Varicose veins during pregnancyis an ectasia of the venous vessels that formed during gestation and with which it is pathogenetically related. It is manifested by severity, paresthesia, pain in the lower extremities and external genitalia, swelling, muscle twitching, trophic skin lesions. It is diagnosed by examination, ultrasound methods of angioscanning. During pregnancy, treatment is usually limited to compression therapy with correction of sleep and rest, physical activity, and diet. Perhaps the appointment of phlebotonics, phleboprotectors, anticoagulants, antiplatelet agents. Surgical treatments are usually used after childbirth.
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 are caused by pregnancy. The disease is usually first diagnosed 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 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
Considering the statistics on the frequency of varicose veins during gestation, most specialists in the field of obstetrics and gynecology consider the disease a complication of pregnancy. The predisposing factor that causes vascular ectasia in 91% of patients is genetically conditioned failure of the median vein sheath, in which the amount of collagen substance decreases and the polysaccharide content increases. The development of varicose veins in women who are helpful during pregnancy is facilitated by:
- Increased circulating blood volume. The increase in BCC in pregnant women ranges from 30-50% (when carrying one child) to 45-70% (if there are 2 or more fetuses in the uterus). This compensatory mechanism enables the provision of an adequate supply of blood to the child, the vital organs of the woman and the fetoplacental system.
- Hormonal adjustment 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 is worn upwards with increased intravenous pressure.
- Compression of blood vessels in 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 damaged, the 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 coagulation factors increases. This adjustment mechanism is aimed at reducing the amount of physiological blood loss during childbirth. This increases the likelihood of thrombosis of pathologically altered veins.
An additional etiofactor that contributes to the formation of varicose veins in pregnant women is the reduction of physical activity. With insufficient work of 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 amount of blood circulating in the patient's vascular bed.
Pathogenesis
The starting point in the development of varicose veins during pregnancy is a violation of the compensatory capabilities of the venous network valve apparatus. Due to the increase in BCC and the mechanical obstacle to coming out of the lower extremities, when the main veins are compressed, the blood exerts increased pressure on the vascular wall. The failure of genetically inherited connective tissue fibers is enhanced by the relaxation of vascular smooth muscle under the action of progesterone. As a result, the lumen of the vein expands, the valves stop closing, and blood settles in the vascular system of the lower extremities. As the disease progresses, the pathological process may extend to the vessels of the vulvar ring, vagina, and small pelvis.
Classification
The main criteria for systematizing the shape of varicose veins are the anatomical prevalence of venous congestion and the severity of the disease. This approach allows differentiated selection of treatment regimens for different variants of the disorder. Taking into account the participation of different organs in the process, varicose veins of the lower extremities, varicose veins of the vulva, varicose veins of the pelvic organs are distinguished. According to the severity of clinical symptoms, the following stages of dilatation of the venous vessels of the lower extremities are distinguished:
- Compensated varicose vein. There are no external signs of vascular ectasia, the pregnant woman notices leg fatigue by the end of the day, discomfort in the muscle leaves during exercise and fast 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 vein. The patient is constantly worried about pain in the legs, the swelling increases. The veins are markedly enlarged, nodular. The skin is hyperpigmented. There are signs of eczema and trophic disorders.
In 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 vessel is 6, 0-10, 0 mm. The third is characterized by venous ectasia of more than 10 mm with total involvement of 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 physical exertion. The symptoms of varicose veins gradually increase. As the disease progresses in some areas of the muscles, pain occurs that 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 has difficulty moving independently. Up to 60% of patients notice cramps in the muscle leaves, up to 40-50% - loss of sensitivity, numbness of the legs, up to 30% - itching.
In the subcompensated phase of varicose veins, external signs of superficial vein dilation appear. Areas of reticular vessels and telangiectasias ("reticles" and "stars") first form on the skin. After that, the venous pattern becomes different. The veins look dilated, twisted, and eventually nodular. The spread of ectasia to the deep vessels is evidenced by the appearance of edema in the ankle joints and lower legs. With decompensation of varicose veins, the skin of the legs looks hyperpigmented, eczema develops. If the pathology arose long before pregnancy, dystrophy of subcutaneous adipose tissue, trophic ulcers is possible.
