A diagnostic dilemma: round ligament varicosities in pregnancy

Abstract

A 30-year-old waitress booked at 15 weeks in her second pregnancy. At her booking visit she gave a history of a painless swelling in her left groin. On examination she had a 10-cm lump in her left groin. The swelling was reducible, soft and non-tender. On further questioning she gave a history of the same swelling in her left groin in her first pregnancy that resolved spontaneously after delivery. A provisional diagnosis of a left inguinal hernia was made. She was referred to the general surgeons for advice on subsequent management. On review at 28 weeks' gestation she was well but the groin swelling had persisted (see Fig. 1) and was no longer reducible. There were no signs of obstruction. The general surgeons recommended conservative management with a plan to discuss surgical repair postnatally. She also reported unsightly varicose veins on her left leg and an occasional ache from the groin swelling. Left inguinal swelling caused by round ligament varicosities. An ultrasound of the lump was arranged and revealed multiple dilated varicosities within and around the round ligament extending from the left inguinal ring, through the inguinal canal. No loops of bowel were present and there was no evidence of a varix thrombus. She went into spontaneous labor at term followed by an uncomplicated vaginal delivery. She was reviewed at 6 weeks' postdelivery and on examination the inguinal swelling was no longer present. There are several differential diagnoses for a groin swelling. The most common of which, is an inguinal hernia, although it occurs 10 times less frequently in women than in men. Its incidence in pregnancy has been reported as 1 in 1000–3000 (1). Other causes of a groin swelling include a femoral hernia, an enlarged lymph node, a vascular aneurysm and a subcutaneous lipoma. In women, persistent embryonic remnants of the process vaginalis can enlarge to form cysts and by traversing the inguinal canal may produce a bulge in the anterior part of the labium majora. Less commonly round ligament varicosities may also present as an inguinal mass (2). We report a case of round ligament varicosities mimicking an inguinal hernia in pregnancy. The distinction between the two is difficult clinically as the symptoms and signs are similar. Both traverse the inguinal canal. Both can be reducible or irreducible, as round ligament varicosities are valveless and may not empty completely. Round ligament varicosities also transmit cough impulses, similar to inguinal hernias, because transmitted abdominal pressure leads to vein distension. A clue that may suggest round ligament varicosities is the coexistence of lower limb or labial varicosities. The incidence of round ligament varicosities is unknown, but physiological changes in pregnancy can precipitate their formation. These include relaxation of venous smooth muscle, an increase in venous return from the lower limbs and pelvic venous obstruction caused by the gravid uterus. Ultrasound examination has been reported as a useful diagnostic tool in distinguishing round ligament varicosities from an inguinal hernia (2). The characteristic ultrasound appearances of varicosities simulating pelvic masses in pregnant and non-pregnant women have been described using high-resolution real time ultrasonic equipment (3). These include a prominent venous plexus with accompanying dilated draining veins and the typical ‘bag of worms’ appearances of smaller varices. Round ligament varicosities require close monitoring during pregnancy as rupture of varices and acute variceal thrombosis, especially in the peripartum period, have both been reported (4,5). Painful groin swellings need prompt investigation, and surgical exploration may be required. This case highlights the potential difficulty in diagnosing inguinal swellings clinically in pregnancy. By increasing the awareness of round ligament varicosities as part of the differential diagnosis and by highlighting the importance of ultrasound examination, we hope unnecessary surgery and its associated morbidity can be avoided.