Severe vulvar varicosities in pregnancy with the detailed sequential clinical course and management considerations: A case report

A 40-year-old woman, gravida 8, para 6, with one spontaneous abortion, presented at 28 weeks of gestation with vulvar swelling ( Fig. 1 a). The patient had received regular antenatal care at a primary clinic. The symptoms had developed at approximately 20 weeks of gestation and worsened as the pregnancy continued. The patient reported that vulvar varicosities had first appeared during her fourth pregnancy and that they had regressed after each delivery. She also mentioned that the vulvar varicosities in this pregnancy were the more severe and larger than they had been previously. All the deliveries had been vaginal and the pregnancies otherwise uneventful, with no complications such as massive bleeding from vulvar varicosities. The patient's medical history was otherwise unremarkable. Her BMI was 20.9 kg/m 2 . She was not taking any medication. Fig. 1 Antepartum physical findings at 28 weeks of gestation. (a) Vulvar varicosities. (b) Varicose veins in lower extremities. Fig. 1 Antepartum physical findings at 28 weeks of gestation. (a) Vulvar varicosities. (b) Varicose veins in lower extremities. Physical examination revealed severe vulvar varicosities in the labia majora and minora. Varicose veins were also marked in both lower extremities ( Fig. 1 b). The cervix could not be visualized with a speculum due to venous engorgement of the vaginal wall. Doppler ultrasonography of the lower extremities revealed varicose veins in the main branches of the small saphenous veins bilaterally. Perforating veins, which merged with the varicose veins on each side, were confirmed in the proximal portion of the popliteal fossa on both lower extremities. Reflux in the great saphenous vein was detected on the right side. No evidence of deep venous thrombosis was detected in either lower limb. All laboratory blood and urine findings were within normal limits. The size of the vulvar varicosities remained stable until term. Based on the patient's medical past history and current stability of the vulvar varicosities, vaginal delivery was considered minimally invasive and safe. At 41 weeks of gestation, labour was induced with oxytocin due to a post-term pregnancy. Compression stockings and intermittent pneumatic compression devices were used to prevent venous thrombosis. Immediately after vaginal delivery, continuous venous bleeding from an engorged vein in the cervix was observed ( Fig. 2 ). Although haemostasis of the cervical veins was achieved using pressure with gauze and suturing, bleeding due to uterine atony could not be controlled with pressure alone, and uterine balloon tamponade was performed. The total labour time was 5 h and 35 min, and the estimated blood loss during delivery was 1070 mL. Fig. 2 Physical findings immediately after delivery. (a) Vulvar varicosities. (b) Venous bleeding (white arrow) from an engorged vein in the cervix. Fig. 2 Physical findings immediately after delivery. (a) Vulvar varicosities. (b) Venous bleeding (white arrow) from an engorged vein in the cervix. Following delivery, a rapid reduction in the size of the varicosities was observed within 2 h ( Fig. 3 a) but not of the varicose veins in the lower extremities. On postpartum day 1, the intrauterine balloon was successfully removed without additional haemorrhage. The total amount of postpartum blood loss was 1900 mL. By postpartum day 2, the varicose veins in the lower extremities had completely disappeared. Compared with their antepartum state, the size of the vulvar varicosities reduced significantly, with marked improvement over the following days. The overall postpartum period was stable and uneventful, and the patient was discharged on postpartum day 4. Fig. 3 Postpartum regression of vulvar varicosities. (a) Two hours after delivery. (b) One month postpartum. Fig. 3 Postpartum regression of vulvar varicosities. (a) Two hours after delivery. (b) One month postpartum. At two weeks postpartum, the varicosities persisted; however, a reduction in size was observed. At the 1-month postpartum follow-up, both vulvar varicosities and engorged vaginal veins had completely regressed ( Fig. 3 b).

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Written informed consent was obtained from the patient for publication of the case report and accompanying images.

In summary, a case is presented of large vulvar varicosities during pregnancy with detailed documentation of the antepartum, intrapartum, and postpartum clinical course. The progression and regression of varicose veins were consistent with known physiological haemodynamic changes during pregnancy. Close postpartum monitoring suggested that even large vulvar varicosities may undergo immediate postpartum regression. Appropriate delivery planning is critical to mitigate complications such as massive haemorrhage and deep vein thrombosis.

