Varicose Veins in Pregnancy: Why They Develop, What They Mean, and How to Manage Them

Heavy legs and swollen ankles in pregnancy are usually filed under "part of being pregnant." Much of the time that is exactly what they are. But a substantial share of those symptoms are the first sign of chronic venous disease developing, and pregnancy is one of the strongest risk factors there is.

Roughly one in three women develop chronic venous disease during pregnancy, and the risk rises with each subsequent pregnancy.

This article covers three things: why it happens, what recent research suggests it means beyond the legs, and what can safely be done about it while pregnant.

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Why pregnancy drives varicose veins — three mechanisms

1. Hormones act directly on the vein wall

Progesterone and oestrogen rise steeply in pregnancy, and both act on venous smooth muscle, relaxing it and reducing the elasticity of the vein wall. As the wall stretches, the valves inside no longer meet properly, reflux begins, and varicosities form.

This is not merely inferred from timing. García-Honduvilla and colleagues examined varicose vein tissue with immunohistochemistry and RT-qPCR, and found that oestrogen and progesterone receptor expression is increased and redistributed through the vein wall in premenopausal women with varicose veins — evidence that sex hormones participate directly in the remodelling rather than acting only through fluid shifts.

2. Blood volume rises while venous return is obstructed

Circulating blood volume increases by roughly 40–50% during pregnancy. At the same time, the growing uterus compresses the inferior vena cava and the iliac veins. More volume has to return to the heart through a partially obstructed route, which raises pressure in the leg veins and promotes both varicosities and oedema.

The Cochrane review on this topic states the position plainly: 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.

3. Pelvic compression produces vulvar and perineal varices

Uterine growth does not only raise intra-abdominal pressure. It compresses the pelvic venous plexus directly, which is why vulvar and perineal varices — rarely discussed, often distressing — appear in pregnancy specifically.

There may be consequences beyond discomfort. A nationwide cross-sectional study by Asúnsolo and colleagues examined 256,531 vaginal births in Spain in 2015 and found that women with varicose veins of the legs, vulva, perineum, or haemorrhoids had higher odds of intrapartum fetal compromise. The association held after adjustment: odds ratio 1.25 (99.5% CI 1.05–1.50).

That is a modest association from a cross-sectional design, and the authors present it as a signal worth investigating rather than a settled finding. It should not be read as evidence that varicose veins harm the baby.

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What recent research suggests — and how firmly

A research group in Alcalá, Spain has published a series of studies on what maternal venous disease does beyond the legs. The findings are consistent and biologically coherent, and they are worth knowing about. They also come largely from one group, in mechanistic and associative studies rather than outcome trials, so they should be held with appropriate tentativeness.

Oxidative stress in the placenta. Comparing 62 pregnant women with venous insufficiency against 52 healthy controls, Ortega and colleagues found significantly increased expression of oxidative stress markers (NOX1, NOX2, iNOS, PARP, ERK) in placental tissue. Plasma malondialdehyde was elevated at 32 weeks of gestation and remained elevated postpartum. Fetuses of affected women had significantly lower venous pH.

A pro-inflammatory shift in mother and newborn. In the same cohort, serum from women with pregnancy-induced chronic venous disease and from their newborns showed significant alterations across a broad spectrum of cytokines — IL-6, TNF-α, IL-12, IL-2, IL-23 and others — indicating a systemic pro-inflammatory environment extending to the infant.

A proposed common pathway. The group's review in Cells frames maternal chronic venous disease alongside preeclampsia and fetal growth restriction as conditions in which placental dysfunction is central.

What this body of work establishes is that venous disease in pregnancy is measurably systemic, not purely local. What it does not yet establish is that treating or preventing it changes outcomes for the baby. That trial has not been done.

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Management during pregnancy

Compression is the mainstay

Medical compression stockings are the best-supported intervention. Started early and worn consistently, they improve venous return, reduce oedema, and limit symptom progression. Class I (15–21 mmHg) or Class II (23–32 mmHg) is typical, put on first thing in the morning before swelling accumulates.

The Cochrane review (seven trials, 326 women) found the overall evidence base modest but identified two interventions with measurable benefit for oedema:

• Water immersion for 20 minutes reduced leg volume (RR 0.43, 95% CI 0.22–0.83)
• Reflexology improved oedema symptoms compared with rest (RR 9.09, 95% CI 1.41–58.54) — note the very wide confidence interval, from a trial of 55 women

Compression stockings versus rest and foot massage versus routine care showed no significant difference in leg volume in the trials included. The honest summary is that compression is standard care on strong physiological grounds, while the randomised evidence in pregnancy specifically remains thin.

