From the Guidelines
Vasovagal syncope during pregnancy should initially be managed with conservative measures, including adequate hydration, avoiding triggers, and position changes, as these methods are effective in reducing the frequency and severity of episodes, thereby improving quality of life and reducing morbidity 1.
Conservative Management
Conservative measures are the first line of treatment for vasovagal syncope in pregnancy. These include:
- Adequate hydration to maintain blood volume
- Avoiding triggers such as prolonged standing, hot environments, and stress
- Position changes, such as sitting or lying down with legs elevated, or assuming a squatting position when feeling faint
- Regular small meals to prevent hypoglycemia
- Compression stockings to improve venous return
- Increased salt and fluid intake (2-3 liters daily) to maintain blood volume
- Physical counterpressure maneuvers like leg crossing with muscle tensing to increase venous return and abort an impending episode
Pharmacological Management
For recurrent or severe cases, medications may be considered after weighing risks and benefits. However, the use of medications should be approached with caution, as the evidence for their effectiveness in vasovagal syncope is limited, and they may have adverse effects 1.
- Beta-blockers like metoprolol may be used with caution, particularly in the second and third trimesters, but their effectiveness in vasovagal syncope is not well established 1.
- Midodrine, a vasoconstrictor, may be used at 2.5-10 mg three times daily, but should be avoided in the first trimester and monitored closely due to potential adverse effects 1.
- Fludrocortisone can increase blood volume, but requires monitoring for hypertension and edema 1.
Quality of Life and Morbidity Considerations
The primary goal of treatment for vasovagal syncope in pregnancy is to improve quality of life and reduce morbidity by reducing the frequency and severity of episodes. Conservative measures should be the first line of treatment, as they are effective and have minimal risks, and medications should only be considered for recurrent or severe cases 1.
From the Research
Treatment Approaches for Vasovagal Syncope
The treatment for vasovagal syncope, including in pregnancy, typically involves a combination of non-pharmacological and pharmacological approaches. The key strategies include:
- Increasing dietary salt and water intake, unless contraindicated by conditions such as hypertension 2, 3
- Using compression garments and physical counter-maneuvers to help prevent fainting episodes 4, 5
- Tilt-training and orthostatic training exercises, which may be beneficial for some patients, especially younger and highly motivated ones 5, 3
- Medications such as midodrine, which has been shown to be effective in preventing vasovagal syncope recurrences 2, 6, 3
Non-Pharmacological Interventions
Non-pharmacological treatments form the foundation of managing vasovagal syncope. These include:
- Patient education on the mechanism of fainting and the non-lethal nature of vasovagal syncope 4
- Liberalization of fluid and salt intake 2, 3
- Teaching physical counterpressure maneuvers to patients, especially those who experience prodromal warning signs 2, 5, 3
- Regular exercise and application of physical counterpressure maneuvers 5
Pharmacological Interventions
Pharmacological treatments may be considered when non-pharmacological approaches are inadequate. The evidence for pharmacological treatment is modest, but certain medications have shown efficacy:
- Midodrine is considered a first-line therapy for patients with frequent presyncope or syncope, or those with brief or no prodromes 2, 6, 3
- Other medications like beta-blockers, serotonin-specific reuptake inhibitors, and fludrocortisone may be used in specific cases, but their use should be restricted due to contradictory results on efficacy 2, 6, 3