This report of large vulvar varicosities in a pregnant woman presents a detailed clinical course spanning the antepartum, intrapartum, and postpartum periods, during which rapid regression was observed following delivery. It offers insight into delivery management strategies aimed at preventing complications such as massive intrapartum haemorrhage and deep vein thrombosis of the lower extremities. While most vulvar varicosities resolve within a few months postpartum [ 2 ], few reports document their comprehensive clinical course with close monitoring. Proposed mechanisms for the development of vulvar varicosities during pregnancy include pelvic venous congestion resulting from increased pelvic blood flow and reduced venous return, mechanical compression of the inferior vena cava and iliac veins by the gravid uterus, and increased venous wall fragility due to hormonal changes [ 5 , 6 ]. Moreover, increased cardiac output and circulating plasma volume during pregnancy can contribute to the development of vulvar varicosities. By 30 weeks of gestation, cardiac output and circulating plasma volume increase on average by 54 % and 50 % respectively [ 7 , 8 ]. In the present case, the patient was referred at 28 weeks of gestation with already extensive varicosities, but these remained stable until delivery. This clinical course aligns with known physiological changes during pregnancy, where haemodynamic alterations peak in the second and early third trimesters and stabilise until labour and delivery [ 9 ]. Although spontaneous regression of vulvar varicosities is common postpartum, in approximately 8 % of cases they persist or enlarge after delivery [ 2 , 10 ]. However, few studies have described the detailed process of postpartum resolution. Physiological changes during pregnancy significantly impact blood volume distribution, contributing to both the progression and the regression of varicosities. For example, venous flow velocity in the lower extremities decreases by up to 50 % between 25 and 29 weeks of gestation and returns to baseline by approximately six weeks postpartum [ 11 ]. Additionally, femoral venous pressure increases from 8 mmHg in the first trimester to 24 mmHg at term, subsequently returning to normal postpartum [ 12 ]. After delivery, these contributing factors undergo significant reversal as blood volume decreases, uterine pressure is relieved, and hormonal levels normalise, typically resulting in natural regression of varicosities within 6 weeks [ 13 ]. In the present case, a marked reduction in vulvar varicosity size was noted shortly after delivery, with complete resolution by four weeks postpartum. This clinical course was consistent with the expected physiological changes. However, to the authors' best knowledge, few case reports have documented the rapid regression of vulvar varicosities immediately after delivery. Since the patient had massive haemorrhage during delivery, the decreased circulating plasma volume may be another factor in the rapid regression of varicose veins. This case highlighted the clinical course reflecting rapid postpartum physiological changes of vulvar varicosities. Although the presence of vulvar varicosities during pregnancy does not inherently increase the risk of future pregnancy complications [ 14 ], careful management is necessary throughout the pregnancy and the postpartum period. The most concerning complication is a massive intrapartum haemorrhage. Currently, no consensus exists regarding the optimal mode of delivery. Some studies indicate that the risk of intrapartum bleeding is not elevated in vaginal deliveries involving vulvar varicosities [ 15 , 16 ], while the risk of haemorrhage during caesarean delivery remains a concern. In the present case, although the varicosities were extensive, the absence of other risk factors led to the decision to proceed with vaginal delivery. Operative vaginal delivery methods, such as forceps or vacuum extraction, were avoided to reduce the risk of haemorrhage and severe lacerations. It is suggested that vaginal delivery can be feasible in pregnancy with vulvar varicosities based on careful risk evaluation. Lower extremity varicosities, which often co-occur with vulvar varicosities in pregnancy, represented another clinical concern in the present case. While compression stockings are generally effective for symptom management [ 17 ], signs such as pain, erythema, or edema necessitate differentiation from thrombosis or thrombophlebitis and may require targeted treatment. In this case, venous ultrasound revealed perforating veins and reflux, but no thrombosis was identified, and further intervention was unnecessary. Given the severity of varicosities at initial presentation, a cardiology consultation was conducted, and the delivery plan was coordinated with relevant departments to prepare for potential postpartum complications, including postpartum haemorrhage. Early planning with multidisciplinary collaboration for such complications is essential to ensure safe and successful vaginal delivery outcomes.

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Yuka Nomura contributed to acquiring and interpreting the data, conception of the case report, drafting the manuscript, undertaking the literature review and revising the article critically for important intellectual content. Kiichiro Furuya contributed to patient care, conception of the case report, drafting the manuscript and revising the article critically for important intellectual content. Koki Hayashi contributed to revising the article critically for important intellectual content. Airi Kuruma contributed to revising the article critically for important intellectual content. Saya Yamashita contributed to revising the article critically for important intellectual content. Yangsil Chang contributed to revising the article critically for important intellectual content. Kayoko Shikado contributed to revising the article critically for important intellectual content. Hiroaki Tsubouchi contributed to revising the article critically for important intellectual content. Kazuhide Ogita contributed to revising the article critically for important intellectual content. All authors approved the final submitted manuscript.

Vulvar varicosities occur in approximately 4 % of pregnant women, with high prevalence in multiparous women [ 1 ]. They typically resolve within a few months postpartum without any intervention [ 2 ]. Careful management during delivery is essential because of the risks of massive bleeding from dilated veins associated with the increased venous pressure resulting from pregnancy. Nevertheless, safe and successful vaginal delivery is possible regardless of the size of vulvar varicosities [ 3 , 4 ]. However, few studies have investigated the detailed clinical progression of vulvar varicosities over the course of the antepartum and postpartum periods. Moreover, limited literature addresses the clinical considerations for managing vaginal delivery and preventing complications in such cases. This report presents the case of a patient with severe vulvar varicosities across the antepartum, intrapartum, and postpartum periods, and discusses management strategies.

The authors declare that they have no competing interest regarding the publication of this case report.