Elastic Venous Compression Devices for Pregnant and Post-Partum Women: Effects on Chronic Venous Disease Signs and Symptoms and Compliance

Several terminologies are used in the literature to describe elastic compression devices: compression hosiery/garment, graduated compression stockings, medical compression stockings. The term stockings can be too restrictive as several formats are available in the market (knee-length socks, thigh-length stockings or tights/pantyhose). Elastic Venous Compression Devices (EVCDs) were also proposed to integrate all these different formats. Globally, all these elastic compression devices work by exerting the greatest degree of compression at the ankle, with the level of compression gradually decreasing up the garment. Compression therapy is one of the most effective conservative treatments for alleviating symptoms of chronic venous disease, particularly in pregnant women. 

During pregnancy, women are at an increased risk of venous thrombo-embolism, including deep vein thrombosis or pulmonary embolism [1]. Prevention of venous thrombo-embolism is, therefore, key in reducing maternal mortality rates. The Clinical-Etiology-Anatomy-Pathophysiology, abbreviated as CEAP, classification is an internationally accepted standard allowing the description of patients with chronic venous disorders. The clinical (C) aspect is the most widely used component of CEAP classification [2] and is based on objective clinical signs of chronic venous disease, scored between C0 to C6, supplemented according to presentation (A) for asymptomatic or (S) for symptomatic limbs. This review will focus on C0 (no visible or palpable signs of venous disease), C1 (telangiectasias or reticular veins), C2 (varicose veins) and C3 (oedema). 

The aim of the review is to give an overview of i) epidemiology regarding the first signs of chronic venous disease (C0s to C3) during pregnancy, ii) the knowledge of recommendations of the use of EVCD during ante and post-partum, iii) the effects of compression therapy in pregnant women, and iv) real-life dispensation, compliance, and reticence to use EVCD.

• Symptomatic patients (C0s) 

The gestational changes related to pregnancy result in the occurrence of various subjective symptoms like the feeling of tiredness and heaviness of the legs, bursting sensation, resulting in a discomfort or pain on the lower limbs. Interestingly, 82% of pregnant women describe feelings of discomfort [3]. Pregnant women may also suffer from tiredness and heaviness of the legs from 6% to 93%, depending on the study [4-8]. This variability can be explained by the different methods used to assess symptom intensity, and by the subjective nature of this assessment. Furthermore, more than 60% suffered from pain [4-9] and 40% from bursting sensation in the limbs [7]. Lower-limbs itch sensations have been observed in 19% of the pregnant women [5]. 

• Telangiectasias, spider veins (C1) 

The term telangiectasias was used in 1807 by Von Graf to describe superficial vessels, just visible to the human eye. Nowadays, this term is used for small cutaneous vessels from 0.1 to 1.0 mm diameter [10]. Importantly, the prevalence of telangiectasias in pregnant women is between 31% [5] and can affect more than 50% [11]. Women who had been pregnant at least once were more likely to have minor telangiectasias, or spider veins [12]. This is mainly influenced by the modifications of hormones levels [10]. However, most disappear post-partum. 

• Varicose veins (C2) 

Varicose veins, classified as C2 by the Classification CEAP [2], are defined as tortuous, dilated superficial veins >3 mm in diameter [13,14]. A study conducted on 352 pregnant women showed that 20.5% presented varicose veins [11]. The number of previous pregnancies was positively associated with the presence of varicose veins [15-18]. The appearance or worsening of varicose disease during pregnancy can be explained by different factors like i) a mechanical compression of the uterus on the iliac veins by the gravid uterus and inferior vena cava, especially in the last trimester of pregnancy which may explain the emergence of vulvar varicose veins; ii) hormonal modifications; iii) an increase in the uterine blood debit; iv) an increase in volemia; and v) structural alterations of the venous wall [11]. These changes will increase the pressure on the venous valves in the lower limbs and contribute to the development of venous distention and potentially to varicose veins. 

• Oedema (C3) 

Venous oedema is defined by a perceptible increase in volume of fluid in skin and subcutaneous tissue, characteristically indented with pressure. Venous oedema usually occurs in the ankle region, but may extend to leg and foot [13]. The venous oedema increases during the time-course of the pregnancy [7]. Leg edema (swelling) can affect up to 80% of pregnant women [3-9,19,20]. The discrepancies observed between studies on the percentage of pregnant women suffering from leg edema can be partly due to methodological differences, including the measurement system used, variability of the subject regarding the time of pregnancy. Interestingly, a study conducted by Ponnapula [20] described the location of the edema in the lower limb. On 100 post-partum women for whom 87% experienced swelling, the authors showed that the edema was mainly present in the foot, and the ankle and to a lower extend on the leg for 84%, 80%, and 52%, respectively [20] (Table 1).

