, Volume 62, Issue 12, pp 2188–2199 | Cite as

White coat hypertension in early pregnancy in women with pre-existing diabetes: prevalence and pregnancy outcomes

  • Marianne VestgaardEmail author
  • Björg Ásbjörnsdóttir
  • Lene Ringholm
  • Lise Lotte T. Andersen
  • Dorte M. Jensen
  • Peter Damm
  • Elisabeth R. Mathiesen



Hypertensive disorders are prevalent among pregnant women with pre-existing diabetes, but the prevalence and impact of white coat hypertension are unknown. Measurement of home BP before initiation of antihypertensive treatment is necessary to identify white coat hypertension since international guidelines recommend that white coat hypertension is left untreated. The aim of this study, conducted among women with pre-existing diabetes, was therefore to examine the prevalence of white coat hypertension in early pregnancy, and pregnancy outcome in women with white coat hypertension in early pregnancy.


A prospective cohort study was undertaken involving women with pre-existing diabetes from a geographically well-defined area. Based on office BP in early pregnancy and home BP measured for 3 days, women were categorised in three groups: (1) white coat hypertension, defined as office BP ≥ 135/85 mmHg and mean home BP < 130/80 mmHg; (2) chronic hypertension, defined as pre-pregnancy hypertension including newly detected office BP ≥ 135/85 mmHg with home BP ≥ 130/80 mmHg; and (3) normotension. Office BP was measured every 2 weeks and, if ≥ 135/85 mmHg, home BP measurements were performed. White coat hypertension was left untreated, and tight antihypertensive treatment was initiated when both office BP ≥ 135/85 mmHg and home BP ≥ 130/80 mmHg. Pregnancy-induced hypertensive disorders were defined as office BP ≥ 140/90 mmHg with home BP ≥ 130/80 mmHg when available, with onset after 20 weeks of gestation.


In total, 32 out of 222 women with pre-existing diabetes had newly detected office BP ≥ 135/85 mmHg in early pregnancy. White coat hypertension was present in 84% (27/32) of these women, representing 12% (95% CI 8%, 17%) of the whole cohort. Chronic hypertension was present in 14% (n = 32) and normotension in 74% (n = 163). Women with white coat hypertension were characterised by higher pre-pregnancy BMI (p = 0.011), higher home BP (p < 0.001) and higher prevalence of type 2 diabetes (p = 0.009), but similar HbA1c (p = 0.409) compared to women with normotension. Regarding pregnancy outcome, pregnancy-induced hypertensive disorders developed in 44% (12/27) of women with white coat hypertension in comparison with 22% (36/163) among initially normotensive women (p = 0.013), while the prevalence of preterm delivery was comparable (p = 0.143). The adjusted analysis, performed post hoc, suggested approximately double the risk of developing pregnancy-induced hypertensive disorders (OR 2.43 [CI 0.98, 6.05]) if white coat hypertension was present in early pregnancy, independently of pre-pregnancy BMI and parity.


White coat hypertension is prevalent in women with pre-existing diabetes and may indicate a high risk of later development of pregnancy-induced hypertensive disorders. To distinguish between persistent white coat hypertension and onset of pregnancy-induced hypertension, repeated home BP monitoring is recommended when elevated office BP is detected.

The study was registered at (ID: NCT02890836).


Aspirin Diabetes Home blood pressure Hypertension Preeclampsia Pregnancy Pregnancy-induced hypertensive disorders Pregnancy outcome White coat hypertension 



Albumin/creatinine ratio


Interquartile range


Large for gestational age


Neonatal intensive care unit


Small for gestational age


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The authors are grateful to research-midwife M. A. Mikkelsen (Center for Pregnant Women with Diabetes, Rigshospitalet, Denmark) and A. Boa (Department of Obstetrics, Odense University Hospital, Denmark) for help with recruitment, collection and handling of data. Thanks to the nurses at the Center for Pregnant Women with Diabetes, Rigshospitalet, Denmark, for help with recruitment. We also thank the pregnant women for their time and interest in the study.

