Management of Hormonal Fluctuation-Related Dizziness and Heart Palpitations

Introduction to Treatment

• The American College of Cardiology and the American Heart Association recommend treating thyroid disorders with thyroxine replacement for hypothyroidism, and addressing other endocrine disorders by correcting electrolyte imbalances and treating the underlying condition, with a moderate to high strength of evidence 1, 2
• Patients with symptoms of dizziness and palpitations should not have all symptoms attributed to hormonal fluctuations without ruling out structural heart disease or arrhythmias, with a strength of evidence based on expert opinion 2

Diagnosis and Evaluation

• A thorough diagnostic evaluation is necessary to rule out structural heart disease or arrhythmias, and to identify underlying endocrinopathies, with a high strength of evidence 1, 2
• Laboratory testing, including complete blood count, electrolytes, glucose, and thyroid function tests, is recommended to evaluate common causes of dizziness in pregnancy 3
• Cardiovascular assessment, including 12-lead ECG to assess for arrhythmias, is recommended to evaluate common causes of dizziness in pregnancy 4, 5
• Selective neuroimaging, such as MRI without contrast, may be indicated by red flags, including focal neurological deficits, new-onset severe headache, atypical or persistent vertigo, and abnormal neurological examination 5, 6

Treatment of Underlying Conditions

• Thyroid dysfunction should not be overlooked, as it can cause both palpitations and dizziness, with a high strength of evidence 1
• The American Heart Association recommends treating thyroid disorders with thyroxine replacement for hypothyroidism, and addressing other endocrine disorders by correcting electrolyte imbalances and treating the underlying condition, with a moderate strength of evidence 1

Medication Management

• Class I or III antiarrhythmic drugs should be avoided without documented arrhythmia due to proarrhythmic risk, with a high strength of evidence 2
• Paracetamol (acetaminophen) is recommended as the first-line medication for dizziness in pregnancy, with NSAIDs to be avoided except during the second trimester 6
• Propranolol may be considered for prevention of migraine-related vertigo under specialist supervision, and beta-1 selective blockers (e.g., metoprolol or propranolol) may be used for arrhythmia-related dizziness in pregnancy 7, 8, 6
• Meclizine may be used with caution for vestibular-related vertigo during pregnancy 6

Patient Monitoring and Follow-up

• The following table summarizes the recommended management of dizziness in pregnancy:

6, 7, 8

• Patients with severe symptoms, persistent dizziness, dizziness with signs of pre-eclampsia, dizziness with neurological symptoms, and dizziness with significant cardiac symptoms require immediate specialist referral 9, 6
• Patients should avoid activities with a risk of falling, excessive heat exposure, and stop physical activity and seek medical attention if dizziness persists 7, 4, 9
• Patients should be educated on the importance of avoiding activities that may exacerbate dizziness and seeking medical attention if symptoms persist or worsen 7, 4, 9
• Manual therapy of cervical and thoracic spine may be considered for pregnancy-related dizziness 4, 9