CONSULTATION DRAFT
6.3 Varicose veins
Varicose veins occur often within the general population and are a common symptom during pregnancy. While there is little evidence to support any particular treatment, use of compression stockings may help to relieve symptoms.
6.3.1 Background
Varicose 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 and inside of the legs, and cause itching and general discomfort. Feet and ankles can also become swollen.
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).
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).
Factors influencing varicose veins in pregnancy
• Elevated pressure: Increased blood volume early in pregnancy, followed by fetal growth and weight gain, increase intra-abdominal pressure and central venous return, with the potential for the elevated pressure to lead to valve failure and development of varices (Beebe-Dimmer et al 2005).
• Hormones: Hormonal fluctuations in early pregnancy strongly influence the development of varicose veins (Carr 2006; Lenkovic et al 2009).
6.3.2 Discussing varicose veins
Summary of the evidence
There 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 veins
• Compression 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, will not cause harm and usually improve after the birth.
6.3.3 Practice summary: varicose veins
When: A woman had varicose veins before pregnancy or has symptoms of varicose veins.Who: Midwife; GP; obstetrician; Aboriginal and Torres Strait Islander Health Practitioner; Aboriginal and Torres Strait Islander Health Worker; multicultural health worker.
Provide advice: Explain that varicose veins are common in pregnancy, especially in second and subsequent pregnancies and multiple pregnancies.
Discuss treatments: Advise women that symptoms can be relieved by elevating the feet while resting and avoiding long periods of standing.
Take a holistic approach: Women may not mention that they have varicose veins and they may not be visible to the health professional. Asking about itching or discomfort in the legs can assist in identifying varicose veins.
6.3.4 Resources
Common discomforts in pregnancy. In: Minymaku Kutju Tjukurpa Women’s Business Manual, 4th edition. Congress Alukura, Nganampa Health Council Inc and Centre for Remote Health. http://www.remotephcmanuals.com.au
6.3.5 References
Bamigboye 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.
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.