J Nephropharmacol. 2013; 2(1): 5–9.

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Journal of Nephropharmacology

Ambulatory monitoring of blood pressure and pregnancy

outcome in pregnant women with white coat hypertension in
the third trimester of pregnancy
Nahid Shahbazian1, Heshmatollah Shahbazian2, Razieh Mohammadjafari3, Mahsan Mousavi3*
1
Fertility Infertility and Perinatology Research Center, Ahvaz Jundishapur University of Medical Sciences, Ahvaz, Iran
2
Department of Nephrology, Ahvaz Jundishapur University of Medical Sciences, Ahvaz, Iran
3
Department of obstetric & gynecologist, Ahvaz Jundishapur University of Medical Sciences, Ahvaz, Iran

ARTICLE INFO ABSTRACT

Article Type: Introduction: If the blood pressure of a pregnant woman is ≥140/90 mmHg at the clinic, but her ambulatory
Original blood pressure is less <135/85 mmHg at daytime and <125/75 at night and her average ambulatory in 24
hours is <130/80 mmHg, her high blood pressure at clinic is considered white coat hypertension.
Article History: Objectives: To evaluate the value of ambulatory blood pressure monitoring in pregnant women.
Received: 22 November 2012 Patients and Methods: This prospective cohort study was conducted in Imam-Khomeini hospital of
Accepted: 14 December 2012 Ahwaz, Iran between 2011 to 2012. A total of 105 pregnant women who had blood pressure of higher

Original
ePublished: 1 January 2013 than 140/90 mmHg during the third trimester of pregnancy were monitored. Thirty five women with
white coat hypertension, 35 women with gestational hypertension and 35 women with normal blood
Keywords: pressure were followed. The data were analyzed using the Kolmogorov-Smirnov test, Pearson correlation
Hypertension coefficient and Chi-square tests.
White coat hypertension Results: The prevalence of white coat hypertension was 31.3%. The maternal and neonatal outcomes and
Holter monitoring laboratory examinations in white coat hypertension were similar to the normal blood pressure, but the
frequency of caesarean section was more than the other two groups.
Conclusion: The findings of the study indicate the efficacy of 24 hour holter monitoring of blood pressure
and using it more comprehensively , compared to the limited visits.

Implication for health policy/practice/research/medical education:

Prospective cohort study indicated the efficacy of 24-hour holter monitoring of blood pressure and using it in a more comprehensive way
compared to the limited visits.

Please cite this paper as: Shahbazian N, Shahbazian H, Mohammadjafari R, Mousavi M. Ambulatory monitoring of blood pressure and
pregnancy outcome in pregnant women with white coat hypertension in the third trimester of pregnancy: A prospective cohort study. J
Nephropharmacol 2013; 2(1): 5-9.

Introduction All current clinical criteria are usually based on the mean of
Hypertension (HTN) occurs in approximately 5-10% of all at least two seated BP measurements during two outpatient
pregnancies. Among a wide variety of the causes of high blood visits. Generally, the results of home monitoring or 24-hour
pressure (BP) in pregnancy, preeclampsia syndrome, whether ambulatory BP measurements are lower than the clinical
alone or in the form of added on the chronic hypertension, is measurements (6-8). Since the mobile devices measure BP
considered as the most hazardous condition (1). several times during the day and at night, these devices are
In developed countries, hypertensive disorders are responsible considered as more comprehensive assessment tools compared
for around 16% of maternal deaths, and the important concern with limited visits (9-14).
is that more than half of these deaths are associated with high A growing body of evidence suggests that, the home
BP that can be prevented (2-4). Gestational HTN is defined monitoring, during work hours at office or ambulatory BP
when BP of ≥140/90 mmHg is detected for the first time measurements have a better relationship with the end-organ
during pregnancy (5). damages compared to the measurements of the physicians’

*Corresponding author: Mahsan Mousavi, Department of gynecology and obstetric, Fertility Infertility and Perinatology Research Center, Ahvaz Jundishapur
University of Medical Sciences, Ahvaz, Iran. E-mail: [email protected]
Shahbazian N et al.

