What is the appropriate workup for dizziness in pregnancy?

Workup for Dizziness in Pregnancy

The appropriate workup for dizziness in pregnancy should include assessment for common physiological causes while ruling out serious pathology through targeted laboratory tests, cardiovascular evaluation, and selective neuroimaging when indicated by red flags.

Initial Assessment

History

• Characterize the dizziness:
  • Vertigo (spinning sensation) vs. lightheadedness
  • Timing and triggers (positional changes, specific head movements)
  • Associated symptoms (nausea, hearing changes, neurological symptoms)
  • Relationship to physical activity or environmental factors

Physical Examination

• Vital signs including orthostatic blood pressure measurements
• Dix-Hallpike maneuver to assess for BPPV
• Neurological examination focusing on cerebellar function and cranial nerves
• Cardiovascular examination including heart rate and rhythm

Laboratory Evaluation

First-line Tests

• Complete blood count to assess for anemia 1
• Electrolytes and glucose to rule out metabolic causes 1
• Thyroid function tests to evaluate for hyperthyroidism 1

Additional Tests Based on Clinical Suspicion

• HbA1c if gestational diabetes is suspected
• Liver function tests if pre-eclampsia is suspected

Cardiovascular Evaluation

When to Consider

• Persistent dizziness
• Palpitations or irregular heartbeat
• History of cardiac disease

Tests

• 12-lead ECG to assess for arrhythmias 2
• Echocardiogram if structural heart disease is suspected (e.g., cardiac myxoma) 3

Neuroimaging

Indications for Brain MRI

• Focal neurological deficits
• New-onset severe headache
• Atypical or persistent vertigo not responding to conservative measures
• Abnormal neurological examination 2

Imaging Selection

• MRI without contrast is preferred over CT during pregnancy
• DWI sequence is particularly important if stroke is suspected 2
• MRA may be considered if vertebrobasilar insufficiency is suspected 2

Management Algorithm

1. For mild, intermittent dizziness without red flags:

   • Reassurance and education about physiological changes in pregnancy
   • Hydration and nutrition counseling
   • Avoidance of triggers (sudden position changes, prolonged standing)

2. For moderate symptoms:

   • Complete laboratory workup as outlined above
   • Follow-up within 1-2 weeks 1
   • Consider manual therapy of cervical and thoracic spine 1

3. For severe or persistent symptoms:

   • Immediate evaluation
   • Consider cardiology and/or neurology consultation
   • Appropriate imaging based on clinical presentation 1

Red Flags Requiring Urgent Evaluation

• Dizziness with signs of pre-eclampsia
• Persistent dizziness not responding to rest
• Dizziness with neurological symptoms
• Significant cardiac symptoms accompanying dizziness 1
• Dizziness with hearing loss or tinnitus (may indicate inner ear pathology) 4

Special Considerations

• Benign paroxysmal positional vertigo (BPPV) may be exacerbated during pregnancy 5
• Vestibular migraine can worsen during pregnancy 5
• Arrhythmias become more frequent during pregnancy and may present with dizziness 2
• Environmental exposures should be assessed (e.g., toxins, carbon monoxide) 6

Pitfalls to Avoid

• Attributing all dizziness to normal pregnancy without adequate evaluation
• Overuse of neuroimaging in cases of typical physiological dizziness
• Failure to recognize cardiac causes of dizziness in pregnancy
• Delaying evaluation of persistent symptoms with red flags

By following this structured approach, clinicians can effectively evaluate dizziness in pregnant women while minimizing unnecessary testing and identifying potentially serious underlying conditions.