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Chronic venous disease during
pregnancy
André CORNU-THENARD1,
Pierre BOIVIN2
1 CHU Saint Antoine,
Service de Gynéco-Obstétrique,
75012 Paris, France
2 136, boulevard Haussmann
75008 Paris, France
Keywords:
compression stockings; hormones;
nocturnal leg elevation; postpartum
regression; pregnancy; varicose veins;
venoactive agents
Phlebolymphology. 2014;21(3):138-145
Copyright © LLS SAS. All rights reserved
www.phlebolymphology.org
138
Phlebolymphology - Vol 21. No. 3. 2014
Abstract
Pregnancy plays an important role in the onset and development of chronic venous
disease in women. Changes to the venous system that occur during pregnancy
are linked to hormonal secretions, as well as compression of the iliac veins by the
gravid uterus. The clinical signs are varied and can be distressing. The reasons that
pregnant women consult can be grouped under the terms aesthetic, preventative,
and therapeutic. Treatment is essentially noninterventional based on: (i) the wearing
of medical compression stockings, adapted to the severity of the venous disease;
(ii) sufficient elevation of the lower limbs when in the supine position; and (iii) the
prescription of venoactive agents in case of symptoms.
Introduction
Chronic venous disease (CVD) refers to a group of disorders associated with the
dysfunction of one or more of the 3 lower extremity venous systems: superficial,
deep, or perforating.1-3 CVD affecting the superficial venous system results in the
appearance of 3 clinical signs: telangiectasia and venulectasia, classified as C1
in the C class of the CEAP classification; and varicose veins, classified as C2. These
signs are often associated with classical venous symptomatology, although this as-
sociation has never been proven.4
Other signs of an impaired venous system include edema (C3), trophic skin disor-
ders (C4a and C4b), and leg ulcers (healed C5 and open C6).1 The appearance
and progression of CVD often occurs during pregnancy.5 Women frequently consult
early in pregnancy to find out about the risks, complications, and treatment options.
Pathophysiology
Pregnancy results in numerous adaptations to the circulatory system.5-12 CVD during
pregnancy is caused by a combination of two main mechanisms: (i) an increase
in venous pressure of the lower limbs due to compression of the inferior vena cava
and iliac veins by the gravid uterus; and (ii) an increase in venous distensibility due
to the effect of hormonal mediators. There is a linear increase in lower limb venous
pressure from the beginning to the end of pregnancy. By the end of pregnancy, the
femoral venous pressure in the supine position is increased threefold.6
CVD and pregnancy André CORNU-THENARD, Pierre BOIVIN
CVD and pregnancy Phlebolymphology - Vol 21. No. 3. 2014
139
The increase in venous distensibility occurs from the first
months of pregnancy and affects leg and arm veins in the
same manner. The placenta secretes a large quantity of ste-
roid hormones from the sixth week of pregnancy. Oestradiol
and progesterone may have a vasodilating action, which
would contribute to the increasing diameter of the veins ob-
served throughout pregnancy, and the significant decrease
that occurs after childbirth.8,9 They do not, however, exactly
return to their initial diameter, particularly in patients with a
history of varicose veins.5,8,10,12 Knowledge of this pathophysi-
ology explains the rate of occurrence and development of
CVD during pregnancy. It also explains the therapeutic ef-
fectiveness of medical compression stockings.
Clinical Epidemiology
Approximately 15% of pregnant women present with vari-
cose veins, which mostly occur at the beginning of the sec-
ond trimester.13 Age, gender, and a family history of CVD in-
creases the risk of occurrence of varicose veins during preg-
nancy.12 The relative risk of varicose veins increases 4-fold in
women over 35 years of age compared with those under 29
years of age. The risk is also increased twofold in multipa-
rous women compared with those in their first pregnancy.5 If
hereditary risk factors are present, the relative risk increases
6.2-fold.
