A guest blog about varicose veins in pregnancy written by Dr Karen Morton, consultant obstetrician and gynaecologist and Founder of Dr Morton’s – the medical helpline
Just as one starts to look and feel like an elephant, another insult to injury appears: snake-like blue veins down your calves, behind your knees, and up your thighs. As if that isn’t bad enough, the feeling of a bunch of grapes between your legs as the varicose veins extend into the vulva, is just too much to bear. It’s not quite so bad in winter as at least you can cover them with thick tights, although being ‘centrally heated’ by the baby, and finding it hard to get tights big enough to cover the bump, make it not quite as good a solution as it sounds.
In fact the changes in blood vessels occur much earlier in pregnancy than you might think. Contrary to what might seem logical, there is little evidence that direct pressure of the baby and uterus, however big and heavy, on the veins in the pelvis, causes a problem with venous drainage from the legs. Large numbers of women (if not the majority) do not end up with unsightly varicose veins in the legs nor vulval varicose veins.
In fact varicose veins seem to be mainly due to hormonal changes which have an effect on the connective tissue in the vein wall. This is probably why some women develop varicose veins when they take a contraceptive pill, or hormone replacement therapy. During pregnancy another factor is the expansion of the circulating blood volume, with an additional 2 L (40% of the blood volume) by the third trimester. Finally there is a large genetic component as varicose veins really do run in families.
Varicose veins can take different forms and apart from the obvious twisting snakes, there may be fine spider veins, ranging from tiny red, blue or purple lines, to a whole wide area of purply-blue discolouration. The area blanches white when pressed and refills immediately, and improves when the legs are elevated.
The varicose veins (snakes or spiders) may become damaged or blocked leading to inflammation of the overlying skin which becomes red, hot and painful. The right name for this is ‘thrombophlebitis’. It is not the same thing as ‘deep vein thrombosis’ (DVT). It is treated with leg elevation, painkillers and anti-inflammatory gel or cream smoothed over its surface. Unfortunately nonsteroidal anti-inflammatory drugs such as ibuprofen cannot be taken by mouth during pregnancy. Ibuprofen can cause an important blood vessel called the ductus venosus, which enables blood to bypass the baby’s lungs until after birth, to close prematurely. The gel applied to the inflamed area is perfectly safe, and should be used with paracetamol for the pain. Antibiotics are not required nor helpful, as there is no infection. This is in contrast to when thrombophlebitis occurs in an arm vein which has been damaged by having a cannula inserted for an intravenous drip, perhaps during labour. In this case infection has been introduced from the skin. Infective thrombophlebitis can spread up the arm along the course of the vein, and it does require antibiotic treatment.
Now we come to two important questions:
DVT is the formation of blood clot in the large veins deep within the legs or pelvis. Left untreated, it is possible for a portion of this clot to break away and travel up to the lungs as a pulmonary embolism. Fortunately this is very uncommon, but nonetheless very important as a significant cause of the very low maternal mortality seen in the UK. All pregnant women have an increased risk of DVT because there is an increase in clotting factors from early on in pregnancy, with a huge surge after the delivery, making the blood stickier than ever and the risk of DVT at its highest.
Every woman’s risk of thromboembolism is assessed using a scoring system at the beginning of pregnancy and during any pregnancy event such as hospital admission for any reason, and then again after they have had their baby. Superficial thrombophlebitis and bad varicose veins are not a major risk factor, but rather one of the many risk factors taken into account when deciding whether prevention of DVT is needed, and if so, should it be antenatally or just postnatally, and with compression stockings, low dose aspirin, or daily injections of a blood thinning agent such as dalteparin.
Although in the past, the recommendation to have babies before getting veins fixed was pretty universal, this was due to the fact that traditional treatment with stripping (literally pulling out the veins) was ineffective. With the new endovenous techniques which permanently close veins by apoptosis and subsequent fibrosis, this advice has now been reversed and varicose veins should be treated before pregnancy.
Troublesome leg or vulval veins which appear in a first pregnancy should similarly be treated before expanding the family, even if they have apparently disappeared from view after the baby is born. These women should have a duplex ultrasound scan performed three months after delivery to find out the severity of the venous reflux and in the case of vulval varicose veins, a transvaginal duplex ultrasound scan to look at pelvic venous reflux in the ovarian and internal iliac veins.
If you develop troublesome veins during pregnancy, knee high compression stockings together with the very best maternity support tights are about all one can do. Thigh leg stockings rarely stay up. Vulval varicosities are almost impossible to help and the advice of putting a sanitary towel inside firm supportive pants seems embarrassingly feeble. Fortunately where vulval varicose veins are concerned you can be pretty confident that they will at least disappear from view and be more comfortable instantly as the baby is born, and they very rarely cause any problem with bleeding at delivery, even though they look pretty scary from that point of view.
So if you are lucky enough to get the right advice before babies, or even after your babies, and have the best treatment, your legs will be great when it’s all over. The NICE guidelines recommend treatment of all forms of venous reflux by expert teams, with vascular technologists performing venous duplex ultrasound scans, and with endovenous techniques of both leg refluxing veins and pelvic refluxing veins that cause fibrotic occlusion that is permanent. There is absolutely no reason that a woman who has varicose veins or vulval varicose veins that become apparent during pregnancy should not have them treated and end up with legs as good as a woman who has never had children. Exciting news!
And what of those of us who are old enough to have had our veins stripped long ago, and who sadly depend on long linen skirts for the summer and feel a sense of relief when the winter comes and out come the thick woolly tights? Well don’t despair. Even those people who have had stripping in the past and who have had pregnancies are curable with the new techniques and should not need to resign themselves to “covering up”. Such patients are more complex, and often need more treatment because of the previous stripping, but if they are investigated properly and treated correctly they too should expect excellent results.
Dr Karen Morton is the founder of Dr Morton’s – the medical helpline© – a service for busy people wanting speedy access to an experienced doctor for confidential reassurance or advice by phone or email. When needed, Dr Morton’s doctors are able to prescribe for a wide variety of medical issues and arrange for medication to be sent to the customer’s door. For more information call 012 123 123 123 www.drmortons.co.uk