By John D. Horowitz, MD
Pregnancy begets varicose veins, like the night follows the day. Few associations in healthcare are as definitive. Possibly the adage: “if a man lives long enough, he will get prostate cancer.” The joys of pregnancy and motherhood are tempered by the bodily changes women experience. Almost all pregnant women develop venous insufficiency, irrespective of the number of pregnancies and how healthy they remain throughout their pregnancies The hormones of pregnancy, the fluid shifts, the weight gain, and the pressure created by the gravid uterus compressing the abdominal venous return all serve to destroy the normal function of the vein system. Although the inciting factors subside as the pregnancy is completed and a women’s physiology returns to normal, the damage to her veins is irreversible and lingers, only to become noticeable years later often with great clinical sequelae.
By way of review, the venous system relies on valves to maintain unidirectional blood flow returning to the heart. There is no pump to drive the venous system like the heart drives the arterial system. It is more passive, relying on valves to prevent retrograde flow. When these valves are incompetent, hydrostatic pressure gets transmitted to surface veins and subcutaneous tissues giving rise to the secondary effects of ambulatory venous hypertension and symptomatic varicose veins.
The events of pregnancy create irreversible changes in a woman’s vein valve leaflets and forever destroy normal venous flow. When these valve leaflets become weakened, or incompetent, venous reflux occurs and creates ambulatory venous hypertension. There is a great deal of evidence in the Obstetric literature that even before the hydrostatic pressures of pregnancy take hold, the hormonal milieu of pregnancy has a degradative effect on the integrity of the vein valve leaflets. As early as the first trimester of pregnancy, long before the hydrostatic pressures are ever exerted, vein valve dysfunction begins. The weight gain, fluid shifts and gravity effects that take place later during the pregnancy only serve to make the impaired venous return exponentially worse.
A particularly harsh form of pregnancy related venous reflux comes in the form of vulvar or labial varicosities. The elevated venous pressure in these cases is multifactorial, stemming from sapheno-femoral venous reflux, perineal venous reflux, and pelvic venous reflux through the ovarian veins and the pelvic circulation. Symptoms from these veins can be quite debilitating, especially during the congestion of menstruation, or during sexual activity. Luckily, these veins are amenable to minimally invasive vein therapy, endovenous laser ablation and ultrasound guided foam sclerotherapy.
Most women take years after pregnancy to seek treatment for their post-partum venous reflux. While this may be due to a focus on their babies and toddlers, it more likely reflects the fact that it takes time for the valvular reflux created during pregnancy to translate into the ambulatory venous hypertension that causes symptoms from venous insufficiency. Symptoms are wide ranging and include prominent palpable varicosities that become painful and tender, generalized leg pain, tiredness, heaviness, and aching in the legs. A progressive disease, venous insufficiency often culminates in leg swelling, sclerotic skin changes around the calf region and the very tender maleolar complex known as corona phlebectasia if left untreated.
Unfortunately, women have difficulty accessing the healthcare system for vein treatment because of inherent biases amongst physicians and patients alike that these problems are not serious enough to warrant therapy. Frequently, women use their Ob-Gyn as their primary care and feel uncomfortable or inappropriate speaking to their OB about their legs. As providers, many Ob-Gyn physicians don’t feel comfortable initiating the venous insufficiency conversation or referral. Consequently, many women with post-partum venous insufficiency never get to treatment.
Venous reflux is a progressive problem that does not correct itself. While conservative measures such as compression therapy and weight management will control the side effects, they do nothing to address the underlying disease process. Subsequent pregnancies will only serve to worsen the problem, so it makes no clinical sense to wait until all intentions of subsequent pregnancies are complete. The recurrence rate of symptomatic venous reflux, even in the face of multiple subsequent pregnancies, is quite low when treated appropriately at the outset.
Minimally invasive vein therapy in the form of endovenous saphenous and perforator vein ablation coupled with ultrasound guided foam sclerotherapy remains the state of the art method to eliminate the core problem of venous reflux and provide women long term relief from the deleterious effects of venous hypertension.
John D. Horowitz, M.D. is Board Certified in both Vascular Surgery and Phlebology and is uniquely trained to offer patients the most advanced vein care possible. He graduated a member of the AOA Honor Medical Society from Temple University School of Medicine in 1986, from Temple University Hospitals General Surgery Residency in 1991, and from The Ohio State University Hospitals Vascular Surgery Fellowship in 1993. Dr. Horowitz is an active member in many nationally recognized societies including the Southern Vascular, Florida Vascular and Society for Vascular Surgery, as well as the American College of Phlebology. He is nationally renowned for his innovative practice of Minimally Invasive Vein Therapy, has presented his work at many national society meetings and has authored numerous journal articles and book chapters. The Central Florida Vein and Vascular Society is routinely used as a training site for physicians seeking to learn Minimally Invasive Vein Therapy. Dr. Horowitz may be contacted at 407-293-5944 or by visiting www.cfvein.com.