Varicose Veins In Pregnancy

Introduction

Varicose veins are enlarged, twisted veins that lie just beneath the skin. Although varicose veins can be found in other parts of the body, like around the genitals and rectal area
(in the case of haemorrhoids), they are most prominent in the legs because the veins in the lower part of the body are most impacted by the pressure of standing and walking.¹

Varicose veins are usually harmless but may sometimes cause discomfort or pain. They occur in a lot of pregnant women because of hormonal changes and the uterus applying pressure on the inferior vena cava, a large vein that carries blood back to the heart from the feet and legs. This article intends to shed more light on varicose veins, its prevalence in pregnancy, effects and possible cure or management.

Understanding Varicose Veins

Varicose veins, also known as spider veins, varicoses, or varicosities are defined as dilated, elongated, and palpable superficial veins as a result of venous hypertension. Any vein close to the surface of the skin can become varicose. They are caused by damaged or weak vein walls and valves. The valve acts as a guide that directs the flow of blood toward the heart. Once weakened, this blood flow is disrupted, and blood might begin to pool in the veins or flow in the wrong direction. This then leads to an enlarged, distorted vein known as a varicose vein.²

Varicose veins may form due to an increase in blood pressure inside the veins caused by several factors including pregnancy. This weakens the walls of the vein, and the valves do not function properly and causing blood to back up in the vein or even flow backwards, a process called reflux.³ The affected veins may grow larger, and a blue or purple discolouration is seen, resulting in varicose veins. 

Veins are an important part of the cardiovascular system that carry blood to the heart. There are two (2) main types of veins: pulmonary and systemic veins. The former carries oxygen-rich blood from the lungs to the heart, while the latter collects oxygen-deficient blood from around the body back to the heart. In addition to these two types, there are the superficial veins and deep tissue veins. The superficial is located close to the surface of the skin and is not close to any corresponding artery. The deep tissue veins are found deep within the muscle and are typically located near corresponding arteries.⁴

Prevalence of Varicose Veins in Pregnancy 

Pregnancy is a known risk factor for developing varicose veins. Approximately 40% of pregnant women get varicose veins and in 70 to 80% of these, the symptoms appear in the first trimester.⁵ During pregnancy, hormone changes and the weight of the growing baby increase women’s susceptibility to varicose veins. This is due to: 

• Higher levels of the hormone progesterone relaxes blood vessel walls and may decrease the function of the valves found within the vessels. 
• Increase in the blood volume in the body.
• Pressure from the baby in the pelvic region can change blood flow in this region and in the legs. 

These factors increase the workload of the veins and make it more difficult for blood to move from the lower parts of the body to the heart. Other factors that may increase the risk of developing varicose veins during pregnancy include age, poor diet, genetics, or family history, increasing parity, excessive weight gain, and pre-eclampsia.

Symptoms of Varicose Veins in Pregnancy

Varicose veins often come with a visible sign (discolouration of affected veins) but sometimes no symptoms. However, some experience the following symptoms while sitting or standing for extended periods. These include heavy feelings in the legs, itching around the veins, leg cramps, swelling in the legs and ankles and tenderness in the lower legs. Varicose veins can be associated with an increased risk of a blood clot in a deep vein (also known as a deep vein thrombosis). This can lead to more serious complications, including pulmonary embolism (a blood clot from the leg that travels to the lungs) and ulcers.

Diagnosis and Evaluation

Physical or visual examination of the affected area is normally used to diagnose varicose veins. If symptoms are severe, the doctor may recommend diagnostic tests like an ultrasound to check the blood flow in the veins. An example is the Doppler ultrasound to measure blood flow in the superficial and deep tissue veins. This non-invasive test uses sound waves to show the direction and speed of blood in the arteries and veins and can detect blood clots and other issues that affect the blood vessels.

Early diagnosis is important as varicose veins may indicate deeper circulatory problems and in rare cases, may lead to complications like ulcers or blood clots.⁶ Although it is impossible to stop varicose veins from forming, early detection can lead to simpler treatments and better outcomes. If left untreated, varicose veins can cause pain and other symptoms that can impact mobility.

Management and Treatment

Most times, varicose veins are not harmful to either mother or baby and do not require any treatment. However, there are signs that should not be ignored and should be reported to your healthcare provider. These include: 

• Bleeding from the vein
• Open sore or ulcer on the skin near the varicose vein
• Pain, swelling, and redness in the leg or affected area

The first line of treatment normally begins with lifestyle adjustments, such as dietary changes, losing weight, exercising, elevating the legs to increase blood flow, and wearing compression stockings. If simple interventions do not work, medical procedures are also available to remove or close the affected veins:

• Sclerotherapy – injecting the varicose veins with a solution that scars and closes the veins. The treated veins fade over time but may require more than one injection. 
• Endovenous laser treatment (EVLT) – a minimally invasive procedure performed using a local anaesthetic. Strong bursts of light are sent into the vein that makes them gradually fade or disappear.
• Catheter-based procedures – this method uses radiofrequency or laser energy and is preferred for treating larger varicose veins. A tube is inserted into the enlarged vein, the tip is heated using radiofrequency or laser energy, and the heat destroys the vein, causing it to collapse and seal shut. 
• Ambulatory phlebectomy – smaller varicose veins are removed through a series of tiny punctures to the skin.⁷

If the above interventions are not suitable, a surgical procedure can be used to remove affected veins under general anaesthetic. 

• High ligation and stripping – this is a surgical procedure that requires tying off a vein through small cuts before it joins a deep tissue vein.
• Transilluminated powered phlebectomy – a new treatment where small incisions are made in the leg, and an endoscopic transilluminator is then placed underneath the skin to see the affected veins. These veins are cut before they are removed through the incisions using a suction device.⁸ 

Prevention

Varicose veins are very common in pregnancy; they tend to get better three (3) to four (4) months postpartum when the uterus is no longer pushing on the pelvic cavity and inferior vena cava. The most common way to reduce the prevalence of varicose veins during and after pregnancy is to improve circulation. This can be achieved in many ways including: 

• Regular physical activity or exercise 
• Wearing maternity pantyhose or compression stockings
• Sitting with legs uncrossed to improve circulation
• Changing position to avoid long periods of sitting or standing
• Putting feet up several times a day
• Sleeping on the left side to keep pressure off the inferior vena cava

Other strategies include lifestyle changes and adhering to a healthy, low-sodium diet.

During pregnancy, managing varicose veins should also be done by conservative means since they are usually harmless and often get better after the baby is born. The above preventive measures can, therefore, be followed to relieve symptoms or prevent them from getting worse. Managing stress levels should also be considered during pregnancy. Although stress does not directly cause varicose veins, it may amplify the symptoms.

Coping with varicose veins during pregnancy

Living with varicose veins during pregnancy may have a psychological impact on the woman. The visible signs and symptoms of varicose veins can make it challenging to feel comfortable in your own body, therefore affecting self-esteem. It can also cause anxiety, stress, isolation from others, and in extreme cases where daily activities are impacted, depression, affecting overall quality of life.⁹ To combat these, the following strategies can improve overall well-being.

• Practising self-care
• Staying active – this can help reduce pain and improve blood circulation as well as improve physical and mental health.
• Seeking support from loved ones or speaking to a therapist

Summary

Varicose veins are often harmless, twisted veins often seen in the legs, genitals or rectum but get better after the baby arrives. Many factors can increase the risks of developing them and can be managed with minimal intervention. Pregnant women with varicose veins should be encouraged to seek medical advice if they develop painful symptoms and should be given the required physical and psychological support to improve overall well-being.