 Table 1: Epidemiology of the clinical signs and symptoms of pregnant women.

The European Society for Vascular Surgery recommends the use of EVCDs for pregnant women presenting with symptoms and/or signs of chronic venous disease [21]. Furthermore, the French National Authority for Health (Haute Autorité de Santé, HAS) endorses the use of EVCDs during pregnancy and up to six weeks after delivery, or even six months after Cesarean section [22]. Finally, the National Institute for Health and Care Excellence (NICE) advocates EVCDs for symptom relief of leg swelling associated with varicose veins during pregnancy [23]. These considerations are followed by the United Kingdom National Health Service (NHS) who is in favor of EVCDs for pregnant women, by recommending the prescription of two pairs of EVCDs so that one can be worn while the other is being washed and dried [24] and these EVCDs should be replaced every six months [25]. 

The statement of two pairs is mainly based on practice as depicted by the publications of Allaert [26,27]. In 2008, in a cross-sectional study conducted in daily practice of downtown French pharmacies, it has been shown that the prescriptions included one, two and three or more pairs of compression in 44.8%, 51.9% and 3.3%, respectively [26]. Interestingly, in 2013, in a prospective study on the French general population conducted on 332 pharmacies, the authors showed that the number of pairs of compression is mentioned on 94.3% of prescriptions and those foreseen the dispensation of one, two and three pairs of compression in 26.9%, 65.8%, and 7.3%, respectively. The mean of prescription of compression was 1.9 ± 0.8 pair [27]. These results are in line with the one from Joassard et al., showing that among pregnant women who were dispensed at least one EVCD during ante or post-partum, the majority (41.9 %) were dispensed with two pairs of EVCDs [28].

EVCDs are assigned to classes 1 to 4, depending on the compression exerted on the leg, in a supine position, at the B point in the area of the ankle. EVCDs must exhibit a continual decline in pressure from distal to proximal, with the greatest pressure in the ankle region (B point) and the lowest pressure in the thigh region (G point). The pressures exerted by the EVCD, expressed in millimeters of Mercury (mmHg) or in hectoPascals (hPa) (1 mmHg = 1,33322 hPa), are determined based on laboratory measurements, according to standards. Unfortunately, there is no single standard used worldwide, which may cause confusion. There are three main standards for EVCDs: RAL-GZ 387/1 in Germany, BS 7505 in United Kingdom, and AFNOR in France. According to the most commonly used throughout the World, RAL-GZ 387/1, the ankle interface pressure is 18-21 mmHg (24-28 hPa) for Class 1, 23-32 mmHg (31-43 hPa) for Class 2, 34-46 mmHg (45-61 hPa) for Class 3 and > 49 mmHg (> 65 hPa) for Class 4 [29]. 

EVCD is one of the most effective conservative treatments for alleviating symptoms of chronic venous disease, particularly in pregnant women. Fourteen publications, published between 1992 to 2022, and focusing on the effect of EVCDs on pregnant women’s venous disorders or pregnancy-related symptoms were selected for this review (Table 2). These articles included 10 to 98 pregnant women. The thigh-length stockings format was the most studied (nine articles) [3,4,30-36], compared to one publication with tights compression devices [9] and four articles including knee-length socks [8,37-39] (Table 2). Several levels of compression were analyzed from 13 mmHg to 25-32 mmHg at the ankle (Tables 2&3). 

Table 2: Summary of clinical trials evaluating efficacy of EVCDs on pregnant women.

Table 3: Summary of the effects of EVCDs on signs, symptoms and hemodynamic parameters on pregnant women.

• Efficacy on the leg symptoms 

Leg symptoms (pain, discomfort) improved significantly (p = 0.045) in pregnant women wearing EVCDs compared to no EVCDs [31]. Several publications confirm these findings [3,4,8,9,34,39]. 

• Efficacy on blood flow/venous pump function 

When EVCDs were worn during ante and post-partum, venous pump function improved [3,4,32] and refilling time lengthened significantly [4]. Duplex sonography showed an increase in blood flow velocity [30] and flow volume in the superficial femoral vein with applied compression; the vessel diameter decreased [4,8,30,37]. 

