What is the workup for dizziness (dizziness) in pregnancy?

Workup for Dizziness in Pregnancy

A thorough evaluation of dizziness in pregnancy should focus on distinguishing between benign causes and potentially serious conditions, with immediate medical attention required for persistent dizziness that doesn't resolve with rest.

Initial Assessment

History

• Timing and triggers of dizziness
  • Positional changes (suggests BPPV)
  • Association with physical activity
  • Persistent vs. episodic symptoms
• Associated symptoms
  • Hearing loss (suggests Meniere's disease)
  • Headache (possible vestibular migraine)
  • Cardiac symptoms (palpitations, chest pain)
  • Neurological symptoms (visual changes, weakness)
• Severity of symptoms and impact on daily activities
• Hydration status and dietary habits

Physical Examination

• Vital signs including orthostatic blood pressure measurements
• Cardiac examination
• Neurological examination
• Assessment for nystagmus
• Dix-Hallpike maneuver to evaluate for BPPV
• HINTS examination (Head-Impulse, Nystagmus, Test of Skew) to distinguish peripheral from central causes 1

Safety Considerations

Pregnant women experiencing dizziness should be advised to:

• Avoid activities with risk of falling or physical contact
• Avoid excessive heat, especially with high humidity
• Maintain adequate hydration and nutrition
• Stop physical activity and seek medical attention if dizziness persists 2

Diagnostic Testing

First-line Tests

• Complete blood count (to assess for anemia)
• Electrolytes and glucose (to rule out metabolic causes)
• Thyroid function tests (hyperthyroidism can cause dizziness) 2

Additional Testing Based on Clinical Suspicion

• ECG if cardiac etiology is suspected
• Audiometry if hearing loss is present
• Brain imaging (MRI preferred over CT in pregnancy) only if central neurological causes are suspected

Common Causes of Dizziness in Pregnancy

Benign Causes

1. Physiologic changes of pregnancy

   • Increased blood volume
   • Decreased peripheral resistance
   • Postural hypotension

2. Benign Paroxysmal Positional Vertigo (BPPV)

   • Often exacerbated during pregnancy 3
   • Can be treated with canalith repositioning procedures (Epley maneuver)

3. Vestibular migraine

   • May worsen during pregnancy due to hormonal changes 3

4. Meniere's disease

   • May be exacerbated during pregnancy 3

Serious Causes (Require Urgent Evaluation)

1. Cardiac conditions

   • Arrhythmias (more frequent during pregnancy) 2
   • Structural heart disease (e.g., cardiac myxoma) 4

2. Central nervous system disorders

   • Stroke or TIA
   • Intracranial mass

3. Severe pre-eclampsia

Management Approach

Non-pharmacological Management

• Position changes (rising slowly from sitting/lying position)
• Adequate hydration
• Small, frequent meals
• Manual therapy of cervical and thoracic spine (shown to be effective for pregnancy-related dizziness in 94.5% of cases) 5
• Vestibular rehabilitation exercises for peripheral vestibular causes

Pharmacological Management

• Use medications only if symptoms are severe and non-pharmacological measures fail
• Meclizine: Can be considered for severe symptoms, though epidemiological studies have not shown increased risk of major birth defects, animal studies showed fetal malformations at doses similar to clinical doses 6
• Metoprolol: May be considered for dizziness related to arrhythmias 2

When to Refer or Hospitalize

• Persistent dizziness not responding to rest
• Dizziness with signs of pre-eclampsia
• Dizziness with neurological symptoms
• Dizziness with significant cardiac symptoms
• Severe, recurrent, or disabling symptoms

Follow-up

• Mild, intermittent symptoms: routine prenatal care
• Moderate symptoms: follow-up within 1-2 weeks
• Severe symptoms: immediate evaluation and appropriate specialist referral

Remember that dizziness in pregnancy is common but should never be dismissed without proper evaluation, as it can occasionally signal serious underlying conditions requiring prompt intervention.