pregnancy. The importance 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.
Causes
Given the statistics on the incidence of varicose veins during pregnancy, most obstetricians and gynecologists view the disease as a complication of pregnancy. The predisposing factor causing vascular ectasia in 91% of patients is genetically determined failure of the median vein sheath, in which the amount of collagen substance is reduced and the polysaccharide content is increased. The development of varicose veins in constitutionally predisposed women during pregnancy is facilitated by:
- Increased circulating blood volume. The increase in BCC in pregnant women varies from 30-50% (when carrying 1 child) to 45-70% (if there are 2 or more fetuses in the uterus). This compensatory mechanism allows to ensure adequate blood supply to the child, the vital organs of the woman and the fetoplacental system.
- Hormonal correction during pregnancy. During pregnancy, 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 vessel wall copes worse with increased intravenous pressure.
- Vascular compression of the pregnant uterus. The growing uterus compresses the inferior vena cava and iliac veins. The blood flow from the pelvis and lower extremities is disturbed, 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 birth approaches, the fibrinolytic activity of the blood decreases and the number of coagulation factors increases. This mechanism of adaptation is aimed at reducing the volume of physiological blood loss during childbirth. This increases the likelihood of thrombosis of pathologically altered veins.
An additional etiofactor contributing to the appearance of varicose veins in pregnant women is the reduction of physical activity. Insufficient skeletal muscle function increases blood stagnation in the legs and pelvis. The situation worsens in the presence of excess body weight, with 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 violation of the compensatory capabilities of the valvular apparatus of the venous network. Due to an increase in BCC and a mechanical obstruction to drainage from the lower extremities, when the main veins are squeezed, the blood exerts increased pressure on the vessel wall. Genetically inherited connective tissue deficiency is exacerbated by the relaxation of vascular smooth muscle under the action of progesterone. As a result, the lumen of the vein dilates, the valves stop closing, and blood is deposited in the vascular system of the lower extremities. With the development of the disease, the pathological process can spread to the vessels of the vulvar ring, vagina and pelvis.
Classification
The main criteria for systematizing the forms of varicose veins are the anatomical distribution of venous stasis and the severity of the disease. This approach allows a differentiated choice of treatment regimens for different variants of the disorder. Taking into account the involvement of different organs in the process, a distinction is made between varicose veins of the lower extremities, varicose veins of the vulva, varicose veins of the pelvic organs. The following stages of dilatation of the venous vessels of the lower extremities differ according to the severity of the clinical symptoms:
- Compensated varicose veins. There are no external signs of vascular ectasia, the pregnant woman notes fatigue in the legs 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, tingling, pain. Bruises and scratches heal longer than usual.
- Decompensated varicose veins. The patient is constantly worried about leg pain, swelling increases. The veins are significantly enlarged, nodules. The skin is hyperpigmented. There are signs of eczema and trophic disorders.
In pelvic varicose veins in pregnant women, the disease develops in stages. In the first stage, the diameter of the affected vessels in each venous plexus of the pelvis does not exceed 5. 0 mm. With the second uterus or ovaries involved in the process, the lumen of the vessels is 6, 0-10, 0 mm. The third is characterized by venous ectasia over 10 mm with general damage to all pelvic venous plexuses.
Symptoms of varicose veins
In 80-82% of patients, the disease debuts with a feeling of heaviness, tension, "buzzing" in the legs, increasing in the evening and during exercise. The symptoms of varicose veins increase gradually. As the disease progresses, pain occurs in some areas of the muscles, which first develops during 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 has difficulty moving independently. Up to 60% of patients report cramps in the calf muscles, up to 40-50% - loss of sensation, tingling in the legs, up to 30% - itching.
In the subcompensated stage of varicose veins, external signs of varicose veins appear. First, areas of reticular vessels and telangiectasias ("reticles" and "stars") form on the skin. Subsequently, the venous pattern becomes clear. The veins appear dilated, curved, and eventually nodular. The spread of the ectasia process on the deep vessels is evidenced by the appearance of swelling in the ankle joints and lower legs. With decompensation of varicose veins, the skin of the legs appears hyperpigmented, eczema develops. If the pathology occurred long before pregnancy, subcutaneous adipose tissue dystrophy, trophic ulcers are possible.
In 4% of patients, the disease affects the veins of the vulva, vagina and pelvis. With varicose veins of the vulva and vagina, there is discomfort, stretching, heaviness, itching in the external genitalia. There may be swelling of the perineum and labia, contact vaginal bleeding after sex. Pelvic congestion syndrome is manifested by pulling or pain in the lower abdomen that radiates to the lower back, sacrum, groin, and external genitalia. Dyspareunia (pain during intercourse) is typical. In severe cases, dysuric disorders are found.
