VERTIGO

 Introduction
- Vertigo is a symptom (sensation of spinning dizziness) of a range of conditions in which person
may experience balance problems and lightheadness.
- Dizziness, including vertigo, can happen at any age, more common at age of 60 or older.
- Falling can be a direct consequence of dizziness in this population, and the risk is compounded
in elderly persons with other neurologic deficits and chronic medical problems.
- It is not an illness but a symptom. Many different conditions can cause vertigo.
- The patient’s history and findings on vestibular examination are critical in identifying underlying
causes.
- Auditory, vestibular, complementary blood and radiologic tests help in narrowing the
differential diagnosis and tailoring treatment. Vestibular tests should be ordered after careful
history taking and examination because they do not provide the clinician with diagnostic
information.
 Etiology of vertigo
- Vertigo can be defined based upon whether the cause is peripheral or central
- Central causes of vertigo arise in the brain or spinal cord, while peripheral vertigo is due to a
problem within the inner ear.

BPPV: benign paroxysmal

positional vertigo

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 Is it hereditary?
- Vertigo itself is not necessarily hereditary, but it is commonly a symptom of various
conditions and syndromes.
- Examples of conditions that can trigger vertigo and appear to involve genetic factors
include: familial episodic ataxia, migrainous vertigo, bilateral vestibular hypofunction, amilial
Ménière ‘s disease

 Aggravating and provoking factors

- Specific head movements or postures (e.g., rolling over in bed, extending the neck).
- Coughing, sneezing, exertion, or loud noises.
- Head trauma.
- Barotrauma, middle ear surgery.
- Straining with weight lifting and bowel movements.
- Recent hyperextension injury to the neck, usually with persistent neck pain.
- Viral illness.
- Perilymphatic fistula, when inner ear fluid leaks into the middle ear due to a tear in either of
the two membranes between the middle ear and inner ear.
- Shingles in or around the ear (herpes zoster oticus).
- Syphilis.
- Otosclerosis, when a middle ear bone growth problem leads to hearing loss.

 Drugs that induce dizziness

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 Signs & symptoms
- Balance problems
- Lightheadedness
- A sense of motion sickness
- Nausea and vomiting
- Tinnitus
- Feeling of fullness in the ear
- Headaches
- Nystagmus
- There are some clinical features that is specific to either central or peripheral vertigo
(discussed in diagnosis )
 Warning signs
- Sudden vertigo not affected by change of position
- Vertigo associated with neurological signs such as severe lack of muscle coordination or new
weakness
- vertigo associated with deafness and no history of Meniere’s disease

 Diagnosis:
- Assessment of a patient with complaints of dizziness requires a thorough history and
physical examination in order to determine the actual issue.
- It is important to note the onset, duration, number of episodes, triggers, and any associated
auditory and neurologic signs.
A. Patient History:
- A common feature of true vertigo is a spinning sensation that may present as objective
(patients complain of objects moving around them) or subjective vertigo (patients feel they
are spinning).
- It is important to determine whether the cause of vertigo is central or peripheral

