Varicose veins represent the most common vascular condition that occurs in women. It is estimated that 15-25% of all women have varicose veins, and the true prevalence could be higher due to the fact that many patients do not seek treatment for this issue. While the pathogenesis of varicose vein is not completely understood, it is believed that it occurs when venous valves become incompetent, leading to a retrograde of blood flow and subsequently vein dilation. This would suggest that any condition that increases intra-abdominal pressure or causes hormonal changes could provoke or exacerbate this condition. One such condition that fits this description is pregnancy. It is believed that between 30-70% of pregnant women develop varicose veins during pregnancy, representing a serious and common issue. However, it should be pointed out that while pregnancy tends to exacerbate varicose veins, it is not a common cause of the condition itself.
Definition of Varicose Veins
In contrast, there are few medical treatments that can be offered to help the venous function. The treatment of varicose veins will be regarded as a symptomatic improvement rather than a cure.
Many would think that varicose veins are only a physical condition. However, studies have shown that the condition may affect the patient’s quality of life, self-esteem, work productivity, and activities they take part in. Fortunately, varicose veins may not cause symptoms or lead to severe health problems. Often, people find that the appearance of varicose veins is unacceptable in society. But it’s often overlooked as a physiological condition.
Varicose veins are twisted, enlarged veins near the surface of the skin. They are most common in the legs and ankles. They usually appear as a result of blood pooling in the veins, which causes them to bulge. They may cause the legs to feel heavy, achy, itchy, and in severe cases, they may cause pain and swelling. Factors which can increase the risk of developing varicose veins include heredity, being overweight, and being on your feet for long periods.
Prevalence of Varicose Veins in Pregnancy
There are some preventive measures that can be taken. Regular exercise can help to improve circulation in the legs and thus reduce the risk of varicose veins. It can also help to regulate your weight, which is another significant factor in whether you will develop varicose veins. In instances of being overweight, the pressure on the veins increases, which in turn can cause the veins to become varicose. If you already have varicose veins, exercise can help to alleviate your symptoms. When resting or sleeping, try to elevate your legs to a height above your heart whenever possible. This will prevent blood from pooling in the leg veins. The use of compression stockings can also help to prevent blood from accumulating in the veins in your legs.
The change in hormone levels during pregnancy is also a huge factor in causing varicose veins. The female sex hormone estrogen affects the walls of blood vessels. Poorly functioning vein valves can be expected to deteriorate more rapidly in those who have increased levels of estrogen, i.e. women. Progesterone, another hormone more prevalent in the female body, has a dilating effect on the blood vessels. When you consider the effects these hormones can have on a pregnant woman, it is no surprise that so many women develop varicose veins during pregnancy. In most cases, your varicose veins will improve within 3 months of completing your pregnancy or endoscopic vein surgery within a few weeks without any medical intervention.
The prevalence of varicose veins during pregnancy is very common. The truth is that more than 70% of pregnant women will experience some form of varicose vein symptoms during their term. This is because pregnancy increases the volume of blood in the body, which in turn causes the veins to enlarge. The increased blood volume is necessary to support the growing fetus and also prepare the body for the extra blood loss sustained during childbirth. This can cause veins to become more noticeable, but this is not the only cause.
Causes of Varicose Veins during Pregnancy
Hormonal changes are tremendously plausible as a factor in the expanded rate of venous issue amid pregnancy. The impacts of progesterone on the veins have been accounted for. Progesterone makes vein dividers more casual and causes a more noteworthy pooling of blood. Hormonal components are subsidiary to expanded vein estimations amid pregnancy. An expanded rate of venous widening has been watched histologically and by ultrasound examination in pregnant ladies. This impact of pregnancy on the veins may deliver changeless change.
Physiologically, pregnancy has been said to incite an expanded danger of varicose veins in females. Prior to a planned pregnancy, varicose veins brought about distress or more regrettable in 30% of females. During early pregnancy, the occurrence of leg capillary changes and leg indications are higher in females with a more prominent family background of venous issue. An investigation following 49 females with a family background of incessant venous issue found that the rate of venous extending expanded from 16% at 16 weeks gestation to 52% at 36 weeks. Just a single small time study has been attempted to explore the common history of venous issue amid pregnancy. It is very clear that venous issue is a typical condition among women with numerous occurrences happening amid pregnancy.
