Varicose veins during pregnancy

Varicose Veins in Pregnancy: Why they occur and what you can do

Up to 30-40% of all pregnant women develop visible varicose veins (varices) during pregnancy - and for many, the condition worsens with each subsequent pregnancy [1,2]. The good news is that a large proportion of these changes disappear again after giving birth, and that both prevention and treatment are safe and effective.

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Why do pregnant women get varicose veins more often?

Three factors work together:

• Increased blood volume. During pregnancy, blood volume increases by 30-50%, which increases the pressure in the leg veins [3].
• Hormonal changes. Progesterone and oestrogen relax the blood vessel walls and dilate the veins - starting from the first trimester [4].
• Mechanical pressure. The growing uterus presses on the vena cava and pelvic veins, particularly on the right side, and impedes the return of blood from the legs [5].

In addition, there is a hereditary predisposition - if your mother or sister has varicose veins, your own risk increases significantly. Read more in Varicose veins and heredity.

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Typical symptoms

• Heavy, tired legs at the end of the day
• Swelling around the ankles and feet
• Night cramps and restless legs
• Visible, winding veins on the thighs, calves and behind the knees
• Spider veins
• Vulval varicosities (varicose veins on the labia) - seen in ~10% of pregnant women [6]
• In rare cases: superficial blood clots (thrombophlebitis)

Please note: haemorrhoids are actually varicose veins in the blood vessels of the rectum - the same mechanism applies during pregnancy. Also read Haemorrhoids during pregnancy.

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Prevention and relief

Almost everything can be done without medication or procedures:

• Compression stockings (Class 1-2) are the first-line choice. A Cochrane review shows that they reduce both symptoms and the development of new varicose veins during pregnancy [7]. Put them on in the morning before you get out of bed.
• Exercise: 30 minutes of walking daily activates the calf muscle pump.
• Elevate your legs above heart level for 15-20 minutes several times a day.
• Lie on your left side when you sleep - this relieves pressure on the vena cava.
• Avoid standing or sitting still for long periods without moving your feet.
• Weight management and a high-fibre diet help prevent both varicose veins and haemorrhoids.

What about medication? Phlebotonics (e.g. micronised diosmin/hesperidin) are NOT routinely recommended during pregnancy, as their safety has not been sufficiently documented [8].

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When to contact a doctor

See a doctor if you have:

• A tender, red, and hard vein (possible superficial thrombophlebitis)
• A swollen, warm, and painful leg - this can be a sign of deep vein thrombosis (DVT), the risk of which is 5-6 times higher during pregnancy and the postpartum period [9]
• Skin changes at the ankle (brownish discolouration, eczema or ulcers)
• Sudden heavy bleeding from a ruptured superficial vein

Acute shortness of breath or chest pain → call 112 (on suspicion of a pulmonary embolism).

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Treatment after childbirth

Most pregnancy-related varicose veins disappear or improve significantly within 3-6 months postpartum, as hormones, blood volume, and pelvic pressure return to normal [10]. Therefore, you should wait to have treatment until:

• At least 3-6 months after giving birth, so the actual need for treatment can be assessed
• After you have finished breastfeeding - especially before sclerotherapy or endovenous laser, as the effect of treatment on breast milk has not been fully studied

If symptoms or visible varicose veins persist, the following are offered:

• Doppler ultrasound to map valve function and reflux
• Endovenous Laser Treatment (EVLT) - a modern and gentle treatment with a 95% closure rate after 5 years [11]
• Sclerotherapy for smaller varicose veins and spider veins
• Only rarely, classic surgery

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Will they return in a future pregnancy?

Yes, there is a risk. Previous pregnancies are an independent risk factor for new varicose veins, and approx. 30-50% of women with previous pregnancy-related varicose veins experience a worsening with their next pregnancy [2,12]. Treatment before a new pregnancy can therefore be a sensible option if symptoms are pronounced.

At our clinic, we are happy to see women who have been through a pregnancy for an ultrasound assessment and potential modern laser treatment under the public health insurance scheme.

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References

1. Smyth RM, et al. Interventions for varicose veins and leg oedema in pregnancy. Cochrane Database Syst Rev 2015;(10):CD001066.
2. Bamigboye AA, Smyth R. Interventions for varicose veins and leg oedema in pregnancy. Cochrane Database Syst Rev 2007;(1):CD001066.
3. Hytten F. Blood volume changes in normal pregnancy. Clin Haematol 1985;14(3):601-12.
4. Boivin P, et al. Estradiol- and progesterone-receptor expression in the wall of varicose veins from pregnant women. Phlebology 2000;15(2):85-9.
5. Ikard RW, et al. The aetiology of varicose veins of pregnancy. Obstet Gynecol Surv 1972;27(11):753-63.
6. Van Cleef JF. Pelvic and vulvar varicosities in pregnancy. Phlebolymphology 2011;18(3):126-32.
7. Allegra C, et al. Compression therapy in pregnancy. Int Angiol 2006;25(2):174-7.
8. Mansilha A, Sousa J. Pathophysiological mechanisms of chronic venous disease and implications for venoactive drug therapy. Int J Mol Sci 2018;19(6):1669.
9. Heit JA, et al. Trends in the incidence of venous thromboembolism during pregnancy or postpartum. Ann Intern Med 2005;143(10):697-706.
10. Sparey C, et al. The effect of pregnancy on the lower-limb venous system of women with varicose veins. Eur J Vasc Endovasc Surg 1999;18(4):294-9.
11. Rasmussen LH, et al. Randomized clinical trial comparing endovenous laser ablation, radiofrequency ablation, foam sclerotherapy and surgical stripping for great saphenous varicose veins. Br J Surg 2011;98(8):1079-87.
12. Beebe-Dimmer JL, et al. The epidemiology of chronic venous insufficiency and varicose veins. Ann Epidemiol 2005;15(3):175-84.