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- Patient’s medication history should be reviewed as well.
- Patients who chronically use vestibular suppressants (e.g., meclizine, scopolamine) may
become sensitized to these drugs and experience withdrawal symptoms when they are
discontinued.
B. Social history should be evaluated, as many factors can precipitate or worsen dizziness and
vertigo:
a. Alcohol, nicotine, caffeine, illicit drug use and sexual history (e.g., syphilis, herpes).
b. Traumatic head injury, cervical trauma.
c. Depression, anxiety, and other conditions (e.g., blood pressure alterations,
arrhythmias, hypoglycemia, and dehydration).
C. Physical Examination:
a. Ocular examination, papillary reactivity and extraocular movements are tested
because abnormalities can suggest cerebellar disease.
b. Otologic examinations evaluate for the presence of impacted cerumen or other
foreign objects in the ear canal, which may require removal for relief of vertiginous
symptoms. Signs of middle ear disease (e.g., fluid behind the eardrum, perforation,
extensive scarring, and hearing loss) should be further evaluated.
c. The patient’s blood pressure should also be taken—once in a supine position and then
a minute later upon standing
 If the systolic blood pressure decreases by 20 mm Hg, diastolic blood pressure
decreases by 10 mm Hg, or pulse increases by 30 beats per minute (bpm) 
patient may have orthostatic hypotension.
d. Auscultation of heart and carotid arteries could reveal other vascular causes of
dizziness. Findings of a carotid bruit, heart murmur, or irregular rhythm should be
followed by a thorough cardiovascular workup, particularly in elderly patients.
e. Lightheadedness may be caused by a hyperventilation syndrome where a patient
inhales and exhales faster than the body can accommodate, resulting in respiratory
alkalosis. Diagnosis can be attested by having the patient rapidly inhale and exhale
deeply 20 times, which simulates the symptoms.
f. A neurologic examination is vital and should include a complete cranial nerve
evaluation to help identify localized lesions in the brain.
i. Romberg’s test: Doctor will ask the person to stand with their arms by their
sides and their feet together and ask them to close their eyes. If the person
becomes unsteady on closing their eyes, this could be a sign of a CNS problem.
ii. Fukuda-Unterberger’s test: patient is asked to march on the spot for 30 seconds
with their eyes closed. If they rotate to one side, this may indicate a lesion in
the inner ear labyrinth, which could cause peripheral vertigo.

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 g. Radiologic imaging should be considered in patients with new-onset vertigo, findings
of neurologic abnormalities, or symptoms lasting longer than 2 weeks.
 MRI, vascular imaging, and cardiac imaging should also be considered in people
at risk for stroke.
 If a patient has an implanted metal device or if there is middle ear pathology,
CT of the temporal bones is recommended.
D. Other Tests:
a. Complete blood and chemistry panel can be useful in patients without clinical findings
or with near syncope.
b. Electrocardiogram (ECG) should be obtained in older adults and those with significant
or troubling cardiac risk factors. If arrhythmia is suspected, a 24- to 48-hour
continuous ECG could help determine whether the dizziness is due to an arrhythmia.
c. Electronystagmography (ENG) is a diagnostic test that records eye movements in
response to vestibular, visual, cervical, caloric, rotational, and positional stimulation
and is helpful in detecting vestibular dysfunction and nystagmus.

 General treatment approach

Identify if the problem is peripheral (inner ear or vestibular nerve)

Determine severity, onset, duration, positional,
fatigable, symptoms associated and type of Distinguish between central or peripheral causes
nystagmus)

Determine if the patient needs to be admitted to the hospital or referred to a specialist

If a central cause for vertigo is suspected based onclinicOnly the patient with extreme dehydration (from
the history and clinical examination imaging should vomiting) or if central disorder is suspected should
be carried out be admitted to the hospital

Offer initial management of the problem.

An acute and severe episode of vertigo, will usually During the acute phase, supportive measures, bed
settle by itself within 24-48 h due to the effect of rest, antiemetics and vestibular blocking agents can
brainstem compensation be used to provide symptomatic relief

 Non- Pharmacological therapy

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 A. Lifestyle changes
- Lying still in a quiet, dark room when the spinning is severe
- Sitting down as soon as the feeling of dizziness appears
- Taking extra time to perform movements that may trigger symptoms, such as getting
up, looking upward, or turning the head
- Squatting instead of bending over to pick something up
- Use a cane when walking, if necessary
- Sleeping with the head raised on two or more pillows
- Turning on lights when getting up at night to help prevent falls
B. Physical Therapy:
- In certain cases of dizziness and vertigo, vestibular rehabilitation may be beneficial.
- These activities help the brain to use certain visual and proprioceptive cues to
maintain balance and gait.

