Varicose veins of the vagina and external genitalia in pregnant women

Varicose veins in pregnant women are a common pathology, diagnosed in every fifth woman of reproductive age, and the development of the disease in 96% of cases correlates with bearing a child and childbirth. Most often, it manifests itself in the system of the great, less often - the small saphenous vein and begins with the tributaries of the trunk vein on the shin. Varicose veins of the vagina and external genitalia are a relatively rare symptom of the disease, but at the same time require great attention, since varicose nodes of this localization are dangerous due to their complications.

Slowing of blood flow in varicose veins and unstable balance between hemostasis and fibrinolysis systems are the background against which the process of intravascular thunderclap formation is realized when the vascular wall is damaged. A history of varicose veins of the external genitalia and vagina is one of the main risk factors in terms of venous thrombosis in obstetric practice.

Symptoms of Varicose Veins in the Vagina During Pregnancy

Clinical symptoms of varicose veins of the vagina and external genitalia are quite typical and are expressed during pregnancy and childbirth (after childbirth, varicose veins in this localization, as a rule, practically disappear). With external varicose veins, in 60% of pregnant women the disease remains in the compensation stage (there are no complaints in the form of subjective sensations), in 40% signs of decompensation appear. The leading symptom is the occurrence of chronic pain in the vulva and vagina of a pulling, aching, dull, burning nature with irradiation to the lower limbs, occurring after prolonged static and dynamic loads. Some patients experience pain crises, periodically occurring exacerbations provoked by exogenous (cooling, fatigue, stress) and endogenous (exacerbation of chronic diseases of the internal organs) causes.

In addition to pain, most patients experience discomfort and a feeling of heaviness in the vulva and vagina. A less common symptom is dyspareunia (pain and discomfort during and after sexual intercourse).

Diagnosis of varicose veins of the vagina in pregnant women

An important stage of diagnostics of this pathology is gynecological examination. When examining the labia majora, one can detect telangiectasias, varicose nodes, tortuosity of the venous wall, hyperemia, cyanosis of the skin and mucous membrane. During bimanual vaginal examination and examination with mirrors, one can detect sharp pain, cyanosis of the mucous membrane, its swelling, hypertrophy, dilated, tortuous, in places compacted and thrombosed vessels, leukorrhea (increased amount of watery leucorrhoea). An additional method of examination for varicose veins of the specified localization is the study of the hemostasis function: determination of blood clotting time, prothrombin index, plasma tolerance to heparin, plasma recalcification time, determination of fibrinogen concentration, soluble fibrin monomer complexes, antithrombin III, fibrinolytic activity of blood, and conducting an autocoagulation test.

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Patient management tactics

In obstetric practice, patient management tactics should be considered separately during pregnancy, childbirth and the postpartum period.

Pregnancy management involves both general principles and drug therapy. General principles of management for all groups of pregnant women with varicose veins:

• outpatient observation by a surgeon and obstetrician-gynecologist;
• diet (complete, varied, easily digestible food rich in vitamins);
• prevention of constipation (enriching the diet with fermented milk products and plant fiber);
• limitation of significant physical activity;
• normalization of working and rest conditions;
• daily stay in a horizontal position with the pelvis raised by 25-30° 3 times for 30 minutes;
• Physical therapy (exercises aimed at improving the function of the muscular-venous pump);
• dynamic monitoring of coagulogram (once every 2 weeks).

The main principle of drug therapy is the use of drugs with venotonic and angioprotective properties (endotelon, diovenor, escusan), as well as antiplatelet agents (fraxiparin, trental, curantil, aspirin). In addition, it is necessary to take into account that, despite hypercoagulation on the eve of childbirth, women with varicose veins are characterized by hypocoagulation and a tendency to significant blood loss during childbirth and in the early postpartum period. This fact entails the need for a blood reserve in patients with varicose veins. The most optimal in this case is the autodonation technique (preparation of one's own plasma from the 32nd week of pregnancy in 2 stages with a seven-day break in a volume of 600 ml). In 74% of cases, compensated or subcompensated fetoplacental insufficiency is diagnosed, which requires the use of drugs that improve the function of the fetoplacental complex. An important principle of therapy is also the implementation of psychocorrective therapy, which involves the inclusion of sedative drugs (persen, sedasene, valerian extract) in the therapeutic complex.

The management of labor in patients with varicose veins of the external genitalia and vagina requires special attention, since it is during this period that the risk of bleeding and thromboembolic complications is high. In terms of injury to varicose veins, the most dangerous is the end of the second stage of labor, that is, the moment of insertion and cutting of the head. During each of the pushing efforts, to prevent varicose veins from overflowing with blood, it is necessary to gently squeeze the tissues with varicose veins with the palm of the hand through a sterile diaper. To prevent rupture of varicose veins, perineotomy should be performed, which in many cases allows to avoid rupture of tissues of the external genitalia and vagina affected by varicose veins. When trying to perform an episiotomy, varicose veins invisible under the skin can be injured.

Rupture of varicose veins, vaginal veins and external genitalia is accompanied by active bleeding immediately after the birth of the fetus. In this case, immediately begin to examine the vaginal mucosa, isolate the ends of the ruptured vessels from the adjacent tissues and ligate them with catgut, since blind suturing leads to a violation of the integrity of intact nodes, increased bleeding and the formation of extensive hematomas. The wound is widely opened, the conglomerate of nodes is isolated and repeatedly sutured in a direction transverse to the length of the vagina or labia majora. After this, a sterile condom filled with ice is inserted into the vagina. After ligating the varicose vessels and suturing the wound on the labia majora, an ice pack is applied to them for 30-40 minutes.

In case of unsuccessful attempt of suturing and ligation of bleeding vessels of vaginal walls, tight tamponade of vagina with gauze soaked in aminocaproic acid solution or isotonic sodium chloride solution for 24 hours or more is recommended. For the same purposes, ice should be introduced into vagina and rectum should be tamponed with gauze soaked in Vaseline.

In case of severe varicose veins of the external genitalia and vagina, a cesarean section is indicated.

In the postpartum period, early rising (12 hours after delivery) and exercise therapy are recommended. Women in labor with severe varicose veins of the vagina and external genitalia, as well as after surgical delivery, are prescribed fraxiparine 0.3 ml subcutaneously into the tissue of the anterolateral surface of the abdomen after 6 hours (taking into account the thromboelastogram and coagulogram indicators).

Thus, varicose veins of the vagina and external genitalia during pregnancy and childbirth significantly increase the risk of bleeding and thrombotic complications, which requires special attention and special obstetric tactics. Strict implementation of adequate prevention during pregnancy, adherence to the principles of labor and postpartum management in women with varicose veins of the external genitalia and vagina can significantly reduce the frequency of complications in this contingent of pregnant women.

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