by Jose I Almeida, MD, FACS, RVT, Miami Vein Center
Pelvic vein enlargement typically occurs during the second trimester of pregnancy, and during this time, pelvic veins can extend into the groin, mimicking inguinal hernias. Therefore, in a pregnant female who presents with bilateral tender groin masses, the examining physician must keep round ligament varicosities in the differential diagnosis.
Round ligament varicosities are engorged pelvic veins, which have extended into the inguinal canal in juxtaposition with the round ligament. As they protrude out the external inguinal ring they present as inguinal masses. Distinguishing between round ligament varicosities and inguinal hernias can be challenging because of their similar presentations, with both presenting as nontender, soft masses that are more apparent when the patient stands erect, and recede when the patient is supine.1-3
A correct diagnosis is critical, because of differing treatments for the two conditions. Although inguinal hernias are uncommon in women, increased intra-abdominal pressure during pregnancy can lead to this condition. Symptomatic inguinal hernias in pregnant women should be surgically repaired during, or after, the second trimester. In contrast, varicosities of the round ligament should be managed conservatively.
The diagnosis is difficult to establish based on history and physical examination alone. However, the diagnosis is straightforward with color flow duplex imaging. The varicosities appear as large dilated spaces on grey scale imaging, but when interrogated with color, the spaces are clearly vascular as the blood reflects the sound waves.4
In patients with asymptomatic inguinal hernias, surgical repair can be delayed until the postpartum period. However, as stated earlier, symptomatic hernias can be considered for repair during the second trimester. Round ligament varicosities can be observed during pregnancy, and most will resolve spontaneously during the postpartum period. If there is progressive variceal enlargement and increased discomfort, analgesics that are safe for pregnancy can be prescribed for pain control.
1. Chi C, taylor A, Munjuluri N, et al. A diagnostic dilemna: round ligament varicosities in pregnancy. Acta Obstet Gynecol Scand. 2005;84(11):1126-1127.
2. Guillem P, Bounoua F, Duval G. Round ligament varicosities mimicking inguinal hernia: a diagnostic challenge during pregnancy. Acta Chir Belg. 2001;101(6):310-311.
3. Huang A, Tweedie JH. Reducible inguinal swelling presenting during pregnancy- not always a hernia. J Obstet Gynaecol. 1998;18(3):284.
4. Cheng D, Lam H, Lam C. Round ligament varices in pregnancy mimicking inguinal hernia: an ultrasound diagnosis. Ultrasound Obstet Gynecol. 1997;9(3):198-199.