Epley maneuver or canalith repositioning Brandt-Daroff exercises

During this treatment, specific head movements
lead to movement of the loose crystals (canaliths)
within the inner ear.
By repositioning these crystals, they cause less
irritation to the inner ear and symptoms can
resolve.
Because these movements can initially lead to
worsening of the vertigo, they should be done by
an experienced health care professional or physical
therapist.
Needs to be repeated multiple times
daily for the best benefit. Other
movements that have been identified as
decreasing symptoms of vertigo or
dizziness include the Semont maneuver
and the Foster maneuver (half
somersault).

- Other customized programs that may improve compliance and outcomes include
habituation exercises, balance and gait exercises, and general conditioning.
- Visual motion desensitization with repeated optokinetic stimulation uses moving
visual environments to improve vestibular-ocular response as the brain attempts
to stabilize gaze.
C. Herbal remedies: Cayenne, Turmeric, Ginkgo biloba, and Ginger root

Epley Maneuver

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 Brandt-Daroff exercises

 Pharmacological therapy
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 A. DISEASE-SPECIFIC TREATMENTS
I- Peripheral vertigo
- About 80% of cases are of this type and results from problems in the inner ear.
- Tiny organs in the inner ear respond to gravity and enables to keep balance while standing up.
Changes to this system can produce vertigo.
1. Vestibular neuritis/labyrinthitis:
- An infection causes vestibular neuritis, which is inflammation of the vestibular
nerve. It is similar to labyrinthitis, but it does not affect a person’s hearing.
- Vestibular neuritis causes vertigo that may accompany blurred vision, severe
nausea, or a feeling of being off balance.
- Treatment with antibiotics and corticosteroids may be effective
- Antiemetic and vestibular suppressants are useful acutely but should be stopped
after few days because their prolonged use may impede the process of central
vestibular compensation
2. Cholesteatoma
- A Noncancerous skin growth develops in the middle ear, usually due to repeated
infection.
- As it grows behind the eardrum, it can damage the middle ear’s bony structures,
leading to hearing loss and dizziness.
3. Ménière’s disease
- A buildup of fluid in the inner ear, which can lead to attacks of vertigo with ringing
in the ears and hearing loss. It tends to be more common in people between the
ages of 40 and 60 years.
- The exact cause is unclear, but it may stem from blood vessel constriction, a viral
infection, or an autoimmune reaction. There may also be a genetic component
that means that it runs in some families.
- Treatment: A doctor may prescribe drugs for people with Ménière’s disease.
 These may include meclizine, glycopyrrolate, or lorazepam.
 limiting sodium intake and using diuretic therapy to reduce fluid levels
 trying pressure pulse treatment, which involves fitting a device to the ear
 Avoiding caffeine, chocolate, and alcohol and not smoking tobacco

4. Herpes zoster oticus

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 - Often called the Ramsay Hunt syndrome, this syndrome is believed to represent
activation of latent herpes zoster infection of the geniculate ganglion.
- In addition to acute vertigo and/or hearing loss, ipsilateral facial paralysis, ear pain,
and vesicles in the auditory canal and auricle are typical features.
- Therapy with corticosteroids or acyclovir should be considered, although these
modalities are not of proven value.
5. Benign paroxysmal positional vertigo (BPPV)
- The inner ear contains structures called the otolith organs, which contain fluid and
particles of crystals of calcium carbonate.
- In BPPV, these crystals become dislodged and fall into the semicircular canals.
There, each fallen crystal touches sensory hair cells within the cupula of the
semicircular canals during movement.
- As a result, the brain receives inaccurate information about a person’s position,
and spinning dizziness occurs. People typically experience periods of vertigo that
last less than 60 seconds, but nausea and other symptoms may also occur.
- Treatment: usually by Epley maneuver and Brandt-Daroff exercises and anti-
emetics (because the exercise may induce nausea and vomiting )  Surgery if
failed
6. Cogan syndrome:
- Autoimmune condition that can cause interstitial keratitis and vestibuloauditory
dysfunction.
- Patients have Meniere-like attacks consisting of vertigo, ataxia, nausea, vomiting,
tinnitus, and hearing loss. Vestibular dysfunction may also cause oscillopsia, which
is the perception of objects jiggling back and forth after abruptly turning the head
to one side or the other.
- Systemic steroids and other immunosuppressants may be required.
7. Recurrent vestibulopathy
- A descriptive diagnosis used for patients who experience spontaneous episodes of
vertigo unassociated with otologic complaints (i.e., no hearing loss, tinnitus, or ear
fullness)
- Symptoms often include nausea, vomiting, and disequilibrium.
- The pathophysiology of recurrent vestibulopathy is uncertain. The condition is
thought to represent a vestibular disorder of uncertain localization. Some cases
appear to cluster in families. This disorder may overlap with vestibular migraine.
- Treatment here is migraine therapy

