WHO recommendation on interventions for the relief of varicose veins and oedema during pregnancy

WHO recommendation on interventions for the relief of varicose veins and oedema during pregnancy

 

Recommendation

Non-pharmacological options, such as compression stockings, leg elevation and water immersion, can be used for the management of varicose veins and oedema in pregnancy, based on a woman’s preferences and available options.

(Recommended)

 

Publication history

First published: November 2016

Updated: No update planned

Assessed as up-to-date: November 2016

 

Remarks

  • Women should be informed that symptoms associated with varicose veins may worsen as pregnancy progresses but that most women will experience some improvement within a few months of giving birth.
  • Rest, leg elevation and water immersion are low-cost interventions that are unlikely to be harmful.

 

Background

Women’s bodies undergo substantial changes during pregnancy, which are brought about by both hormonal and mechanical effects. These changes lead to a variety of common symptoms – including nausea and vomiting, low back and pelvic pain, heartburn, varicose veins, constipation and leg cramps – that in some women cause severe discomfort and negatively affects their pregnancy experience. In general, symptoms associated with mechanical effects, e.g. pelvic pain, heartburn and varicose veins, often worsen as pregnancy progresses. Varicose veins usually occur in the legs, but can also occur in the vulva and rectum, and may be associated with pain, night cramps, aching and heaviness, and worsen with long periods of standing (1).

 

Methods

The ANC recommendations are intended to inform the development of relevant health-care policies and clinical protocols. These recommendations were developed in accordance with the methods described in the WHO handbook for guideline development (2). In summary, the process included: identification of priority questions and outcomes, retrieval of evidence, assessment and synthesis of the evidence, formulation of recommendations, and planning for the implementation, dissemination, impact evaluation and updating of the guideline.

The quality of the scientific evidence underpinning the recommendations was graded using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) (3) and Confidence in the Evidence from Reviews of Qualitative research (GRADE-CERQual) (4) approaches, for quantitative and qualitative evidence, respectively. Up-to-date systematic reviews were used to prepare evidence profiles for priority questions. The DECIDE (Developing and Evaluating Communication Strategies to support Informed Decisions and Practice based on Evidence) (5) framework, an evidence-to-decision tool that includes intervention effects, values, resources, equity, acceptability and feasibility criteria, was used to guide the formulation and approval of recommendations by the Guideline Development Group (GDG) – an international group of experts assembled for the purpose of developing this guideline – at three Technical Consultations between October 2015 and March 2016.

To ensure that each recommendation is correctly understood and applied in practice, the context of all context-specific recommendations is clearly stated within each recommendation, and the contributing experts provided additional remarks where needed.

In accordance with WHO guideline development standards, these recommendations will be reviewed and updated following the identification of new evidence, with major reviews and updates at least every five years.

Further information on procedures for developing this recommendation are available here.

 

Recommendation question

For this recommendation, we aimed to answer the following question:

  • For pregnant women (P), what interventions (pharmacological or non-pharmacological) for varicose veins and oedema (I) compared with no interventions (C) reduce morbidity and improve outcomes (O)?

 

Evidence summary

The evidence on the effects of various interventions for varicose veins in pregnancy was derived from a Cochrane review that included seven small trials involving 326 women with varicose veins and/or oedema, and various types of interventions, including rutoside (a phlebotonic drug) versus placebo (two trials), foot massage by a professional masseur for five days versus no intervention (1 trial, 80 women), intermittent external pneumatic compression with a pump versus rest (1 trial, 35 women), standing in water at a temperature between 29°C and 33°C for 20 minutes (water immersion) versus leg elevation (1 trial, 32 women) and reflexology versus rest (1 trial, 55 women) (1). Another trial comparing compression stockings with rest in the left lateral position did not contribute any data. Fetal and neonatal outcomes relevant to the ANC guideline were not reported in these studies.

Pharmacological interventions versus placebo or no intervention

Only one small trial conducted in 1975 (69 women) contributed data. Low-certainty evidence from this trial suggests that rutoside may reduce symptoms (nocturnal cramps, paraesthesia, tiredness) associated with varicose veins compared with placebo (69 women; RR: 1.89, 95% CI: 1.11–3.22). However, no side-effect data were reported.

Non-pharmacological interventions versus placebo or no intervention

Low-certainty evidence suggests that reflexology may reduce oedema symptoms compared with rest only (55 women; RR: 9.09, 95% CI: 1.41–58.54) and that water immersion may reduce oedema symptoms (leg volume) compared with leg elevation (32 women; RR: 0.43, 95% CI: 0.22–0.83). Low-certainty evidence suggests that there may be little or no difference in oedema symptoms (measured as lower leg circumference in centimetres) between foot massage and no intervention (80 women; MD in cm: 0.11 less, 95% CI: 1.02 less to 0.80 more) and between intermittent pneumatic compression and rest (measured as mean leg volume, unit of analysis unclear) (35 women; MD: 258.8 lower, 95% CI: 566.91 lower to 49.31 higher). Only one study (reflexology versus rest) evaluated women’s satisfaction, but the evidence is of very low certainty.

