Vaginal Varix in Pregnancy - A Therapeutic Dilemma

Author Information

Dharmadhikari M*, Samant PY**, Pai K***
(* Second Year Resident, ** Additional Professor, *** Assistant Professor  Department of Obstetrics and Gynecology, Seth G.S. Medical College and K.E.M. Hospital, Mumbai, India.)

Abstract

Vaginal varices during pregnancy is a rare condition. The vulval varicosities seen in pregnancy are very rare. Vaginal varix can rupture from trauma during the second stage of labor, leading to a  hematoma with subsequent extravasation into the tissues. We report a case of vaginal varices detected on routine examination in early labor.

Introduction

Genital varicosities occur in approximately 4% of pregnant women, & usually develop during third or fourth month of gestation.[1] They mostly regress spontaneously after parturition. Pregnancy is associated with dilatation of the vascular system, increased blood volume, and uterine pressure on pelvic veins.[2] Increased levels of oestrogen & progesterone causing venous distension along with  the scarcity of valves in the pelvic veins contribute to varicosities in pregnancy. Most genital varices are asymptomatic, but a few are associated with pelvic pain and spontaneous bleeding per vaginum. This pelvic congestion syndrome comprises of pelvic pain, dyspareunia, dysmenorrhea, dysuria and vulval/ perivulvar varices.[3,4]  Patients have discomfort during walking. It is essential to understand the underlying causes of vaginal varicosities formation in pregnancy, site of origin and change in course of varicosities  during vaginal delivery so that the mode of delivery can be planned in patients with vaginal varicosities.

Case Report

A 35 years old female,  non-smoker multigravida with previous vaginal delivery, with 38 weeks of gestation presented in early labor. There was no history of any major medical and surgical illness. The full term uterus with cephalic presentation had minimal activity. On speculum examination,  about 4x3 cm size plexus of engorged, tortuous veins was seen on anterior vaginal wall 3 cm below urethral meatus suggestive of vaginal varicosities. Internal os was 1.5 cm dilated, 30% effaced with intact membranes. There were no limb varicosities.


Figure 1: Preoperative vaginal varix.

The patient and family were counseled about cesarean section in view of risk of rupture of vaginal varicosities during delivery. Ultrasound with color Doppler and MRI could not be performed as patient was in labor. A lower segment cesarean section (LSCS) was performed uneventfully. There was no extraordinary pelvic congestion. On postoperative day 4, speculum examination showed a significant decrease in the size of vaginal varicosity to 2x2 cm suggestive of spontaneous regression of vaginal varicosities.


Figure 2: Postoperative day 4.

Discussion

A patient of vaginal varicosities should be examined completely to exclude possibility of associated conditions like leg varices, venous malformation of the labia, clitoral area, or vagina and associated vascular malformation on limbs (Klippel-Trenaunay syndrome).[5] The Klippel-Trenaunay syndrome comprises of skin capillary malformations, varicosities and soft tissue hypertrophy. In cases of Klippel-Trenaunay syndrome, long term treatment with anticoagulant and elastic stockings may be required to prevent thromboembolic events Any two of these three features are diagnostic. The few cases reported in the literature, manifested vaginal variceal bleeding due to portal hypertension.[6,7]
Vaginal varicosities can rupture from trauma leading to vaginal hematoma or thrombus during second stage of labor. They regress spontaneously postpartum. Occasionally there may be pelvic pain and dyspareunia. Transvaginal ultrasonography and Doppler study can confirm diagnosis as well as the extent and anatomy of the varices. Doppler studies can also rule out haemangioma and angiosarcoma. Magnetic resonance imaging helps in anatomical understanding of vaginal varicosities in pregnancy. Conservative measures like firm pelvic support usually relieves symptoms. If symptoms persist for more than 3 months postpartum, sclerotherapy may be used.[8] In cases of Kippel-Trenaunay syndrome, long term  treatment with anticoagulant and elastic stockings may be required to prevent thromboembolic events after delivery.
In case of huge vaginal varicosities, massive bleeding may occur at vaginal delivery. There is paucity of data to predict the risk of rupture during a vaginal delivery. ‘Huge’ vaginal varix itself has not been defined. Furuta et al[9] observed that vulval and vaginal varicose veins markedly diminished at the end of the second-stage of labor with compression by fetal head.[9] This may suggest that extensive vulvovaginal varicosities will decrease in size irrespective of their size or extent during labor and delivery.[9] However in practice, it is important to avoid accidental laceration of the vaginal varicosities at this stage. Careful delivery may minimize but cannot completely eliminate the risk of trauma and rupture of varicosities. A case with fetal death from significant maternal bleeding due to  vaginal variceal rupture, was reported by Purslow et al.[10] Watermeyer et al. reported a 21-year-old primigravida with a massive plexus of varicosities filling the lower uterine segment that required classical cesarean section. In some cases, engorged vessels may bleed periodically on increased intraabdominal pressure.[5]

Conclusion

There is paucity of evidence to recommend either mode of delivery in cases of vulval varicosities. There are no definite guidelines on management of vaginal varices in intra- and postpartum period. The cases are dealt with as per the amount of bleeding encountered and there are no recommendations for or against cesarean section as a preventive measure.
Pelvic varices may surprise an obstetrician even at LSCS  On the other hand, vaginal varicosities may cause extensive hemorrhage during labor.[11] Optimal mode of delivery can only be decided after evaluating the cause of the vaginal varicosity. Hence an antenatal Doppler and MRI studies are advisable.

References
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Citation

Dharmadhikari M, Samant PY, Pai K. Vaginal Varix in Pregnancy- A Therapeutic Dilemma. JPGO 2016. Volume 3 No. 6. Available from: http://www.jpgo.org/2016/06/vaginal-varix-in-pregnancy-therapeutic.html