Varicose veins during pregnancy. Phlebologist's recommendations for pregnant women

Chronic venous insufficiency and pregnancy

Pregnancy is a wonderful natural state. However, pregnancy does not always go smoothly. Hormonal changes during this period of life have a positive effect on a woman's body, protect it, but the same hormones can greatly complicate the work of other organs and systems. Most of the changes occur with the connective tissue. This can cause various problems: pain in the lower back and joints, the appearance of ""stretch marks"" on the skin of the chest and abdomen, flat feet. In addition, 50% of women develop either dilated skin capillaries or varicose veins during pregnancy. With repeated pregnancies, this percentage increases, and the risk of thrombotic complications also increases sharply.

Nature made sure that a woman does not lose a lot of blood during childbirth. To prevent this from happening, during pregnancy, under the influence of hormones, the blood becomes thicker. Thickening of the blood, as well as venous stasis, increase the risk of blood clots in the veins by 3-5 times. The formation of blood clots in the veins can cause an extremely difficult and sometimes fatal complication - thromboembolism of the pulmonary artery, which threatens not only the health, but also the life of the mother and the future child. The high risk of thrombosis persists for 6 weeks after delivery and is very dangerous, especially after cesarean section or heavy blood loss during delivery. Thus, pregnancy is actually a thrombogenic condition. This means that the normal changes that occur in the body during a physiological pregnancy contribute to an increase in the probability of deep vein thrombosis.

These changes are as follows:

• Significant slowing of blood flow in the deep veins of the legs due to increased blood outflow from the placental part of the uterus with congestion of the saphenous veins;
• Decreasing the tone of the vein walls and their physiological expansion, which leads to natural valvular insufficiency and backflow of blood;
• Increased pressure in the veins of the lower extremities by 2-3 times;
• Increased production of sex hormones - progesterone and relaxin, which directly affect elastic fibers and reduce vascular smooth muscle tone;
• A significant increase in the concentration of blood clotting factors;
• Decrease in fibrinolytic (dissolving clots or blood clots) ability of blood at the end of pregnancy and in the first period of childbirth;
• Inflow of active substances into the blood after separation of the placenta.

Difficulty of venous outflow from the lower extremities during pregnancy is caused by a cascade of five mechanisms:

- Mechanical factor. An enlarged uterus is an obstacle to circulation, as it compresses the inferior vena cava, pressing it against the vertebral column and the iliac muscle.

- Circulatory factor. An increase in blood volume and blood outflow from the heart leads to an increase in the load on the veins and their expansion. This is especially important for the veins of the lower extremities and the vaginal area.

- Hormonal factors. Progesterone, by relaxing smooth muscle fibers, leads not only to a decrease in the tone of the venous wall, but also to a decrease in the tone of the urethra, bladder, and small intestine.

- Hemostatic factors. Changes in the hemostasis system always occur in the direction of increased clotting (increased fibrinogen level, increased platelet activity and decreased fibrinolytic activity).

- Hemorheological factors. Blood viscosity increases despite a decrease in hematocrit

- Other contributing factors. These factors include a heavy family history, a sedentary lifestyle, prolonged immobile posture while working, driving a car, too high and thin heels, obesity, hot baths, multiple pregnancies or short intervals between them.

Danger occurs from the 5th month of the first pregnancy, significantly increases with each subsequent one. The starting factor is the hormonal changes that occur in the body of a pregnant woman: the release of a large number of female sex hormones, in particular, hormones of the corpus luteum. In addition, the pregnant uterus grows and gradually compresses the large veins in the small pelvis and abdominal cavity, creating a barrier for the outflow of venous blood from the lower extremities. As a result, there is stagnation of venous blood and an increase in pressure in the veins of the legs and pelvis.

During pregnancy, a woman's body undergoes many changes. The hormone progesterone, which is responsible for the preservation and development of the fetus, affects not only the uterus, but also the veins, their smooth muscle cells, due to which their tone decreases. The effect of progesterone begins from the first days of conception and fetal development. A high level of the hormone leads to the development of degenerative changes in elastic and collagen fibers, as a result of which the veins become less elastic and expand. The process is faster if the hormonal background was disturbed even before pregnancy, as well as if the woman took hormonal drugs (for example, oral contraceptives).