The prevalence of varicose veins in women over 40 years of
age is as follows: 20% in nulliparous women, 40% in wom-
en who have had 1 to 4 pregnancies, and 65% in women
who have had 5 or more pregnancies.14 In addition, correla-
tions have been found between the number of varicosities
affecting the greater and smaller saphenous veins, the size
of the varicosities, and the number of pregnancies.12,13
Clinical Assessment
The objectives of the first assessment are to:
1. Determine the reasons for consultation by analysis of the
questionnaire given to the patient prior to the visit.15,16
2. Capture on a pre-prepared document (which will be in-
cluded in the dossier) what the patient sees and feels.
This will allow future comparisons to be made.1,2,17
3. Prepare a medical record, which will include findings
from the medical examination (diagram of the lower
limbs).
The examination will provide information on the reason for
consultation. The most common reason is the onset of physi-
cal signs and sometimes symptoms. Knowing whether or not
these existed before the pregnancy is important as it gives
a good indication of the progression of the condition. The
examination will also confirm the stage of pregnancy and
the expected delivery date.
Symptoms vary widely, from nonexistent to severe or unex-
pected. Pain (phlebalgia) and the sensation of edema are
frequent. They often occur at the end of the day and are
increased by heat, advancing pregnancy, and professional
activities.17
Signs are also variable and often related to a personal and
family history of CVD.
Telangiectasia and venulectasia are more dense and larger
than in nonpregnant women. Varicose veins are extreme-
ly diverse. They can range from small isolated dilatations
to very impressive varices “pseudo-angiomas” (Figure 1,
Figure 2). The dilatations can affect isolated veins or simul-
Figure 1. Large varicose vein parallel to the path of the greater
saphenous vein and telangiectasia; appeared in the fourth
month of pregnancy. Note the likely perforating vein. (C1 and
C2 of the CEAP classification) (Photo ACT).
Phlebolymphology - Vol 21. No. 3. 2014 André CORNU-THENARD, Pierre BOIVIN
140
taneously affect each element of the superficial venous net-
work: greater and smaller saphenous veins, their collaterals,
and perforating veins. They can also involve one or both
lower limbs. The distribution is relatively homogeneous with
approximately one-third of women having the right leg af-
fected, one third the left, and one third a bilateral distribu-
tion.6,13
In order to follow the progression of these varicose veins, it is
necessary to make a note of the maximum diameter of each
leg. This record is a method for scoring the clinical severity
of the varicose veins.18 Vulvar and perineal varicose veins
exist in about 10% of cases.13 They are often reported by
women worried about a risk of rupture (Figure 3). They are
not generally painful, but can become so when their volume
becomes important.14,19
Complications are mainly cutaneous (skin changes or sub-
cutaneous tissue), but these are rare given the young age
of these women, the short period of progression of the
condition, and improved treatment options in recent years.
Any trauma to an edematous leg may, however, lead to a
chronic wound. Such ulcers (C6) are more likely to occur if
there is a precursor: corona phlebectatica (Figure 4).20 The
appearance of either of these two signs requires the immedi-
ate initiation of treatment with medical compression therapy,
preferably in combination with a venotonic agent.
Thrombotic complications in the superficial and deep venous
systems are a major concern in pregnant women, in whom
the risk of venous thromboembolism is four times higher than
in nonpregnant women of the same age. Assessment of this
risk should form part of the clinical examination.21 Prevention
of thromboembolic risk and antithrombotic treatment should
be adapted on an individual basis.22-24
After childbirth, C1 and C2 diminish rapidly, but often in-
completely.25 C3-C6, if present, improves gradually, pelvic
Figure 2. Wooden reference dowels to illustrate the diameter
(mm) of varicose veins. Allows physicians to determine the
diameter of a palpable varicose vein in comparison with a
reference standard (Photo ACT).
Figure 3. Large vulvar and perineal varicose veins in a pregnant
woman (Photo Roger Mouyou)
Figure 4. A classic corona phlebectatica Van der Molen has
been described as being composed of numerous telangiectasia
grouped together at the edges.
