Interventions for varicose veins and leg oedema in pregnancy

Abstract

Background: Pregnancy is presumed to be a major contributory factor in the increased incidence of varicose veins in women, which can in turn lead to venous insufficiency and leg oedema. The most common symptom of varicose veins and oedema is the substantial pain experienced, as well as night cramps, numbness, tingling, the legs may feel heavy, achy, and possibly be unsightly. Treatments for varicose veins are usually divided into three main groups: surgery, pharmacological and non-pharmacological treatments. Treatments of leg oedema comprise mostly symptom reduction rather than cure and use of pharmacological and non-pharmacological approaches.

Objectives: To assess any form of intervention used to relieve the symptoms associated with varicose veins and leg oedema in pregnancy.

Search methods: We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (31 May 2015) and reference lists of retrieved studies.

Selection criteria: Randomised trials of treatments for varicose veins or leg oedema, or both, in pregnancy.

Data collection and analysis: Two review authors independently assessed trials for inclusion and risk of bias, extracted data and checked them for accuracy.

Main results: We included seven trials (involving 326 women). The trials were largely unclear for selection bias and high risk for performance and detection bias.Two studies were placebo-controlled trials. The first one compared a phlebotonic (rutoside) with placebo for the reduction in symptoms of varicose veins; the second study evaluated the efficacy of troxerutin in comparison to placebo among 30 pregnant women in their second trimester with symptomatic vulvar varicosities and venous insufficiency in their lower extremities. Data from this study were not in useable format, so were not included in the analysis. Two trials compared either compression stockings with resting in left lateral position or reflexology with rest for 15 minutes for the reduction of leg oedema. One trial compared standing water immersion for 20 minutes with sitting upright in a chair with legs elevated for 20 minutes. Women standing in water were allowed to stand or walk in place. One trial compared 20 minutes of daily foot massage for five consecutive days and usual prenatal care versus usual prenatal care. The final trial compared three treatment groups for treating leg oedema in pregnancy. The first group was assigned to lateral supine bed rest at room temperature, women in the second group were asked to sit in a bathtub of waist-deep water at 32 ± 0.5 C with their legs horizontal and the third group included the women who were randomised to sitting immersed in shoulder-deep water at 32 ± 0.5 C with legs extended downward. We did not include this study in the analysis as outcomes reported in the paper were not pre-specified outcomes of this review.We planned to use GRADE methods to assess outcomes for two different comparisons and assign a quality rating. However, only two out of three outcomes for one comparison were reported and could be assessed. Evidence from one trial (rutoside versus placebo) for the outcomes of reduction in symptoms and incidence of complications associated with varicose veins and oedema was assessed as of moderate quality. Rutoside versus placeboOne trial involving 69 women, reported that rutoside significantly reduced the symptoms associated with varicose veins (risk ratio (RR) 1.89, 95% confidence interval (CI) 1.11 to 3.22; moderate quality evidence). The incidence of complications (deep vein thrombosis) did not differ significantly between the two groups (risk ratio (RR) 0.17, 95% CI 0.01 to 3.49; moderate quality evidence). There were no significant differences in side-effects (RR 1.30, 95% CI 0.23 to 7.28). Women's perception of pain was not reported in this trial. External pneumatic intermittent compression versus restOne trial, involving 35 women, reported no significant difference in lower leg volume when compression stockings were compared against rest (mean difference (MD) -258.80, 95% CI -566.91 to 49.31). Reflexology versus restingAnother trial, involving 55 women, compared reflexology with rest. Reflexology significantly reduced the symptoms associated with oedema (reduction in symptoms: RR 9.09, 95% CI 1.41 to 58.54). The same study showed a trend towards satisfaction and acceptability with the intervention (RR 6.00, 95% CI 0.92 to 39.11). Water immersion versus leg elevationThere was evidence from one trial, involving 32 women, to suggest that water immersion for 20 minutes in a swimming pool reduces leg volume (RR 0.43, 95% CI 0.22 to 0.83). Foot massage versus routine careOne trial, involving 80 women reported no significant difference in lower leg circumference when foot massage was compared against routine care (MD -0.11, 95% CI -1.02 to 0.80).No other primary or secondary outcomes were reported in the trials.

Authors' conclusions: There is moderate quality evidence to suggest that rutosides appear to help relieve the symptoms of varicose veins in late pregnancy. However, this finding is based on one study (69 women) and there are not enough data presented in the study to assess its safety in pregnancy. Reflexology or water immersion appears to help improve symptoms for women with leg oedema, but again this is based on two small studies (43 and 32 women, respectively).

1

'Risk of bias' summary: review authors' judgements about each risk of bias item for each included study.

2

'Risk of bias' graph: review authors' judgements about each risk of bias item presented as percentages across all included studies.

1.1. Analysis

Comparison 1 Rutoside versus placebo, Outcome 1 Complications associated with varicose veins (deep vein thrombosis).

1.2. Analysis

Comparison 1 Rutoside versus placebo, Outcome 2 Symptoms associated with varicose veins (trial reported this as number of women with an improvement in symptoms).

1.3. Analysis

Comparison 1 Rutoside versus placebo, Outcome 3 Side‐effects, or adverse events of intervention.

1.4. Analysis

Comparison 1 Rutoside versus placebo, Outcome 4 Neonatal mortality.

1.5. Analysis

Comparison 1 Rutoside versus placebo, Outcome 5 Congenital malformation.

2.1. Analysis

Comparison 2 External pneumatic intermittent compression versus rest, Outcome 1 Symptoms associated with oedema (change in lower leg volume).

3.1. Analysis

Comparison 3 Reflexology versus resting, Outcome 1 Woman's satisfaction and acceptability with intervention.

3.2. Analysis

Comparison 3 Reflexology versus resting, Outcome 2 Symptoms associated with oedem (trial reported this as women with a reduction in symptoms).

4.1. Analysis

Comparison 4 Additional analysis based on different reflexology techniques (lymphatic versus relaxing), Outcome 1 Woman's satisfaction and acceptability with intervention.

4.2. Analysis

Comparison 4 Additional analysis based on different reflexology techniques (lymphatic versus relaxing), Outcome 2 Symptoms associated with oedema.

5.1. Analysis

Comparison 5 Water immersion versus leg elevation, Outcome 1 Women with reduction in leg volume (oedema).

6.1. Analysis

Comparison 6 Foot massage versus routine care, Outcome 1 Symptoms associated with oedema (lower leg circumference (right ankle)).