What is the initial workup for a pregnant woman presenting with dizziness (lightheadedness)?

From the Guidelines

The initial workup for a pregnant woman with dizziness should begin with a thorough history and physical examination to differentiate between common benign causes and potentially serious conditions, including assessment for orthostatic hypotension, anemia, electrolyte imbalances, and hypoglycemia, as recommended by recent clinical guidelines 1. The evaluation should include vital signs assessment, such as blood pressure in both sitting and standing positions, to evaluate for orthostatic hypotension, which is common in pregnancy due to physiologic vasodilation.

• Laboratory tests should include:
  • Complete blood count to check for anemia
  • Basic metabolic panel to assess electrolyte imbalances
  • Blood glucose measurement to rule out hypoglycemia Consider thyroid function tests as thyroid disorders can manifest with dizziness and are more common in pregnancy.
• A focused neurological examination should be performed to evaluate for central causes, including assessment of:
  • Nystagmus
  • Coordination
  • Cranial nerves For positional dizziness, the Dix-Hallpike maneuver can help diagnose benign paroxysmal positional vertigo (BPPV). If symptoms are severe or accompanied by concerning features like headache, visual changes, or focal neurological deficits, further evaluation with MRI (preferred over CT in pregnancy) may be warranted 1. Electrocardiogram should be considered if palpitations or syncope accompany dizziness. Management typically begins with conservative measures such as adequate hydration, slow position changes, and small frequent meals. Most cases of dizziness in pregnancy are benign and related to physiological changes including increased blood volume, hormonal fluctuations, and compression of blood vessels by the enlarging uterus. It is essential to rule out severe hypertensive disorders, as recommended by the International Society for the Study of Hypertension in Pregnancy 1, although this is not directly related to the initial workup for dizziness. The primary focus should be on identifying and managing any underlying conditions that may be contributing to the dizziness, while also providing guidance on self-care measures to alleviate symptoms.

From the Research

Initial Workup for Pregnant Woman with Dizziness

The initial workup for a pregnant woman with dizziness involves a thorough physical examination and medical history to determine the underlying cause of the symptoms.

• The physical examination may include:
  • Orthostatic blood pressure measurement to check for orthostatic hypotension 2, 3, 4
  • A full cardiac and neurologic examination to check for any cardiac or neurologic abnormalities 2, 3, 4
  • Assessment for nystagmus to check for any vestibular abnormalities 2, 3
  • The Dix-Hallpike maneuver to check for benign paroxysmal positional vertigo 2, 3
  • The HINTS (head-impulse, nystagmus, test of skew) examination to distinguish between peripheral and central causes of dizziness 2, 3, 4
• Laboratory testing and imaging are usually not required but can be helpful in certain cases, such as:
  • Complete blood count to check for any underlying infections or anemia 5
  • Other laboratory tests and imaging studies as indicated by the patient's medical history and physical examination findings 2, 3, 4

Considerations in Pregnancy

During pregnancy, physical, hormonal, and psychological changes can occur, leading to symptoms such as vertigo and unsteadiness 6.

• Vertigo in pregnant females may be associated with hormonal changes in peripheral structures and inner ear organs 6
• Meniere's disease, vestibular migraine, and benign paroxysmal positional vertigo are usually exacerbated during pregnancy 6
• Specific changes to hearing and proprioception in the physical examination are also noted between the second and third trimester of pregnancy 6