Chronic venous insufficiency and pregnancy

Chronic venous insufficiency or chronic venous diseases include varicose veins, post-thrombotic disease, congenital and traumatic venous vessel anomalies

ICD-10

• I83 Varicose veins of the lower extremities
  • I83.0 Varicose veins of lower extremities with ulcer
  • I83.1 Varicose veins of lower extremities with inflammation
  • I83.2 Varicose veins of lower extremities with ulcer and inflammation
  • I83.9 Varicose veins of lower extremities without ulcer and inflammation
• I86.3 Varicose veins of the vulva
• I87 Other venous disorders
  • I87.0 Postthrombophlebitic syndrome
  • I87.1 Compression of veins
  • I87.2 Venous insufficiency (chronic) (peripheral)
  • I87.8 Other specified disorders of veins
  • I87.9 Disorders of veins, unspecified
• O22 Venous complications during pregnancy
  • O22.0 Varicose veins of the lower extremities during pregnancy.

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Epidemiology

The frequency of chronic venous insufficiency is 7–51.4%, with 62.3% in women and 21.8% in men. Moderate and severe chronic venous insufficiency occurs in 10.4% of cases (12.1% in women and 6.3% in men), with trophic ulcers developing in 0.48% of the population. According to various authors, chronic venous insufficiency during pregnancy affects 7 to 35% of women, with chronic venous insufficiency developing for the first time during pregnancy in 80% of them.

[ 2 ], [ 3 ], [ 4 ], [ 5 ]

Causes chronic venous insufficiency in pregnancy

The main etiological factors for the development of chronic venous insufficiency outside of pregnancy include:

• weakness of the vascular wall, including connective tissue and smooth muscles;
• dysfunction and damage to the venous endothelium;
• damage to venous valves;
• microcirculation disorder.

If these factors are present, they worsen during pregnancy.

Compression of the inferior vena cava and iliac veins by the pregnant uterus results in venous obstruction, increased venous pressure, and increased venous capacity accompanied by blood stasis. Venous stasis contributes to endothelial cell damage and hinders the removal of activated coagulation factors by the liver or their interaction with inhibitors (due to the low probability of their mixing with each other). During physiological pregnancy, the vessel walls usually remain intact, but the above-mentioned disorders serve as the basis for the development of venous hypertension in both the deep and superficial systems. Increased pressure in the venous system results in an imbalance between hydrostatic and colloid osmotic pressures and, as a consequence, edema. Impaired function of the endothelial cells of capillaries and venules [possibly due to venous stasis, activation of leukocytes, changes in the production of nitric oxide (NO) during pregnancy] leads to their damage. This triggers a vicious circle of pathological changes at the microcirculatory level and leads to increased adhesion of leukocytes to the walls of blood vessels, their release into the extracellular space, deposition of fibrin in the intra- and perivascular space, and the release of biologically active substances.

Leukocyte adhesion is the main etiologic factor of trophic lesions in patients with chronic venous hypertension, which has been confirmed by numerous clinical studies in patients outside pregnancy. However, such a mechanism cannot be excluded during pregnancy. Leukocyte adhesion and migration cause partial obstruction of the capillary lumen and reduce its throughput. This mechanism can also contribute to the development of capillary hypoperfusion accompanying chronic venous insufficiency. The accumulation and activation of leukocytes in the extravascular space are accompanied by the release of toxic oxygen metabolites and proteolytic enzymes from cytoplasmic granules and can lead to chronic inflammation with subsequent development of trophic disorders and venous thrombi.

The persistence of venous dysfunction for several weeks after delivery indicates the influence of not only venous compression by the pregnant uterus, but also other factors. During pregnancy, the extensibility of veins increases, and these changes persist in some patients for 1 month and even a year after delivery. Thus, pregnancy has a negative effect on the function of the venous system.

Pregnancy and the postpartum period create prerequisites for the development of complications of chronic venous insufficiency. Thrombosis is one of the formidable complications of chronic venous insufficiency. Venous thrombi are intravascular deposits consisting mainly of fibrin and erythrocytes with varying amounts of platelets and leukocytes. The formation of a thrombus reflects an imbalance between thrombogenic and protective mechanisms. During pregnancy, the concentration of all coagulation factors in the blood increases, except for XI and XIII (their content usually decreases). Protective mechanisms include the binding of activated coagulation factors to inhibitors circulating in the blood.

