Clinical Practice Guidelines Antenatal Care — Module II
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- 7.8Varicose veins
- Factors influencing varicose veins in pregnancy
- Discussing varicose veins
- Treatments for varicose veins
- Practice summary: varicose veins
- 7.9Resources
7.6ResourcesNHMRC (2013) Australian Dietary Guidelines. Canberra: Commonwealth of Australia. 7.7ReferencesAbramowitz L & Batallan A (2003) Epidemiology of anal lesions (fissure and thrombosed external hemorroid) during pregnancy and post-partum. Gynecol Obstet Fertil 31(6): 546–49. Abramowitz L, Sobhani I, Benifla JL et al (2002) Anal fissure and thrombosed external hemorrhoids before and after delivery. Dis Colon Rectum 45(5): 650–55. Avsar A & Keskin H (2010) Haemorrhoids during pregnancy. J Obstet Gynaecol 30(3): 231–37. Buckshee K, Takkar D, Aggarwal N (1997) Micronized flavonoid therapy in internal hemorrhoids of pregnancy. Int J Gynecol Obstet 57: 145–51. Dietrich C, Hill C, Hueman M (2008) Surgical diseases presenting in pregnancy. Surg Clin North America 88: 403–19. Staroselsky A, Nava-Ocampo AA, Vohra S et al (2008) Hemorrhoids in pregnancy. Can Fam Phys 54(2): 189–90. Wald A (2003) Constipation, diarrhea, and symptomatic hemorrhoids during pregnancy. Gastroenterol Clin North America 32: 309–22.
BackgroundVaricose veins are caused by the pooling of blood in the surface veins as a result of inefficient valves that would normally prevent blood draining back down the leg. They can occur as blue swollen veins on the calves, the inside of the legs and the vulva, and may cause itching and aching. Feet and ankles can also become swollen. In 70–80% of women who develop problems with varicose veins during pregnancy, the symptoms appear during the first trimester, often within 2 to 3 weeks of gestation (Carr 2006). A family history of varicose veins, increasing number of full term pregnancies and increasing age have been found to be risk factors for the development of varicose veins (Dindelli et al 1993; Jawien 2003; Beebe-Dimmer et al 2004).
Summary of the evidenceThere is a lack of evidence about treatments for varicose veins that are effective and safe in pregnancy. Existing systematic reviews are based on small RCTs with a high risk of bias (Bamigboye & Hofmeyr 2006; Bamigboye & Smyth 2007). The evidence on vulval varices is too limited for conclusions to be drawn. Given the overall lack of evidence, there is consensus in clinical reviews that advice to women should be based on reassurance, conservative management and symptom relief. Avoiding long periods of standing, use of compression stockings and elevating the feet have been found to improve symptoms in the general population (Carr 2006). Treatments for varicose veinsCompression stockings: A small RCT on preventing varicose veins in pregnancy with compression stockings (n=42) (Thaler et al 2001) found that compression stockings do not prevent or improve varicose veins, but do improve leg symptoms (pain, discomfort, cramps) (RR 0.74, 95% CI 0.59–0.93). Surgery: Surgical techniques including stripping and ligation, ablation or scleropathy, may be used to remove varicose veins when people remain symptomatic (Carr 2006). As symptoms of varicose veins often improve after the birth (Bamigboye & Smyth 2007), surgery is rarely considered an appropriate intervention for pregnant women. Consensus-based recommendation viii Advise women that varicose veins are common during pregnancy, vary in severity, will not generally cause harm and usually improve after the birth. Correctly fitted compression stockings may be helpful. Practice summary: varicose veins
7.9ResourcesCommon discomforts in pregnancy. In: Minymaku Kutju Tjukurpa Women’s Business Manual, 4th edition. Congress Alukura, Nganampa Health Council Inc and Centre for Remote Health. 7.10ReferencesBamigboye A & Hofmeyr GJ (2006) Interventions for leg edema and varicosities in pregnancy. What evidence? Eur J Obstet Gynecol Reprod Biol 129(1): 3–8. Bamigboye A & Smyth R (2007) Interventions for varicose veins and leg oedema in pregnancy. Cochrane Database Sys Rev 2007, Issue 1. Art. No.: CD001066. DOI: 10.1002/14651858.CD001066.pub2. Beebe-Dimmer JL, Pfeifer JR, Engle JS et al (2005) The epidemiology of chronic venous insufficiency and varicose veins. Annals Epidemiol 15(3): 175–84. Carr S (2006) Current management of varicose veins. Clin Obstet Gynecol 49(2): 414–26. Dindelli M, Parazzini F, Basellini A et al (1993) Risk factors for varicose disease before and during pregnancy. Angiol 44: 361–67. Huerta C, Johansson S, Wallander MA et al (2007) Risk factors and short-term mortality of venous thromboembolism diagnosed in the primary care setting in the United Kingdom. Arch Intern Med 167(9): 935–43. Jawien A (2003) The influence of environmental factors in chronic venous insufficiency. Angiol 54(1): S19–S31. Lenkovic M, Cabrijan L, Gruber F et al (2009) Effect of progesterone and pregnancy on the development of varicose veins. Acta Dermatovenerol Croat 17(4): 263–67. Thaler E, Huch A, Huch R et al (2001) Compression stockings prophylaxis of emergent varicose veins in pregnancy: a prospective randomised controlled study. Swiss Med Weekly 131: 659–62.
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