By Marcello Cherchi, MD PhD
For patients
Some women get symptoms of hearing loss or disequilibrium during pregnancy or labor. Depending on the situation, your doctor may consider checking several tests to figure out the cause.
For clinicians
Overview
While there are no audiologic or vestibular disorders unique to pregnancy or parturition, these biological states may increase the risk of certain audio-vestibular disorders.
Introduction
While there are no audiologic or vestibular disorders unique to pregnancy or parturition, these biological states may increase the risk of certain audio-vestibular disorders. Among auditory disorders during pregnancy, sudden sensorineural hearing loss and Eustachian tube dysfunction are the usual considerations. Vestibular disorders during pregnancy are variegated, and can include otologic causes (benign paroxysmal positional vertigo, Ménière’s disease, semicircular canal dehiscence), neurological causes (migraine associated vertigo, unintended pharmacologic consequences of epidural injections), neurovascular causes (posterior reversible encephalopathy syndrome, vertebral artery dissection) and cardiovascular disorders (orthostatic intolerance, atrial myxoma).
Pathophysiological mechanism of disease for audiologic symptoms
Some degree of hearing fluctuation can occur in pregnancy, but is often mild, transient and self-limiting (Frosolini et al. 2021). However, in some instances this may manifest as sudden onset sensorineural hearing loss (SSNHL) that is moderate to profound, and does not spontaneously resolve; this can occur antepartum or postpartum (Zhang and Young 2017). There are no clear treatment guidelines, but some authors advocate intravenous and transtympanic steroids (Xie and Wu 2020), similar to management of sudden sensorineural hearing loss outside of pregnancy. The mechanisms of sudden sensorineural hearing loss in pregnancy (and whether such mechanisms differ from the occurrence outside of pregnancy) are unknown.
Pathophysiological mechanism of disease for vestibular symptoms
Pregnancy may increase the risk of several conditions that may cause vestibular symptoms, including several otologic, neurologic, neurovascular and cardiovascular disorders (Kirovakov et al. 2024; Serna-Hoyos et al. 2022).
Otologic disorders
Some literature suggests that pregnancy increases the risk of benign paroxysmal positional vertigo (BPPV) (Çoban et al. 2017; Serna-Hoyos et al. 2022).
Some literature suggests that episodes of Ménière’s disease can increase during pregnancy (Serna-Hoyos et al. 2022; Toshniwal et al. 2022; Uchide et al. 1997).
Semicircular canal dehiscence can present during gestation (Ogutha et al. 2009) or during labor (Meehan et al. 2013).
A sensation of ear fullness during pregnancy is usually due to Eustachian tube dysfunction (Swain et al. 2020).
Neurological disorders
In a minority of women, migraine may increase during pregnancy, including migraine associated vertigo (MAV) (Serna-Hoyos et al. 2022).
A case report of a woman who developed disequilibrium following an epidural morphine injection for delivery speculated that, “the time of onset of the symptom coincided with the expected time of arrival of the morphine within intra-cerebral cerebro-spinal fluid” (Goundrey 1990).
Neurovascular disorders
Peri-partum or post-partum posterior reversible encephalopathy syndrome (PRES) can occur and manifest with vestibular symptoms (Ghia et al. 2011). It also often causes seizures and depressed consciousness.
Vertebral artery dissection can occur post-partum (Manasewitsch et al. 2020) or (similar to non-pregnant individuals) after chiropractic manipulation (Monari et al. 2021).
Cardiovascular disorders
Hemodynamics change in several ways during pregnancy. The addition of placental circulation reduces maternal hemodynamic resistance, which can lower blood pressure. In addition, pregnancy may increase the risk of orthostatic intolerance, such as orthostatic hypotension (Oxorn 1960; Serra-Serra et al. 1995; Wright 1962).
Atrial myxoma can develop during pregnancy (Yuan 2015), and rarely can manifest with disequilibrium (Shahbuddin et al. 2024).
Clinical presentation
The clinical presentation depends on the specific disorder.
Physical examination
A pregnant person developing posterior reversible encephalopathy syndrome (PRES) may exhibit cerebellar findings.
Ocular motor examination
Ocular motor examination may reveal findings compatible with benign paroxysmal positional vertigo (BPPV) or semicircular canal dehiscence.
Testing: auditory
In a pregnant patient complaining of hearing loss, audiometry may show sensorineural hearing loss.
Testing: vestibular
One study of video head impulse testing (vHIT) during gestation reported that semicircular canal gain decreases beginning around the 20th week of gestation, then returns to baseline after pregnancy (Castillo-Bustamante et al. 2023); the authors speculated that this might be attributable to, “volumetric changes probably given by hormonal actions.”
If a pregnant patient develops semicircular canal dehiscence, then cervical vestibular evoked myogenic potentials (cVEMP) and ocular vestibular evoked myogenic potentials (oVEMP) may reveal corroborative findings (increased amplitudes and decreased thresholds ipsilateral to the lesion).
Imaging
In a pregnant patient with a history and physical examination compatible with semicircular canal dehiscence, then temporal bone CT (with shielding of the abdomen and pelvis) may confirm semicircular canal dehiscence.
If a pregnant patient with disequilibrium develops seizures or declining consciousness, then brain MRI may reveal findings compatible with posterior reversible encephalopathy syndrome (PRES).
Differential diagnosis: auditory
A pregnant individual complaining of hearing loss should consider a workup similar to that offered to non-pregnant persons, including an audiogram and perhaps otoacoustic emissions. If the overall scenario is compatible with sudden onset sensorineural hearing loss, then referral to otolaryngology is appropriate.
In a pregnant person complaining of isolated aural fullness who has a normal physical examination, Eustachian tube dysfunction is a consideration. If decongestant strategies fail, then referral to otolaryngology is appropriate.
Differential diagnosis: vestibular
The workup of a pregnant person complaining of disequilibrium depends on several aspects of the clinical history and physical examination.
If a pregnant patient complains of brief bursts of positionally-triggered disequilibrium suggests benign paroxysmal positional vertigo (BPPV), and if this is confirmed by corroborative nystagmus on video oculography (VOG), then no further workup is necessary.
If a pregnant patient’s episodes of disequilibrium are protracted and accompanied by aural symptoms (hearing loss, tinnitus, fullness), then Ménière’s disease is a strong consideration.
If a pregnant patient complains of Valsalva-induced disequilibrium, or disequilibrium induced by loud noises (Tullio’s phenomenon), and if video oculography (VOG) reveals Valsalva-induced nystagmus, then semicircular canal dehiscence is a consideration.
If a pregnant patient has a pre-existing history of migraine (with or without vestibular symptoms), then migraine associated vertigo (MAV) is a consideration, though is always a diagnosis of exclusion.
If a pregnant patient develops symptoms following epidural injections, then a pharmacologic mechanism or cerebrospinal fluid leak should be considered.
If a pregnant patient with disequilibrium also develops seizures or progressive deterioration of consciousness, then PRES (posterior reversible encephalopathy syndrome) must be considered.
If a pregnant patient with disequilibrium also complains of neck pain, or if symptoms began during delivery (while pushing), then vertebral artery dissection is a consideration.
If a pregnant patient’s symptoms have an orthostatic pattern, and if bedside examination confirms orthostatic hypotension, orthostatic hypertension, or postural orthostatic tachycardia, then no further workup is needed.
If a pregnant patient’s symptoms and physical examination are compatible with cardiac embolization (including strokes) or cardiac failure, then an atrial myxoma is a consideration.
Treatment and prognosis
Treatment and prognosis depend on the underlying disorder (irrespective of the gravid state).
References
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