Thrombin-initiated fibrin formation increases during pregnancy and leads to hypercoagulation. During normal pregnancy, vessel walls usually remain intact. However, during pregnancy and vaginal delivery or cesarean section, local damage to the endothelium of varicose veins may occur, which will trigger the process of thrombus formation. Increased red blood cell aggregation in chronic venous insufficiency, dysfunction of the endothelium of the affected veins, and other factors help to understand why chronic venous insufficiency significantly increases the risk of thrombotic complications during pregnancy.

Risk factors

There are many risk factors for the development of chronic venous insufficiency both during pregnancy and outside of it. Traditionally, these include living in industrialized countries (due to physical inactivity), female gender, the presence of chronic venous insufficiency in relatives, constipation, obesity, and repeated pregnancies.

The relative risk of developing varicose veins during pregnancy in women aged 30–34 and women over 35 is 1.6 and 4.1, respectively, compared with that in women under 29. The relative risk of developing chronic venous insufficiency in women with a history of 1 birth and women with two or more births is 1.2 and 3.8 compared with the risk in primigravidas. The presence of varicose veins in the family increases the risk of chronic venous insufficiency to 1.6. At the same time, no relationship was found between chronic venous insufficiency and the patient's body weight.

Symptoms chronic venous insufficiency in pregnancy

In order to be able to objectively assess the state of the venous system of patients of different groups, the international classification CEAP (Clinical signs, Etiologic classification, Anatomic distribution, Pathophysiologic Dysfunction) is used, proposed by Partsh G. at the 6th annual congress of the American Venous Forum in 1994.

International Classification CEAP

C	For clinical manifestations (gradation 0–6 points) with the addition of A (for asymptomatic course) and C (for symptomatic course)
E	Etiological classification (congenital, primary, secondary)
A	Anatomical distribution (superficial veins, deep or perforators)
P	Pathophysiological basis (reflux or obstruction, alone or in combination)

Clinical classification (C0–6)

The clinical classification is based on objective clinical signs of chronic venous insufficiency (C0–6) with the addition of: A for asymptomatic disease or C for symptomatic disease. Symptoms include: nagging, aching pain, heaviness in the lower limbs, trophic skin disorders, convulsive twitching of the leg muscles, and other symptoms characteristic of venous dysfunction. The clinical classification is made in ascending order of increasing disease severity. Limbs with a higher score have significantly more severe manifestations of chronic venous disease and may have some or all of the symptoms characteristic of a lower category. Therapy and some conditions (e.g., pregnancy) can change the clinical symptoms, and then the condition of the limb must be re-evaluated.

Clinical classification of chronic venous insufficiency

• Class 0 - No signs of venous disease detected by external examination or palpation
• Class 1 - Telangiectasias or reticular veins
• Class 2 - Varicose Veins
• Class 3 - Edema
• Class 4 - Skin manifestations characteristic of venous diseases (hyperpigmentation, venous eczema, lipodermatosclerosis)
• Class 5 - Skin lesions as described above with healed trophic ulcer
• Class 6 - Skin lesions as described above with active trophic ulcer

Etiological classification (Ec, Ep, Es) of chronic venous insufficiency

The etiologic classification describes 3 categories of venous dysfunction: congenital, primary, and secondary. Congenital abnormalities may be detected immediately at birth or later. Primary disorders are not considered congenital and do not have a clearly established cause. Secondary disorders are those that develop as a result of a known pathogenetic cause, such as thrombosis. The last two categories are mutually exclusive.

• Congenital (Ec).
• Primary (Ep):
  • with an unknown cause.
• Secondary (Es):
  • with a known cause:
    • post-thrombotic;
    • post-traumatic;
    • other.

Anatomical classification (AS, AD, EP) of chronic venous insufficiency

This classification is based on the anatomical location of the disease [in the superficial (AS), deep (AD) or perforating (EP) veins]. The disease may involve one, two or all three parts of the venous system.

For a more detailed description of the site of damage to the superficial, deep and perforating veins, a classification of anatomical segments is used.