The development of varicose veins during pregnancy is caused by many factors. An increase in the volume of circulating blood leads to an increase in pressure on the vessels. Because of this, veins suffer, as their wall has less density and elasticity compared to arteries.

The enlarged uterus presses on the veins of the small pelvis, which leads to a delay in blood flow from the legs to the upper part. For this reason, varicose veins of the lower extremities appear. The increase in pressure on the blood vessels of the lower extremities occurs due to the constant weight gain of a pregnant woman. Subcutaneous veins, which are not surrounded by muscles, are more affected than deep veins. They are most often subject to varicose veins, since their wall is not surrounded by an outer layer of the muscle frame.

The following forms of varicose veins in pregnant women are distinguished:

• Varicose disease of the lower extremities
• Varicose dilatation of the veins of the small pelvis
Varicose veins of the external genitalia
• Pelvic venous congestion syndrome
• Syndrome of the right ovarian vein
• Varicose enlargement of ovarian veins (varicoovarium)

Currently, there are 2 variants of the course of varicose veins of the small pelvis: varicose veins of the perineum and vulva, as well as the syndrome of pelvic venous congestion. It should be emphasized that this separation is quite conditional, since in more than 50% of cases, varicose veins of the perineum and vulva provoke a violation of blood flow from the pelvis and vice versa.

Varicose dilatation of the veins of the perineum and vulva

It is observed in 30% of women during pregnancy. The mechanisms of this condition are similar to varicose veins of the lower extremities. Varicose transformation of the veins of the perineum, which is progressing, is complicated by the compression of the main veins of the retroperitoneal space (the saphenous veins and the inferior vena cava) by the pregnant uterus. Outside of pregnancy, it persists in 2-10% of cases.

Pelvic Congestion Syndrome

The variety of clinical manifestations and the imperfection of diagnosis mask it under various forms of gynecological (inflammatory diseases of the uterus and its appendages, endometriosis), urological (cystitis), surgical (colitis, Crohn's disease, etc.) and even orthopedic (disease of the hip joint) pathology .

This disease is associated with varicose expansion of the venous plexuses of the ovaries and the wide ligament of the uterus. The main mechanism is valvular insufficiency of the ovarian veins, which leads to blood loss and increased pressure in the venous plexuses of the pelvis. Factors can be retroflexion of the uterus, which leads to bending of the wide ligament of the uterus, which complicates the outflow of venous blood, as well as various gynecological diseases (endometriosis, tumors of the uterus and ovaries). In recent years, the adverse effects of hormone therapy and contraception have been discussed. The influence of the hormonal background is evidenced by the fact that the manifestations of the syndrome of venous engorgement of the small pelvis in the post-menopausal period become less pronounced.

The clinical picture of the disease is characteristic and is manifested by varicose veins of the perineum, vulva, vagina, and lower extremities (cosmetic defect), which progresses as the pregnancy period increases.

Signs of such violations will be:

• Itching in the area of ​​enlarged veins.
• Feeling of heaviness and distending pain in the perineum, small pelvis, swelling of the external genitalia, lower limbs.
• Dyspareunia (pain during intercourse)
• Dysmenorrhea
• Pronounced premenstrual syndrome
• Pains when walking and physical exertion
• Pain along the veins
• Pain and ache in legs
• Dysuric disorders
• Fatigue
• Development of acute varicothrombophlebitis and rupture of altered veins, accompanied by massive bleeding.

Thrombosis during pregnancy is an extremely important clinical problem that can cause maternal mortality (20% of all causes). As you know, during pregnancy there is a tenfold increase in the risk of thrombosis. The frequency of thrombosis is 0.7-4.2/1000 in pregnant women against 1/10000 in non-pregnant women of childbearing age.

The critical stage of the thrombotic process is thromboembolism of the pulmonary artery - an extremely difficult and often fatal complication of thrombosis. PE is the leading cause of maternal mortality in obstetric practice in the West - 0.7 cases per 1000 births (from 11 to 27%). The probability of venous thromboembolic complications (VTE) during cesarean section is 3-6 times higher. The risk of VTU development returns to the level characteristic of non-pregnant women 6 weeks after delivery.

