Varicose veins during pregnancyis an ectasia of venous vessels that occurred during pregnancy and is pathogenetically linked to it. It manifests itself in severity, paresthesia, pain in the lower extremities and external genitalia, swelling, muscle twitching, and trophic skin lesions. It is diagnosed through examination, ultrasound angioscanning methods. During pregnancy, treatment is usually limited to compression therapy, correcting sleep and rest, exercise, and diet. Perhaps the appointment of phlebotonics, phleboprotectors, anticoagulants, antiplatelet agents. Surgical treatments are usually used after the birth.
General information
Varicose veins (varicose veins) are one of the most common vascular diseases associated with the pregnancy 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 occurred due to 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 a 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 pregnancy, 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 a genetic failure of the median vein sheath, which decreases the amount of collagen substance and increases the level of polysaccharides. 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 ranges from 30-50% (in 1 child) to 45-70% (in 2 or more fetuses in the uterus). This balancing mechanism enables an adequate blood supply to the child, the vital organs of the woman and the fetoplacental system.
- Hormonal adjustment during pregnancy. During pregnancy, the ovaries and placenta intensely secrete progesterone and relaxin. Under the influence of these hormones, the smooth muscle fibers of the veins relax and the structural reconstruction of the connective tissue occurs. As a result, the vessel wall does not cope with the increased intravenous pressure.
- Compression of vessels by the pregnant uterus. The growing uterus compresses the inferior vena cava and the iliac veins. Blood outflow from the pelvis and lower extremities is impaired, intravascular pressure increases, which leads to stretching of the vein 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 hemostatic system. As labor approaches, the fibrinolytic activity of the blood decreases and the number of clotting factors increases. This adjustment mechanism aims to reduce the volume of physiological blood loss during labor. This increases the likelihood of pathologically altered veins thrombosis.
An additional etiofactor that contributes to the appearance 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 is exacerbated in the case of overweight, in which the blood volume circulating in the patient's vascular bed increases even more.
Pathogenesis
The starting point for 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 BCC and a mechanical obstruction of outflow from the lower extremities, when the main veins are compressed, the blood exerts increased pressure on the vessel wall. The genetically inherited failure of the connective tissue fibers is exacerbated by the relaxation of the smooth vascular 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 systematizing the forms of varicose veins are the anatomical prevalence of venous stasis and the severity of the disease. This approach enables a differentiated selection of treatment regimens for different variants of the disorder. Taking into account the involvement of various organs in the process, a distinction is made between varicose veins of the lower extremities, vulvar varicose veins and varicose veins of the pelvic organs. According to 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 external signs of vascular ectasia. At the end of the day, the pregnant woman noticed tired legs, 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 take longer to heal than usual.
- Decompensated varicose veins. The patient is constantly worried about pain in the legs, the swelling increases. The veins are clearly enlarged, knotty. The skin is hyperpigmented. There are signs of eczema and trophic disorders.
In pelvic varicose veins in pregnant women, the disease also develops gradually. In the first stage, the diameter of the affected vessels in a venous plexus of the pelvis does not exceed 5. 0 mm. With the second, the uterus or ovaries involved in the process, the lumen of the vessels is 6. 0-10. 0 mm. The third is characterized by ectasia of veins larger than 10 mm, in which all pelvic vein plexuses are fully involved.
Symptoms of varicose veins
In 80-82% of patients the disease occurs with a feeling of heaviness, tension, "buzzing" in the legs, which increases in the evening and with physical exertion. The symptoms of varicose veins gradually increase. As the disease progresses in some areas of the muscles, pain develops, which first develops with prolonged standing and physical activity. 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 calf muscles, up to 40-50% - loss of sensitivity, numbness of the legs, up to 30% - itching.
In the subcompensated stage of the varicose veins, external signs of expansion of the superficial veins appear. First, areas of reticular vessels and telangiectasias ("meshes" and "stars") are formed on the skin. Then the venous pattern becomes clear. The veins look dilated, tortuous, and eventually knotty. The spread of the ectasia process to deep vessels is evidenced by the appearance of edema in the ankles and lower legs. With the decompensation of varicose veins, the skin of the legs looks hyperpigmented, eczema develops. If the pathology appeared long before pregnancy, then dystrophy of subcutaneous adipose tissue, trophic ulcers is possible.
In 4% of patients, the disease affects the veins of the vulva, vagina, and pelvis. In the case of vulvar and vaginal varicose veins, discomfort, flatulence, heaviness and 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 is manifested by pulling or pain in the lower abdomen that radiates to the lower back, sacrum, groin, and external genitals. Dyspareunia (painful intercourse) is characteristic. In severe cases, dysuric disorders are noted.