Contribution statement

The overall initiative for the study was taken by ERM, PD and MV. MV and BA collected the data. All co-authors contributed to the conception of the study, the analysis and interpretation of data. MV performed the statistical analysis and prepared the first draft of the manuscript. All co-authors revised the manuscript critically for important intellectual content. MV collected all comments from the co-authors and prepared the final draft. All co-authors approved the final version to be published. ERM is the guarantor of this work.


MV was funded by Rigshospitalet’s Research Foundation. ERM was funded by Novo Nordisk Foundation (grant no. NNF14OC0009275).

Duality of interest

The authors declare that there is no duality of interest associated with the manuscript.


  1. 1.
    Norgaard SK, Vestgaard MJ, Jorgensen IL et al (2018) Diastolic blood pressure is a potentially modifiable risk factor for preeclampsia in women with pre-existing diabetes. Diabetes Res Clin Pract 138:229–237. CrossRefPubMedGoogle Scholar
  2. 2.
    Cundy T, Slee F, Gamble G, Neale L (2002) Hypertensive disorders of pregnancy in women with type 1 and type 2 diabetes. Diabet Med 19(6):482–489. CrossRefPubMedGoogle Scholar
  3. 3.
    Vestgaard M, Sommer MC, Ringholm L, Damm P, Mathiesen ER (2018) Prediction of preeclampsia in type 1 diabetes in early pregnancy by clinical predictors: a systematic review. J Matern Fetal Neonatal Med 31(14):1933–1939. CrossRefPubMedGoogle Scholar
  4. 4.
    American College of Obstetricians and Gynecologists (2013) Hypertension in pregnancy. Report of the American College of Obstetricians and Gynecologists’ Task Force on Hypertension in Pregnancy. Obstet Gynecol 122(5):1122–1131CrossRefGoogle Scholar
  5. 5.
    Brown MA, Magee LA, Kenny LC et al (2018) Hypertensive disorders of pregnancy: ISSHP classification, diagnosis, and management recommendations for international practice. Hypertension 72(1):24–43. CrossRefGoogle Scholar
  6. 6.
    Taylor J (2013) 2013 ESH/ESC guidelines for the management of arterial hypertension. Eur Heart J 34(28):2108–2109PubMedGoogle Scholar
  7. 7.
    Brown MA, Mangos G, Davis G, Homer C (2005) The natural history of white coat hypertension during pregnancy. BJOG 112(5):601–606. CrossRefGoogle Scholar
  8. 8.
    Denolle T, Weber JL, Calvez C et al (2008) Diagnosis of white coat hypertension in pregnant women with teletransmitted home blood pressure. Hypertens Pregnancy 27(3):305–313. CrossRefPubMedGoogle Scholar
  9. 9.
    Magee LA, Singer J, von Dadelszen P, Group CS (2015) Less-tight versus tight control of hypertension in pregnancy. N Engl J Med 372(24):2367–2368PubMedGoogle Scholar
  10. 10.
    Sarafidis PA, Lazaridis AA, Ruiz-Hurtado G, Ruilope LM (2017) Blood pressure reduction in diabetes: lessons from ACCORD, SPRINT and EMPA-REG OUTCOME. Nat Rev Endocrinol 13(6):365–374. CrossRefPubMedGoogle Scholar
  11. 11.
    Ringholm L, Damm JA, Vestgaard M, Damm P, Mathiesen ER (2016) Diabetic nephropathy in women with preexisting diabetes: from pregnancy planning to breastfeeding. Curr Diab Rep 16(2):12. CrossRefPubMedGoogle Scholar
  12. 12.
    Hommel E, Parving HH, Mathiesen E, Edsberg B, Damkjaer Nielsen M, Giese J (1986) Effect of captopril on kidney function in insulin-dependent diabetic patients with nephropathy. Br Med J (Clin Res Ed) 293(6545):467–470. CrossRefGoogle Scholar