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 childbirth. In 40-45% of cases, placental insufficiency is manifested by acute and chronic fetal hypoxia. Birth abnormalities (labor force weakness, discoordination of myometrial contractile activity) were observed in 25% of patients. In vaginal varicose veins, a massive traumatic course of the postpartum period is possible. Almost a third of mothers have defects in placental abruption and placental abruption. The long-term effects of varicose veins that occur during pregnancy are hemorrhoids that damage chronic 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 stage are to determine the stage and location of venous ectasia, to exclude other causes that may cause stagnation in the vasculature of the lower extremities. The most informative research methods are:
- Chair inspection. The study revealed in the area of the vulva and inner thighs characteristic changes in the venous vessels - ectasia, curvature, nodularity. Swelling of the labia and perineum is possible. When viewed in the mirror, the vaginal mucosa appears hypertrophied, cyanotic. Vaginal arches with bimanual palpation are smoothed, often painful.
- USDG of the venous system. In the course of the ultrasound scan, the shape and diameter of the vessels, their length, anatomical position and the condition of the wall are assessed. 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. It is possible to 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 examinations, is not only obtaining detailed information about the parameters of blood flow, but also visualization of the venous network. Duplex angioscanning is used to comprehensively assess the condition of superficial, perforating, and deep vessels.
X-ray diagnostic methods (varicography, selective ovary, ascending phlebography of the limbs, pelvic phlebography, CT venography, phleboscintigraphy, etc. ) are used to a limited extent during pregnancy due to a possible negative effect on the fetus. In difficult cases, with suspected varicose veins of the pelvis, diagnostic laparoscopy is performed with caution. Differential diagnosis of varicose veins of the legs is made with dropsy of pregnant women, heart failure, lymphedema, acute thrombosis of the venous system. Varicose veins of the pelvis should be distinguished 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 advised to consult a phlebologist, cardiologist and oncologist.
Treatment of varicose veins during pregnancy
The main objectives of varicose vein therapy in pregnant women are to stop the progression of the disorder, to alleviate the severity of the clinical picture and to prevent possible thromboembolic complications. Non-pharmacological methods are considered preferred, if necessary, supplemented with pharmacotherapy at safe stages of pregnancy:
- Compression therapy. A woman with a confirmed diagnosis of varicose veins is recommended to wear it daily throughout pregnancy, to use elastic bandages, special compression tights or socks of 1-2 class of compression during childbirth and the postpartum period. Compression therapy by mechanically reducing the diameter of the superficial veins can accelerate blood flow, reduce swelling and congestion.
- Herbal phlebotonics and phleboprotectors. The effect of the use of drugs from this group is associated with increasing the tone of the venous wall, reducing its permeability, improving microcirculation, rheological properties of blood and lymph outflow. The advantage of most bioflavonoids is that they can be used during pregnancy and lactation. Phlebotonic drugs are prescribed both in tablet form and externally.
- Anticoagulants and antiplatelet agents. In the presence of signs showing a tendency to increased coagulation and a threat of developing DIC, drugs with antithrombotic activity are used with caution. To improve the rheology of the blood and vascular microcirculation, pharmaceutical agents have been shown to prevent platelet aggregation and have an angioprotective effect.
For pregnant women with varicose veins are recommended special complexes of physiotherapy exercises, lymphatic drainage massage, dosed walking, daily ascending contrast shower. Dietary adjustments include eating foods rich in fiber and vegetable fats. Injectable sclerotherapy, miniphlebectomy, crossectomy, endovasal laser coagulation and other surgical treatments 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 delivery for varicose veins is natural childbirth, at the beginning of which elastic bandages or compression garments are placed on the lower limbs of the mother. Patients with vulva-vaginal varicose veins need particularly careful support during the persistent period by performing a protective perineotomy as indicated. When ectasic veins rupture, the damaged vessels are carefully ligated by repeated suturing of the conglomerate of nodes. Cesarean section is recommended for patients at high risk of thromboembolic complications and severe varicose veins of the vulva.
Prognosis and prevention
With timely detection and adequate therapy, the prognosis is favorable. For prophylactic purposes, it is recommended to have enough night's sleep and periodic rest throughout the day in a supine position with your feet on a hard surface at an angle of 30 °. Pregnant women with a burdened heredity should refuse to wear shoes with heels larger than 5 cm, limit the length of sitting or standing, and control weight gain.
To prevent varicose veins are effective daily walking, reducing salt intake, taking vitamin preparations that strengthen the vessel wall. Patients with varicose veins who are planning a pregnancy are indicated to undergo surgery to correct the disease.