CVD and pregnancy Phlebolymphology - Vol 21. No. 3. 2014
141
compressions are no longer an issue. A final assessment of
the regression is only made 3 months after childbirth or after
stopping breastfeeding.7,14
Venous Echo-Doppler Examination
Every consultation during the first months of pregnancy
should include a venous Doppler examination of the lower
limbs. This initial assessment of the lesions may be supple-
mented by a more detailed patient history including details
of CVD events: pelvic veins (ovarian and uterine veins), ab-
dominal veins, and laboratory tests.25,26
After the clinical examination, which will help guide treat-
ment and determine the maximum diameters of affected
veins, doctors should:
− Assess the venous networks of the affected limb as well
as the contralateral limb, taking care not to let the wom-
an stand for too long to avoid any discomfort.
− Record all findings on an initial illustration so that chang-
es can be followed with each advancing stage of preg-
nancy.
Treatment
The treatment should, in order of priority: (i) reassure the pa-
tient; (ii) relieve symptoms; (iii) reduce or stop progression of
the disease; and (iv) prevent complications.
Prevention counseling for lifestyle modification
Reassure. Worried patients should be reassured, explaining
that most varices will diminish after childbirth and that com-
plications are rare if treatment is followed.
Advise rest. During the day, extended rest periods are ben-
eficial. We suggest 15 minutes of rest for every hour a patient
spends on their feet. At night, the foot of the bed (and not
the head) should be raised. A question often asked is “How
high?” We propose the following rule: raise 1 cm for each
hour a patient spends on their feet during the day (eg, 10
hours standing=10 cm elevation).25,27 Note: there should be
no cushion under the heels and nothing at the end of the
mattress.
Exercise. Physical exercises that boost muscle power of the
lower limbs and are compatible with pregnancy should be
practiced as often as possible (walking, swimming, yoga,
gentle gymnastics).13
Compression therapy
The French National Authority for Health (La Haute Autorité
de Santé en France, www.has-sante.fr) has produced special
recommendations for compression therapy during pregnan-
cy (Table I). These serve as a useful starting point. Our goal is
to improve them based on the experience we have gained
in daily practice.
Some simple rules to follow:
1. Compression therapy should be prescribed at the ap-
pearance of the first venous disorder or at the start of
pregnancy in case of preexisting CVD.28−30
2. It must be continued throughout pregnancy and the phy-
sician’s role should be to convince their patients of this,
“to convince, we must be convincing, therefore con-
vinced!” Continuing compression therapy for 9 months
to 1 year is acceptable given the benefits that can be
achieved.
3. Regardless of the material used, multilayer bandages
are a very good therapeutic solution: two bandages (or
three) one over the other form a very good bandage.
The same effect is achieved with two (or three) medical
compression stockings (Figure 5).31
4. In general, the pressures used will be higher with more
pronounced signs and symptoms and with more ad-
vanced stages of pregnancy.
Table I. Compression therapy for the prevention of venous thrombosis during pregnancy and postpartum (from a document published
by the French National Authority for Health (La Haute Autorité de Santé en France, HAS)
Clinical situation
Pregnancy or postpartum Type of compression Duration
1. General case Stockings (socks, thigh highs, tights) from 15 to 20 mmHg
The wearing of medical compression therapy
is recommended for the duration of the
pregnancy and for 6 weeks after birth
2. Patients with CVD
Stockings (socks, thigh highs, tights)
1. 20 to 36 mmHg or
2. >36 mmHg according to the severity of CVD
(6 months in case of a cesarean section)
Phlebolymphology - Vol 21. No. 3. 2014 André CORNU-THENARD, Pierre BOIVIN
142
Medical compression stockings
Above-knee stay-up compression stockings are the most fre-
quently prescribed due to their greater acceptability during
pregnancy: no abdominal discomfort, relatively easy to put
on, effects felt immediately (hence the need to have some
samples to hand to patients). In case of an allergic reaction
to the stay-up band, stockings with a band of anti-allergenic
nonslip grips should be prescribed. Maternity tights (extend-
able waist) or socks (more comfortable and less constraining)
may also be prescribed depending on patient preference.
