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Vaginal delivery in the presence of huge vulvar varicosities: a case report with MRI evaluation

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Abstract

Vulvar varicosities are generally not an indication for a caesarean section but in a rare case of severe vulvar varicosities, it would be a controversial issue whether to perform a caesarean section for fear they might rupture during a vaginal delivery. We present a case of huge vulvar varicosities during pregnancy. MRI revealed obstruction of the internal iliac system by the gravid uterus and subsequent incompetence of a collateral pathway via the round ligament vein that emptied into the ovarian vein. The patient went into labour at 38 weeks, and successfully vaginally delivered a baby. The vulvar varicose veins became compressed by the foetal head from the inside, and markedly diminished in size during crowning and after delivery. Women with vulvar varicosities can be allowed to attempt a vaginal birth regardless of their severity. The use of MRI aids in the overall anatomical understanding of vulvar varicosities in pregnancy.

Introduction

Vulvar varicosities occur in approximately 2% of pregnant women, and usually regress spontaneously after parturition [1]. In general, vulvar varicosities are not an indication for a caesarean section delivery, but the vulvar varicose veins may cause extensive haemorrhage should they rupture during the course of labour [2]. Practically, a caesarean section is sometimes performed in extremely severe cases of vulvar varicosities for fear of their rupture during a vaginal delivery [3]. To date, there is no consensus on the mode of delivery in a rare case of extensive vulvar varicosities.

In order to determine the optimal mode of delivery in pregnancies involving vulvar varicosities, it would be important to understand the underlying causes of vulvar varicosity formation in pregnancy and how the varicosities change in the course of vaginal delivery. We present a case of huge vulvar varicosities in pregnancy that ended in an uneventful vaginal delivery. An anatomical evaluation of vulvar varicose veins was conducted using magnetic resonance imaging (MRI). This article sheds light on the anatomical and physiological aspects of vulvar varicosities in pregnancy.

Section snippets

Case

A 32-year-old woman, gravida 1, para 1, complained of swelling and discomfort in the left labia minora at 16 weeks of gestation. Examination revealed mild vulvar varicosities. She had neither varicose veins of the legs nor a history of varicose veins in her first pregnancy. The vulvar varicosities grew larger towards the end of the second trimester with each regular prenatal check-up. There were bilateral (mainly left) extensively swollen varicosities of the labia majora and minora and the

Discussion

It is presently unclear whether a vaginal delivery increases the risk of massive blood loss in the event of huge vulvar varicosities. Labour may be allowed and caesarean delivery is performed for obstetric indications. For example, there is no indication for caesarean section other than known obstetric indications in cases of the Klippel–Trenaunay syndrome, which is a congenital vascular disorder that often presents with vulvar varicosities [4], [5], [6], [7], [8]. However, some reports [2], [3]

Conflict of interest

The authors report no conflict of interest.

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