  13. 13.
    Nielsen LR, Damm P, Mathiesen ER (2009) Improved pregnancy outcome in type 1 diabetic women with microalbuminuria or diabetic nephropathy: effect of intensified antihypertensive therapy? Diabetes Care 32(1):38–44. CrossRefPubMedPubMedCentralGoogle Scholar
  14. 14.
    Nielsen LH, Sundtoft I, Vestgaard M et al (2018) Præeclampsi og hypertension. Available from Accessed 15 August 2019 [article in Danish]
  15. 15.
    Denolle T, Daniel JC, Calvez C, Ottavioli JN, Esnault V, Herpin D (2005) Home blood pressure during normal pregnancy. Am J Hypertens 18(9 Pt 1):1178–1180. CrossRefPubMedGoogle Scholar
  16. 16.
    Ishikuro M, Obara T, Metoki H et al (2015) Parity as a factor affecting the white-coat effect in pregnant women: the BOSHI study. Hypertens Res 38(11):770–775. CrossRefPubMedGoogle Scholar
  17. 17.
    Vestgaard M, Søholm JC, Nørgaard SK et al (2019) Home blood pressure in pregnancy - the upper reference limit. Blood Press Monit 24(4):191–198. CrossRefPubMedGoogle Scholar
  18. 18.
    Reinders A, Cuckson AC, Lee JT, Shennan AH (2005) An accurate automated blood pressure device for use in pregnancy and pre-eclampsia: the Microlife 3BTO-A. BJOG 112(7):915–920. CrossRefGoogle Scholar
  19. 19.
    Bang LE, Christensen KL, Hansen KW, Skov K, Wiinberg N (2006) Diagnostisk blodtryksmåling - på døgnbasis, hjemme og i konsultationen. Available from Accessed 15 August 2019 [article in Danish]
  20. 20.
    Vestgaard M, Ringholm L, Laugesen CS, Rasmussen KL, Damm P, Mathiesen ER (2010) Pregnancy-induced sight-threatening diabetic retinopathy in women with type 1 diabetes. Diabet Med 27(4):431–435. CrossRefPubMedGoogle Scholar
  21. 21.
    Jensen DM, Damm P, Sorensen B et al (2003) Pregnancy outcome and prepregnancy body mass index in 2459 glucose-tolerant Danish women. Am J Obstet Gynecol 189(1):239–244. CrossRefPubMedGoogle Scholar
  22. 22.
    Marsal K, Persson PH, Larsen T, Lilja H, Selbing A, Sultan B (1996) Intrauterine growth curves based on ultrasonically estimated foetal weights. Acta Paediatr 85(7):843–848. CrossRefPubMedGoogle Scholar
  23. 23.
    Rolnik DL, Wright D, Poon LC et al (2017) Aspirin versus placebo in pregnancies at high risk for preterm preeclampsia. N Engl J Med 377(7):613–622. CrossRefPubMedGoogle Scholar
  24. 24.
    Mikami Y, Takai Y, Era S et al (2017) Provisional criteria for the diagnosis of hypertension in pregnancy using home blood pressure measurements. Hypertens Res 40(7):679–684. CrossRefPubMedPubMedCentralGoogle Scholar
  25. 25.
    Iwama N, Metoki H, Ohkubo T et al (2016) Maternal clinic and home blood pressure measurements during pregnancy and infant birth weight: the BOSHI study. Hypertens Res 39(3):151–157. CrossRefPubMedGoogle Scholar

Copyright information

© Springer-Verlag GmbH Germany, part of Springer Nature 2019

Authors and Affiliations

  1. 1.Center for Pregnant Women with Diabetes, Department of Endocrinology and ObstetricsRigshospitalet, University of CopenhagenCopenhagenDenmark
  2. 2.Department of Clinical MedicineUniversity of CopenhagenCopenhagenDenmark
  3. 3.Steno Diabetes Center CopenhagenGentofteDenmark
  4. 4.Department of ObstetricsOdense University HospitalOdenseDenmark
  5. 5.Steno Diabetes Center OdenseOdense University HospitalOdenseDenmark

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