Varicose veins or varicosities are veins that are enlarged, twisted and visible, usually located in the lower leg, but may occur anywhere in the body; they are a type of chronic venous disease involving the dilation of subcutaneous veins that are three to four millimeters in diameter. (1) Varicose veins can sometimes cause no symptoms at all, but for most people they have at least some symptoms which can include fatigability, pain, heaviness, and swelling that can significantly affect quality of life.(2)

Varicose veins develop through the following mechanisms, all of which are exacerbated by pregnancy and are interrelated: venous valve incompetence, weakened vein wall, and increase in venous pressure, which causes pooling and vein dilatation. (3) Increased blood volume by ~20% during pregnancy; venous capacity doesn't change, so there's increased demand on the vascular system (4,5) At the same time, the smooth muscle relaxation and venous dilation caused by elevated progestrone levels, and the intra-abdominal pressure caused by the growing uterus, are both preventing venous return from the lower body. (6)

Epidemiological data shows there is a significant variation in prevalence of varicose veins worldwide. Aslam and colleagues reported prevalence rates ranging from 2% to 73% worldwide, with Pakistan exhibiting rates between 16% and 20%.(7) The condition disproportionately affects women, with 50-55% of women experiencing minor forms compared to 40-50% of men.(8) Pregnancy is a time of vulnerability, as the condition is most likely to appear or get worse during the months of gestation. These changes generally recede after giving birth, but can become chronic if multiple pregnancies occur.(9)

Hormones, blood volume and mechanical compression are associated with pregnancy as an additional risk factor for varicose veins, as are advancing age, family history, obesity and prolonged standing occupations. (10) Chronic venous disease may be categorized with the CEAP (Clinical-Etiology-Anatomy-Pathophysiology) classification system, which ranges from C0 (no visible signs) to C6 (active venous ulcer).(11)

Although pregnancy is known to be associated with varicose veins, there is a lack of research studies in Pakistan on this correlation. Knowledge of the local prevalence and risk factors will inform the development of specific prevention strategies and optimise maternal health outcomes. Hence the purpose of this study was to find the prevalence of varicose veins and risk factors associated with them in pregnant women in second and third trimester of pregnancy in Lahore, Pakistan.

This cross-sectional observational study was carried out at The School of Allied Health Sciences, Children Hospital and University of Child Health Sciences, Lahore with the cooperation of General Hospital Lahore and Bija Hospital Shahdara, Lahore. The study was approved by the institutional ethical committee and all participants gave their verbal informed consent before being included in the study. The pregnant women undergoing second or third trimester pregnant women in the healthcare facilities were included in the study population. The number of participants in the study were 207, who were recruited using convenience sampling method. Sample size was computed as n = (Z/e)² p(1-p) with Z/2 = 1.96 (from Z-table), e = 0.07 (set margin of error) and p = 0.16 (estimated prevalence from previous studies). The calculated sample size was twenty-seven, seventy-five participants. The study included pregnant women between the ages of 16-45 years, who were in their second or third trimester of pregnancy. Those in their first trimester, and women with varicose veins for medical reasons beyond pregnancy were not included. An instrument designed by researcher was used for collecting extensive information such as demographic data, obstetric data, assessment of symptoms, family history, and psychologic data. Closed-ended questions were used on the questionnaire to ask about the signs and symptoms of varicose veins, including tired legs, heavy legs, leg pain (throbbing), leg pain (burning), leg swelling, leg aching, leg changes, and leg appearance. A standardized pain intensity scale (0=not at all, 1=to a slight degree, 2=to a moderate degree, 3=to a great degree, 4=all the time) was employed to assess psychological responses to pain. During normal antenatal checkups, eligible participants were identified and approached for participation. After the purpose and procedures for this study were explained, verbal consent was obtained. Questionnaire was self-designed and was conducted by trained data collectors via face-to-face interviews to ensure complete and clear responses. The confidentiality of the data was observed during the process of collection and analysis. IBM SPSS Statistics Version 23 was used to enter and analyze all data. Categorical variables such as trimester of pregnancy and number of pregnancies were displayed as frequencies and percentages. The chi square test was used to look at associations between presence of varicose veins and risk factors such as age, weight and parity. A p value of < 0.05 was deemed to be statistically significant. Results were presented using tables and figures.

A total of 207 pregnant women participated in this study. The demographic and obstetric features of the participants are shown in table 1. The majority were aged 16-25 years (50.2%), weighed 40-60 kg (51.2%), and were in their third trimester (62.8%). The number of pregnancies ranged between 1 and 9 with 32.4% having been pregnant for the first time as indicated in table 1.

Table 1: Demographic and Obstetric Characteristics of Study Participants (N=207)

The incidence of varicose disease in 207 participants was 2.89% (n=6) and 97.11% (n=201) did not have any visible varicose veins (Table 2). In all cases of positivity the veins in the lower limbs were twisted, bulging or cord-like.

Table 2: Frequency of Varicose Veins among Study Participants

The prevalence of various signs and symptoms is presented in Table 3. Leg tiredness and heaviness (68.6%) was the most common symptom, followed by throbbing and burning pain (43.5%) and pain increasing after long sitting or standing (43.5%). There was a 36.2% reporting ankle or leg swelling.

Table 3: Prevalence of Signs and Symptoms among Study Participants (N=207)

Assessment of psychological reactions to pain associated with varicose veins showed that most subjects did not suffer from severe psychological reactions (Table 4). Over 93% of women said their symptoms caused no significant worry, fear or distress.

Table 4: Psychological Responses Related to Varicose Vein Pain (N=207)

The associations between the different risk factors and the presence of varicose veins are presented in Table 5. There was a significant link between the age group and varicose veins (χ²=12.920, p=0.002). There were no cases in 16-25 years of age group, 4 cases (4.3%) in 26-35 years of age group and 2 cases (18.2%) in 36-45 years of age group.

