Varicose veins during pregnancyis the ecstasy of venous vessels that arose during pregnancy and is pathogenetically associated with it. Manifested by severity, paresthesia, pain in the lower extremities and external genitalia, swelling, muscle tremors, trophic skin lesions. Diagnosed by examination, ultrasound methods of angioscanning. During pregnancy, treatment is usually limited to compression therapy with sleep and rest correction, physical activity, and nutrition. Perhaps the appointment of phlebotonics, phleboprotectants, anticoagulants, antiplatelet agents. Surgical treatments are usually used after childbirth.
General Information
Varicose veins are one of the most common vascular diseases associated with pregnancy. 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 born due to pregnancy. The disease is usually first diagnosed in young patients, 75% of whom are under the age of 30 years. 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.Reasons
Considering the statistical data on the frequency 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 venous envelope, in which the amount of collagen substance decreases and the polysaccharide content increases. The development of varicose veins in women with constitutional predisposition during pregnancy is facilitated by:
- Increase the volume of circulating blood. 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 womb). This compensatory mechanism allows to ensure adequate blood supply to the baby, the woman's vital organs and the fetoplacental system.
- Hormonal regulation 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 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 iliac veins. The outflow of blood from the pelvis and lower limbs is impaired, the intravascular pressure increases, which provokes the 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 adaptation mechanism aims to reduce the volume of physiological blood loss during labor. This increases the likelihood of pathologically altered venous thrombosis.
An additional etiofactor that contributes to the appearance of varicose veins in pregnant women is a decrease in physical activity. With insufficient skeletal muscle work, blood clots in the legs and pelvis increase. The situation is aggravated in 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 disruption of the compensatory capabilities of the venous network valve apparatus. Due to an increase in BCC and mechanical barriers to exit from the lower extremities, when the main veins constrict, the blood exerts increased pressure on the vascular wall. Failure of genetically inherited connective tissue fibers is enhanced by relaxation of vascular smooth muscle under the action of progesterone. As a result, the lumen of the vein dilates, the valves stop closing, blood is deposited in the vascular system of the lower extremities. As the disease progresses, the pathological process can spread to the vessels of the vulvar ring, vagina, and small pelvis.
Classification
The main criteria for the systematization of varicose vein forms are the anatomical prevalence of venous stasis and the severity of the disease. This approach allows a differentiated choice of treatment regimens for different variants of the disorder. Considering the involvement of different organs in the process, there are varicose veins of the lower extremities, veins with vulvar varicose veins, varicose veins of the pelvic organs. According to the severity of the clinical symptoms, the following stages of venous vasodilation of the lower extremities are distinguished:
- Compensated varicose veins. There are no external signs of vascular ectasia, the pregnant woman notices leg fatigue by the end of the day, discomfort in the calf muscles during exercise, and brisk walking.
- Veins with undercompensated 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 more than usual.
- Veins with decompensated varicose veins. The patient is constantly worried about the pain in the leg, the swelling is increasing. The veins are significantly enlarged, with nodules. The skin is hyperpigmented. There are signs of eczema and trophic disorders.
With varicose veins of the pelvis in pregnant women, the disease also develops in stages. In the first stage, the diameter of the affected vessels in each pelvic venous plexus 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 venous ectasia more than 10 mm with total damage to all pelvic venous plexuses.
Symptoms of varicose veins
In 80-82% of patients, the disease debuts with a heavy feeling, 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 some areas of the muscles, pain occurs, which first develops with prolonged stay, performing physical work. In the most severe cases, the pain becomes constant and its intensity can be expressed so much that the pregnant woman experiences difficulty in moving independently. Up to 60% of patients notice calf muscle cramps, up to 40-50% - loss of sensation, numbness of the legs, up to 30% - itching.
In the undercompensated phase of varicose veins, external signs of superficial vein dilatation appear. First, areas of reticular and telangiectasia vessels ("reticula" and "stars") form on the skin. Subsequently, the venous pattern becomes distinct. The veins look dilated, tangled, eventually knotted. The spread of the ectasia process in the deep vessels is evidenced by the appearance of edema in the area of the ankle and lower leg joints. With the decompensation of varicose veins, the skin of the feet appears hyperpigmented, eczema develops. If the pathology arose long before pregnancy, dystrophy of subcutaneous adipose tissue, trophic ulcers are possible.