II- Central vertigo

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- Central vertigo relates to problems with the CNS. It usually stems from a problem in a part of
the brain stem or cerebellum. Approximately 20% of cases are of this type.
1. Vestibular migraine:
- Vestibular migraine may have both central and peripheral vestibular manifestations.
The severity of vertigo is variable lasting for several minutes to a few hours are more
typical.
- A diagnosis of vestibular migraine relies on historical information, in which attacks of
vertigo are associated with migraine headache (visual aura, photophobia, or
phonophobia).
- Treat with migraine relieving drugs along with acute vertigo therapy
2. Brainstem ischemia: Embolic, atherosclerotic occlusions of the vertebrobasilar arterial
system will produce brainstem ischemia
a. Transient Ischemic Attack (TIA) or stroke
- While infarction produces sustained symptoms that improve over several days and
weeks, transient ischemic attacks (TIA) involving the brainstem more usually last
several minutes, perhaps hours.
- Treatment: Ondansetron may be appropriate for severe vertigo and nausea from
stroke as well as reduction of risk factors for cerebrovascular disease and
antiplatelet therapy.
- Coumadin and transluminal angioplasty of vertebral artery stenosis and,
occasionally, aspirin and ticlopidine have been found to be effective in stopping
spells of central vertigo from vertebrobasilar artery insufficiency.
b. Rotational vertebral artery syndrome:
A rare but well-documented phenomenon of symptomatic vertebral artery
compression by bony elements of the spine (usually at CI-C2) that occurs with
physiologic head rotation.
- Diagnosis is made by vascular imaging that includes the neutral as well as the
symptomatic position. Degenerative bone disease as well as congenital foraminal
narrowing can be causative; disease or hypoplasia of the noninvolved vertebral artery
is usually described.
- Surgical decompression may be successful when conservative approaches fail.
Noninvasive interventions, such as traction and enhanced external counter
pulsation (EECP), are under investigation.