 

Additional considerations

Compression stockings combined with leg elevation is the most common non-surgical management for varicose veins and oedema; however, the Cochrane review found no evidence on this practice in pregnancy (1). Compression stockings are also widely used to prevent morbidity in non-pregnant people with varicose veins and the evidence for this practice in a related Cochrane review of compression stockings was generally very uncertain (6).

Resources

Postural interventions are low-cost interventions. The cost of compression stockings varies but they can cost more than US$ 15 per pair. Reflexology and professional massage require specialist training, and are, therefore, likely to be more costly.

Equity

It is not known whether interventions to relieve varicose veins and oedema might impact inequalities.

Acceptability

Qualitative evidence from a range of LMICs suggests that women may be more likely to turn to traditional healers, herbal remedies or TBAs to treat these symptoms (moderate confidence in the evidence) (7). In addition, evidence from a diverse range of settings indicates that while women generally appreciate the interventions and information provided during antenatal visits, they are less likely to engage with services if their beliefs, traditions and socioeconomic circumstances are ignored or overlooked by health-care providers and/or policymakers (high confidence in the evidence). This may be particularly pertinent for an intervention like reflexology, which may be culturally alien and/or poorly understood in certain contexts. Qualitative evidence shows that, where there are likely to be additional costs associated with treatment or where the treatment may be unavailable (because of resource constraints), women are less likely to engage with health services (high confidence in the evidence).

Feasibility

The evidence also suggests that a lack of resources may limit the offer of treatment for varicose veins and oedema (high confidence in the evidence) (8).

 

Further information and considerations related to this recommendation can be found in the WHO guidelines, available at:

http://apps.who.int/iris/bitstream/10665/250796/8/9789241549912-websupplement-eng.pdf?ua=1

 

Implementation considerations

  • The successful introduction of evidence-based policies related to antenatal care into national programmes and health care services depends on well-planned and participatory consensus-driven processes of adaptation and implementation. These processes may include the development or revision of national guidelines or protocols based on this recommendation.
  • The recommendation should be adapted into locally-appropriate documents and tools that are able to meet the specific needs of each country and health service. Modifications to the recommendation, where necessary, should be justified in an explicit and transparent manner.
  • An enabling environment should be created for the use of this recommendation, including changes in the behaviour of health care practitioners to enable the use of evidence-based practices.
  • Local professional societies may play important roles in this process and an all-inclusive and participatory process should be encouraged.
  • Antenatal care models with a minimum of eight contacts are recommended to reduce perinatal mortality and improve women’s experience of care. Taking this as a foundation, the GDG reviewed how ANC should be delivered in terms of both the timing and content of each of the ANC contacts, and arrived at a new model – the 2016 WHO ANC model – which replaces the previous four-visit focused ANC (FANC) model. For the purpose of developing this new ANC model, the ANC recommendations were mapped to the eight contacts based on the evidence supporting each recommendation and the optimal timing of delivery of the recommended interventions to achieve maximal impact.

 

Research implications

The GDG identified this priority question related to this recommendation

  • What is the prevalence of common physiological symptoms among pregnant women in low-resource settings, and can the offer of treatment of these symptoms reduce health inequality, improve ANC coverage and improve women’s pregnancy experiences?

 

 

Related links

WHO recommendations on antenatal care for a positive pregnancy experience

(2016) - full document and evidence tables

Managing Complications in Pregnancy and Childbirth: A guide for midwives and doctors

Pregnancy, Childbirth, Postpartum and Newborn Care: A guide for essential practice

WHO Programmes: Sexual and Reproductive health

Maternal Health

 

 

References

  1. Smyth RMD, Aflaifel N, Bamigboye AA. Interventions for varicose veins and leg oedema in pregnancy. Cochrane Database Syst Rev. 2015;(10):CD001066.
  2. WHO handbook for guideline development, 2nd edition. Geneva: World Health Organization; 2014 (http://www.who.int/kms/handbook_2nd_ ed.pdf, accessed 6 October 2016).
  3. GRADE [website]. The GRADE Working Group; 2016 (http://gradeworkinggroup.org/, accessed 27 October 2016).
  4. GRADE-CERQual [website]. The GRADECERQual Project Group; 2016 (https://cerqual. org/, accessed 27 October 2016).
  5. The DECIDE Project; 2016 (http://www.decide-collaboration.eu/, accessed 27 October 2016).
  6. Shingler S, Robertson L, Boghossian S, Stewart M. Compression stockings for the initial treatment of varicose veins in patients without venous ulceration. Cochrane Database Syst Rev. 2013;(12):CD00881.
  7. Downe S, Finlayson K, Tunçalp Ö, Gülmezoglu AM. Factors that influence the use of routine antenatal services by pregnant women: a qualitative evidence synthesis. Cochrane Database Syst Rev. 2016;(10):CD012392
  8. Downe S, Finlayson K, Tunçalp Ö, Gülmezoglu AM. Factors that influence the provision of good quality routine antenatal care services by health staff: a qualitative evidence synthesis. Cochrane Database Syst Rev. 2016

 

Citation: WHO Reproductive Health Library. WHO recommendation on interventions for the relief of varicose veins and oedema during pregnancy. (November 2016). The WHO Reproductive Health Library; Geneva: World Health Organization.