There was a significant correlation between weight and varicose veins as well (χ²=10.507, p=0.005). Women weighing 40-60 kg had no cases, while those weighing 61-80 kg had 4 cases (4.6%) and those weighing 81-100 kg had 2 cases (14.3%).

The relationship between number of pregnancies and varicose veins was not statistically significant (χ²=10.958, p=0.139) although there were 4 out of 6 positive relationships.

Table 5: Association Between Risk Factors and Varicose Veins

This was a cross-sectional study that examined the prevalence of varicose veins and risk factors in pregnant women of 2nd and 3rd trimester at Lahore, Pakistan. The study revealed that the prevalence of varicose veins was 2.89% in the 207 participants and significant associations were noted with the increasing age of the participant and weight gain. The results of this study are added to the few studies conducted in Pakistan on pregnancy-related varicose veins and thus contribute to the existing knowledge of clinical practice. The rate of 2.89% observed is significantly lower than that reported internationally. There are several factors that could account for the difference in findings with previous studies, including the different prevalence estimates reported from around the world. (12) Similarly, Aslam and colleagues reported global prevalence rates ranging from 2% to 73%, with Pakistan specifically showing rates between 16% and 20%.(2) The discrepancy between our findings and previous reports may be explained by several factors. Limited geographic and sample size could have led to an underestimation of the prevalence. Furthermore, the underreporting may have been due to cultural factors such as dressing that could mask veins. Self-report data for some symptoms may also have affected the results and the cross-sectional design may have affected the results The strong correlation between increasing age and a history of varicose veins had been noticed in this study (p=0,002), but is in line with many previous studies. Epidemiological research has been carried out in a variety of populations and the results have been consistent: the prevalence of varicose veins increases with age. This age rise in prevalence has been reported in the US as less than 1% in people aged 20 to 29 years and rising to more than 50% in people older than 70 years, due to damage of the venous valves and walls over time, including the repeated pregnancies. (13) This study also found no varicose veins in the youngest age group (16-25 years), which further endorses the cumulative effect of age on the development of varicose veins. Weight is strongly linked to the presence of varicose veins (p=0.005), which is consistent with clinical findings and has been found to be either positively or negatively related to varicose veins in epidemiological studies. (14) The prevalence of varicose veins increased as the weight increased, with 14.3% of the women in the highest weight category (81-100 kg) compared with none among those in the lowest weight category (40-60 kg) supporting the role of body weight as a risk factor for varicose veins, as many clinicians consider it to be. This association may be due to the metabolic effects of adipose tissue on venous function and to increased intra-abdominal pressure and venous compression that are associated with higher body mass. Where no association has been found in previous studies, this may be due to inadequate control for factors which influence the association or to the use of different populations in the studies.(12) In this study, parity and varicose veins showed no statistical significance (p=0.139), but the trend towards more varicose veins with greater parity was discussed. Four of the 6 positive cases had higher numbers of pregnancies, indicating a possible cumulative effect. Inconsistent results have been reported in the literature about parity as a risk factor. The number of positive cases was small in this study, potentially limiting the power of the study to detect associations, as some research has indicated increasing prevalence with increasing parity, while others have indicated no independent association after controlling for the age of the women. (15) In this study, the incidence of positive family history was low (2.4%) and its association as a risk factor is comparatively small when compared to other studies. This difference could be because of genetic variability among study subjects or because of the small number of positive cases in our study. (12) However, there is a body of evidence showing that there is a genetic predisposition to developing varicose veins, with as many as 57% of people with varicose veins likely to have a familial tendency to them, depending on the study (16) Based on the symptoms in this study, there is a clinical insight into the clinical presentation of varicose veins in pregnancy. The most common symptom was leg tiredness and heaviness (68.6%), followed by throbbing and burning pain (43.5%) and pain that aggravates during prolonged sitting or standing (43.5%), and ankle or leg swelling (36.2%). The symptoms are consistent with the pathophysiology of venous insufficiency and may be a contributing factor to underdiagnosis, particularly of “hidden” varicose veins or early venous insufficiency, and underscore the need to be thorough in the clinical assessment, including the evaluation of symptoms.(17) It is significant that most participants reported a minimal psychological impact. Worry, fear or distress from varicose vein symptoms was reported by the majority of women as being low. It could be due to the fact that varicose veins develop during pregnancy, and are expected to improve after birth. But at the same time it might be that women were not reporting psychological distress as much as they could because they were influenced by cultural norms or the concerns that usually came to mind were the more immediate pregnancy related issues. Healthcare providers should be aware of the potential for psychological effects, especially in women who have more severe symptoms or who have chronic varicose veins. The findings of this study have important clinical implications. Targeted prevention strategies can be implemented based on significant risk factors identified, which includes age and weight. Women at risk should be given a special education on varicose vein prevention and early detection. Maintaining weight gain during pregnancy should be well-balanced with the body's nutritional requirements, which can lower the odds of developing varicose veins. Further, lifestyle changes such as regular exercise, elevating lower extremities, avoiding long periods of standing or sitting, and compression stockings should be recommended.(18) During pregnancy, physiotherapists can be of crucial importance in managing varicose veins. Physiotherapists can also play a part in appropriate exercise counselling of patients to maintain healthy weight during pregnancy, compression therapy, patient education about positioning and activity modification.(19)

In this study, the incidence of varicose veins in pregnant women is found to be 2.89% and weight gain and age were found to be a significant risk factor. Leg tiredness and leg heaviness were the predominant symptoms. Evidence-based preventive strategies and patient education should be encouraged among healthcare providers, especially physiotherapists, and more large-scale studies are needed.

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