It was identified during the scoping stage that as varicose veins are common during pregnancy (affecting about 40% of pregnant women) that this group required additional consideration in the guideline. The management of vulval varicose veins is out of the scope of this guideline.

11.1. Clinical evidence

None of the literature searches completed for the review questions within the guideline excluded pregnancy as a condition. Therefore we can be confident that all the clinical evidence concerning the management of varicose veins during pregnancy is likely to have been identified. This section aims to collate and summarise the findings across different guideline questions to allow recommendations to be made for this group.

The summary below summarises the literature on pregnant women that was included in the review questions. It also summarises the literature relevant to pregnant women that was not originally included in specific review questions because of exclusion criteria specific to those questions. Evidence tables are available in appendix G

11.1.1. Information and perceptions about varicose veins in relation to pregnancy

Chapter 5 reviews the evidence for the perceptions and expectations of people with varicose veins. Although it is unclear from the evidence how many of the participants were, or had been pregnant, Zubilewicz 2009110, in a survey of patient knowledge of CVI risk factors, found that 58% of patients identified prior pregnancy as a risk factor. This study was assessed to be of very low quality. The principles of giving accurate information to pregnant women are the same as those found in the recommendations in chapter 5, although the risks should be modified based on their condition.

11.1.2. Pregnancy as a risk factor for the progression of varicose veins

Chapter 6.1 investigated the evidence for risk factors which were associated with an increased chance of progression to more serious varicose veins. Two studies were identified which looked at pregnancy as a risk factor for progression.

Venous Reflux

Fowkes 200137 detected a univariate trend for previous pregnancies to be associated with the existence of venous reflux [OR: 1.20 (0.93-1.54)], but this effect disappeared after multivariable analysis [OR: 0.96(0.71-1.29)]. Note that this is not an outcome relevant to progression of varicose veins, as the study was cross-sectional, and there was no measure of any change in severity status. No analysis was undertaken to establish associations between pregnancy and varicosities.

The quality of this outcome was classified as low, downgraded for the lack of assessor blinding and the use of a cross-sectional analysis. This evidence has not been previously included in the guideline as we do not have a review question addressing etiological factors for the incidence of varicosities or reflux; however, this is an important issue in the context of pregnancy.

Progression of varicose veins

Mota Capitao 199563 assessed prior pregnancy as a possible risk factor for progression of varicose veins, but after multivariable analysis it was not shown to be a significant risk factor. The quality of this outcome was classified as very low, downgraded for indirectness, use of a cross-sectional methodology, and a lack of blinding of assessors.

11.1.3. Pregnancy as a predictor of treatment outcome

Chapter 6.2 investigated risk factors which predicted a better or worse outcome after interventional treatment. One study was identified which looked at pregnancy.

Fischer 200635 assessed previous pregnancy as one of many factors influencing reflux recurrence after great saphenous vein ligation and stripping. After multivariable analysis, prior parity was an independent predictor, leading to a 2.69 fold increase in the odds of reflux recurrence (95% CIs: 1.45- 4.97) compared to no parity. Interim pregnancy during follow-up was also an independent predictor of reflux [OR: 4.74(2.47-9.12)]. The quality of these outcomes were classified as moderate, with a single downgrade for the lack of assessor blinding.

11.1.4. Interventions for varicose veins in pregnancy

Chapters 8 and 9 investigate compression and interventional treatment options for the management of varicose veins. All of the studies included in these sections excluded pregnant women.

Thaler 2001104 evaluated compression stockings as prophylaxis of varicose veins in pregnancy (population of all pregnant women under 12 weeks gestation, with no baseline reflux) compared to no treatment. Compression failed to prevent the emergence of superficial varicose veins, although it did appear to reduce the risk of GSV reflux and worse symptoms in those that already had mild varicose veins at baseline. The quality of the three relevant outcomes from this study were all classified as low, based on a lack of allocation concealment and inadequate blinding. Our reason for excluding this study from the compression compared with no treatment review question (chapter 8) was that prophylaxis was out of the scope of the guideline.

11.1.5. Related NICE guidance

NICE produced a guideline on routine care for the healthy pregnant woman (NICE Antenatal guidelines) in 2008.66 Within this guideline there was one recommendation for women with varicose veins:

“Women should be informed that varicose veins are a common symptom of pregnancy that will not cause harm and that compression stockings can improve the symptoms but will not prevent varicose veins from emerging.”

This recommendation was based on was based on the findings from Thaler 2001104.

11.1.6. Economic evidence

Published literature

No cost effectiveness evidence was identified for this specific population.

11.1.7. Evidence Statements

11.1.7.1. Clinical

  • One low quality study comprising 42 participants showed that compression does not prevent the incidence of varicose veins in pregnant women [LOW QUALITY].
  • One low quality study comprising 42 participants showed that compression may decrease the risk of progression of varicose veins in pregnant women [LOW QUALITY].
  • One low quality study comprising 42 participants showed that compression may decrease the symptoms from varicose veins in pregnant women [LOW QUALITY].
  • One low quality study comprising 739 participants showed that pregnancy does not have an association with the existence of venous reflux [LOW QUALITY].
  • One very low quality study comprising 474 participants showed that prior pregnancy does not influence progression of varicose veins [LOW QUALITY].
  • One moderate quality study comprising 1261 participants showed that prior pregnancy may increase the risk of reflux recurrence after varicose veins surgery [LOW QUALITY].
  • One moderate quality study comprising 1261 participants showed that interim pregnancy at follow-up may increase the risk of reflux recurrence after varicose veins surgery [LOW QUALITY].

11.1.7.2. Economic

  • No cost effectiveness evidence was found for this specific population.

11.2. Recommendations and link to evidence

11.2.1. Provision of information

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Table

Give pregnant women presenting with varicose veins information on the effect of pregnancy on varicose veins.

11.2.2. Interventional treatment during pregnancy

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Do not carry out interventional treatment for varicose veins during pregnancy other than in exceptional circumstances. How long after giving birth should women wait before having interventional treatment for varicose veins?

11.2.3. Compression hosiery during pregnancy

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Consider compression hosiery for symptom relief of leg swelling associated with varicose veins during pregnancy.