In 4% of patients the disease affects the veins of the vulva, vagina and small pelvis. In varicose veins of the vulva and vagina, discomfort, stretching, heaviness, itching are noticed in the area of the external genitalia. There may be swelling of the perineum and lips, contact vaginal bleeding after sex. Pelvic congestion syndrome is manifested by pulling or aching pains in the lower abdomen, which radiate 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 childbirth. In 40-45% of cases, placental insufficiency occurs with acute and chronic fetal hypoxia. In 25% of patients, abnormalities in work are observed (weakness of the workforce, discordance of the contractile activity of the myometrium). In vaginal varicose veins, a massive traumatic course of the postpartum period is possible. Almost a third of mothers have defects in separation of the placenta and discharge of the placenta. The long-term consequences of varicose veins that occur during pregnancy are hemorrhoids, disability of chronic venous insufficiency and pelvic pain.
Diagnostics
With the appearance of characteristic skin signs, the diagnosis of varicose veins during pregnancy is usually not difficult. 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 vasculature of the lower extremities. The most informative test methods are:
- Stool inspection. The study reveals characteristic changes in the venous vessels in the region of the vulva and on the inner side of the thigh - ectasia, tortuosity, nodularity. Swelling of the labia and perineum is possible. When viewed in mirrors, the vaginal mucosa looks hypertrophied, cyanotic. Vaginal arches are smoothed by bimanual palpation, often painful.
- USDG venous system. During the ultrasound scan, the shape and diameter of the vessels, their length, anatomical position and the condition of the wall are assessed. The method enables the determination of branching zones, consistency of the valve apparatus, vein patency, presence and direction of reflux. You can also scan the vessels of the lower extremities and the inferior vena cava (IVC ultrasound).
- Duplex leg vein scan. 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 to comprehensively assess the condition of superficial, perforating, and deep vessels.
Radiodiagnostic methods (varicography, selective ovaries, ascending limb phlebography, pelvic phlebography, CT venography, phleboscintigraphy, etc. ) are used to a limited extent during pregnancy due to the possible negative impact on the fetus. In severe cases, with suspected dilated pelvic veins, diagnostic laparoscopy is performed with caution. Differential diagnosis of varicose veins on the legs is carried out with water droplets of pregnant women, heart failure, lymphedema, acute thrombosis of the venous system. Varicose veins of the pelvis must 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 recommended to consult a phlebologist, cardiologist and oncologist.
Treatment of varicose veins during pregnancy
The main goals of varicose vein therapy in pregnant women are to stop the progression of the disorder, alleviate the severity of the clinical picture, and prevent possible thromboembolic complications. Non-pharmacological methods are considered more desirable, if necessary supplemented by pharmacotherapy in safe periods of pregnancy:
- Compression therapy. A woman with a confirmed diagnosis of varicose veins is recommended to wear it every day during pregnancy, to use elastic bandages, special compression leggings or socks of 1-2 compression class during childbirth and the postpartum period. Compression treatment by mechanically reducing the diameter of the superficial veins accelerates blood flow, reduces swelling and congestion.
- Plant 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, and rheological properties of blood and lymph outflow. The advantage of most bioflavonoids is that they can be used during pregnancy and breastfeeding. Phlebotonic drugs are prescribed in the form of tablets and externally.
- Anticoagulants and antiplatelet agents. In the presence of signs indicating a tendency to increase coagulation and the risk of developing DIC, drugs with antithrombotic action are used with caution. To improve blood rheology and vascular microcirculation, pharmaceutical agents have been shown to prevent platelet aggregation and have an angioprotective effect.
Pregnant women with varicose veins are recommended special complexes of physiotherapy exercises, lymphatic drainage massage, dosed walking, daily ascending contrast shower. Diet correction involves eating foods rich in fiber and vegetable fats. Injectable sclerotherapy, miniphlebectomy, crosssectomy, endovasal 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. Surgical correction is usually 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 vulvar-vaginal varicose veins must be especially careful to maintain a persistent period by performing a protective perineotomy according to the indications. When the 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, sufficient night's sleep and occasional rest during the day in a lying position with the feet laid on a solid surface at an angle of 30 ° is recommended. Pregnant women with a burdened heredity should refuse to wear shoes with heels longer than 5 cm, limit the duration of sitting or standing and control weight gain.
To prevent varicose veins, daily walking, reduction of salt intake, taking vitamin preparations that strengthen the vascular wall are effective. According to the indications, patients with varicose veins who are planning a pregnancy undergo surgical interventions in order to correct the disease.