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By Adriane Fugh-Berman, MD
Although pregnancy-associated leg edema is not dangerous, it can be very bothersome, causing pain, night cramps, and paraesthesias. Several factors associated with pregnancy may contribute to edema, including increased fluid volume and decreased smooth muscle tone in veins. Pressure of the gravid uterus may also increase venous pressure by decreasing venous return from the lower body. Treatments used for venous insufficiency in pregnancy are compression hosiery and leg elevation, but neither method has been adequately tested.
A Cochrane collaboration review identified only three randomized, controlled trials of treatments to reduce leg edema or to relieve symptoms.1 One trial each of three treatments (rutosides,2 external pneumatic compression,3 and water immersion4) were included; a total of 115 women were subjects. The reviewers concluded that rutosides relieve symptoms of venous insufficiency in late pregnancy; that external pneumatic compression appears to temporarily reduce ankle swelling; and that immersion in water for 50 minutes results in diuresis and fall in blood pressure. It should be noted that these conclusions are based on only one trial of each treatment.
Rutosides are flavonoids derived from plants containing rutins (a rhamnoglucoside of quercitin, rutins are found in many plants, including tobacco, buckwheat, and eucalyptus). A placebo-controlled trial of 69 women in the Netherlands at 28 weeks gestation tested the effects of rutosides on improvement of symptoms.2 Women were given placebo or rutoside capsules (300 mg tid) for eight weeks. Two-thirds of the 37 women given rutoside capsules noted an improvement in symptom scores (pain, feelings of heaviness and/or tiredness, nocturnal cramps, and paraesthesias), significantly higher than the placebo group, one-third of whom experienced improvement (odds ratio 0.30, 95% confidence interval 0.12 to 0.77). Changes in ankle circumference after eight weeks of treatment were also noted; there was a decrease in women receiving rutosides, while women given placebo had a small increase.
Rutosides in a dose of 1000 mg/d have also been tested in healthy volunteers for induced leg edema. In a randomized, controlled, double-blind study with a placebo run-in, 12 volunteers stood motionless for an hour once a week, with before and after measurement of leg edema (by water displacement).5 Compared to placebo, there was a progressive reduction in induced edema in the rutosides group, which was significant at the second and third weeks. Another study in healthy volunteers found that after three weeks of treatment with 1000 mg/d, halving the dose to 500 mg/d was adequate to maintain a beneficial effect.6
External Pneumatic Intermittent Compression
In a trial of 35 pregnant women in the third trimester with dependent leg edema, 17 women received external pneumatic intermittent compression (EPIC) for 30 minutes at 40 torr while in the left lateral position.3 Eighteen women in the control group were placed in the same position but did not receive EPIC. Afterwards, both groups walked for 10 minutes. Four circumference measures were made before and after positioning and after walking. Compression had an immediate effect, but this effect had already lessened within 10 minutes. Later time points were not measured, and women were not asked whether symptoms were relieved, so it is unclear whether the effect of EPIC is clinically significant.
Immersion vs. Bed Rest
Shoulder-deep immersion in water resulted in greater diuresis and fall in blood pressure than either waist-deep immersion or 50 minutes bed rest.
A three-way crossover trial compared bed rest, waist-deep immersion in a bathtub, and shoulder-deep immersion in an immersion tank, with legs extended downward.4 The water temperature in both immersion interventions was 32° C (90° F, about bathtub warmth). It is not stated how many women began the study but 11 women completed the study, which measured urine output and mean arterial pressure immediately after each 50-minute treatment period. There was no significant difference in urine output between bed rest and bathtub treatment. Diuresis after shoulder-deep immersion was significantly greater than the other two treatments. All treatments caused a significant decrease in mean arterial pressure; increased sodium and potassium clearance; decreased serum potassium levels; and decreased maternal heart rate. Neither immersion treatment produced a change in calculated plasma volume; the hour of bed rest produced a small but significant increase of 2.4% in plasma volume. Symptom relief was not recorded.
The authors of this study state that it demonstrates the safety of immersion, because significant diuresis without a change in calculated plasma volume indicates that fluid is being pulled from the extravascular space without decreasing intravascular volume. Although the immersion tank was specially constructed, the authors point out that shoulder-deep immersion can be done in a swimming pool. Aerobic exercise in water also increases diuresis.
Leg elevation and compression hosiery are the usual treatments for pregnancy-associated leg edema but shoulder-deep immersion appears to be a simple and effective treatment. (A Japanese bathtub is an option, although admittedly not the most accessible one. A hot tub with the temperature turned down may be another option.) Swimming and water aerobics may also be useful and are particularly comfortable exercises for pregnant women. Rutosides appear to be effective; although these plant-derived substances are unlikely to be toxic it bears noting that long-term toxicity studies have not been done in adults, nor has safety for fetuses been established. EPIC is cumbersome and appears to work only temporarily.
More research needs to be done in this area: simple, low-cost treatments for pregnancy-induced leg edema would be welcome. It would be useful to compare standard treatments with immersion and water aerobics, for example. Massage (especially lymphatic massage) also would be an interesting therapy to test for this problem.
1. Young GL, Jewell D. Interventions for varicosities and leg oedema in pregnancy. In: The Cochrane Library. Issue 3. Oxford: Update Software; 1999.
2. Bergstein NA. Clinical study on the efficacy of O-(beta-hydroxyethyl)rutoside (HR) in varicosis of pregnancy. J Int Med Res 1975;3:189-193.
3. Jacobs MK, et al. Leg volume changes with EPIC and posturing in dependent pregnancy edema. Nurs Res 1986;35:86-89.
4. Katz VL, et al. A comparison of bed rest and immersion for treating the edema of pregnancy. Obstet Gynecol 1990;75:147-151.
5. Rehn D, et al. Time course of the anti-oedematous effect of O-(beta-hydroxyethyl)-rutosides in healthy volunteers. Eur J Clin Pharmacol 1991;40:625-627.
6. Rehn D, et al. Time course of the anti-oedematous effect of different dose regimens of O-(beta-hydroxyethyl)rutosides in healthy volunteers. Arzneimittelforschung 1993;43:335-338.