Indeed, there is no difference in efficacy between the differ-
ent types of stocking (socks, above-knee stockings, or tights).
The compression stocking material is important to consider.
The choice of stocking will be based on its tolerance, com-
fort, and patient preference.
Compression force
Whether indicated by class of compression or by mmHg
(International Unit), the compression force will be adapted
to the severity of CVD and to patient acceptance (Table II).28
Note: a compression stocking exerting a pressure of 40 to
45 mmHg will reduce the diameter of the varicose vein by
half. A minimum of 90 mmHg pressure is required for venous
reflux to disappear and the diameter of the vein to return to
normal.32,33 A high pressure can always be obtained by lay-
ering compression stockings. Appliances exist that facilitate
the application of elastic stockings at high pressure, such as
the Extensor or Butler stocking aids.34
Layering
The layering of compression stockings can be particularly
useful during pregnancy. When layered, the pressure of
the stockings is additive,31 similar to the number of revolu-
tions when a bandage is used to apply pressure. For ex-
ample, a compression stocking exerting a pressure of 30 to
40 mmHg can be replaced by layering two compression
stockings of 20 mmHg (Figure 6).35
Figure 5. Two layered medical compression stockings. The fabric
of the two stockings is identical so that the outer stocking slips
easily over the under stocking. In this photo, two knee-high
stockings are worn one on top of the other.
Table II. Choice of compression force as a function of disease severity in pregnant women
Clinical condition Medical compression stocking pressure Duration
C0S − C1S 10 to 20 mmHg
The wearing of medical compression
therapy is recommended for the
duration of the pregnancy and for
6 weeks after the birth
C2: varices with a maximum diameter <8 mm 20 to 30 mmHg
C2: varices with a maximum diameter >8 mm 30 to 40 mmHg
C3: prevention of edema 15 to 20 mmHg
C3: treatment of edema 20 to 30 mmHg
C4, C5, C6 30 to 40 mmHg
The use of superimposed medical compression stockings (above- and below-knee stockings) during pregnancy is particularly
effective for resolving problems associated with putting on the stockings.
For example: medical compression therapy of 30 to 40 mmHg can be replaced by layering two 20 mmHg stockings.
CVD and pregnancy Phlebolymphology - Vol 21. No. 3. 2014
143
This technique reduces the effort required in applying and
adjusting the force of compression. The top compression
stocking is simply put on or removed by the patient to adjust
the force of compression: stronger or weaker depending on
their activities. In addition, as pregnancy advances, fitting
compression therapy becomes more and more difficult due
to the increased volume of the abdomen. This difficulty is
increased when applying high pressure compression stock-
ings. Layering of the stockings therefore can be particularly
useful.
In the case of a localized painful varice (often associated
with an incompetent perforating vein), a localized circular
compression (ie, using an adhesive bandage) applied un-
der the stocking produces effective relief.
Compression therapy is often very well accepted during
pregnancy as the duration is short. The women clearly and
rapidly feel the efficacy. In addition, they welcome the op-
portunity to conceal unsightly lesions.36
After childbirth
Compression therapy still has its place, but should be adapt-
ed to changes in the level of CVD.
Venoactive agents
The use of venoactive agents is very useful for treating symp-
toms.37 The duration of their use will depend on their toler-
ability and the preference of the patient. Their efficacy is
known and recognized, but it is a function of their chemical
characteristics and dosing. It should be noted that in the
updated guidelines on the management of chronic venous
disorders, the recommendation for the micronized purified
flavonoid fraction (MPFF) is strong, based on benefits that
clearly outweigh the risks and evidence of moderate quality
(grade 1B).37
The duration of treatment is between 1 and 3 months, but
can be repeated in case of a recurrence of symptoms on
discontinuation of treatment. The manufacturers do not rec-
ommend taking venoactive agents while breast feeding.
