Round Ligament Varicosity in Pregnancy

Published Date: 19th July 2016

Publication Authors: Idama TO, Myagerimath R

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Introduction 

Round ligament varicosity (RLV) is an important clinical entity that has not been reported extensively. The incidence of RLV is unknown. It may be easily mistaken for inguinal hernias in gravid patients because these conditions have similar presentations. Distinguishing between varicosities and hernias is critical to avoid performing unnecessary surgery. We report a case of round ligament varicosity in pregnancy.

Case Report 

Twenty-six year-old Para one presented at 26 weeks of gestation with second episode of painful left groin swelling. On clinical examination there was a demonstrable swelling, which increased on standing and valsalva maneuver, disappeared on lying down. Working diagnosis was left inguinal hernia during pregnancy. Ultrasound revealed clusters of serpiginous venous channels, which significantly increased in volume and flow on valsalva maneuver or standing up. It communicated with distended and tortuous venous track seen along the course of left round ligament; appearance was consistent with round ligament varix with no evidence of hernia. MRI scan confirmed the findings. She was managed conservatively with simple analgesics and physiotherapy. Following delivery at 37 weeks, the swelling and pain subsided remarkably.

Discussion 

The pathophysiology of round ligament varices includes: Progesterone-mediated venous smooth muscle relaxation; raised cardiac output and pelvic venous obstruction by the gravid uterus causes increased venous return from the lower limbs leading to engorgement of venous tributaries. Varicosities of round ligament presenting during pregnancy are easily misdiagnosed as an obstructed hernia. A painful groin mass needs prompt investigation, to avoid the need for a more extensive operation. Clinical examination alone can lead to diagnostic dilemma. Ultrasound is a diagnostic tool, which can help avoid unnecessary surgical exploration and associated morbidity. Ultrasonographic features of multiple dilated veins in round ligament of the uterus extending from deep inguinal ring through inguinal canal with no evidence suggestive of a hernia is consistent with round ligament varicosities. MRI may complement ultrasound in confirming the diagnosis. RLV should be managed conservatively if possible during pregnancy, with use of simple analgesics.

Conclusion 

Round ligament varicosity should be included in the differential diagnosis in a pregnant woman complaining of a groin mass. Ultrasound diagnosis can avoid unnecessary surgical intervention in most of the women. Where possible round ligament varicosities should be managed conservatively during pregnancy as, most of the cases resolve spontaneously postpartum.

Myagerimath, R and Idama, T. (2013).  Round ligament varicosity in pregnancy, a rare case . BJOG: An International Journal of Obstetrics and Gynaecology. 120 (Supplement), 128

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