c. Wallenberg syndrome:
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 - The blood supply to the lateral medulla is the posterior inferior cerebellar artery.
- Most patients with Wallenberg syndrome have an occlusion of the ipsilateral
vertebral artery that gives rise to the posterior inferior cerebellar artery.
- Examination also reveal abnormal eye movements, an ipsilateral Horner syndrome,
ipsilateral limb ataxia, and a dissociated sensory loss (loss of pain and temperature
sensation on the ipsilateral face and contralateral trunk with preserved vibration and
position sense). Hoarseness and dysphagia are often present.
- Treatment: reduction of risk factors for cerebrovascular disease and antiplatelet
therapy plus therapy for acute vertigo
d. Labyrinthine infarction: occlusion of the internal auditory artery.
3. Epileptic vertigo:
- Vertigo can be an ictal symptom in patients with focal epilepsy, but it is uncommon
for seizures to manifest as isolated vertigo.
4. Chiari malformation:
- A Congenital anomaly in which the cerebellar tonsils extend below the foramen
magnum.
- This is usually asymptomatic but may be associated with a constellation of neurologic
deficits (headache or neck pain, weakness with long tract signs, dysphagia, and other
lower cranial nerve impairments).
- The diagnosis is confirmed with sagittal MRI.
- Surgical decompression may be required to relieve symptoms and is usually
successful.
5. Multiple sclerosis:
- Vertigo has been estimated to occur in 20 percent of multiple sclerosis (MS) patients,
most commonly with plaques near the vestibular nuclei and in the root entry zone of
cranial nerve VIII.
- A syndrome similar to vestibular neuritis may occur, with acute sustained vertigo with
peripheral characteristics.
- The diagnosis is usually evident in patients with an established history of MS.
Symptoms related to an MS flare last days to weeks.
- Treatment: A short course of corticosteroids may shorten disabling attacks + disease
modifying therapy for MS
6. Episodic ataxia type 2:
- Autosomal dominant condition caused by mutations in a brain-specific P/Q type
calcium channel gene on chromosome 19.
- Attacks of severe vertigo, nausea and vomiting, and ataxia begin in childhood or early
adult life. That may last few hours or few days.
- The attacks respond to acetazolamide in a dose of 250 to 750 mg/day.
7. Disembarkment (mal de debarquement) syndrome:
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 - A perception of self-motion and imbalance is described by some individuals following
exposure to passive motion.
- Water travel is the most usual trigger. In addition to imbalance and a sense of motion,
patients describe difficulty tolerating complex visual stimuli (e.g., video games); they
also report disabling cognitive difficulties and fatigue.
- Many patients develop depression and anxiety (reaction to symptoms, not a cause).
- Treatment options are limited. The longer symptoms persist, the less likely they are
to remit. Benzodiazepines can provide limited symptomatic relief; clonazepam 0.25
to 0.5 mg twice daily is most often used. Higher doses are not likely to be more
effective.
- Physical therapy and vestibular rehabilitation have not been reported to be helpful.

III- Summary of treatment of specific causes:

Cause Treatment
Benign paroxysmal - Meclizine 25-50 mg orally every 4 to 6 h
positional vertigo - Epley maneuver
- Vestibular rehabilitation

Ménière disease - Salt restriction (<1-2 g to sodium per day)

and/or diuretics
- Intratympanic dexamethasone or gentamicin
- Endolymphatic sac surgery

Vestibular neuritis Methylprednisolone 100 mg orally daily then

tapered to 10 mg orally daily over three weeks

Migrainous vertigo Migraine prophylaxis with serotonin receptor

agonists (triptans)

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 B. SYMPTOMATIC TREATMENT
- Medications to suppress vestibular symptoms are best used for alleviating acute episodes of
vertigo that last at least a few hours or days.
- These drugs are not useful for very brief episodes of vertigo, such as benign paroxysmal
positional vertigo, except when the frequency of spells is very high.
- Three general classes of drugs can be used to treat acute vertigo (effective in ameliorating
vertigo, when concern for side effects is not paramount) :
1. Antihistamines:
- Drugs of choice in most patients; meclizine is the drug of choice in pregnancy.
2. Benzodiazepines:
- Can be sedating and are used when antihistamines are not adequately effective.
3. Anti-emetics:
- Phenothiazine antiemetics (eg, prochlorperazine, promethazine) are also more sedating
and usually reserved for patients with severe vomiting.
- Extrapyramidal symptoms are a risk with phenothiazine antiemetics and metoclopramide
but less so with domperidone, a peripheral dopaminergic antagonist that does not cross
the blood-brain barrier.
- Ondansetron, especially the oral disintegrating preparation, may also be helpful for
nausea and vomiting associated with acute vertigo
- Responses are generally dose related.
- Symptomatic treatments should be stopped as soon as possible after severe symptoms and
vomiting cease (usually within one or two days) to avoid compromising long-term adaptation
to vestibular loss by the brain.