2.1. Hormonal Changes
At the time of ovulation and at the beginning of pregnancy, a hormone called progesterone begins to be secreted in greater amounts. These elevated levels of progesterone have an effect of relaxing the blood vessels. The function of this is to allow the blood vessels to dilate as a preparation to increase blood volume and to lower blood pressure. It acts as a preparation for the body to help accommodate the developing fetus but has the added effect of increasing the chance of varicose veins. With the increased vein pressure and already slow-moving blood from other factors of pregnancy, the weakened vein is more likely to become varicose. This is an explanation as to why many women who have been pregnant can be susceptible to varicose veins in periods of high hormone activity, summer, or with increased body weight.
There are two types of veins in the legs: superficial veins and deep veins. Varicose veins are a problem of the superficial veins. There is normally a small amount of blood in the surface veins, which the body increases at certain times to meet different needs, such as around the time of active muscle use or to dissipate body heat during warm weather. The blood is then moved back to the deep veins by a connecting system of veins called perforator veins. Normally, the upper and lower ends of the vein act as entry and exit points for blood being moved out of the vein. Valves in the vein keep blood moving to the exit point. If these valves become faulty, blood will flow backwards, and once the pressure of the vein reaches a certain point, a varicose vein is formed.
Pregnancy is an amazing time, with many changes that happen in a woman’s body. There are many factors that can lead to the development of varicose veins, and it is believed that the overall presence of a combination of these factors is responsible. One of the primary considerations in the development of varicose veins during pregnancy revolves around hormonal influences. During pregnancy, the body goes through some major hormonal changes. For this reason, it is helpful to understand the normal function of the vein.
2.2. Increased Blood Volume
The good news is that there is a lot that you can do to help relieve the discomfort from varicose veins. This can also help to prevent varicose veins from getting worse. Measures include: avoiding standing for prolonged periods, regular walking, and maintaining a healthy weight. This is all very useful and safe exercise. It will help to improve your overall health at a time when looking after yourself is especially important.
For the same reason, it is better to wait until your family is complete before you have treatment to improve the appearance of your leg veins. This is best discussed in detail with a vascular surgeon. He or she can explain the treatment options and provide advice. This will help you to make a fully informed decision on what is best for you.
During pregnancy, the volume of blood in a woman’s body increases. This can cause veins to enlarge. The growing uterus also puts pressure on the veins. Varicose veins usually improve within 3 months after giving birth. This is because there is no longer the increased pressure from the womb on the pelvic veins.
2.3. Pressure on the Veins
The pressure from the expanding uterus, especially in the later months of pregnancy, can also interfere with blood flow. This is because the uterus exerts an added load on the Inferior Vena Cava, a large vein on the right side of the body that receives deoxygenated blood from the lower limbs. In turn, this can increase the amount of blood in the veins in the legs. The change in pressure can cause the relaxation of the walls and valves of the veins, making them more likely to become varicose. This explains why varicose veins can be a lot worse in the evening for some people. In worse cases, the complex network of pelvic veins can become distended under the increased pressure and result in pelvic congestion syndrome. This can cause considerable pain in the pelvis and lower back and can be quite distressing. This is also sometimes a condition that can occur in women not following pregnancy, and those with varicose veins may already have experienced it to some degree.
3. Symptoms and Complications
This can also lead to a brown discoloration of the skin overlying the affected veins due to the iron in the blood, which has a staining effect when it breaks down. The high pressure in the veins can also force some of the fluid portion of the blood out of the vein and into the surrounding tissue. This will cause swelling and edema, most commonly in the ankles but also in the lower leg and at times in the thigh. The fluid build-up can cause the skin to become very itchy, and in severe cases, the skin can break down to form an ulcer.
Visible veins during pregnancy are not only markers of the unsightly, but they are also an indication of venous problems that can become severe. Under the influence of pregnancy hormones (which are necessary to sustain the pregnancy), the walls of the vein become relaxed. This makes the vein much more distensible, or “stretchy”. Increased vein distensibility is specifically what allows the vein to accommodate increased blood volume during pregnancy. However, it also allows the vein to become more deformed under a given amount of pressure. Veins near the surface of the skin become visibly distorted. This is the first sign of vein problems. Usually, the distended veins will recede within 3-4 months after delivery. In some cases, however, they will remain permanently dilated after having reached a certain critical degree of distension.