In 4% of patients, the disease affects the veins of the vulva, vagina and pelvis. With varicose and vaginal varicose veins, discomfort, stretching, heaviness, itching are observed in the area of the external genitalia. There may be swelling of the perineum and labia, bleeding contact from the vagina after sex. Pelvic block syndrome is manifested by withdrawal or aching pain in the lower abdomen, which radiates to the lower back, sacrum, hips, and external genitalia. Dyspareunia (bitterness during sexual 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 thromboembolism and 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 labor force, lack of coordination of the contractile activity of the myometrium). With varicose veins, massive traumatic course of the postpartum period is possible. Almost a third of women at birth have defects in placental abruption and placental discharge. The long-term consequences of varicose veins that arise during pregnancy are hemorrhoids, chronic venous insufficiency and pelvic pain.
Diagnosis
With the appearance of characteristic skin signs, the diagnosis of varicose veins during pregnancy usually does not present any difficulty. The tasks of the diagnostic phase are phase determination and localization of venous ectasia, excluding other causes that may cause stagnation in the vascularity of the lower extremities. The most informative survey methods are:
- Inspection of the chair. The study reveals in the vulvar region and in the inner thighs characteristic changes in venous vessels - ectasia, tortuosity, nodules. Swelling of the labia and perineum is possible. When viewed in mirrors, the vaginal mucosa appears hypertrophied, cyanotic. Vaginal chambers with bimanual palpation are softened, often painful.
- USDG venous system. During the ultrasound scan, the shape and diameter of the vessels, their length, anatomical position and wall condition are assessed. The method allows you to determine the areas of branching, the stability of the valve apparatus, the opening of the veins, the presence and direction of the reflux. It is possible to scan both the vessels of the lower extremities and the inferior vena cava (IVC ultrasound).
- Double scan of leg vessels. The advantage of the non-invasive method, which combines traditional ultrasound and Doppler studies, is not only obtaining detailed information about blood flow parameters, but also visualization of the venous network. Angioscanning duplex is used for a comprehensive assessment of the condition of superficial, perforated and deep vessels.
Radiodiagnostic methods (varicography, selective vesography, adhesive phlebography of the extremities, pelvic phlebography, CT venography, phleboscintigraphy, etc. ) are used to a limited extent during pregnancy due to a possible negative effect on the fetus. In severe cases, with suspicion of varicose veins of the pelvis, diagnostic laparoscopy is performed carefully. Differential diagnosis of varicose veins of the legs is carried out with a decrease in pregnant women, heart failure, lymphedema, acute thrombosis of the venous system. Varicose veins of the pelvis should be differentiated from genital endometriosis, chronic inflammatory pathology of the pelvic organs, submucosal and subserosal fibroids of the uterus, 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 therapy for varicose veins 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 preferable if it is necessary to supplement with pharmacotherapy in safe stages of pregnancy:
- Compression therapy. A woman with a confirmed diagnosis of varicose veins is recommended to wear it every day throughout pregnancy, to use elastic bandages, special compression tights or compression class 1-2 socks during childbirth and the postpartum period. Compression treatment by mechanically reducing the diameter of superficial veins accelerates blood flow, reduces swelling and overload.
- Plant phlebotonics and phleboprotectors. The effect of the use of drugs of this group is accompanied by an increase in the tone of the venous wall, a decrease in its permeability, improvement of microcirculation, rheological properties of blood and lymph flow. 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 indicating a tendency for increased coagulation and threatening the development of DIC, drugs with antithrombotic activity are used with caution. To improve blood rheology and vascular microcirculation, pharmaceutical agents that prevent platelet aggregation and have an angioprotective effect are indicated.
Pregnant women with varicose veins are recommended special complexes of physiotherapy exercises, lymphatic drainage massage, dose walking, shower with daily sticky contrast. Diet correction includes eating foods rich in fiber and vegetable fats. Injection sclerotherapy, miniflebectomy, crytectomy, 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. Most often, surgical correction is performed at the end of the lactation period.
Delivery Tactics
The preferred birth method for varicose veins is natural childbirth, at the beginning of which elastic bandages or compression stockings are applied to the lower limbs of the woman giving birth. Patients with varicose-vaginal varicose veins require particularly careful maintenance of the continuous period by performing a protective perineotomy according to the indications. When the ectasia veins rupture, the damaged vessels are carefully connected with repeated sutures of the joint conglomerate. Cesarean section is recommended for patients at high risk of thromboembolic complications and veins with severe vulvar varicose veins.
Prediction and prevention
With timely detection and adequate therapy, the prognosis is favorable. For prophylactic purposes, it is recommended to have enough night sleep and periodic rest throughout the day in the supine position, with the feet placed on a firm surface at an angle of 30 °. Pregnant women with a charged heredity should refuse to wear shoes with heels longer than 5 cm, limit the length of sitting or staying, and control weight gain.
To prevent varicose veins, daily walking, reducing salt intake, taking vitamin supplements that strengthen the vascular wall are effective. Patients with varicose veins who are planning a pregnancy, according to the indications, undergo surgical interventions to correct the disease.