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Patient coordinatorVenous disease in pregnancy
Introduction
Venous disease in pregnancy is a complex health problem covering a wide range of conditions, including: venous insufficiency of the lower limbs, pelvic venous insufficiency, venous thrombosis and its consequences, i.e. incidents thromboembolism and post-thrombotic syndrome. Pregnancy in itself is a significant risk factor for the development of venous disease, as the changes taking place in the mother-to-be's body, such as an increase in hormone levels, an increase in circulating blood volume or pressure from the uterus on the venous vessels, predispose to venous pathologies. Each subsequent pregnancy worsens the venous problems. It is therefore important to prepare adequately for pregnancy, childbirth and the postpartum period. The prevention of venous disease and the treatment of pelvic venous insufficiency before a planned pregnancy are two key issues that expectant mothers should be aware of.
Genetic and anatomical predisposition also play a key role in the development of venous disease in pregnancy. Genetic predisposition in combination with anatomical conditions is particularly important for the development of pelvic venous insufficiency and secondary venous insufficiency of the lower limbs. A large stasis of venous blood in the parametrial venous plexuses and branches of the internal iliac veins, in turn, increases the risk of venous thrombosis during pregnancy and postpartum.
Venous disease in pregnancy is a significant medical problem, affecting up to 40-80% pregnant women according to recent epidemiological studies (the incidence depends on the number of pregnancies and births). Venous thromboembolism in turn poses a serious health risk to pregnant women, being one of the leading causes of maternal morbidity and mortality in developed countries. It is estimated that the risk of thromboembolic disease in pregnancy is 4-5 times higher than in women who are not pregnant. Furthermore, multiple pregnancy, ovarian hyperstimulation syndrome and pre-eclampsia further increase the risk of venous thrombosis. Particularly dangerous is thrombosis of the parametrial venous plexuses and the right ovarian vein, which is often underdiagnosed and can lead to massive pulmonary embolism.
Factors that increase the risk
occurrence of venous disease in pregnancy
Venous insufficiency
- genetic predisposition (presence of varicose veins in first-degree relatives)
- subsequent pregnancies (each subsequent pregnancy significantly increases the risk of venous insufficiency)
- Pregnant woman's age over 35
- being overweight or obese before pregnancy
- venous insufficiency diagnosed and untreated before pregnancy
- history of thrombosis or thrombophlebitis
- standing or sitting for long hours
- non-use of medical compression therapy during pregnancy
Venous thrombosis
- congenital or acquired thrombophilia (hypercoagulability)
- history of venous thrombosis (especially idiopathic, gestational or oestrogen-dependent)
- Pregnant woman's age over 35
- caesarean section (especially emergency)
- immobilisation during pregnancy
- ovarian hyperstimulation syndrome
- multiple pregnancy
- comorbidities (pre-eclampsia, antiphospholipid syndrome, lupus, inflammatory bowel disease, nephrotic syndrome)
Mechanism of venous disease in pregnancy
Mechanism of formation venous insufficiency in pregnancy is complex and involves several overlapping pathophysiological processes. At the level of haematology and haemodynamic Pregnant women experience a significant increase in circulating blood volume (up to 30-50%), with the increase in plasma volume (45%) outweighing the increase in erythrocyte count (30%), leading to a decrease in blood cell concentration. The viscosity of the blood increases and there is a activation of prothrombotic factors. The venous system experiences venous stasis and slowed blood flow, particularly in the lower limbs.
Hormonal changes play a key role during pregnancy and throughout its entire duration. High concentrations of progesterone cause the smooth muscles in the walls of the venous vessels to relax and weaken their tension. Estrogens increase the permeability of the vessel walls and influence the remodelling of the connective tissue in the vessel walls. Relaxin additionally affects the weakening of collagen structure in the vein walls. These changes lead to an increased susceptibility of the venous vessel walls to stretching and a weakening of venous valve function.
At anatomical aspect The compression of the enlarging uterus is crucial. In the third trimester of pregnancy, the uterus presses on the iliac vein drain and, in time, on the inferior vena cava and the renal vein drain, leading to obstruction of blood outflow from the lower limbs and pelvis. Increased abdominal pressure further impedes venous return. Pressure on the inferior vena cava can cause blood flow to be redirected to the spinal veins and the unpaired venous system, which does not fully compensate for the haemodynamic disturbance.
Did you know?
According to our many years of research and observations of women, 'pregnancy' is the most important factor responsible for the development of widespread venous insufficiency, including pelvic venous insufficiency.
Dr Justyna Wilczko-Kucharska, MD
When it comes to venous thrombosis in pregnancyits pathogenesis is based on Virchow's classical triadbut with pregnancy-specific modifications. Venous stasis is exacerbated by the mechanical compression of the uterus described above. The hypercoagulable state in pregnancy results from an increase in the concentration of coagulation factors (especially fibrinogen, factors VII, VIII, X) with a concomitant decrease in the activity of natural anticoagulants (protein S) and increased resistance to activated protein C. In addition, the mechanism of fibrinolysis, the process of physiological breakdown of fibrin (fibrin) - the key component of a blood clot - is impaired.