3.1. Visible Veins and Skin Discoloration
The high levels of progesterone during pregnancy are thought to cause the walls of your blood vessels to relax. This, coupled with the pressure on the inferior vena cava – the large vein on the right side of the body that receives blood from the lower limbs, can cause the veins in the legs to become enlarged. Increased blood volume may also play a part in adding to the pressure on the leg veins. These factors would also increase the likelihood of developing varicose veins.
Spider veins may appear for the first time in a pregnant woman. They may develop on the inner leg, upper thigh, and sometimes on the face. Occasionally, spider veins completely disappear after the baby is born. Spider veins that occur during pregnancy usually worsen with successive pregnancies but are likely to improve in the time between pregnancies. The reason for this is not known.
3.2. Swelling and Pain
Varicose veins can be very painful. The level of pain does not always reflect the size of the varicose vein. Sometimes, a very small varicose vein can be extremely painful. Symptoms caused by varicose veins can also be worse at the end of the day, in warm weather, or if you have been standing for long periods.
Venous pressure is always higher in the lower body than the upper body, but when you are pregnant, this pressure increases further. This happens because of the increased volume of blood in the body. The blood flow from the legs to the pelvis is reduced. Also, during pregnancy, the increase in hormones, in particular progesterone, can cause the walls of the blood vessels to dilate. Because of these reasons, almost every pregnant woman will have some edema (swelling) of the lower legs, mostly at the end of the day. This is completely normal and will resolve a few months after the baby is born.
3.3. Increased Risk of Blood Clots
When a clot occurs, the body’s natural response is to try to dissolve the clot with increased platelet activity and clotting in the affected area. This will often result in the formation of a secondary clot, which may block the flow of blood to surrounding tissues. When this occurs in a varicose vein, it will likely cause more skin discoloration, hardening of the skin, and a painful inflamed vein known as superficial phlebitis. If you have any type of clotting disorder or have had previous issues with blood clots, you should consult your doctor before becoming pregnant so that steps may be taken to prevent any adverse complications.
Pregnant women are at a much higher risk of developing blood clots. They have more clotting factors in their bloodstream, increased pressure on pelvic blood vessels from the heavy uterus, and decreased blood flow from the lower extremities. Blood clots can be life-threatening if they travel to the lungs and block an artery. If you develop a clot in a pelvic vein, you may experience pain and swelling in the affected leg and could develop a more serious condition known as deep vein thrombosis. Typically, blood clots will dissolve on their own, but in more severe cases, doctors may prescribe an anticoagulant medication.
4. Prevention and Treatment
Compression stockings are a special hosiery that is specifically designed to compress the leg. This increases pressure on the tissues under the skin and helps the veins push blood in the right direction. Although it can be quite uncomfortable, research has shown that compression stockings are an effective treatment for varicose veins. This is the first thing to attempt if conservative self-help methods are not effective. This is also an option that women with the worst vein problems can attempt during pregnancy. Typically, compression stockings come in gradients, with tighter compression at the ankle that gradually reduces up the leg. This helps fight the effects of gravity. Other methods of compression, such as wraps, are also available. These are a far cry from the “grandma’s stockings” stereotype, and many are almost indistinguishable from normal hosiery.
Regular, low-impact physical activity can help keep blood flowing normally and reduce pressure on the veins. Walking is a great form of exercise. Swimming is especially useful, as it is low-impact and the pressure of the water can help reduce swelling in the legs. High-impact activities like running may actually exacerbate the problem, so it’s best to avoid these. Exercise also helps control a woman’s weight during pregnancy, which can also be a factor in the development of varicose veins and has numerous other benefits for the pregnancy and delivery.
4.1. Exercise and Physical Activity
The concept of exercise as a preventative measure for varicose veins is still a good platform for future research, but at the very least it can be said this is an example of how overall health is beneficial for prevention of many diseases and conditions.
