Varicose veins during pregnancyis an ectasia of venous vessels that appeared in the gestational period and is pathogenetically associated with it. It is manifested by severity, paresthesia, pain in the lower extremities and external genitals, swelling, muscle spasms, trophic lesions on the skin. It is diagnosed by examination, ultrasound angioscanning 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 generally used after delivery.
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 arise due to pregnancy. The disease is usually diagnosed for the first time in young patients, 75% of whom are under the age of 30. In more than two thirds of cases, the varicose veins clinic opens after the 20th week of the first pregnancy. The relevance of timely diagnosis of varicose veins is associated with the 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 to be a complication of pregnancy. The predisposing factor that causes vascular ectasia in 91% of patients is a genetically determined failure of the middle vein sheath, in which the amount of collagen is reduced and the content of polysaccharides is increased. The development of varicose veins in women with a constitutional predisposition during pregnancy is facilitated by:
- Increased circulating blood volume. The increase in BCC in pregnant women ranges 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 an adequate blood supply to the child, the woman's vital organs and the fetoplacental system.
- Hormonal changes during pregnancy. During pregnancy, the ovaries and placenta secrete progesterone and relaxin intensely. Under the influence of these hormones, the smooth muscle fibers in the veins relax and structural reconstruction of connective tissue occurs. As a result, the vascular wall faces worse with increased intravenous pressure.
- Compression of the vessels by the pregnant uterus. The growing uterus compresses the inferior vena cava and the iliac veins. The flow of blood out of the pelvis and lower limbs is impaired, the intravascular pressure increases, which causes the venous walls to stretch. The influence of this factor plays a fundamental role in the formation of varicose veins after the 25th week of pregnancy.
- Changes in the hemostasis system. As delivery approaches, blood fibrinolytic activity decreases and the number of clotting factors increases. This adaptation mechanism aims to reduce the physiological volume of blood loss during labor. This increases the likelihood of thrombosis of pathologically altered veins.
An additional etiofactor that contributes to the appearance of varicose veins in pregnant women is the decrease in physical activity. With insufficient work of skeletal muscles, blood stagnation in the legs and pelvis increases. 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 rupture of the compensatory capacities of the valve apparatus of the venous network. Due to the increase in BCC and the mechanical obstruction of the flow of the lower extremities, when the main veins are compressed, the blood exerts increased pressure on the vascular wall. The failure of the genetically inherited connective tissue fiber 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 the forms of 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, we distinguish the varicose veins of the lower limbs, the vulvar varicose veins, the varicose veins of Organs pelvic organs. 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 tiredness in the legs at the end of the day, discomfort in the calf muscles during exercises and brisk walking.
- Subcompensated varicose veins. A vascular pattern ("stars") appears on the skin. At night, the legs swell, at night there are cramps, numbness, pain. Bruises and scratches heal more than normal.
- Decompensated varicose veins. The patient is constantly concerned about pain in the legs, the swelling is increasing. The veins are markedly enlarged, knotty. The skin becomes hyperpigmented. There are signs of eczema and trophic disorders.
In pelvic varices 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 vessels is 6, 0-10, 0 mm. The third is characterized by ectasia of veins of more than 10 mm with total damage to all pelvic venous plexuses.
Symptoms of varicose veins
In 80-82% of patients, the disease begins with a feeling of heaviness, tension, "tingling" in the legs, increasing at night and during physical exertion. The symptomatology of varicose veins increases gradually. As the disease progresses in some areas of the muscles, pain arises, which first develops with prolonged standing, doing 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 on her own. Up to 60% of patients notice cramps in the calf muscles, up to 40-50% - loss of sensation, numbness in the legs, up to 30% - itching.
In the subcompensated phase of varicose veins, external signs of expansion of the superficial veins appear. First, areas of reticular vessels and telangiectasias ("reticles" and "stars") are formed on the skin. Subsequently, the venous pattern becomes distinct. The veins appear dilated, convoluted and eventually nodular. The spread of the ectasia process to deep vessels is evidenced by the occurrence of edema in the ankle joints and in the lower legs. With the decompensation of varicose veins, the skin on the legs becomes hyperpigmented and eczema appears. If the pathology appeared long before pregnancy, dystrophy of the subcutaneous adipose tissue, trophic ulcers are possible.
In 4% of patients, the disease affects the veins of the vulva, vagina and small pelvis. In the vulvar and vaginal varicose veins, discomfort, distension, heaviness and itching are observed in the external genital region. There may be swelling of the perineum and lips, contact bleeding from the vagina after sex. The pelvic congestion syndrome is manifested by distension or painful pain 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 labor. In 40-45% of cases, placental insufficiency occurs with acute and chronic fetal hypoxia. Abnormalities of labor are observed in 25% of patients (weakness of labor forces, uncoordination of myometrial contractile activity). With vaginal varicose veins, the massive traumatic course of the postpartum period is possible. Nearly a third of women in labor have defects in placental separation and placental secretion. The long-term consequences of varicose veins that arise during pregnancy are hemorrhoids, disabling chronic venous insufficiency and pelvic pain.