• Efficacy on Oedema 

Oedema was reduced with 13 mmHg EVCDs [32] to 20-32 mmHg EVCDs [3,8,9,32,38,39]. Interestingly, the skin thickness significantly decreased after the use of 27 mmHg elastic socks [38]. Furthermore, the venous emptying (expelled volume), corresponding to a measure of the ability of the muscle pump and venous system to reduce the venous volume, was significantly increased after a 3-day compression period. A reduction of the inflow rate was also observed. Altogether, these results should be interpreted as a diminishing reflux induced by compression (Figure 1). This fact might be the reason for the lesser degree of edema subjectively evaluated [3]. Interestingly, a study, confirming these results, also quantitatively assessed the venous muscle pump function through pregnancy weeks 16, 30, 38 and 3 months (week 53) following delivery.

 Figure 1: Effects of compression on pregnant women.

• Efficacy on varicose veins 

The mean venous reflux increased significantly (p < 0.01), and was restored to initial values post-partum. On the contrary, while the expelled calf volume remained stable throughout pregnancy, an increase was observed following delivery [40]. Twenty five percent of pregnant women suffering with varicose veins have venous reflux [41]. While compression significantly decreased the reflux of the emergent third trimester long saphenous vein at the sapheno-femoral junction [4/15 for controls vs. only 1/27 compressed women (p = 0.047)], compression to a maximum of 32 mmHg fails to prevent the emergence of superficial varicose veins [31]. However, the group was too small to substantiate or exclude a benefit. A larger study would be required to determine whether compression prevent truncular varicosis in the long term. Interestingly, even low compression levels (13 mmHg at the ankle) were found to improve the venous emptying, measured during exercise in the standing position [32]. 

• Efficacy on heart rate 

During pregnancy, an increase in heart rate on standing was recorded for both mother and fetus [33]. Interestingly, 25 mmHg at the ankle EVCDs decreased significantly these changes in the standing position, showing that 25 mmHg EVCDs are effective in the management of maternal and fetal circulatory response to alterations in posture during pregnancy [33]. However, these results were not confirmed later by Norgren et al., [36] that did not show significant decrease of mother and fetal heart rate [36]. Both studies were performed on small population, 18 and 10 pregnant women for Austrell et al., and Norgren et al., [33,36] respectively. Studies on larger pregnant population are needed to substantiate the effect of compression on both mother and fetal rates. 

EVCDs could exert their beneficial effects through a decrease of the diameter of the common femoral vein [30] and the great and small superficial veins [4,8], thereby allowing previously incompetent venous valves to coapt, resulting in restoration of the venous competence of damaged vessels. One could easily envisage a relation between a lower diameter of the veins and an increase in both blood flow velocity [4,30,36] and venous emptying [3,4,32]. Altogether, these results allow to reduce the signs and subjective symptoms of pain, oedema, and leg heaviness related to pregnancy [4,8,9,31,34] (Figure 1).

• Real-life dispensation 

Recently, a retrospective cohort study (using the French Health Insurance database) conducted on 15,528 pregnant women showed that, in current practice, EVCD dispensation rates were low regarding the recommendations [28] made by the French National Authority for Health who is in favor of the EVCDs use during pregnancy and up to 6 weeks after delivery, or even 6 months after C-section [22]. In fact, authors noticed that only 31.7 % women were dispensed at least one EVCD during their pregnancy. During the post-partum period, 17.3 %, 46.7 % and 44.1 % women were dispensed at least one EVCD after vaginal delivery, planned C-section or unplanned C-section, respectively [28]. These interesting results on dispensation were either due to, on the one hand, a low level of prescription by healthcare professional or on the other hand, the fact that pregnant women did not provide their prescription for compression to the pharmacist. Importantly, the results of this retrospective study suggest that recommendations are not being followed by prescribers, or that there are issues with patient compliance. 

• Compliance and reasons to not use EVCD 

Allegra et al., [34] showed that 30.6% of pregnant women presenting symptoms of venous disease (CEAP C0s to C3s) refused to wear compression stockings (15-20 mmHg) [34]. Among the pregnant women who accepted to wear compression stockings, 10.6% wear their compression at least once every two days and 58.8% wore them every day. Importantly, legs pain decreased more significantly for women wearing compression every day compared to women wearing compression at least once every two days and to women who did not wear compression. Similar results were observed for pregnant women quality of life. It was noticeable that the effect of EVCDs was proportional to the regularity of the pregnant women to wear the compression, confirming the efficiency of the EVCD in alleviating chronic Veinous Disease symptoms during pregnancy [34]. 