Medications for acute vertigo

Drug Dose as-needed Main side effects

Orally administered agents:
1- Antihistamines, first-generation
Dimenhydrinate 50 to 100 mg every 4 to 6 hours Anorexia, blurred vision, dizziness,
drowsiness, nausea
Behatistine 4-6 mg 8 h per day Dizziness, somnolence, headaches, Nausea,
diarrhea, palpitations, Bronchospasm,
hypersensitivity reactions, urticarial, rash,
and pruritus
Meclizine 25 to 50 mg every 6 to 12 hours Blurred vision, drowsiness, fatigue,
headache, vomiting

Promethazine 12.5 to 25 mg every 8 hours Agitation, bradycardia, confusion,

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 25 mg every 6 hours orally, constipation, drowsiness, dizziness,
IM, or rectally every 4 to dystonia, extrapyramidal symptoms,
12 hours gynecomastia, photosensitivity, urinary
retention
2- Benzodiazepines
Alprazolam 0.5 mg immediate release every Drowsiness, depression, HA, dry mouth,
(short-acting) 8 hours constipation, memory impairment,
insomnia, anorexia, and myasthenia gravis
(dose dependent)
Clonazepam 0.25 to 0.5 mg every 8 to 12 Somnolence, ataxia, depression , URTI,
(intermediate) hours rhinitis, cough, impotence, and worsening
of tonic-clonic seizures
Diazepam 1 mg every 12 hours Amnesia, drowsiness, slurred speech,
(long-acting) vertigo, dry mouth
Lorazepam 1 to 2 mg every 8 hours Amnesia, dizziness, drowsiness, slurred
(intermediate) speech, vertigo
3- Antiemetics (Rare adverse cardiac reactions have been described with most antiemetics
particularly following parenteral use. These agents should be avoided in patients with known
QT interval prolongation or other risk factors for torsade’s de pointes (TdP) eg,
hypomagnesaemia, hypokalemia. Phenothiazines and metoclopramide can cause
extrapyramidal side effects (eg, akathisia, dystonia) particularly with parenteral use. )
Domperidone 10 mg every 8 hours Akathesia, atrioventricular block,
bradycardia, bronchospasm,
Metoclopramide 5 to 10 mg every 6 hours dizziness, drowsiness, dystonic reaction,
gynecomastia, nausea, tardive dyskinesia
Ondansetron 4 mg every 8 to 12 hours Headache, Malaise/fatigue, Drowsiness,
Gynecologic disorder, Urinary retention,
Pruritus, Injection-site pain, Elevated liver
function test results, Arrhythmias (including
ventricular and supraventricular
tachycardia, premature ventricular
contractions, and atrial fibrillation and
abnormal hepatic function
Other serotonin 5HT3 antagonist antiemetics (eg, dolasetron, granisetron) may be used if
ondansetron is not available.
Prochlorperazine 5 to 10 mg every 6 hours Agitation, dizziness, drowsiness, dystonic
reaction, extrapyramidal symptoms,
photosensitivity, tardive dyskinesia

Parenterally administered agents for acute emergency ward use:

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(If IV access is unavailable, these agents may be administered IM. However, with the exception of
promethazine, IM use is not preferred due to injection site pain)
1- Antihistamines, first-generation
Diphenhydramine 10 to 50 mg IV Drowsiness, Skin rash, Dry mouth,
Dimenhydrinate  50 mg IV epigastric distress, nausea, headache,
excitation, Blurred vision, Dry nose, dry
throat, thickening of bronchial secretions
2- Antiemetics
Metoclopramide 10 mg IV
Ondansetron¶ 4 to 8 mg IV
Prochlorperazine 2.5 to 10 mg IV Same as PO but more
Promethazine 12.5 to 50 mg IM or
IV (vesicant, use caution with IV
intensive
administration)

