Varicose veins in pregnancyis an ectasia of the venous vessels that appeared during the gestational period and is pathogenically associated with it. It is manifested by severity, paresthesias, pain in the lower limbs and external genitalia, swelling, muscle contractions, trophic skin lesions. It is diagnosed by examination, ultrasound CT angiography methods. 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 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 have occurred as a result of pregnancy. . The disease is usually first diagnosed in young patients, 75% of whom are under 30 years old. In more than two-thirds of cases, the varicose vein clinic begins after the 20th week of the first pregnancy. The relevance of prompt diagnosis of varicose veins is associated with a high probability of foeto-placental insufficiency and the risk of fatal thromboembolic complications in the absence of adequate treatment.
Reasons
Given the statistical data on the incidence of varicose veins during gestation, most specialists in the field of obstetrics and gynecology consider the disease to be a complication of pregnancy. The predisposing factor to 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:
- Increased circulating blood volume. The increase in CBC in pregnant women ranges from 30-50% (when carrying a child) to 45-70% (if there are 2 or more fetuses in the uterus). This compensatory mechanism ensures an adequate blood supply to the child, to the woman's vital organs and to the foeto-placental system.
- Hormonal adjustment during pregnancy. During gestation, the ovaries and the placenta intensively secrete progesterone and relaxin. Under the influence of these hormones, the smooth muscle fibers of the veins relax, and structural reconstruction of connective tissue occurs. As a result, the vascular wall is less resistant to increased intravenous pressure.
- Vascular compression by 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 impaired, 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.
- Modifications to the hemostasis system. As labor approaches, the fibrinolytic activity of the blood decreases and the number of clotting factors increases. This coping mechanism is aimed at reducing the volume of physiological blood loss during labor. This increases the likelihood of thrombosis of pathologically altered veins.
An additional etiofactor contributing to the development of varicose veins in pregnant women is decreased physical activity. With insufficient work of the skeletal muscles, stagnation of blood in the legs and pelvis increases. The situation is aggravated in the presence of overweight, in which there is an even greater increase in the volume of blood circulating in the vascular bed of the patient.
Pathogenesis
The starting point for the development of varicose veins during pregnancy is the disturbance of the compensatory capacities of the valve system of the venous network. Due to an increase in BCC and mechanical obstruction at the exit of the lower extremities, when the main veins are compressed, the blood puts increased pressure on the vascular wall. The genetic failure of 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, 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 small pelvis.
Classification
The main criteria for systematizing 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. Depending on the severity of 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, the pregnant woman notes fatigue in the legs at the end of the day, discomfort in the calf muscles during exercise and brisk walking.
- Undercompensated varices. 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 the 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 disturbances.
With pelvic varicose veins in pregnant women, the disease also develops in stages. At 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 an ectasia of the veins of more than 10 mm with total involvement of all the pelvic venous plexuses.
Symptoms of varicose veins
In 80 to 82% of patients, the disease begins with a feeling of heaviness, tension, "buzzing" in the legs, increasing in the evening and during physical exertion. The symptomatology of varicose veins gradually increases. As the disease progresses in certain areas of the muscles, pain appears, which first develops with prolonged standing, doing physical labor. In more 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 note cramps in the calf muscles, up to 40-50% - loss of sensitivity, numbness in 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. Subsequently, the venous pattern becomes distinct. The veins appear dilated, convoluted, possibly nodular. The spread of the process of ectasia to the 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 appears hyperpigmented, eczema develops. If the pathology occurred long before pregnancy, dystrophy of the subcutaneous fatty tissue, trophic ulcers is possible.
In 4% of patients, the disease affects the veins of the vulva, vagina and pelvis. With vulvar and vaginal varicose veins, discomfort, distension, heaviness, itching is 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 congestion syndrome manifests as a pulling or aching pain in the lower abdomen, which radiates 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, superficial and deep vein thrombosis, pulmonary artery thromboembolismand other large vessels during labor. In 40-45% of cases, placental insufficiency occurs with acute and chronic fetal hypoxia. In 25% of patients, work abnormalities are observed (weakness of the work forces, 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 women in labor have defects in the separation of the placenta and discharge from the placenta. The long-term consequences of varicose veins that occur during pregnancy are hemorrhoids, crippling 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 difficulties. The tasks of the diagnostic phase are to determine the stage and localization of venous ectasia, to exclude other causes that can provoke stagnation of the vascular system 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 inside the thighs - ectasia, tortuosity, nodularity. Swelling of the lips and perineum is possible. Seen in the mirrors, the vaginal mucosa appears enlarged, cyanotic. Bimanual palpation vaginal arches are smooth, often painful.
- USDG venous system. During ultrasound, the shape and diameter of the vessels, their length, anatomical position and the condition of the wall are assessed. The method allows you to determine the areas of branching, the consistency of the valve apparatus, the patency of the veins, the presence and direction of reflux. You can scan both the vessels of the lower limbs and the inferior vena cava (IVC ultrasound).
- Double-sided scan of leg vessels. 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. The duplex CT angiography is used for a comprehensive assessment of the condition of superficial, perforating and deep vessels.
Radiodiagnostic methods (varicography, selective ovarycography, ascending venography of the extremities, pelvic venography, computed tomography 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 varices, diagnostic laparoscopy is carried out 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 should 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 recommended to consult a phlebologist, cardiologist and oncologist.
Treatment of varicose veins during pregnancy
The main goals of treating varicose veins in pregnant women are to stop the progression of the disorder, reduce the severity of the clinical picture and prevent possible thromboembolic complications. Non-pharmacological methods are considered preferable, 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, use elastic bandages, special compression tights or compression class 1-2 stockings during childbirth andthe 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 lymph 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 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 upward contrast shower. Correcting the diet involves the consumption of foods rich in fiber and vegetable fats. Injection sclerotherapy, miniflebectomy, crossectomy, laser endovasal 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 delivery for varicose veins is natural childbirth, at the beginning of which elastic bandages or compression garments are applied to the lower limbs of the laboring woman. Patients with vulvovaginal varices require particularly careful management of the persistent period with the performance of a protective perineotomy, as indicated. When the ectasized veins rupture, the damaged vessels are carefully tied off with repeated seams of the conglomerate of nodes. Cesarean section is recommended in patients at high risk of thromboembolic complications and severe vulvar varices.
Forecasting and prevention
With early detection and adequate treatment, the prognosis is favorable. As a prophylactic, it is recommended to get enough sleep at night and to rest periodically throughout the day in supine position with the legs resting on a firm surface at an angle of 30 °. Pregnant women with overwhelmed heredity should refuse to wear shoes with a heel of more than 5 cm, limit the time 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, as indicated, undergo surgeries to correct the disease.