Women, Pregnancy and Vein Health
Pregnant women experience a multitude of physical changes as their bodies prepare for birth. Some changes are exquisite – others, not so much. Safe to say, you can put varicose veins in that latter category.
Varicose veins are a symptom of venous disease, or the impairment of blood flow back towards the heart. This impairment occurs when healthy vein valves become damaged and the backward flow of blood “pools” in the legs or feet. Symptoms may present as discomfort, fatigue, or heaviness in the leg, as well as varicose veins and other skin changes. Over time, the increased pressure can cause additional valves to fail. If left untreated, it can lead to extreme leg pain, swelling, ulcers, and other health problems.
Why varicose veins?
About forty percent of pregnant women are likely to develop varicose veins. During pregnancy, a combination of hormonal changes— specifically, greater amounts of estrogen and progesterone— and increased pressure on the abdomen can cause varicose veins to manifest. Interestingly, the most damage seems to happen in the first trimester, so those with known risk factors for venous disease should be instructed to wear graduated compression stockings throughout the first three months of pregnancy and possibly longer.
The volume of blood in a healthy woman increases by about 50% more than before the pregnancy, with the largest increase in the second trimester. With more volume to move, all of the blood vessels are under increased stress and veins can become very swollen. In the final trimester, the expanding uterus can put pressure on the inferior vena cava, and further restrict proper venous return to the heart.
Pregnancy is also a time when women are more prone to blood clots, so phlebitis (inflammation of the walls of a vein that can cause a clot to form) can also be a concern.
Prevention during pregnancy
A common complaint during pregnancy is swollen ankles. Due to the increase of blood volume and fluid, retention of fluid can cause swelling in the ankles, feet, and legs. But there is something that can help. Graduated compression stockings promote circulation and venous efficiency, which helps to reduce swelling and pain— and, in many cases, can prevent or minimize varicose veins.
Ideally, any woman with a positive family history should wear full-length stockings (or at least knee-high stockings) throughout her entire first trimester. Stockings come in a variety of styles and strengths, from knee-highs and thigh-highs, to full-length stockings. For pregnant women, there are even panty hose styles with more room in the belly, specially designed to expand during pregnancy without restricting the abdomen. They are graded on the basis of the strength of the compression at the ankle. Commonly prescribed strengths include: 15-20 mmHg for spider veins or patients with varicose veins, but only mild symptoms or swelling; 20-30 mmHg for mild to moderate varicose veins; and 30-40 mmHg for patients with varicose veins associated with symptoms such as pain and swelling.
Maternity graduated compression stockings are specially designed to fit more snugly at the ankles and calves and less so toward the top. The gradual change in compression helps the weak valves in the veins to circulate the blood more effectively. Though pregnancy compression stockings (and body garments) are available with a doctor’s prescription, many maternity stores also offer them. Accurate sizing is critical, so it is best to check with a doctor prior to purchasing any type of compression while pregnant. If you do try a pair of compression stockings and don’t like them, don’t give up. You may not have found the right fit or brand yet. Before you purchase maternity stockings, be sure to ask what the return policy is.
In addition to compression, periodically elevating the legs can provide some relief. The most effective way to improve blood circulation is to raise the legs above heart level. The perfect position is to lie on a couch with your back on the cushions and feet up on the armrest, so feet are at a slight angle higher than the heart. (Lying down with your legs resting on three or four pillows also works well.)
What about after?
After labor, most women who had significant venous disease during pregnancy notice a big improvement after the baby is born, but it doesn’t always resolve completely. If women still have symptoms that persist several months later, they should consider evaluation by a board-certified phlebologist (vein specialist) and, possibly, treatment.
Patients can be safely treated for varicose veins 6-8 weeks after delivery. Hormonal levels are back to normal within that time (if the patient is not breastfeeding), and water retention and any clotting risks have usually returned to baseline.
Depending on the type of treatment, breastfeeding may be an issue for some patients. Treatments that require a local anesthetic, such as endovenous laser ablation (ELVA) have been proven safe. Sclerotherapy is not recommended if the patient is breastfeeding, as certain medications used during this procedure have not yet been proven safe and may be excreted in breast milk. However, if the patient is willing to forgo breastfeeding for 24 hours, sclerotherapy is possible.
If a woman was uncomfortable because of her veins during the first pregnancy, then she should seriously consider seeking treatment between pregnancies— the next one could be worse if veins go untreated. Some vein specialists may recommend that women seek treatment for problematic veins before their first pregnancy, especially if there is a strong family history of vein issues.
Dr. Cindy Asbjornsen is the founder of the Vein Healthcare Center in South Portland, Maine. Certified by the American Board of Venous and Lymphatic Medicine, she cares for all levels of venous disease, including spider veins, varicose veins and venous ulcers. She is the only vein specialist in Maine to be named a Fellow by the American College of Phlebology. You can contact Dr. Asbjornsen at 207-221-7799 or firstname.lastname@example.org.