office or clinics (15-17). during the night for 24 hours, the device was set to measure
If the BP of a pregnant woman is ≥140/90 mmHg, but the the blood pressure.
ambulatory measured value during the day is lower than 135/85 Out of the 105 pregnant women, who were undergoing Holter
mmHg, less than 125/75 mmHg at night, and during the first monitoring device, 47 people had negative holter results and
24-hour is less than 130/80 mmHg, this BP is considered as 103 people had positive Holter results. Out of the 47 people
white coat or office only HTN. White coat HTN happens due with negative Holter results, 35 women who had blood pressure
to the adrenergic transient response to the stressful condition less than 125/75, 135/85 and 130/80 mmHg during the day,
of measuring the BP in the physician’s office (18-20). night, and 24 hours, respectively, entered the study as group
One of the key variables that often remains far from the mind is of white coat hypertension (negative Holter group). Also, out
the used method of the study and the necessity to standardize of 103 patients with positive results during the outpatient
the measurements. White coat or office only HTN occurs in monitoring, 35 patients, who had blood pressure higher than
about 30% of the patients (21-26). Household tools or 24-hour the above mentioned values, entered the study as gestational
ambulatory monitoring devices are often proper tools for hypertension (positive Holter group). Furthermore, 35
those patients that have normal BP out of the physician’s office pregnant women who were diagnosed with normal blood
or clinic (15,27-29). pressure alone, entered the study as the control group.
In the study conducted by Bellomo et al, it was found that,
the prevalence of white coat hypertension was 29.2% (20). In Laboratory tests
another study conducted by Mc Grath et al, the outpatient To compare the outcomes of pregnancy, up to the end of the
monitoring of blood pressure in predicting the pregnancy pregnancy, these three groups were followed every two weeks
outcome was evaluated. Adverse pregnancy outcomes, and their blood pressure, complete blood count (CBC), liver
including the incidence of preeclampsia, intrauterine growth enzymes, creatinine and proteinuria were assessed.
retardation (IUGR) and preterm delivery were compared Finally, duration of pregnancy, the rout of delivery (cesarean
between two groups of with white coat hypertension and those section, normal vaginal delivery with or without induction),
with gestational hypertension. Undesirable consequences were the incidence of preeclampsia and eclampsia, the preterm
significantly more common in the gestational hypertension labor, duration of maternal and neonatal hospitalization,
group (30). the weight of the their babies, intrauterine fetal death and
laboratory examinations among three groups were studied
Objectives and compared among the studied groups.
The present study aimed to evaluate 24-hour ambulatory
monitoring of blood pressure by holter monitoring devices Definition of preeclampsia and eclampsia
in patients with white coat hypertension and also to evaluate Preeclampsia was defined as blood pressure of equal to or
the prevalence of white coat hypertension among the pregnant more than 140/90 mmHg after 20 weeks of gestation along
women and its effect on pregnancy outcomes. with proteinuria equal to or more than 300 mg in 24 hours.
Eclampsia was defined as having a seizure episode non-
Patients and Methods attributable to other causes in women with preeclampsia.
Patients Preterm labor was defined as the baby’s birth before 37 weeks
This was a prospective cohort study. A total of 105 pregnant of the pregnancy; intrauterine fetal death was defined as fetal
women, who had BP of more than 140/90 mmHg during the death after 20 weeks of gestation; and low birth weight (LBW)
prenatal visits in the third trimester of pregnancy in two visits was defined as birth weight between 500 and 2500 g.
and at least two times with a time interval of five minutes, were
studied. Ethical issues
The total number of samples was 105 women: thirty five The research followed the tenets of the Declaration of Helsinki.
pregnant women with white coat hypertension, 35 pregnant Written informed consent was obtained from all patients.
women with gestational hypertension and 35 pregnant women This study was approved by ethical committee of Ahvaz
with normal blood pressure. Jundishapur University of Medical Science.

