Varicose Veins

What are varicose veins?

Varicose veins are superficial veins that have become enlarged, twisted, and swollen, due to blood leaking backward through valves that have evolved to keep blood running in one direction. Blood normally flows toward the heart, which in the case of your legs or lower torso means upward, against the direction of gravity. Hormonal changes during pregnancy make the walls of your veins more flexible than usual, while the growing womb puts pressure on deep veins in your pelvis. Since deep veins are connected with superficial veins through a system of short connecting veins, a backlash of blood flow can develop, resisting the upward flow of blood through superficial veins in your legs. Typically, this happens in a great saphenous vein, the longest in the body, running along your leg, but it also can happen on superficial veins of the torso.

How common are varicose veins during pregnancy?

Studies in the medical literature have reported the prevalence of varicose veins ranging widely from just above 1 percent to as high as 73 percent of women overall, including those who pregnant. The risk of developing varicose veins increases in people whose occupation keeps them standing without walking around for long periods of time. Teachers fall into this category, as do surgeons.

How are varicose veins diagnosed?

Your doctor can determine that you have varicose veins by examining the veins that concern you and seeing that they are swollen and that they remain swollen if you continue standing up. Once the presence of varicose veins is established, your doctor needs to grade the severity of the varicose veins. This is done by means of whats called the Clinical-Etiologic-Anatomic-Pathophysiologic (CEAP) score, which runs from C0 to C6, depending on your symptoms, the appearance of the veins, the amount of swelling, skin damage, and the presence or absence of ulcers (sores). A score of C0 means that there are no varicose veins, C6 means there is a venous ulcer, and C1-C5 grades indicate various levels of severity. The distinction between higher grades (C4-C6) helps to determine whether or not you could be in danger, while distinctions between lower grades (C0-C3) is more relevant to whether your health insurance will cover treatment, or which treatment will be covered. In addition to the physical examination, the main procedure for diagnosing your venous system is called duplex ultrasound.

Do varicose veins cause problems during pregnancy?

A CEAP score of 2 or lower generally means that your varicose veins are a cosmetic issue. From C3 upward, the swelling and stagnation of blood can cause pain and ultimately interfere with tissues in your legs, and make you tired, especially after you are standing all day. Grades C5 and C6 mean that there have been (C5) or are (C6) ulcers, which can potentially become infected, leading to possibly life-threatening complications. Having this condition at such a severe level is rare in young women. The regurgitation of blood and the resulting stagnation in the superficial veins also can lead to blood clots in these veins. Generally, this is not as dangerous as clots in the deep veins, but a small fraction of such superficial clots can produce the same complications as deep vein clots, particularly if the clots are near branching points close to where the superficial vein is sending blood toward the deep vein system. The ultimate dangerous complication of such clots, if they break away and travel through the blood as emboli (traveling clots) is a life-threatening lung condition called a pulmonary embolism. This is quite rare with superficial vein problems, but sometimes varicose veins are the result of an underlying problem that also is affecting the deep venous system, and this is why a thorough examination of your entire venous system is important.

Do varicose veins during pregnancy cause problems for the baby?

If varicose veins are the only problem with your venous system, this does not cause problems for the baby. If your condition is reflecting a problem in the deep venous system, however, or if you develop a blood clot, the risk of venous embolism that could threaten your life carries over to the baby as well.

What to consider about taking medications when you are pregnant:

• The risks to yourself and your baby if you do not treat the varicose veins
• The risks and benefits of each medication you use when you are pregnant
• The risks and benefits of each medication you use when you are breastfeeding

What should I know about using medication to treat varicose veins during pregnancy?

If there is evidence of clotting, or if your varicose veins are severe such that your doctor considers you at risk for clotting, and if you have other risk factors (such as a history of smoking, being overweight, cancer) that make you especially prone to clotting, you will likely require anticoagulation therapy. Normally, the gold-standard treatment to prevent clotting is warfarin, but this is avoided during pregnancy as it can harm the developing baby. Instead, the choice treatment against clotting during pregnancy is low molecular weight heparin (LMWH).

Who should NOT stop taking medication for varicose veins during pregnancy?

If you require LMWH, this means you are at high risk for clots, so you need to continue with the treatment.

What should I know about choosing a medication for my varicose veins during pregnancy?

You may find Pregistrys expert reports about the individual medications to treat varicose veins here. Additional information can also be found in the sources listed at the end of this report.

What should I know about taking a medication for my varicose veins when I am breastfeeding?

Neither warfarin (used in North American for long-term anticoagulation therapy), nor a similar drug called acenocoumarol (used in Europe) enter breastmilk or otherwise affect a nursing infant. LMWH does enter breast milk, but in very tiny amounts and is not harmful because it is degraded in the infants digestive system (LMWH is not taken orally for this reason, but must be injected or infused).

What alternative therapies besides medications can I use to treat my varicose veins during pregnancy?

The principle treatments for varicose veins are not medications, but compression stockings and exercise for mild to moderate cases. More severe cases can be managed with sclerotherapy and other surgical approaches, which work by closing up the affected vein. Vascular surgeons will want to wait for a few months after you give birth to see if your condition improves on its own since its the hormonal changes of pregnancy that aggravate varicose veins. Many surgeons also prefer to wait until you are finished breastfeeding.

What can I do for myself and my baby when I have varicose veins during pregnancy?

Be reassured that this is generally not a life-threatening condition, as long as you dont develop clots and sores, that it can resolve in part after pregnancy, and that otherwise there are surgical treatments.

Resources for varicose veins in pregnancy:

For more information about varicose veins during and after pregnancy, contact http://www.womenshealth.gov/ (800-994-9662 [TDD: 888-220-5446]) or read the following articles:

• Mayo
  Clinic: Varicose Veins During Pregnancy
• Cleveland Clinic: Varicose and Spider Veins