What is the appropriate workup for a pregnant patient experiencing dizziness, tachycardia, and abdominal cramping?

Workup for a Pregnant Patient with Dizziness, Tachycardia, and Abdominal Cramping

This patient should be evaluated for possible arrhythmia with a Holter monitor and referred to the emergency department if symptoms recur or worsen, particularly given the risk of cardiovascular events in patients with dizziness and tachycardia during pregnancy. 1

Initial Assessment

• The patient's symptoms (dizziness, tachycardia, tingling, back pain, and abdominal cramping) warrant investigation for both cardiac arrhythmias and pregnancy-related complications 1
• The documented tachycardia (pulse 119) during the episode is concerning for a possible supraventricular tachycardia (SVT), which occurs in 20-44% of pregnancies 1
• While most palpitations during pregnancy are benign, new-onset symptoms require investigation to rule out underlying structural heart disease 1

Immediate Management

• The current management with Tylenol and hydration is appropriate for initial symptom relief 1
• The recommendation to go to the ER if symptoms recur is correct, as immediate evaluation would be needed 1

Recommended Workup

Cardiac Evaluation

• Holter monitor as suggested is appropriate to detect any arrhythmias if symptoms continue 1
• 12-lead ECG to evaluate for any underlying conduction abnormalities or evidence of structural heart disease 1
• Echocardiogram to rule out structural heart disease, particularly if arrhythmias are documented 1
• Consider evaluation for peripartum cardiomyopathy, especially if symptoms persist or worsen, as it can present with new-onset arrhythmias during pregnancy 1

Obstetric Evaluation

• Fetal monitoring is reassuring with heart rate of 140 bpm and normal 20-week ultrasound 1
• Continued monitoring of uterine contractions to evaluate the abdominal cramping 1
• Assessment for signs of preterm labor given the patient's cramping 1

When to Escalate Care

• Immediate ER referral if the patient experiences:
  • Recurrent episodes of dizziness and tachycardia 1
  • Development of shortness of breath 1
  • Syncope or near-syncope 1, 2
  • Worsening or persistent abdominal cramping 1
  • Any signs of hemodynamic instability 1

Important Considerations

• Supraventricular arrhythmias can cause serious hemodynamic consequences for both mother and fetus if sustained 1
• Patients with dizziness/vertigo have a 2-fold higher risk of subsequent vascular events compared to those without these symptoms 3
• The patient's anxiety about the pregnancy (especially as a surrogate) should be addressed, as stress can exacerbate symptoms 1
• Timing and triggers of dizziness episodes are more clinically useful than the quality of symptoms for diagnosis 4, 2

Follow-up Plan

• If Holter monitor shows evidence of arrhythmia:
  • Beta-blockers (particularly cardioselective ones like metoprolol) are first-line treatment for SVT during pregnancy 1
  • Avoid AV nodal blocking agents if pre-excitation is present on ECG 1
• If symptoms persist without clear cardiac etiology, consider other causes of dizziness including vestibular disorders, which may require specific treatment 4, 5
• Regular follow-up to monitor both maternal symptoms and fetal well-being 1