Diagnosis
With the appearance of characteristic cutaneous signs, the diagnosis of varicose veins during pregnancy generally presents no 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 limbs. The most informative search methods are:
- Chair inspection. The study reveals characteristic changes in the venous vessels in the vulvar region and in the inner thighs - ectasia, tortuosity, nodosis. Swelling of the lips and perineum is possible. When seen in the mirrors, the vaginal mucosa appears hypertrophied, cyanotic. Vaginal vaults with bimanual palpation are softened, usually painful.
- USDG of the venous system. During ultrasound, the shape and diameter of the vessels, their length, anatomical position and the condition of the wall are evaluated. The method allows to determine the branching zones, the consistency of the valve apparatus, the permeability of the veins, the presence and direction of the reflux. It is possible to scan the vessels of the lower extremities and the inferior vena cava (IVC ultrasound).
- Duplex scanning of the leg vessels. The advantage of the non-invasive method, which combines traditional ultrasound with Doppler, is not only to obtain detailed information about blood flow parameters, but also to visualize the venous network. Duplex angioscanning is used for a comprehensive assessment of the condition of superficial, perforating and deep vessels.
Radiodiagnostic methods (varicography, selective ovaricography, ascending phlebography of the extremities, pelvic phlebography, CT venography, phleboscintigraphy, etc. ) during pregnancy are used to a limited extent due to a possible negative effect on the fetus. In difficult cases, with suspected pelvic varices, diagnostic laparoscopy is performed with caution. The differential diagnosis of varicose veins in the legs is made with hydrops of the pregnant woman, heart failure, lymphedema, acute thrombosis of the venous system. Varicose veins of the small pelvis must be distinguished from genital endometriosis, chronic inflammatory pathology of Organs pelvic organs, submucosal and subserous uterine fibroids, cysts and other ovarian tumors. In addition to the observation of an obstetrician-gynecologist, it is recommended that the patient 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 disease, mitigate the severity of the clinical condition and prevent possible thromboembolic complications. Non-pharmacological methods are considered preferable, if necessary supplemented with pharmacotherapy in safe periods of pregnancy:
- Compression therapy. A woman with a confirmed diagnosis of varicose veins should wear it daily during pregnancy, wear elastic bandages, special compression pants or socks of 1 to 2 classes of compression during childbirth and the postpartum period. The compression treatment by mechanically reducing the diameter of the superficial veins accelerates blood flow, reduces swelling and congestion.
- Phlebotonics and phytotherapic phleboprotectors. The effect of drug use in this group is associated with increased venous wall tone, decreased permeability, improved microcirculation, blood rheological properties and lymph flow. The advantage of most bioflavonoids is that they can be used during pregnancy and lactation. Phlebotonic drugs are prescribed in tablets and externally.
- Anticoagulants and antiplatelet agents. In the presence of indicative signs of a tendency to increase clotting and a threat of development of ICD, drugs with antithrombotic activity are used with caution. To improve blood rheology and vascular microcirculation, pharmaceutical agents are 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 rising contrast shower. The correction of the diet involves the consumption of foods rich in fiber and vegetable fats. Injection sclerotherapy, miniflebectomy, cruzectomy, laser endovasal coagulation and other surgical treatment methods are used in exceptional cases with severe forms of the disease, severe pain syndrome and the presence of complications. Most of the time, surgical correction is performed at the end of the lactation period.
Delivery tactics
The preferred method of delivery for varicose veins is natural delivery, at the beginning of which elastic bandages or compression garments are applied to the woman's lower limbs. Patients with vaginal-vaginal varicose veins require a particularly careful maintenance of the persistent period with the performance of a protective perineotomy, as indicated. When the ectasized veins rupture, the damaged vessels are carefully connected with repeated points of the nodule cluster. Cesarean section is recommended for patients at high risk for thromboembolic complications and severe vulvar varicose veins.
Prediction and prevention
With timely detection and adequate therapy, the prognosis is favorable. As a prophylactic measure, it is recommended to have enough night sleep and periodic rest throughout the day in a supine position with your legs resting on a firm surface at an angle of 30 °. Pregnant women with heredity under load should refuse to wear shoes with a heel of more than 5 cm, limit the time spent sitting or standing and control weight gain.
To prevent varicose veins, daily walks, reduced salt intake and intake of vitamins that strengthen the vascular wall are effective. Patients with varicose veins planning to become pregnant, according to the indications, are submitted to surgical interventions to correct the disease.