Anatomical classification of chronic venous insufficiency

• 1 - Superficial veins (AS) / Telangiectasias/reticular / Great saphenous
• 2 - Above the knee
• 3 - Below the knee
• 4 - Small saphenous vein
• 5 - Others / Deep Veins (A)
• 6 - Inferior vena cava / Iliac
• 7 - General
• 8 - Internal
• 9 - External
• 10 - Pelvic / Femoral
• 11 - General
• 12 - Deep
• 13 - Superficial
• 14 - Popliteal
• 15 - Anterior tibial, posterior tibial
• 16 - Muscular branches (all paired) / Perforating veins (EP)
• 17 - Femurs
• 18 - Shins

Pathophysiological classification (Pr, Po, Pr,o) of chronic venous insufficiency

Clinical manifestations of venous dysfunction may be due to reflux (Pr), obstruction (Po), or both (Pr,o). Since the severity of venous dysfunction depends on the location and extent of reflux and/or obstruction, these parameters are determined using duplex angioscanning. To simplify and standardize measurements, well-recognized sites of venous occlusion are used: inferior vena cava, iliac, femoral, popliteal, and tibial.

Quantitative assessment of venous dysfunction

Based on the opinion of the experts who developed the CEAP scale, a quantitative assessment of venous dysfunction is carried out for scientific comparison and evaluation of treatment results. Although the gradations of symptoms are subjective, the symptoms themselves are objective).

Assessment of physical capacity

• 0 - Asymptomatic course
• 1 - Symptomatic course, can do without supportive measures
• 2 - Cannot do without supportive care
• 3 - Physical activity is difficult even with supportive measures

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Diagnostics chronic venous insufficiency in pregnancy

Among the subjective and objective symptoms, the following are predominant:

• heaviness and nagging pain in the legs;
• swelling;
• dry skin;
• symptoms that often precede thromboembolic complications:
  • erythema of the skin over the vein;
  • pain along the veins;
• the presence of varicose veins of the lower extremities and perineum.

As pregnancy progresses, the frequency of occurrence of these signs increases, decreasing only on the 5th-7th day of the postpartum period. As pregnancy progresses, the number of affected areas of the veins increases, reaching a maximum at the time of delivery.

The incidence of venous thromboembolic complications during pregnancy in pregnant women with chronic venous insufficiency is 10%, in the postpartum period - 6%.

In addition to the standard obstetric examination, all patients undergo examination and palpation of varicose, deep and main subcutaneous veins of the lower extremities, followed by an assessment of the state of the venous system of the lower extremities using the CEAP scale.

Special research methods

Ultrasound Dopplerography

The study of veins in pregnant women with chronic venous insufficiency is carried out using sensors with frequencies of 8 MHz (posterior tibial vein, great and small saphenous veins) and 4 MHz (femoral and popliteal veins).

Doppler examination is performed to determine:

• patency of the deep venous system;
• valve integrity;
• localization of reflux areas in perforating veins and anastomoses;
• determining the presence and location of blood clots.

Compression tests are used to assess not only the patency of deep veins, but also the viability of the valves of deep, subcutaneous and perforating veins. Normally, during proximal compression and distal decompression, blood flow in the veins of the legs stops.

Ultrasound methods of visualization of veins of the lower extremities

Ultrasound is performed on a device with 5-10 MHz linear sensors. Ultrasound duplex angioscanning determines:

• diameter of the lumen of the main venous trunks;
• presence or absence of reflux;
• venous patency;
• the nature of venous blood flow.

Hemostasisogram

All patients with chronic venous insufficiency are recommended to undergo a hemostasiogram monthly and twice in the postpartum period. Blood from a vein is collected in a standard test tube containing 0.5 ml of sodium citrate on an empty stomach at 16–18, 28–30, and 36–38 weeks of pregnancy, as well as on days 2–3 and 5–7 of the postpartum period. The hemostasis study includes:

• platelet aggregation;
• activated partial thromboplastin time;
• coagulogram;
• prothrombin index;
• soluble complexes of fibrin monomers and/or D-dimer;
• fibrinogen.

In addition to the standard hemostasiological study, in pregnant women suffering from chronic venous insufficiency, factors responsible for the decrease in the coagulation properties of the blood are determined: protein C, antithrombin III, plasminogen and batraxobin time.

