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Changes of blood pressure and heart rate variability precede a grand mal seizure in a pregnant woman

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Changes of blood pressure and heart rate variability precede a grand mal seizure in a pregnant woman
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  J. Perinat. Med. 32 (2004) 538–540  •  Copyright    by Walter de Gruyter  •  Berlin  •  New York. DOI 10.1515/JPM.2004.124 Changes of blood pressure and heart rate variability precedea grand mal seizure in a pregnant woman Renaldo Faber 1, *, Holger Stepan 1 , MathiasBaumert 2 , Andreas Voss 2 and Thomas Walther 3 1 Department of Obstetrics and Gynecology, Universityof Leipzig, Germany 2 Faculty of Medical Engineering, University of AppliedSciences, Jena, Germany 3 Department of Pharmacology, Erasmus MedicalCenter, The Netherlands  Abstract In order to evaluate blood pressure- and heart rate vari-ability as a potent diagnostic tool for different hyperten-sive pregnancy disorders we started a clinical trialrecording these variables in early pregnancies predis-posed for preeclampsia. During routine measurementsone of the patients experienced a grand mal epilepticseizure. Since the parameters of both heart rate andblood pressure variability were sequentiallyalteredimme-diately before the seizure, this case report provides aninteresting insight into autonomic cardiovascular controlin a developing convulsive fit and the pathophysiologicalgeneration of a grand mal seizure in pregnancy. Keywords:  Blood pressure variability; eclampsia; grandmal seizure; heart rate variability; pregnancy. Case report Heart rate variability and blood-pressure variability (HRV/ BPV) have been shown to be relevant predictors for themortality of patients with cardiovascular disorders  w 1, 6 x . Also patients with epilepsy show significant changes inHRV and BPV caused by anticonvulsive drugs or by epi-lepsy  w 3, 4 x . Our group could show that normal pregnantwomen exhibit significant alterations in autonomic car-diovascular control in comparison to non-pregnant wom-en  w 5 x .In an ongoing longitudinal study we investigated preg-nancies with and without risk factors for preeclampsia(e.g. pathological uterine perfusion) in order to evaluatewhether HRV and BPV differ between various hyperten- *Corresponding author:Renaldo Faber M.D.Universita¨tsfrauenklinik Philipp-Rosenthalstr. 5504103 Leipzig/GermanyTel.:  q 49-341-9723467Fax.:  q 49-341-9723669E-mail: fabr@medizin.uni-leipzig.de sive disorders in pregnancy  w 3 x . Furthermore, the predic-tive value of selected variability parameters relevant topreeclampsia was assessed. Pregnant women weremonitored for 30 minutes every four weeks, beginning at20 weeks, using a PORTAPRES non-invasive blood pres-sure monitor with a sampling frequency of 200 Hz  w 5 x . A 21-year old gravida 1 para 0 suffered from epilepsydue to a fronto-temporal arterio-venous malformationand was treated with carbamazepine and valproate. Var-iability parameters at the first measurement at 20 weekswere normal (data not shown) and the woman experi-enced no epileptic seizure during pregnancy. In the 24thweek of gestation, during the second monitoringsession,the patient developed a grand mal seizure. The gener-alized tonic-clonic convulsions appeared clinically to bea typical epileptic fit but this could not be confirmed byconcomitant EEG. Blood pressure and heart rate wererecorded over 12 minutes until the onset of unconscious-ness. As described by Voss et al.  w 5 x , the data was ana-lyzed comparative to a 12-minute reference curverecorded from the woman at 20 weeks. Since importantabnormalities were obvious (Figure 1, Panel A), we divid-ed the values into 4-minute-intervals in order to detectthe beginning of possible changes before the seizure.Both BPV and HRV showed an important increase inthe very low frequency band (VLF) at the beginning ofmonitoring (12 minutes prior to seizure). At this time thelow frequency (LF) domain was upregulated with delay,but the high frequency bands remained unchanged. Thedelayed LF abnormalities are first manifest in the BPVfollowed by an increase in LF of HRV (Figure 1, Panel B).Since VLF bands mainly reflect sympathetic activity, thispart of the autonomic control seems to be important forthe evolution of epileptic seizures.The analysis shows for the first time the behavior ofHRV and BPV immediately before a grand mal seizure ina pregnant woman. However, we cannot exclude thepossibility that the observed convulsions represent onlythe end of a complex seizure generated from the fronto-temporal focus. Recently, reduced HRV and BPV havebeen reported in non-pregnant patients with epilepsy inthe interictal period  w 4 x . However, our patient showed nodifferences to normal pregnant women during the firstmeasurement. This is in contrast to the documentedfind-ing that epilepsy  per se , as well as anticonvulsive drugs,has an impact on HRV and BPV  w 3, 4 x .Our case report shows that simple blood pressure andheart rate monitoring with high resolution may allow pre-diction of a generalized convulsive seizure. Since our  Faber et al., BPV and HRV in grand mal seizure  539 Figure 1 (A)  Systolic blood pressure (SBP) and beat-to-beat intervals (BBI) of a pregnant woman 4 weeks (control) and 12 minutesbefore epileptic seizure.  (B)  Comparison of blood pressure and heart rate variability (BPV and HRV) between measurementsbeginning12 minutes before grand mal seizure (GMS) and 4 weeks before the seizure (con). Frequencies are divided into very low (VLF), low(LF), and high (HF) frequency. 1 s 1–4 minutes, 2 s 5–8 minutes, 3 s 9–12 minutes interval before seizure.  540  Faber et al., BPV and HRV in grand mal seizure group has shown that different types of hypertensivepregnancy disorders including preeclampsia are charac-terized by distinct HRV and BPV alterations  w 2 x , it is ofgreat interest to discover how these parameters mightchange before the onset of an eclamptic fit. We areawarethat this method is not clinically applicable for the pre-diction of a seizure in pregnancy. However, the measuredalterations in the autonomic cardiovascular control, par-ticularly in the VLF of HRV and BRV, provide an interest-ing insight into the pathophysiological generation anddevelopment of a grand mal seizure in pregnancy. References w 1 x  Algra A, JGP Tijssen, JRTC Roelandt, J Pool, J Lubsen:Heartrate variability from 24-hour electrocardiography and the 2-year risk for sudden death. Circulation 88 (1993) 180 w 2 x  Faber R, H Stepan, M Baumert, A Voss, T Walter: Analysis ofblood pressure waveform – a new method for the classifi-cation of hypertensive pregnancy disorder. J Human Hyper-tens 18 (2004) 135 w 3 x  Persson H, M Ericson, T Tomson: Carbamazepine affectsautonomic cardiac control in patients with newly diagnosedepilepsy. Epilepsy Res 57 (2003) 69 w 4 x  Tomson T, M Ericson, C Ihrman, LE Lindblad: Heart rate var-iability in patients with epilepsy. Epilepsy Res 30 (1998) 77 w 5 x  Voss A, H Malberg, N Wessel, A Schumann, Th Walther, HStepan, R Faber: Baroreflex sensitivity, heart rate and bloodpressure variability in normal pregnancy. Am J Hypertens 13(2000) 1218 w 6 x  Zuanetti G, JMM Neilson, R Latini, E Santoro, AP Maggioni,DJ Ewing: Prognostic significance of heart rate variability inpost-myocardial infarction patients in the fibrinolytic era. Cir-culation 94 (1996) 432Received January 29, 2004. Revised June 6, 2004. AcceptedJune 9, 2004.
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