In the general population, while hot environments worsen venous disease symptoms [42,43], by increasing the leg volume [44] and the venous pressure in the great saphenous vein near the ankle [45], lower dispensation rates were observed in summer [28]. Also, a study conducted on 332 French pharmacists followed by 2,223 patients showed that the main reasons for the lack of regular wearing of EVCD were the difficulty to bear (in 23.8% of the cases), the difficulty of putting (in 14.5% of the cases), and the existence of a sufficient number of pairs in their disposition (in 24.5% of the cases) [27,46]. The lack of information given by healthcare professional regarding the interest and the real benefit of the EVCD, the way to don them, the storage and maintenance is also a reason of non-compliance by the patient [27,47,48]. Finally, an inappropriate dispensation of the adequate format (socks, stockings, or tights) underlined by Joassard et al., [28], and the poor choice in texture and color [46] may also contribute to the absence of compliance by the patient. Recently, a systematic review described five main overarching themes for non-compliance, including physical limitations, health literacy, discomfort, financial issues and psychosocial issues [49]. One could easily envisage that these reasons are also applicable to pregnant women. 

Interestingly, using a self-subjective evaluation questionnaire, the pregnant women’s perception on the use of 20-30 mmHg compression stockings, authors showed that most women stated that they did not have difficulty in wearing their compression stockings, did not need to remove them during the study period (63.33%), and did not need assistance to put on the stockings (80%). All pregnant women (n = 30) reported that they would use the compression stockings again as they felt an improvement of symptoms in their legs [8,39]. Furthermore, in a randomized trial, Coughlin et al., [41] investigated the acceptability, compliance and usage of Class 1 compression tights in 331 pregnant women at various time points (initiation, 34 weeks, and 6 weeks post-partum) via participant questionnaires. Authors notices a reticence at the beginning of the study to use compression. Furthermore, as pregnancy processed, the number of women rejecting the tights increased: seven women wore them up to 20 weeks, four to 28 weeks, 14 to 34 weeks, two to term and four to 6 weeks post-partum. Only 55% of the pregnant women stated that the tights were still comfortable at 34 weeks [41]. This is even more damaging as the venous symptoms worsen over time [8], season [42,43,50], and number of pregnancies [51]. Irritation was a reason why some participants stopped wearing tights. Coughlin et al., [41] concluded that Class 1 compression tights were unacceptable in pregnant women because of their abdominal size, being the most significant factor associated with tights rejection, suggesting the consideration of a different type of hosiery for pregnant women [41]. 

To be effective on the reduction of chronic venous disease symptoms and signs, EVCDs must be worn every day. It is therefore crucial that the pregnant woman is involved in the decision-making process, which may increase the likelihood that the EVCD will be worn. Progresses have been made regarding textile compression devices, in terms of technicity, formats (knee-length socks, thigh-length stockings or tights/pantyhose), open or closed toe, colors and aesthetics. In fact, some devices of elastic compression are dedicated to pregnant women like the one developed by Laboratoires Innothera: SMARTLEG® BB, co-designed by pregnant women and industrial engineers. These tights feature no seam under the belly, herringbone-designed sole. Furthermore, considered the physical dexterity conditions of pregnant women, particularly during late pregnancy, and as the maternity tights can be perceived as too tight in the abdominal and genital area [9], the belt of SMARTLEG® BB tights can be worn under the belly thanks to the V-design in the hip for a better compliance, especially in hot conditions and during ultrasonography screening.

In conclusion, during pregnancy, women are at an increased risk to see their quality of life being impaired due to modifications chronic venous disease signs and symptoms. EVCD has been considered to be one of the most effective conservative treatments for alleviating symptoms of chronic venous disease. EVCD works by exerting the greatest degree of compression at the ankle, with the level of compression gradually decreasing up the garment. The pressure gradient ensures that blood flows upward toward the heart instead of refluxing downward, especially by reducing the diameter of major veins. As signs and symptoms worsen with advanced pregnancy, the blood in the veins can become concentrated and may easily form blood clots, increasing the risk of venous thrombo-embolism, higher in post-partum. Importantly, even if several formats and compression class exist, it seems that the efficacy were not different on the signs, symptoms and hemodynamic parameters on pregnant women. However, there is a loss of chance for the patient if a compression device is not used; the compliance being crucial for alleviating chronic venous disease signs and symptoms. The most important consideration being that the EVCDs must be worn the earliest, every day during pregnancy and even in post-partum to prevent these blood conditions and impairment of pregnant women quality of life.

This review was funded by Laboratoires Innothera.

The authors would like to thank Guillaume Duport for providing assistance in the design of the figure.

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