[ 7 ], [ 8 ], [ 9 ]

Differential diagnosis

Differential diagnostics are carried out with the following diseases:

• acute deep vein thrombosis;
• dropsy of pregnant women;
• lymphedema;
• chronic arterial insufficiency;
• circulatory failure (ischemic heart disease, heart defects, myocarditis, cardiomyopathy, chronic pulmonary heart disease);
• kidney pathology (acute and chronic glomerulonephritis, diabetic glomerulosclerosis, systemic lupus erythematosus, nephropathy of pregnancy);
• liver pathology (cirrhosis, cancer);
• osteoarticular pathology (deforming osteoarthrosis, reactive polyarthritis);
• idiopathic orthostatic edema.

Acute deep vein thrombosis. Edema in this disease appears suddenly, often against the background of complete health. Patients note that in a few hours the volume of the limb has increased significantly compared to the contralateral one.

In the first days, the development of edema is progressive, accompanied by bursting pains in the limb, increased venous pattern on the thigh and in the groin area on the affected side. After several weeks, the edema becomes permanent and, although it tends to regress (due to recanalization of thrombotic masses and partial restoration of patency of deep veins), it almost never completely disappears. Venous thrombosis usually affects one limb. Often, edema affects both the lower leg and thigh - the so-called iliofemoral venous thrombosis.

Changes in the superficial veins (secondary varicose veins) develop only several years after acute thrombosis, along with other symptoms of chronic venous insufficiency.

An additional criterion for acute venous thrombosis is the absence of trophic disorders of the superficial tissues (hyperpigmentation, lipodermatosclerosis, trophic ulcer), which are often found in chronic venous insufficiency.

Edema caused by pregnancy (dropsy of pregnant women) usually occurs at the end of the second – beginning of the third trimester of pregnancy. They do not change during the day, are often combined with increased pressure and the presence of protein in the urine (with the development of gestosis). Chronic venous insufficiency is characterized by the appearance of edema in the early stages of pregnancy, the presence of varicose veins, and the absence of signs of gestosis.

Lymphedema (lymphostasis, elephantiasis). Lymphatic drainage disorders may be congenital (primary lymphedema). The first signs of the disease are detected in childhood, adolescence or young age (up to 35 years). At first, a transient nature of edema is usually noted, which develops in the second half of the day on the foot and shin. In some cases, the symptoms of the disease disappear for several weeks or even months. Then, at later stages, the edema becomes permanent and can cover the entire limb. Cushion-like edema of the foot is characteristic. Varicose veins in primary lymphedema are rare.

Secondary lymphedema is most often a consequence of repeated erysipelas. In this case, edema usually develops only after the second or third acute episode and then persists permanently. Erysipelas often occurs in patients with chronic venous insufficiency. In this regard, with secondary lymphedema of post-infectious genesis, signs of venous system pathology can be detected: varicose veins, trophic disorders of the skin and subcutaneous tissue.

Osteoarticular pathology. Edema due to inflammatory or degenerative-dystrophic changes in the joints of the lower extremities is quite easy to distinguish. It is almost always local, occurs in the area of the affected joint in the acute period of the disease and is combined with severe pain syndrome and limited movement in the affected joint. Deformation of the surrounding tissues (pseudoedema) becomes permanent with a long course and frequent exacerbations. Patients with a joint cause of edema are characterized by flat feet and valgus deformity of the foot. Usually, this pathology is detected before pregnancy, which facilitates differential diagnostics.

Diseases of internal organs. Severe pathology of internal organs can lead to the development of edema in the distal parts of both (always!) extremities. The severity of the clinical signs of the underlying pathology (shortness of breath, oliguria, etc.) almost never leaves any doubt about the nature of the edema syndrome.

Chronic arterial insufficiency is a rare pathology during pregnancy. Disturbances in the arterial blood supply to the lower extremities may be accompanied by edema only in the case of critical ischemia, i.e. in the terminal stage of the disease. The edema develops subfascially, affecting only the muscle mass of the lower leg. During examination, attention is paid to the pallor and coldness of the skin, a decrease in the hair of the affected limb, the absence or sharp weakening of the pulsation of the main arteries (tibial, popliteal, femoral).