Practical measures

• Break up long periods of standing or sitting. Walking or doing ankle pumps every 30 minutes engages the calf muscle pump.
• Rest in the left lateral position. This reduces uterine compression of the inferior vena cava.
• Elevate the legs above heart level when resting.
• Manage weight gain within recommended ranges; excess weight raises venous pressure further.
• Walk or swim. Low-intensity aerobic activity drives the calf pump.

Medication — one option, thinly supported

The Cochrane review reports a single trial of 69 women in which rutoside significantly reduced varicose vein symptoms in late pregnancy (RR 1.89, 95% CI 1.11–3.22, graded moderate-quality evidence). Complications did not differ significantly from placebo.

That is one small trial. The reviewers explicitly state there are not enough data to assess its safety in pregnancy. Any use is a decision for the obstetric team, not a self-care option.

Procedures are deferred

Sclerotherapy and thermal ablation are not performed during pregnancy as a matter of routine. Two reasons: the evidence base is limited, and varicose veins have a high probability of regressing spontaneously after delivery, so intervening means accepting risk for a problem that may resolve on its own.

If you had sclerotherapy before you knew you were pregnant

This situation is common enough to address directly, and the answer is reassuring.

Reich-Schupke and colleagues reviewed the case reports and retrospective series of sclerotherapy performed during intended or unrecognised pregnancy. With commonly used sclerosants at standard doses, these showed no increased risk to the mother or the unborn child. Their conclusion is explicit: on current data, there is no reason to terminate a pregnancy because sclerotherapy was performed before the pregnancy was known.

Their recommendation for planned care is nonetheless clear — avoid sclerotherapy in pregnancy where possible, prefer conservative measures during pregnancy or treatment before conception. They note one exception where treatment during pregnancy may be justified: painful genitoanal varices, with thorough counselling and written consent.

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After delivery

Varicose veins that appear during pregnancy often improve substantially on their own. Waiting and observing for three to six months postpartum is the usual advice, and many women need nothing further.

Veins that persist beyond that window warrant a proper duplex ultrasound assessment. Treating before a subsequent pregnancy is worth considering, since starting the next pregnancy with competent valves gives a better baseline — though it is worth saying that this rationale is physiological reasoning rather than something demonstrated in a trial.

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Planning a pregnancy

If you have a family history of varicose veins, or developed them in a previous pregnancy:

• Have a duplex ultrasound to map reflux before conceiving, and complete any treatment beforehand
• Consider compression stockings from early pregnancy rather than waiting for symptoms
• Maintain a healthy weight and stop smoking

At da Re-Fit, women planning a pregnancy or presenting with venous symptoms during one are assessed with duplex ultrasound, and management during pregnancy is conservative by design — compression and activity, with any procedural treatment deferred until after delivery and coordinated with the obstetric team. Our source vein treatment page describes what treatment involves once it is appropriate.

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In closing

"Heavy legs are just part of pregnancy" is half true. Much of it is physiological and resolves. But a third of pregnant women develop chronic venous disease, the mechanisms are well described, and there is emerging evidence that the effects are systemic rather than confined to the legs.

None of that calls for alarm or for intervention during pregnancy. It calls for the symptoms to be taken seriously enough to assess, managed conservatively while pregnant, and reviewed properly afterwards rather than assumed to have resolved.

If your legs ache and swell, say so at an antenatal visit. It is a reasonable thing to have looked at.

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References

• García-Honduvilla N et al. Increase and Redistribution of Sex Hormone Receptors in Premenopausal Women Are Associated with Varicose Vein Remodelling. Oxid Med Cell Longev. 2018;2018:3974026. (PMID: 30250632)
• Ortega MA et al. Pregnancy-associated venous insufficiency course with placental and systemic oxidative stress. J Cell Mol Med. 2020;24(7):4157-4170. (PMID: 32141705)
• Ortega MA et al. Chronic Venous Disease during Pregnancy Causes a Systematic Increase in Maternal and Fetal Proinflammatory Markers. Int J Mol Sci. 2022;23(16):8976. (PMID: 36012236)
• Ortega MA et al. The Pivotal Role of the Placenta in Normal and Pathological Pregnancies: A Focus on Preeclampsia, Fetal Growth Restriction, and Maternal Chronic Venous Disease. Cells. 2022;11(3):568. (PMID: 35159377)
• Asúnsolo Á et al. Association Between Lower Extremity Venous Insufficiency and Intrapartum Fetal Compromise: A Nationwide Cross-Sectional Study. Front Med (Lausanne). 2021;8:577096. (PMID: 34307390)
• Smyth RMD, Aflaifel N, Bamigboye AA. Interventions for varicose veins and leg oedema in pregnancy. Cochrane Database Syst Rev. 2015 Oct 19;(10):CD001066. (PMID: 26477632)
• Reich-Schupke S et al. Sclerotherapy in an undetected pregnancy - a catastrophe? Vasa. 2012;41(4):243-7. (PMID: 22825857)