Varicose veins of the vagina and external genital organs in pregnant women

Varicose veins in pregnant women is a widespread pathology that is diagnosed in every fifth woman of reproductive age, and the development of the disease in 96% of cases correlates with childbearing and childbirth. Most often, it manifests itself in the system of a large, less often - small saphenous vein and begins with tributaries of the trunk of the vein on the lower legs. Expansion of the veins of the vagina and external genital organs is a relatively rare symptom of the disease, but it requires a lot of attention, since the varicose nodes of this localization are dangerous because of their complications.

The slowing down of blood flow in varicose veins and the unstable balance between the systems of hemostasis and fibrinolysis are the background against which the process of intravascular thrombus occurs when the vascular wall is damaged. A history of varicose veins of the vulva and vagina is one of the main risk factors for venous thrombosis in obstetric practice.

Symptoms of varicose veins of the vagina during pregnancy

Clinical symptoms of varicose veins of the vagina and external genital organs are quite typical and expressed during pregnancy and childbirth (after childbirth, varicose veins with this localization, as a rule, almost 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), 40% show signs of decompensation. The leading symptom is the occurrence of chronic pain in the region of the vulva and vagina of the pulling, aching, dull, burning character with irradiation to the lower extremities that occur after prolonged static and dynamic loads. In some patients, there are pain crises, intermittent exacerbations provoked by exogenous (cooling, overwork, stress) and endogenous (exacerbation of chronic diseases of internal organs) causes.

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

Diagnosis of varicose veins of the vagina in pregnant women

An important stage in the diagnosis of this pathology is a gynecological examination. On examination of the labia majora, it is possible to detect telangiectasia, varicose nodes, tortuosity of the venous wall, hyperemia, cyanosis of the skin and mucous membrane. During bimanual vaginal examination and examination with the help of mirrors, sharp pain, cyanosis of the mucous membrane, its edema, hypertrophy, dilated, tortuous, compacted and thrombosed vessels, leukorea (increased amount of watery whiter) are determined. An additional research method for varicose veins of the indicated localization is the study of hemostasis function: determination of blood clotting time, prothrombin index, heparin plasma tolerance, plasma reclamation time, determination of fibrinogen concentration, soluble fibrin monomer complexes, antithrombin III, fibrinolytic activity of the blood, carrying out autocoagulation test.

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Patient Management Tactics

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

Conducting pregnancy involves the observance of both general principles and the conduct of drug therapy. General principles of reference for all groups of pregnant women with varicose veins:

• dispensary observation of the surgeon and obstetrician-gynecologist;
• diet (full, varied, easily digestible, vitamin-rich food);
• prevention of constipation (enrichment of the diet with fermented milk products, plant fiber);
• limiting significant physical exertion;
• normalization of working and rest conditions;
• daily stay in a horizontal position with a pelvis raised by 25-30 ° 3 times 30 minutes each;
• Exercise therapy (exercises aimed at improving the function of the muscular-venous pump);
• dynamic control of the coagulogram (once every 2 weeks).

The main principle of drug therapy is the use of drugs that have venotonic and angioprotective properties (endothelon, diovenor, escuzan), as well as antiaggregants (fraxiparin, trental, curantil, aspirin). In addition, it is necessary to take into account that, despite the hypercoagulation on the eve of childbirth, hypocoagulation and a tendency to large blood loss during childbirth and in the early postpartum period are characteristic of women with varicose disease. This fact entails the need for blood supply in patients with varicose disease. The most optimal in this case is the method of auto-donation (procurement of 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 conduct of psycho-corrective therapy, which includes the inclusion of sedative drugs (Percen, Sedasin, valerian extract) into the therapeutic complex of drugs.

Conducting labor in patients with varicose veins of the external genital organs and vagina requires special attention, since it is during this period that the risk of bleeding and thromboembolic complications is high. At the same time, in terms of injury to varicose knots, the end of the second stage of labor is most dangerous, that is, the moment of insertion and cutting of the head. During each of the attempts, to prevent the overflow of varicose nodes with blood, it is necessary to gently squeeze the tissue with varicose veins with the palm of your hand through a sterile diaper. For the prevention of the rupture of varicose nodes, perineotomy should be performed, which in many cases allows avoiding the rupture of the vulva and vaginal tissues affected by varicose veins. When you try to episiotomy, you can injure the invisible under the skin of the varicose nodes.

The rupture of varicose nodes, veins of the vagina and external genital organs is accompanied by active bleeding immediately after the birth of the fetus. In this case, they immediately proceed to the examination of the mucous membrane of the vagina, isolate the ends of the ruptured vessels from adjacent tissues and bandage them with catgut, since blindly flashing leads to disruption of the integrity of intact nodes, increased bleeding and the formation of extensive hematomas. Widely open the wound, allocate a conglomerate of nodes and repeatedly sew it in the direction transverse to the length of the vagina or the labia majora. After that, a sterile condom filled with ice is inserted into the vagina. After tying up the varicose vessels and suturing the wound on the labia majora, an ice bubble is applied to them for 30-40 minutes.

In the case of a failed attempt at flashing and applying ligatures on the bleeding vessels of the vaginal walls, a tight vaginal tamponade with gauze soaked in an aminocaproic acid solution or an isotonic sodium chloride solution for 24 hours or more is recommended. For the same purpose, ice should be inserted into the vagina and tamponing the rectum with gauze soaked in vaseline.

With marked varicose veins of the vulva and vagina, cesarean section is indicated.

In the postpartum period, an early rise (12 hours after delivery) and exercise therapy are recommended. For mothers with severely expressed varicose veins of the wetting and external genital organs, as well as after operative delivery, after 6 hours, fraxiparin is administered 0.3 ml subcutaneously into the tissue of the anterolateral surface of the abdomen (taking into account the indicators of thromboelastogram and coagulogram).

Thus, varicose veins of the vagina and external genital organs 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 prophylaxis during pregnancy, adherence to the principles of delivery and the postpartum period in women with varicose veins of the external genital organs and vagina can significantly reduce the incidence of complications in this cohort of pregnant women.

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