Management of Dizziness in Pregnancy
For managing dizziness during pregnancy, first-line treatment should include non-pharmacological approaches, with paracetamol (acetaminophen) as the preferred pharmacological option when medication is necessary. 1, 2
Causes of Dizziness in Pregnancy
- Physiological changes during pregnancy can exacerbate or precipitate dizziness due to hormonal fluctuations, decreased blood pressure, and increased vascular permeability 3
- Dizziness may be associated with migraine, which often improves during pregnancy due to stable estrogen levels 4
- Cardiovascular changes during pregnancy can lead to orthostatic hypotension causing dizziness 3
- Underlying conditions such as benign paroxysmal positional vertigo (BPPV) or vestibular disorders may be exacerbated during pregnancy 5
Non-Pharmacological Management (First-Line)
- Lifestyle modifications including adequate hydration, avoiding sudden position changes, and regular small meals to maintain blood glucose levels 3
- The Dietary Approaches to Stop Hypertension (DASH) eating pattern with reduced sodium and increased potassium intake may help if dizziness is related to blood pressure fluctuations 1
- Bed rest alone might be sufficient for short-duration episodes, particularly in younger patients 1
- Vestibular rehabilitation exercises can be helpful for treating many peripheral and central causes of dizziness 5
- For positional vertigo, canalith repositioning procedures (e.g., Epley maneuver) can be effective and safe during pregnancy 5
Pharmacological Management
First-Line Medications
- Paracetamol (acetaminophen) is the preferred medication for symptom management during pregnancy despite relatively poor efficacy 1, 2
- For dizziness associated with migraine, paracetamol should be used as first-line treatment 1, 2
Second-Line Medications
- Beta-1 selective blockers (except atenolol) can be considered for dizziness related to tachycardia or migraine 1
- Metoprolol (50-100 mg oral twice daily) or propranolol (80-160 mg oral once or twice daily in long-acting formulations) are preferred options 1
- Digoxin may be considered for heart rate control if beta-blockers are ineffective or not tolerated 1
Medications to Avoid
- NSAIDs should be avoided in the first and third trimesters due to potential fetal risks, but can be used with caution during the second trimester if absolutely necessary 1, 2
- ACE inhibitors, angiotensin receptor blockers (ARBs), direct renin inhibitors, mineralocorticoid receptor antagonists, and neprilysin inhibitors are contraindicated throughout pregnancy 1
- Carbamazepine may cause dizziness as a side effect and should be taken at bedtime if needed for other indications 1
- Amiodarone should be avoided due to the risk of fetal hypothyroidism (reported in approximately 17% of cases) 1
Special Considerations
- For dizziness associated with nausea in pregnancy, metoclopramide can be used 1
- For severe migraine-associated dizziness, sumatriptan may be considered under strict specialist supervision if other treatments fail 1, 2, 6
- Meclizine, a common anti-vertigo medication, should be used with caution and only when benefits outweigh risks 7
- For pregnant patients with cardiovascular-related dizziness, maintaining blood pressure in the range of 110-135/85 mmHg is recommended 1
Monitoring and Referral
- Immediate evaluation is warranted for pregnant patients with sudden onset dizziness, especially when accompanied by tachycardia or abnormal blood pressure readings 3
- Persistent or severe dizziness requires specialist referral, particularly if associated with neurological symptoms 8
- Pregnant patients can develop hypoxemia rapidly due to decreased functional residual capacity, emphasizing the need for prompt evaluation 3