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

Workup for Dizziness in Pregnancy

The appropriate workup for dizziness in pregnancy should include a targeted evaluation of common causes while considering pregnancy-specific conditions, with laboratory testing, cardiovascular assessment, and selective neuroimaging when indicated by red flags.

Initial Assessment

• History focusing on specific triggers and timing:

  • Onset, duration, and frequency of dizziness episodes
  • Relationship to position changes (suggests BPPV)
  • Association with hearing changes (suggests Meniere's disease)
  • Headache association (suggests vestibular migraine)
  • Cardiovascular symptoms (palpitations, chest pain)
  • Neurological symptoms (focal deficits, visual changes)

• Physical examination:

  • Orthostatic blood pressure measurements
  • Comprehensive neurological examination
  • Assessment for nystagmus
  • Dix-Hallpike maneuver for BPPV
  • HINTS examination (Head-Impulse, Nystagmus, Test of Skew) to distinguish peripheral from central causes 1

Laboratory Testing

• Complete blood count (to assess for anemia)
• Electrolytes and glucose (to rule out metabolic causes)
• Thyroid function tests
• Consider HbA1c in women at risk for gestational diabetes 2

Cardiovascular Assessment

• 12-lead ECG to assess for arrhythmias
• Consider echocardiogram if cardiac symptoms are present or if there's suspicion of structural heart disease 2, 3

Neuroimaging

• MRI without contrast is preferred over CT during pregnancy when imaging is indicated
• MR angiography (MRA) should be considered if vertebrobasilar insufficiency is suspected 2

Red Flags Requiring Urgent Evaluation

• Focal neurological deficits
• New-onset severe headache
• Atypical or persistent vertigo
• Abnormal neurological examination
• Dizziness with signs of pre-eclampsia
• Significant cardiac symptoms 2

Condition-Specific Management

For Benign Paroxysmal Positional Vertigo (BPPV)

• Canalith repositioning procedures (e.g., Epley maneuver) are safe in pregnancy 1

For Vestibular Migraine

• Paracetamol (acetaminophen) is the first-line medication
• NSAIDs should be avoided except during the second trimester
• Propranolol may be considered for prevention under specialist supervision 4, 2

For Meniere's Disease

• Salt restriction and hydration management
• Meclizine may be used with caution, though animal studies showed fetal malformations at doses similar to clinical doses 2, 5

For Cardiovascular-Related Dizziness

• Beta-1 selective blockers (metoprolol or propranolol) for arrhythmia-related dizziness 2

Follow-up and Monitoring

• Continue routine prenatal care for mild symptoms
• Follow-up within 1-2 weeks for moderate symptoms
• Immediate specialist referral for severe symptoms or red flags 2

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 2

Remember that dizziness in pregnancy can be caused by normal physiological changes, but it's important to rule out serious underlying conditions that could affect maternal and fetal outcomes.