Lipedema. This term refers to a symmetrical increase in the volume of subcutaneous fat tissue only on the shin. This leads to the appearance of fairly characteristic outlines of this part of the limb while maintaining the unchanged volume and shape of the thigh and foot. At the same time, this condition cannot be called edema, although this is how patients formulate their main complaint. Palpation of the shin in these patients often causes painful sensations.

The etiology of this condition is unknown, and it is most likely an inherited defect of the subcutaneous tissue, since lipedema is diagnosed only in women. A similar picture can also be observed in their female relatives in the descending or ascending line.

Ultrasound Dopplerography and duplex angioscanning allow to determine the state of the venous system with high accuracy and detect acute thrombotic lesion or chronic venous pathology. In addition, angioscanning can help to judge the cause of edema by the nature of changes in the subcutaneous tissue. Lymphedema is characterized by visualization of channels filled with interstitial fluid. In chronic venous insufficiency, the scanographic picture of the subcutaneous fat tissue can be compared to a "snow storm". These data complement the previously obtained information and help to establish which system's pathology (venous or lymphatic) plays a leading role in the genesis of the edema syndrome.

Treatment chronic venous insufficiency in pregnancy

The goal of treating chronic venous insufficiency is to prevent disease progression, reduce the severity of clinical symptoms, and prevent the development of thromboembolic complications.

Indications for hospitalization

Development of thromboembolic complications (thrombophlebitis, varicothrombophlebitis, deep vein thrombosis, pulmonary embolism).

Non-drug treatment of chronic venous insufficiency

The most modern method of non-specific prevention and treatment of chronic venous insufficiency during pregnancy is the use of special compression hosiery of the 1st–2nd compression class, including hospital hosiery. The conducted studies of the effectiveness of therapeutic hosiery of the 1st–2nd compression class during pregnancy and in the postpartum period have shown that its use during pregnancy, childbirth and the postpartum period contributes to the acceleration of venous blood flow in the lower extremities and improves the subjective sensations of patients. According to ultrasound data, patients who used products made of therapeutic hosiery of the 1st–2nd compression class showed a more pronounced decrease in the diameter of the venous trunks in the postpartum period.

Patients must use compression hosiery daily throughout pregnancy and in the postpartum period, for at least 4-6 months.

The use of compression means does not cause reliable changes in the hemostasiogram, which allows them to be used during childbirth (both through the natural birth canal and during cesarean section). The antithromboembolic effect of medical compression hosiery is associated mainly with the acceleration of venous blood flow, reducing blood stasis. The use of compression therapy prevents damage to blood vessels (with their excessive stretching), eliminating one of the causes of thromboembolic complications.

The use of antithromboembolic stockings in obstetrics in pregnant women suffering from chronic venous insufficiency reduces the risk of thromboembolic complications by 2.7 times. According to some researchers, compression hosiery improves uteroplacental blood flow.

Drug treatment of chronic venous insufficiency

One of the most important methods of treating chronic venous insufficiency is the use of local topical forms. Ease of use, lack of systemic action make it indispensable, especially in the early stages of pregnancy. Most often used are heparin-containing ointments and gels, which vary in effectiveness and content of sodium heparin (from 100 to 1000 IU). Gels are somewhat more effective than ointments.

The use of local agents reduces the severity of such symptoms of venous insufficiency as swelling, fatigue, heaviness and cramps in the calf muscles. Against the background of the therapy, there are usually no side effects. It should be noted that compression therapy is often combined with gel forms of heparin and is not recommended to be combined with ointment forms (due to the fatty component in the ointment, which prolongs the absorption process and increases the risk of developing a skin infection).

Local forms of heparin have a fairly effective symptomatic effect in chronic venous insufficiency, but do not have a significant preventive effect on venous thromboembolic complications. Thus, the use of a topical agent in the treatment of chronic venous insufficiency can only be an addition to the main therapy.

The drugs of choice in drug therapy are phlebotonics (dipyridamole, etc.). Drug therapy is prescribed for pronounced clinical symptoms: pain in the lower extremities, edema, etc. (clinical class of chronic venous insufficiency C3 and above).