C. Vestibular rehabilitation therapy:

- Form of physical therapy that uses specialized exercises that result in gaze and gait
stabilization.
- Most VRT exercises involve head movement, and head movements are essential in
stimulating and retraining the vestibular system.
- Vestibular rehabilitation therapy has been a highly effective modality for most adults and
children with disorders of the vestibular or central balance system.
- The basis for the success of VRT is the use of existing neural mechanisms in the human brain
for adaptation, plasticity, and compensation.
- Specifically designed VRT exercise protocols take advantage of this plasticity of the brain to
increase sensitivity and restore symmetry.
- This results in an improvement in vestibuloocular control, an increase in the gain of the
vestibuloocular reflex (VOR), better postural strategies, and increased levels of motor
control for movement.

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 When to refer to Primary care?
 Sudden, severe headache
 Chest pain
 Difficulty breathing
 Numbness or paralysis of arms or legs
 Fainting
 Double vision
 Rapid or irregular heartbeat
 Confusion or slurred speech
 Stumbling or difficulty walking
 Ongoing vomiting
 Seizures
 A sudden change in hearing
 Facial numbness or weakness

 Vertigo in pregnancy
 Nausea and dizziness are common problems during pregnancy.
 Hormonal changes appear to play a role, as they affect the characteristics of the fluid in the
body.
 Causes of vertigo according to trimester
A-Dizziness in early pregnancy
Etiology Mechanism Treatment
Changing  Hormone levels change to help  Doctor will check your blood
hormones and increase the blood flow in your body pressure at your prenatal
lowering blood (helps the baby develop in utero) appointments.
pressure  Increased blood flow can cause your  Generally, lower blood
blood pressure to change. pressure is not a cause for
 Often, your blood pressure will drop concern and it will return to
during pregnancy normal levels after
 Low blood pressure can cause pregnancy.
vertigo
Hyperemesis  Inability to keep down food or  Recommend a particular diet
gravidarum water, resulting in dizziness and  Hospitalize you so you can
weight loss receive extra fluids and be
monitored
 Prescribe a medication
Ectopic  You may experience dizziness as well  Your doctor will have to
pregnancy as pain in your abdomen and vaginal perform a procedure or
bleeding. prescribe a medication to
remove the fertilized egg.

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B- Dizziness in the second trimester
Etiology Mechanism
Pressure on  Experienced dizziness if the pressure  Sleep and rest on your side to
your uterus from your growing uterus presses on
your blood vessels.
 This can occur in the second or third
trimester, and is more common
when the baby is large.
Gestational  Vertigo occurs in diabetes if your
diabetes blood sugar gets too low.
 Also occur when your hormones
affect the way your body produces
insulin.
Treatment
prevent this blockage from
occurring.
- Lying on your back can
also cause dizziness.
Pregnancy can cause your
expanding uterus to block
blood flow from your
lower extremities to your
heart.
Monitor your blood sugar
regularly, and stick to a strict
diet and exercise plan.

C- Dizziness in the third trimester

- Many of the causes of dizziness in the first and second trimesters can cause the same
symptom later in your pregnancy.
- It’s important that you see your doctor regularly in the third trimester to monitor potentially
dangerous conditions that can cause dizziness.
- Watch for signs of feeling faint to avoid falling, especially during your third trimester.
- Stand up slowly and reach for support to avoid lightheadedness, and make sure to sit as
often as you can to avoid long periods of standing.

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D-Dizziness throughout pregnancy (not tied to a specific trimester)

Etiology Mechanism Treatment

Anemia  This occurs when you don’t have  Iron and folic acid
enough iron and folic acid in your supplementation
body
 In addition to dizziness, anemia
may cause you to feel tired,
become pale, or feel short of
breath.
Dehydration  Dehydration can occur at any point  Drink at least 8 to 10 glasses of
in your pregnancy water a day in early pregnancy.
 Experienced in the first trimester if  Increase that amount as you
you’re nauseous or vomiting. add more calories to your diet,
generally in the second and
third trimesters.
 This may increase your water
intake by 300 milliliters per day.

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