The main risk factors of VTU include:

• Age > 35 years
• Caesarean section
• Weight > 80 kg
• Individual and family history of thrombosis
• Repeated childbirth
• Ovarian hyperstimulation
• Prolonged immobilization
• Varicose disease
• Thrombophilia

The complexity of treating VTU during pregnancy is as follows:

• Direct dependence on the period of pregnancy (safe periods of pregnancy for active treatment tactics – 7-8, 13-17, 23-27 weeks).
• Difficulty in selecting the type and dosage of anticoagulant
• High probability of termination of pregnancy and (or) development of complications
• The need to solve a difficult question about the choice of treatment tactics
• Ethical problem of choosing to preserve life
• The problem of achieving compliance with the patient and her relatives

As for varicose veins of the lower extremities during pregnancy, this problem is broad and ambiguous. Patients with varicose veins who plan to become pregnant must clearly understand the risks for themselves, adequately assess the danger that the disease poses not only for the mother, but also for the future child, so as not to transfer all responsibility to doctors, who in such a case will have very limited opportunities. Such responsibility should primarily lie with the parents of the future child. Experts always insist that varicose veins should be treated before pregnancy, then there will be no corresponding risk.

On the one hand, the presence of varicose veins is the main risk factor for the occurrence of VTU, that is, there is a strong need for the prevention of such complications - surgical treatment. On the other hand, during pregnancy, the possibilities of surgical treatment are sharply limited by safe periods of pregnancy. And if the patient has a wide enough choice of treatment methods before pregnancy, then if complications of varicose veins occur during pregnancy, for example, thrombophlebitis, only a standard operation will be a possible method of vein removal. And this is general anesthesia and the need to prescribe medication, which is a direct threat to the fetus, and in addition, there is also a pronounced surgical trauma that causes certain changes in the body that are clearly not beneficial to the pregnant woman and the fetus. In this case, modern minimally traumatic methods of surgical treatment - EVLO and RCHO - have a clear advantage, since they do not require the use of general anesthesia and the prescription of a large number of medications, and also do not cause severe surgical trauma and are safe. However, in this case, taking into account the constant growth of the pregnant uterus and changes in venous circulation with a sharp increase in pressure in the veins, the probability of relapse is very high. An important factor will be certain conditions and technical possibilities of such an intervention.

Therefore, if a patient with varicose veins seeks help already during pregnancy, in most cases conservative methods of prevention are still prescribed, as a rule, compression therapy, taking phlebotropic drugs during safe periods of pregnancy, dynamic monitoring with an objective assessment of the condition . In the absence of complications during pregnancy, surgical treatment is prescribed already after the period of breastfeeding. However, the high risk of VTU with varicose veins in pregnant women, even with compression therapy, remains, especially in the presence of several risk factors, which we mentioned above.

For example, the standard of VTU prevention in Europe in the presence of several risk factors for thrombosis and varicose veins is the appointment of daily injections of drugs that thin the blood for the entire period of pregnancy. Is it worth it not to operate on your varicose veins before pregnancy using modern methods - quickly and painlessly, and to be absolutely calm for yourself and for your future child?

Therefore, the main measure of preventing the development of VTU in the presence of varicose veins is timely and adequate treatment (timely surgical treatment, compliance with the compression therapy regimen, correction of the rheological properties of blood and blood clotting processes, an active lifestyle).

Simple preventive measures:

• Wear comfortable underwear;
• Limit physical activity, while performing simple exercises to keep in shape (for example, with the help of swimming)
• Monitor nutrition by adding more fiber to the diet
• Drink a sufficient amount of liquid
• Walk in comfortable shoes (heels no more than 4 cm) and clothes
• Do not take hot baths, do not visit the bathhouse, sauna
• Take a daily ascending contrast shower
• Follow an active mode of mobility, avoid a long stationary position, walk for 2 hours a day
• Perform special venous gymnastics
• Watch your weight
• Sleep on the left side
• Wear compression jersey
• See a phlebologist

Taking into account all of the above, our advice to pregnant women with varicose veins:

• wear compression knitwear during pregnancy;
• follow an active driving regime;
• obey a phlebologist during pregnancy;
• strictly follow the recommendations of a specialist;
• at the first signs of deterioration, seek help immediately.

If you are planning a pregnancy and you have varicose veins - operate on them before pregnancy and protect yourself and the future child.

To receive information about treatment and make an appointment, call the contact center of MM ""Dobrobut"":
044 495 2 888 or 097 495 2 888 .



Appointment with a phlebologist
Prophylaxis of varicose veins