Complications
Without proper 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 in acute and chronic fetal hypoxia. Work disorders are observed in 25% of patients (weakness of the workforce, discoordination of the contractile activity of the myometrium). With vaginal varicose veins, a massive traumatic course of the postpartum period is possible. Almost a third of working women have defects in the separation of the placenta and the discharge of the placenta. The long-term consequences of varicose veins that appear during pregnancy are hemorrhoids, the obstruction of chronic venous insufficiency, and pelvic pain.
Diagnosis
With the appearance of characteristic skin signs, the diagnosis of varicose veins during pregnancy is usually not difficult. The tasks of the diagnostic stage are to determine the stage and location of venous ectasia and exclude other causes that can lead to stagnation in the vascular network of the lower extremities. The most informative survey methods are:
- Chair inspection. The study shows characteristic changes in the venous vessels in the vulva region and on the inner thighs - ectasia, tortuosity, knottyness. Swelling of the labia and perineum is possible. When viewed in the mirrors, the vaginal mucosa looks hypertrophied and cyanotic. Vaginal vaults with bimanual palpation are smoothed, often painful.
- USDG of the venous system. During the ultrasound examination, the shape and diameter of the vessels, their length, anatomical position and the condition of the wall are assessed. This method allows you to determine the zones of branching, the consistency of the valve apparatus, the patency of the veins, the presence and direction of reflux. You can scan the vessels of the lower extremities as well as the inferior vena cava (IVC ultrasound).
- Duplex scanning of leg vessels. The advantage of the non-invasive method, which combines traditional ultrasound and Doppler studies, is not only to get detailed information about the blood flow parameters, but also to visualize the venous network. Duplex angioscanning is used for the comprehensive assessment of the condition of superficial, perforating and deep vessels.
Radiodiagnostic methods (varicography, selective ovariancography, ascending venography of the extremities, pelvic phlebography, CT venography, phleboscintigraphy, etc. ) are used only to a limited extent during pregnancy due to possible negative effects on the fetus. In difficult cases, if pelvic varices are suspected, diagnostic laparoscopy is performed with caution. Differential diagnosis of varicose veins of the legs is carried out in case of dropsy 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 a gynecologist, the patient is recommended to consult a phlebologist, cardiologist and oncologist.
Treatment of varicose veins during pregnancy
The main goals of therapy for varicose veins in pregnant women are to stop the progression of the disorder, alleviate the severity of the disease and prevent possible thromboembolic complications. Non-pharmacological methods are considered preferred, if necessary, supplemented by pharmacotherapy in safe stages of pregnancy:
- Compression therapy. A woman with a confirmed diagnosis of varicose veins is recommended to wear them daily during pregnancy and to use elastic bandages, special compression tights, or compression class 1-2 stockings during childbirth and postpartum. 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 vein wall, a decrease in its permeability, an 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 tablet form and externally.
- Anticoagulants and platelet aggregation inhibitors. If there are signs of signs of increased coagulation and the risk of developing DIC, drugs with antithrombotic activity are used with caution. In order to improve the blood rheology and the vascular microcirculation, active pharmaceutical ingredients are shown that prevent platelet aggregation and have an angioprotective effect.
Pregnant women with varicose veins are recommended to use special complexes of physiotherapy exercises, lymphatic drainage massage, metered walking and a daily contrast shower. Diet correction involves consuming foods rich in fiber and vegetable fats. In exceptional cases with severe forms of the disease, severe pain syndrome and the presence of complications, injection sclerotherapy, miniflebectomy, crossectomy, endovascular laser coagulation and other surgical methods of treatment are used. Most often, surgical correction is performed at the end of breastfeeding.
Delivery tactics
The preferred method of delivery for varicose veins is natural birth, which begins with elastic bandages or compression clothing placed on the woman's lower limbs. Patients with vulvar-vaginal varicose veins require particularly careful maintenance of the persistent period with the performance of a protective perineotomy as indicated. When ectatic veins tear, the damaged vessels are carefully tied off by repeated suturing of the knot conglomerate. Caesarean section is recommended for patients at high risk for thromboembolic complications and severe vulvar varicose veins.
prognosis and prevention
With early detection and adequate therapy, the prognosis is favorable. For prophylactic purposes, it is recommended to have adequate sleep throughout the day and regular rest in the supine position with the legs placed on a firm surface at a 30 ° angle. Pregnant women with a burdened heredity should refuse to wear shoes with heels larger than 5 cm, limit the time they can sit or stand, and control weight gain.
To prevent varicose veins, daily walking, reducing salt intake and taking vitamin preparations to strengthen the vascular wall are effective. Patients with varicose veins who are planning to conceive will have surgery, if indicated, to correct the disease.