How is dysautonomia managed during pregnancy?

Management of Dysautonomia During Pregnancy

Dysautonomia during pregnancy requires individualized treatment planning that balances non-pharmacologic approaches with careful medication management to optimize maternal and fetal outcomes.

Understanding Dysautonomia in Pregnancy

• Pregnancy causes profound adaptive changes in maternal hemodynamics that can exacerbate dysautonomic symptoms, with the beginning of pregnancy associated with increased sympathetic reactivity and the latter half characterized by improved hemodynamic stability during orthostatic stress 1
• Studies show that in pregnant women with autonomic dysfunction, sympathetic effects typically predominate, which may contribute to symptoms and complications 2
• Common forms of dysautonomia include Postural Orthostatic Tachycardia Syndrome (POTS), neurocardiogenic syncope, and orthostatic hypotension, which may present with orthostatic dizziness, palpitations, exercise intolerance, cognitive dysfunction, and fatigue 3

Diagnostic Approach

• Diagnosis should include an in-office 10-minute stand test or tilt table testing to evaluate orthostatic changes in heart rate and blood pressure 3
• Heart rate variability testing may be valuable as it is significantly reduced in the second trimester of pregnancy 1
• Cardiovascular reflex tests (Valsalva maneuver, deep breathing test, isometric handgrip test) can be used to non-invasively assess autonomic function during pregnancy 1

Non-Pharmacologic Management

• Implement preventive measures as first-line therapy:

  • Proper hydration with increased fluid intake 4
  • Higher salt intake to maintain blood volume 4
  • Use of compression stockings and abdominal support garments 4
  • Careful attention to postural changes (rising slowly, avoiding prolonged standing) 4
  • Smaller, more frequent meals to prevent post-prandial hypotension 4

• Physical activity modifications:

  • Supervised exercise programs focusing on recumbent or water-based activities 4
  • Avoiding activities that worsen orthostatic symptoms 4

Pharmacologic Management

• Medication decisions should balance maternal symptom control with fetal safety:

  • Fludrocortisone may be considered for orthostatic hypotension when non-pharmacologic measures are insufficient 4, 3
  • Midodrine can be used with caution for refractory orthostatic symptoms 4, 3
  • Beta blockers may help manage inappropriate tachycardia but require careful monitoring 3

• For patients with supine hypertension (common in neurogenic orthostatic hypotension):

  • Sleeping with head elevated 20-30 cm 4
  • Short-acting antihypertensives at bedtime may be necessary in severe cases 4
  • Blood pressure values up to 160/90 mmHg may be tolerable to prevent orthostatic symptoms 4

Special Considerations

• Monitoring for venous dysfunction is important, particularly in normotensive pregnant women with dysautonomia, as this poses a risk for adverse cerebrovascular outcomes 2
• Careful multidisciplinary management is essential, involving obstetrics, neurology, and cardiology 4
• Close monitoring of maternal hemodynamic parameters throughout pregnancy is necessary, with particular attention during labor and delivery 1

Postpartum Considerations

• Continued monitoring for dysautonomic symptoms is important in the postpartum period 3
• Medication adjustments may be needed based on breastfeeding status and symptom changes 3
• Early development of infants should be carefully monitored when mothers require medication for dysautonomia 5