Chapter VII
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THE TREATMENT OF VENOUS INSUFFICIENCY DURING PREGNANCY
The technique of compression sclerotherapy was developed in the varicose veins clinic of the Rotunda Hospital, and a great part of the work has been carried out on pregnant women. While many workers hold that the definitive treatment of varicose veins during pregnancy is unnecessary and possibly meddlesome, our experience shows that it is not only valuable in producing symptomatic relief but that it also markedly reduces the incidence of venous complications during the puerperium.
The appearance of varicose in pregnant patients suggests that varicosities reflect a generalized change in the patient’s physiological condition, leading to dilatation of lower limb veins with the production of secondary incompetence.
These changes appear to occur at a very stage of pregnancy; some patients show marked venous dilatation in the leg, with pain, even the first missed period. These patients demonstrate that the leg vein changes in pregnancy cannot be attributed to proximal venous obstruction by the gravity uterus, and that other factors must be involved, such as increased blood volume and flow or hormonal changes affecting the walls and valves of the vein.
The case against treatment of varicose veins in pregnant women is largely based on the fact that a considerable degree of recovery occurs spontaneously following delivery. The significance of this observation is that it demonstrates unequivocally that varicose superficial veins are capable to returning to clinical normality in response to the physiological changes that occur post-partum. It must be stressed that full recovery does not occur in patients with primary valvular defect. The reserve capacity of the peripheral pump is often adequate to compensate for one or more leaking perforator veins. However, with patients with primary valvular defects its capacity has been permanently reduced and these women are prone to develop severe varicosities, with or without the burden of subsequent pregnancies. Furthermore, they bear an increased risk of thrombophlebitis and deep vein thrombosis during the puerperium when the veins are recovering. The improvement which occurs at this stage is due to the restoration of competence in those valves which are secondarily affected by dilatation of the veins. This would appear to affect the function in the same way as the application of an elastic stocking. Keane & Fegan (1966) showed that this produced a diminution of the diameter of the superficial veins and a return of competence in the valves of those veins.
There are three principal reasons for treating varicose veins during pregnancy:
1. Immediate relief of the distressing symptoms (cramps in the leg, tiredness, hot throbbing pain, swelling, eczema and ulceration).
2. The ever-present danger of acute thrombophlebitis is minimized.
3. In patients with a pre-existing mild degree of venous insufficiency the vein walls may become permanently damaged because of the additional stress to which they are subjected during pregnancy, unless treated.
In these patients treatment of incompetent perforating veins will reduce the stress to which the superficial veins are subjected, and facilitate the spontaneous return to normality. Formerly in the Rotunda Hospital there was an established ulcer clinic. In the past ten years this has become unnecessary, and for more than seven years no patient who attended the varicose vein clinic has required admission because of any complication of varicose veins.
In the fifteen years since compression sclerotherapy has been adopted in the Rotunda Hospital as the routine treatment for venous insufficiency during pregnancy the incidence of puerperal superficial and deep vein thrombosis in patients attending the varicose vein clinic has become negligible. In the past five years only twenty-five cases of puerperal superficial phlebitis have been referred to the clinic. All of these were patients who did not complete their treatment at the clinic. No case of deep vein thrombosis or pulmonary embolism has been seen in this group of patients during the same period. Thus we are confident that adequate therapy during pregnancy pays additional dividends in the eradication of serious venous complications in the puerperium.
The technique as used in pregnant patients does not differ in any way from that described in the previous chapter. The diagnosis and localization of the incompetent perforating veins are carried out in exactly the same manner in both pregnant and non-pregnant patients. These veins are injected, and compression is applied with bandages and elastic stockings. However, compression is maintained throughout the duration of the pregnancy, even in those patients who no longer require further injections. In this clinic treatment by injection continues throughout pregnancy without adverse effects. Patients are finally reviewed at approximately six weeks following delivery, and any residual leaks are then dealt with. As in the case of non-pregnant patients, compression with an elastic stocking is maintained for two months after the bandages have been removed.
Vulval varices
Varicosities of the labial veins develop frequently during pregnancy, and are particularly common in women who have undergone repeated pregnancies. While they are not strictly comparable with varicosities of the lower limb, much relief can be obtained by the use of a slightly modified technique of compression sclerotherapy. Opinion is divided with regard to the necessity for treating these varicosities. McPheeters & Anderson (1938) and Solomons (1950) favoured active therapy during pregnancy, while Foote (1960) stated that these veins are unsuitable for injection. We find that vulval varices are eminently suitable for compression sclerotherapy.
The case for the treatment of vulval varices can be argued on the same basis as that stated for the treatment of varices in the legs. Labial varices are a great source of discomfort, and often cause considerable anxiety in pregnant patients. Many of them complain of extreme pressure in the vulva. Pruritus is common and patients often suffer from a disturbing sensation of prolapse. The alleviation of these symptoms results in a considerable improvement of the patient's physical and psychological state throughout the pregnancy.
Extensive vulval varices, if untreated, may rupture during parturition and fatal haemorrhage from vulval varices is not unknown (Foote, 1960).
The clinical date of these patients are recorded by a method similar to that used in cases of leg varices. Figures 61 and 62 show the type of punch card which has been designed. Each patient suffering from vulval varices is issued with one of these and the relevant symptoms are noted by punching out the appropriate note in the card. Subsequently the sites and amounts of any injections are marked on the card.
The vulval veins are tributaries of the internal pudendal veins and communicate with the vasical, vaginal and rectal venous plexuses, and with the superficial external pudendal veins posteriorly and the superficial epigastric veins anteriorly. They become grouped together at the anterior and posterior aspects of the labia and these points serve as the most suitable sites for injection (Fig.63).
Each injection consists of 1 ml. of 3% sodium tetradecyl mixed in the syringes with a little air so as to form a foam. This is them injected into the selected vein. When about three-quarters of a millilitre has been injected the needle is gently withdrawn from the lumen of the vein and the remainder of the injection is given immediately deep to and around the vein. While perivascular injection has been discarded from general use in therapy of lower limb varices it has been found to be of value in the treatment of vulval veins and haemorrhoids.
Compression of the injection site is applied in the following manner: the patient wears four protective pads which are held firmly over the vulva by a tight paid of two-way stretch pants. Further injections are given as required at subsequent visits.
References
Foote, R. R. (1960), Varicose Veins, 3rd Edition. Bristol: Wright.
Keane, T. F. L. & Fegan, W. G. (1966), to be published.
McPheeters, H. O. & Anderson, J. K. (1938), Injection Treatment of Varicose Veins. Philadelphia: Davis.