The most effective is diosmin + hesperidin, which consists of plant micronized bioflavonoids: diosmin 450 mg (90%) and hesperidin 50 mg (10%). According to experimental and clinical studies, diosmin + hesperidin does not have toxic, embryotoxic and mutagenic properties, is well tolerated by women, and has a pronounced venotonic effect. Under the influence of norepinephrine, the extensibility of varicose veins approaches normal. The drug also has a pronounced positive effect on lymphatic drainage. It leads to a significant increase in the outflow of lymph from the affected limb due to increased peristalsis of the lymphatic vessels and an increase in oncotic pressure. An equally important effect of the drug is the prevention of migration, adhesion and activation of leukocytes - an important link in the pathogenesis of trophic disorders in chronic venous insufficiency.

The drug is recommended to be taken 1 tablet 2 times a day, starting from the second trimester of pregnancy, the course of treatment is 1 month, if necessary, it can be increased. The use of micronized flavonoids during pregnancy helps to accelerate venous blood flow in the lower extremities, improve subjective sensations of patients. Among women who received treatment, the frequency of thromboembolic complications is significantly reduced (own data). The use of the drug in pregnant women leads to a significant reduction in the risk of thromboembolic complications both during pregnancy and in the postpartum period, improvement of the condition of the lower extremities, and a decrease in subjective and objective symptoms.

The use of a complex of measures, including compression therapy, local agents and phlebotropic drugs, gives the best effect.

Surgical treatment of chronic venous insufficiency

Treatment during pregnancy is limited mainly to therapeutic measures, since surgical correction is associated with a high risk of postoperative complications. Surgical treatment is performed only in the case of thromboembolic complications (thrombophlebitis proximal to the upper third of the thigh, deep vein thrombosis).

Indications for consultation with other specialists

In severe cases (CVI C3 and above) or if complications develop, a consultation with a vascular surgeon or phlebologist is indicated. After consultation with a phlebologist or vascular surgeon, in some cases conservative treatment without hospitalization is possible.

Further management of the patient

After the end of pregnancy, improvement is usually observed (both in case of limb damage and perineal varicose veins), however, in the postpartum period, it is recommended to continue using local and compression agents for 4-6 months (the period of the highest risk of developing thromboembolic complications). In the future, if CVI symptoms persist, a consultation with a vascular surgeon or phlebologist is necessary to choose a treatment strategy.

Prevention

Varicose veins are a fertile ground for the development of thrombosis, since changes in the vascular wall and slowing of blood flow are the most important causes of thrombus formation. With corresponding changes in the adhesive-aggregation properties of blood cells and the plasma link of hemostasis (which is facilitated by venous congestion and turbulent blood flow), thrombi occur in them. That is why eliminating these factors helps prevent thromboembolic complications. It is important to emphasize that they are a potentially preventable cause of maternal morbidity and mortality.

It is known that the risk of developing thromboembolic complications in young healthy women is 1-3 per 10,000 women. Pregnancy increases this risk by 5 times. Fortunately, the absolute risk of developing a clinically significant thromboembolic complication during pregnancy or after childbirth is relatively low. However, despite the low absolute figures, pulmonary embolism is the leading cause of maternal mortality after childbirth, the incidence is 1 per 1000 births, the fatal outcome is 1 per 100,000 births. The greatest risk of developing this complication occurs in the postpartum period. Many researchers note that the incidence of deep vein thrombosis increases sharply (20 times) in the postpartum period compared to the corresponding age group of non-pregnant women. Smoking, previous episodes of thromboembolic complications and hereditary forms of thrombophilia increase the risk of developing this complication in pregnant women.

In patients suffering from chronic venous insufficiency, the incidence of thromboembolic complications increases to 10%.

The most modern and effective methods of preventing thromboembolic complications in women suffering from chronic venous insufficiency include supplementation with low-molecular-weight heparins (dalteparin sodium, enoxaparin sodium, nadroparin calcium, etc.). The dose of the drug and the duration of the course are selected individually in each specific situation.

The use of low-molecular heparins quickly normalizes the hemostasiogram indices. Low-molecular heparins are highly effective for the prevention of thromboembolic complications. Their use is usually not accompanied by side effects and does not increase the risk of bleeding.

[ 10 ], [ 11 ], [ 12 ], [ 13 ], [ 14 ]

Forecast

The prognosis for life is favorable.