The best form of exercise would be a low-impact cardiovascular exercise such as walking or swimming. This allows one to get the aerobic conditioning needed which has countless health benefits, and it carries a low risk of exacerbating varicose veins or causing new ones to form. With weight training, the individual should avoid heavy lifting as this also can increase intra-abdominal pressure and increase venous pressure in the legs.
In high-impact sports, one runs the risk of traumatic damage to veins in the legs and exacerbation of existing varicose veins, which could increase the severity of the condition. High-impact sports include running, soccer, and basketball. While there is no evidence to directly support that these sports cause varicose veins, the rationale is there because long periods of standing or running do increase venous pressure. In a study done by Fowkes et al., it was found that standing at work doubles the risk of getting varicose veins.
According to varicose veins, “Regular, low-impact exercises are beneficial in toning the vein walls and promoting good circulation.” Losing weight and physical activity are often presented as preventative measures of varicose veins, and physical activity is also mentioned as a part of conservative management of varicose veins (without surgical intervention). Although there is a general consensus that exercise is good pertaining to prevention and conservative management of varicose veins, there is a lack of guidelines as to what kind of exercise is best, as well as what should be avoided.
4.2. Compression Stockings
During pregnancy, increased blood volume and pressure on the veins in the pelvis can cause the veins in the legs to become more dilated and tortuous. Graduated compression stockings can be recommended to help prevent the symptoms of varicose veins from developing, or if they have already developed, to help prevent them from becoming worse. Compression stockings are an elastic garment worn around the leg which compresses the veins, helping to improve the circulation of blood. They are able to limit the increase in venous pressure in the lower limb and reduce the risk of blood pooling in leg veins. This will help relieve the symptoms of varicose veins and reduce the risk of more severe vascular problems developing. Strong compression is more effective, and it has been shown that compression stockings have little effect if the pressure is too low. Although compression stockings are effective, they can be uncomfortable and hard to get used to wearing. They are most effective when worn during waking hours, therefore it is recommended that pregnant women wear the stockings throughout the day. A professional fitter can help find the correct size and ensure that the pressure exerted is correct to best treat the symptoms. Professionally fitted, graduated, higher pressure compression stockings are more effective than over-the-counter support hose.
4.3. Elevating Legs and Avoiding Prolonged Standing
If you have varicose veins, elevating your legs can help to improve your symptoms. Leg elevation helps to counteract the effects of gravity. This will reduce the pressure in the leg veins and improve the return of blood from the legs to the heart. At the end of the day, lie down and rest with your legs higher than your heart. It is a good idea to elevate your legs for 10 minutes every 2 hours throughout the day, particularly if your work or home life involves a lot of standing. When you are seated, avoid sitting with your legs crossed and try to elevate your legs with a footstool. Picture when your favorite film or TV program finishes and the TV asks, “Do you want to delete this program?” Your answer is usually yes because it’s something you want to erase from the memory. To help delete your varicose veins, try to spend less time on your feet trying to erase the memory of the day’s events, and more time lying down with your legs elevated! This simple remedy can be incredibly effective!
4.4. Surgical and Minimally Invasive Procedures
4.4.2 There are various techniques which can be performed as an outpatient case. High tie and stripping involves tying off the highest point of refluxing blood flow followed by stripping the vein through multiple small incisions. This is considered invasive surgery but newer forms of the procedure use the keyhole technique which causes less pain and bruising. Endovenous laser treatment and radiofrequency ablation are minimally invasive methods which cause heat damage to the vein resulting in closure by scar tissue. These techniques are performed by threading a small catheter into the vein where the heat source is applied. Foam sclerotherapy may also be used in some cases where it is injected into the affected veins and causes inflammation and closure of the vein.
4.4.1 Do not offer surgery for uncomplicated varicose veins, including for people with skin discoloration. This is because further assessment of patient outcome has shown that the outcome of this procedure is no better than injection and compression treatment.
In 1993, the National Institute of Clinical Excellence (NICE) published guidance which made the following recommendations.
If conservative measures fail to control symptoms, surgery is the only option to resolve the more severe form of varicose veins and their complications. Minimally invasive techniques are generally the preferred method of treatment and can be performed under local anaesthetic as an outpatient or day-case procedure. These techniques cause less pain and have a quicker recovery time compared with traditional surgery. A referral to a vascular surgeon is appropriate to determine the most suitable treatment option.
