Risk factors for the development of venous insufficiency of the lower limbs during pregnancy – part 1

Abstract

The venous system alters its function in pregnancy - the changes are both functional and structural. It becomes particularly vulnerable to the development of venous thrombosis and related complications. These adverse factors acting on the veins in pregnancy include: an increase in circulating blood volume, expansion of the uterus, weight gain, reduced physical activity, hormonal changes. The changes in the plasma have a significant impact on the venous system. In pregnancy, an increased level of fibrinogen and coagulation factors VII, VIII, IX and X, and von Willenbrand factor, can be observed. Smooth muscle relaxation and relaxation of collagen fibers are caused by progesterone and estrogen, and it may result in the development of varicose veins, venous thrombosis and venous insufficiency. The relationships between the hormones and the muscle pump efficiency has not been proven as yet. Estrogens cause an increase in the synthesis of coagulation proteins and it may result in the high risk of venous thrombosis and its consequences. Progesterone inhibits smooth muscle contraction, while estrogens cause relaxation and loosening of the bonds between the collagen fibers. The increase in the level of progesterone is of particular importance. It has a relaxing effect on the muscle, resulting in disorders of the vein shrinkage, affecting the increase of their capacity, and valvular insufficiency, and valvular edges are not in contact with each other due to the vasodilatation. Estrogens have a similar effect, and additionally it may also cause an impairment in the collagen fibers connection and synthesis. This can result in the formation of telangiectasia without venous hypertension. Estrogens may also affect the synthesis of prostaglandins and nitric oxide. Estradiol inhibits vascular smooth muscle cell proliferation and stimulates cell migration and secretion of matrix proteins, as well as regeneration of the damaged vessels. Estrogen inhibits the production of cytokines, adhesion molecules, and reduce platelet response, i.e. the aggregation and adhesion in the presence of monocytes. Estradiol increases the production, activity and bioavailability of nitric oxide, a molecule with a strong vasodilating effect. Additionally, adverse affects may appear due to short intervals between pregnancies, genetics, presence of venous thrombosis or venous insufficiency in the superficial and deep system in anamnesis. Caesarean section is also a risk factor for venous thrombosis. Family factors are associated with inheritance of the formation of varicose changes and venous insufficiency in both ways, dominant and recessive, and also sex-related. Among other factors affecting the development of venous insufficiency during pregnancy, the following can be distinguished: type of work (standing, sitting, in forced positions and vibration), interval between pregnancies (determining the possibility of regeneration of physiological regeneration of the system). In case of women who were pregnant more than once, the risk of developing varicose veins and other venous insufficiency is doubled.