What are the treatment options for dizziness in pregnancy?

Treatment Options for Dizziness in Pregnancy

The first-line management of dizziness in pregnancy should focus on non-pharmacological interventions including adequate hydration, position changes, and compression stockings, with pharmacological options reserved for specific underlying causes.

Causes and Assessment

Dizziness in pregnancy is common and can result from several physiological and pathological causes:

• Physiological causes:

  • Postural hypotension due to vasodilation
  • Hormonal changes affecting inner ear function
  • Compression of inferior vena cava by enlarging uterus
  • Anemia

• Pathological causes:

  • Arrhythmias
  • Vestibular disorders (BPPV, Meniere's disease)
  • Vestibular migraine
  • Metabolic disorders

Initial Assessment

• 12-lead ECG to assess for arrhythmias 1
• Complete blood count to evaluate for anemia
• Electrolytes, glucose, and thyroid function tests 1
• Neurological examination for focal deficits

Treatment Algorithm

1. Non-pharmacological Interventions (First-line)

• Hydration and nutrition:

  • Maintain adequate fluid intake
  • Small, frequent meals to maintain blood glucose levels
  • Avoid prolonged standing or sudden position changes 1

• Position changes:

  • Rise slowly from sitting or lying positions
  • Avoid prolonged standing
  • Left lateral decubitus position when resting to prevent inferior vena cava compression

• Compression stockings:

  • Significantly improve dizziness symptoms (mean dizziness score improvement of -3.2 with compression vs -0.4 without, P<0.0001) 2
  • Also improve quality of life related to nausea and vomiting in pregnancy

• Manual therapy:

  • Cervical and thoracic spine manipulation has shown 94.5% success rate in treating pregnancy-related dizziness 3
  • Consider referral to appropriate manual therapy practitioner

2. Pharmacological Interventions (For specific causes)

• For arrhythmia-related dizziness:

  • Beta-1 selective blockers (excluding atenolol) are recommended 4
  • Metoprolol or propranolol are reasonable options 4
  • Digoxin should be considered if beta-blockers are ineffective 4

• For vestibular-related vertigo:

  • Meclizine is FDA-approved for vertigo associated with vestibular system diseases 5
  • However, use with caution in pregnancy and only when benefits outweigh risks

• For migraine-related vertigo:

  • Paracetamol (acetaminophen) is the first-line medication during pregnancy 4
  • Avoid NSAIDs except during second trimester 4
  • Propranolol may be considered for prevention under specialist supervision 4

3. Management Based on Severity

• Mild symptoms:

  • Continue routine prenatal care
  • Implement non-pharmacological interventions
  • Patient education on red flag symptoms

• Moderate symptoms:

  • Follow-up within 1-2 weeks
  • Consider referral to specialist if symptoms persist despite interventions 1

• Severe symptoms requiring immediate evaluation:

  • Dizziness with signs of pre-eclampsia
  • Dizziness with neurological symptoms
  • Persistent dizziness not responding to rest
  • Dizziness with significant cardiac symptoms 1

Special Considerations

• Red flags requiring urgent evaluation:

  • Focal neurological deficits
  • New-onset severe headache
  • Atypical or persistent vertigo
  • Abnormal neurological examination 1

• Safety precautions:

  • Advise patients to avoid activities with risk of falling
  • Avoid excessive heat exposure
  • Stop physical activity and seek medical attention if dizziness persists 1

Monitoring and Follow-up

• For mild symptoms with effective non-pharmacological management, routine prenatal visits are sufficient
• For moderate symptoms or those requiring pharmacological intervention, follow-up within 1-2 weeks to assess response
• For patients with severe symptoms or red flags, immediate specialist referral and close monitoring are essential

By following this structured approach to managing dizziness in pregnancy, clinicians can effectively address symptoms while minimizing risks to both mother and fetus.