At postpartum period The risk of thrombosis is particularly high in the first six weeks due to rapid hormonal changes, vascular trauma associated with childbirth (especially with caesarean sections), temporary immobilisation and persistent hypercoagulability. An additional factor is the increase in factor VIII and von Willebrand factor concentrations in the early postpartum period. The return of haemostasis parameters to their pre-pregnancy state occurs gradually within 6-8 weeks after termination of pregnancy.
The totality of these changes creates a specific environment that favours both the development of venous insufficiency and the formation of venous thrombosis, requiring particular diagnostic vigilance and appropriate prophylactic management, especially in patients with additional risk factors (see table above).
Most common abnormalities in the venous system of pregnant women
- inferior vena cava syndrome - Inferior vena cava compression caused by the enlarging uterus.
- left renal vein stenosis - most commonly occurs in the third trimester of pregnancy
- left common iliac vein stenosis - occurs already in the second trimester of pregnancy
- dilatation of ovarian veins – najczęstsza przyczyna pociążowej niewydolności żylnej miednicy u kobiet
- dilatation of the parietal venous plexuses - usually monstrous in size - derived from ovarian venous insufficiency
- external iliac vein compression
- dilatation of the internal iliac veins
- varicose veins of the perineum and vulva
- partial insufficiency left saphenous vein
Recognition and diagnosis
Diagnosis and recognition venous disease in pregnancy is based on a multi-stage approach. Analysis of the problem always begins with a detailed medical history. It is crucial to establish the presence of symptoms typical of venous insufficiency and to determine the timing of their onset. A family history of venous disease and thrombophilia is of prognostic importance.
The physical examination includes a detailed visual and palpation assessment of the lower limbs and the vulva and perineal area. It is standard practice to measure the circumference of the limbs at specific levels to select the compression therapy for pregnancy (stockings or compression tights appropriately selected for the patient).
The examination of choice in the evaluation of the venous system in pregnancy (both in terms of assessing venous system capacity and thrombotic changes) is Doppler ultrasonography. The examination is performed in the standing and supine positions, assessing the flow in the main venous trunks, the condition of the valves in the vessel lumen, the presence of reflux and the patency of the main vascular trunks.
Pregnant patients with advanced limb venous insufficiency, a history of pelvic venous insufficiency, perineal and vulvar varicose veins and those with suspected venous thrombosis should always have an examination of the transabdominal Doppler ultrasound with evaluation of veins in the abdominal and pelvic cavities.
Diagnostics venous thrombosis in pregnancy - in addition to performing a venous Doppler ultrasound - is sometimes supplemented by determining D-dimer levels (taking into account the physiological increase during pregnancy). Compression ultrasound remains the gold standard for diagnosis. In doubtful cases or when pulmonary embolism is suspected, additional imaging studies may be necessary taking into account fetal safety.
In doubtful and life-threatening cases (especially in the third trimester of pregnancy), it is sometimes resorted to MR venography (It is preferable to perform the examination without the administration of a contrast agent). Venography is quite difficult in pregnant women due to fetal movements It does, however, provide high sensitivity and specificity in detecting thrombi within the internal iliac and ovarian veins.
Prevention and treatment of venous disease in pregnancy
Treatment venous disease in pregnancyIf it occurs, it is limited to minimising its complications and progression. We recommend conservative management consisting of lifestyle changes (avoiding prolonged standing and sitting, lifting and staying in one position that impairs venous outflow in the abdominal and pelvic cavities). Regular walking or leg exercises that activate the calf muscles are recommended. With regard to exerciseThe exercises are always adapted to the patient's capabilities and the stage of pregnancy. In addition to the aforementioned walks, exercises such as swimming or gentle yoga are recommended. When resting, it is recommended to raise the legs above the level of the heart.
Hot baths, sauna or underfloor heating can exacerbate the symptoms of venous insufficiency. They should therefore be avoided during pregnancy. Healthy dietrich in fibre and low in salt, helps maintain a healthy body weight and prevents constipation, which can significantly exacerbate the symptoms of pelvic venous insufficiency.
Compression therapy plays a key role in pregnancy. It represents both treatment and prevention. Compression stockings or tights improve venous blood flow, reduce swelling, prevent vein dilatation in the legs, significantly reducing the risk of venous thrombosis.
During pregnancy, products in compression class II (CCL: 23-32 mmHg) are usually used. Class I (CCL1) is more likely to be used for women with their first pregnancy who have very little venous complaints. The sizing of compression stockings or tights takes place every 10-14 weeks due to the possibility of changing circumferences. It is important that the compression is applied by pregnant women throughout the day.