Special case: treatment of vulvar varicose veins38
Treatment is only considered if there are associated symp-
toms: pain, feeling of heaviness, burning. In this case, we
advise the application of a gel or cooling the lesions with
reusable thermal pads (ie, the ColdHot 3M! device). An ab-
dominal pregnancy support belt can also be of use. Wear-
ing a sanitary towel can also strengthen the local compres-
sive effect. The objective is to reduce the pressure inside the
vulvar varicose veins.
Is sclerotherapy possible during pregnancy?
No causal relationship between the use of sclerotherapy
and an adverse effect on either mother or child has been
determined. However, there are no well-established clinical
data on the use of sclerotherapy during pregnancy and lac-
tation. For the authors, sclerotherapy is contraindicated dur-
ing pregnancy and lactation. The European guidelines con-
sider sclerotherapy as a relative contraindication (Individual
benefit-risk assessment mandatory).13
Summary
The two fundamental treatments are: daytime medical com-
pression therapy and nighttime elevation of the lower limbs.
Four points to remember:
1. Always consider the complaints of a woman at the begin-
ning of a pregnancy: preventative action is likely to slow
down or even stop the progression of venous disease!
2. The presence of varicose veins early in pregnancy, even
of small diameter, must lead to implementation of the two
fundamental treatments.
3. Without exception, no sclerotherapy during pregnancy.
Figure 6. Hysteresis curves for one, two, and three layered
medical compression stockings. The pressures are additive. One
medical compression stocking on an ankle with a perimeter of
23 cm gives a pressure of ±20 mmHg; two stockings provide a
pressure of ±42 mmHg, and a third stocking raises the pressure
to ±66 mmHg.
Phlebolymphology - Vol 21. No. 3. 2014 André CORNU-THENARD, Pierre BOIVIN
144
4. Do not let a pregnant woman believe that nothing can
be done for her legs: the combination of compression
and elevation is a simple and very effective therapy!
Action to be taken in women who
want to become pregnant
Opinions differ concerning what should be recommended
to women wishing to become pregnant. Two situations are
possible: there are no visible signs (C0a of the CEAP clas-
sification) or signs are present!
− No signs are evident. Advise patients to consult a spe-
cialist in the event that venous symptoms or signs charac-
teristic of CVD appear.39
− Signs of CVD are present:
Moderate signs: previously prescribed treatment should be
continued during pregnancy. Treatment should be increased
if new signs or symptoms appear, or if existing signs or symp-
toms worsen.
Signs are important, such as dilatation of a varicose vein or
edema: treatment as above including medical compression
therapy, but interventional therapy may also be proposed.
Pregnancy may damage the venous networks, but to what
extent, and in what form?
“If the patient has had major treatment before pregnancy
(for example, sclerotherapy or surgery in combination with
medical compression), the varicose network will have most-
ly regressed; the maximum diameter will have become
very small. Pregnancy will not make this reappear, espe-
cially if preventative medical compression stockings (30 to
40 mm Hg) are worn.”
“Conversely, if there was no curative treatment before the
pregnancy and if the objective is to stop progression, al-
most mandatory for varicose disease, it will be necessary to
wear 30 to 40 mm Hg compression stockings during the
pregnancy! This becomes all the more important if there is
a major risk of thrombosis or if the woman has experienced
venous problems during a previous pregnancy.”22
Conclusion
Always take into consideration women’s concerns about their
lower limbs in early pregnancy and do not let them believe
that nothing can be done. Appropriate treatment is likely
to slow down or even stop CVD progression. The presence
of even moderate symptoms or signs of CVD in early preg-
nancy should lead to implementation of two fundamental
treatments: daytime medical compression therapy and night-
time elevation of the lower limbs. Venoactive agents should
be offered if patients are symptomatic. The combination of
“daytime compression and nighttime elevation” of the lower
limbs is a simple, “ecologic,” and particularly effective treat-
ment. It is up to us as physicians to convince people that it is
possible to eradicate this condition.
Corresponding author
André CORNU-THENARD, MD,
2 rue Faidherbe 75011, Paris,
France
E-mail: andre.cornuthenard@wanadoo.fr
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