Round ligament varicosities

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Round ligament varicosities are dilated and tortuous veins in the round ligament, these are rare although most commonly seen during pregnancy and the postpartum period. They constitute an important differential diagnosis for inguinal masses as to avoid unnecessary surgery and associated complications ¹. 

Epidemiology

The condition has an incidence of ~0.15% in pregnant females and is commonly seen in 18-to-40 year olds. It is unilateral, with the right side being the more common site of occurrence. ~45% of the cases are reported in the second trimester of pregnancy ³.

Diagnosis

The condition has a clinical presentation similar to inguinal hernia and requires radiological investigation to confirm the diagnosis, although hernias usually do not initially present in pregnancy ³. 

Clinical presentation 

Patients present with inguinal swelling in the antepartum or postpartum period. The swelling is usually painless, reducible when uncomplicated, and enlarge with the Valsalva maneuver. In the presence of complications such as thrombosis or hemorrhage, the swelling can be painful and irreducible, resembling a strangulated hernia ¹. Labial varicose veins may be seen when the labial veins are involved ⁵. The patient may also present with an abdominal mass or as a case of acute abdomen when there is an associated thrombosis or rupture of the ovarian vein ⁵. 

Pathology

Various physiological changes that commonly occur during pregnancy have been implicated in the causation of varicosities including: 

• progesterone induced smooth muscle relaxation in veins ²

• pressure exerted by gravid uterus on the veins ⁵

• pregnancy induced procoagulant state ⁵

• increased cardiac output during pregnancy ³

Radiographic features

Uncomplicated cases can be diagnosed using a grayscale and/or color Doppler ultrasound while the presence of complications such as thrombosis may warrant the use of CT or MRI, with MRI being the preferred imaging modality in antepartum females to avoid radiation exposure ³. 

Ultrasound

Grayscale ultrasound shows anechoic tortuous tubules with a ‘bag of worms’ appearance and color Doppler shows hypervascular veins with venous pattern of flow which increases on performing the Valsalva maneuver ^1,3.  

CT

CT is only preferred in postpartum cases of complicated round ligament varicosities and in that case, varicosities are hyperdense on precontrast CT and do not enhance on postcontrast CT ⁴. 

MRI 

MRI will show dilated varicosities in the inguinal canal. They are hyperintense on T1 and hypointense on T2, and associated thrombosis can also be visualized ⁴. 

Treatment and prognosis 

Round ligament varicosities are managed conservatively as they generally resolve spontaneously following delivery ¹. Anticoagulants (e.g. low molecular weight heparin) are used in the management of round ligament varicosities complicated by thrombosis ⁴. 

Differential diagnosis

The condition needs to be distinguished from inguinal hernia. If there is any associated pain, strangulated hernia must be ruled out ¹. Other causes of inguinal mass need to be excluded including ^2,3: 

• femoral hernia

• lymphadenopathy

• lipoma 

• hydrocele of canal of nuck 

• vascular aneurysm

• endometriosis