Phlebotropic drugs are sometimes used in pregnancy. However, prior consultation with a gynaecologist or phlebologist is required.
Pregnant women (usually from the second pregnancy onwards) experience pelvic venous insufficiency and varicose veins of the intimate area. In such cases it is recommended to use specialised belts and tourniquets fixated with adhesives and braces. They provide support to the groin and perineal area, improving blood circulation and reducing symptoms.
For women at high risk venous thrombosis (e.g. in ladies with known thrombophilia, a history of miscarriages or advanced pelvic venous insufficiency), the doctor may consider implementing thromboprophylaxis.
Treatment methods
Mostly
questions asked
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As much as possible. Pain and a feeling of skin tension in the vulva and perineal area are often associated with pelvic venous insufficiency and so-called varicose veins of the intimate area. This problem is quite common - it affects about 20% pregnant women, especially in the 3rd trimester. In women who are in their 3rd or 4th pregnancy, vulvar and perineal varicose veins are much more common. Special compression straps for the intimate area, avoidance of prolonged sitting, regular walking and pelvic pressure-relieving positions are helpful in these situations. In cases of intense discomfort, consultation with a phlebologist or gynaecologist is necessary.
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The increased risk of thromboembolic complications persists for about 6-8 weeks after delivery (the postpartum period). This is a particularly dangerous period due to the persistent hypercoagulability of the blood and the often limited physical activity of the woman giving birth. During this period, special care should be taken with thromboprophylaxis, use of compression therapy and maintenance of adequate physical activity. Pharmacological prophylaxis may be required for additional risk factors.
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Immediate phlebology consultation require the following symptoms (the symptoms listed below may indicate a thrombotic or thromboembolic incident):
- sudden, unilateral pain in the calf or thigh
- asymmetrical swelling of one limb (more often on the left side)
- reddening and overheating of the leg skin (easily visible at the varicose vein's projection; the varicose vein also becomes hard and painful)
- sudden onset of dyspnoea, especially if combined with lower abdominal pain or leg swelling
- unusual, severe chest pain.
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- superficial thrombophlebitisThis is considered the least serious form of thrombosis. However, it is sometimes complicated by deep vein thrombosis even in 20% cases. The typical symptom of superficial thrombophlebitis is a large inflammatory reaction accompanied by soreness and redness. It is most commonly located within a varicose vein lesion. Treatment is usually conservative, consisting of the use of topical preparations and the use of compression properly selected for the affected lower limb.
- deep vein thrombosis: it is estimated that during pregnancy and the postpartum period its incidence can exceed as many as 1% cases. Any deep vein thrombosis in pregnancy must be treated as a life-threatening condition that can end in pulmonary embolism. Venous thrombosis in pregnancy is treated with low molecular weight heparins, coumarin derivatives are contraindicated.
- During pregnancy, so-called venous compression syndromes become a major problem. This is most often due to uterine enlargement and pressure on the iliac drains. Venous thromboses in the iliac-femoral segment are found far more frequently on the left side. This is mainly due to the asymmetrical anatomy and unfavourable arteriovenous to venous relationships.
- thrombosis of the venous plexuses of the small pelvis and the ovarian vein: it is an underestimated and underdiagnosed type of venous thrombosis in pregnant women, especially in ladies with varicose vein plexuses of the parietal veins giving birth for the 3rd or 4th time, in those with undiagnosed hypercoagulability or in ladies after deliveries resolved by caesarean section. The most common type of thrombosis in this location involves the right ovarian vein (more than 70% cases). Symptoms of severe pain (it can mimic the pain of appendicitis), raised body temperature or nausea usually appear up to 2-14 days after delivery. It is a dangerous condition that can end in massive pulmonary embolism.
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Compression therapy (compression treatment) is best started prophylactically already in the first trimester of pregnancy, even if no symptoms of venous insufficiency are yet present. Early implementation of compression significantly reduces the risk of developing varicose veins and other venous complications. Stockings should be put on in the morning before getting out of bed, when the legs are not yet swollen. If the first symptoms of venous disease appear (feeling of heavy legs, swelling, vascular spider veins or varicose veins), you should start wearing compression products immediately. Please remember that the selection of compression devices should be combined with a Doppler ultrasound examination and an assessment of the severity of the venous disease.
Pregnancy planning and venous insufficiency of the lower limbs
Planning a pregnancy and worried about varicose veins? 😟 In this video you will learn how to prepare your legs for this special time! Learn the key steps to minimise your risk of venous insufficiency and enjoy a healthy pregnancy. 💪
Dr Venus: virtual patient advisor
Looking for an answer to your vein question? Ask our Dr. Venus!
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Can you advise me on compression therapy in pregnancy? -
Of course! Compression therapy in pregnancy is an important part of the prevention and treatment of venous problems.
Modern vein treatment
We offer treatment both on an outpatient basis and in day ward admissions. The stay is of short duration. The patient spends between 1 and 5 hours in the Clinic.