Measurement of blood pressure Statistical analysis

After explaining the objectives and details of the study, if the The Kolmogorov-Smirnov test was used to identify the
patients agreed to take part, the consent forms were obtained normal distribution of variables and ANOVA test was used
and they were enrolled. The BP measuring method included to compare the means of the three groups. Furthermore,
measuring twice with a five minute interval while the patient Pearson correlation coefficient and Chi-square tests were
seated upright in a chair and t her arm kep at heart level. An used for comparing qualitative variables between the three
adult size of BP cuff was used to measure blood pressure. The groups. Data analysis was performed using SPSS version 19.0
patient’s right arm was used to measure BP. Then these patients software and the P-values ≤ 0.05 were considered statistically
underwent the 24-hour ambulatory monitoring of blood significant.
pressure with a Holter monitoring device (Agillis, Australia).
Holter monitoring device was comprised of a small and special Results
pressure gauge, which at first was programmed and set by a In our study the prevalence of white coat hypertension
computer and then it was connected to the patient. In the was 31.3%. Among the variables investigated, the time of
specified intervals while the patient was busy with everyday termination of pregnancy, the baby’s weight at birth, the
activities, every half hour during the day and every two hours number of babies and maternal hospitalization days (Table 1).
6 Journal of Nephropharmacology, Volume 2, Number 1, January 2013 http://www.jnephropharmacology.com
 Ambulatory blood pressure monitoring in pregnancy

The mean weight of babies, born in the gestational hypertension (20). Only in the study conducted by Parati et al., prevalence
group was significantly less than the other two groups (p= of white coat hypertension was more common than our study
0.004). The neonatal hospitalization duration (Table 1) in (24). However, the frequency of caesarean of pregnants with
the gestational hypertension group was significantly more white coat hypertension was more often than pregnants with
than the other two groups (p= 0.01). As shown in Table 2, the normal blood pressure and the those with high blood pressure
Cesarean section procedure in the white coat hypertension of pregnancy. The cause of an increase in the caesarean
group was significantly more common than the other two section in the group of white coat hypertension was hard to
groups. There was no significant difference in the average interpret, although in the group of white coat hypertension
proportion of the incidence of intrauterine death (Table 3; p= may be due to the decision on how to end a pregnancy based
0.13) among the groups. The average incidence of preeclampsia on the measurement of blood pressure in the physician’s office
and eclampsia (Table 3) in the gestational hypertension group or clinic. Another cause for it, is the common and a normal
were significantly more than the other two groups (p= 0.01, p= blood pressure increase in passing of blood pressure around
0.0003, p= 0.012, and p= 0.005, respectively). Normal vaginal the pregnancy term.
delivery was significantly more common in the normal In the study conducted by Bellomo et al. on how to end a
pregnancy group. Induction procedure was significantly more pregnancy in the white coat hypertension, it was shown that
common in the gestational hypertension group (p= 0.012). the frequency of the termination of the pregnancy using the
The average ratio of occurrence of reducing the number of cesarean section technique in the group of the white coat
platelets, increased creatinine, the incidence of abnormal liver hypertension was more than the gestational hypertension and
function test and albumin in the random urine (Table 3) in the normal blood pressure groups (20). In the study by Mc Grath
gestational hypertension group was significantly higher than et al. the consequences of prenatal in white coat hypertension
the other two groups (p= 0.005, p= 0.0001, p= 0.0001, and p= was desirable, and undesirable outcomes such as low birth
0.0001, respectively). weight, IUGR and premature pregnancy in the gestational
hypertension group were more common (30). In Parati et al.
Discussion study of pregnancy outcomes in white coat hypertension,
This study showed that, the prevalence of white coat adverse outcomes such as prematurity and preterm labor and
hypertension in pregnant women was 31.3%. That mentioned intrauterine fetal death (IUFD) in white coat hypertension
prevalence was slightly more than non-pregnant population were not observed (24).

Table 1. Mean ± SD duration of gestation, birth weight and infant and maternal hospital stay in the pregnant women studied
Duration of gestation Length of infant 's Length of mother 's
Birth weight (Gram)
Group (Week and day) hospital stay (Day) hospital stay (Day)
Mean SD Mean SD Mean SD Mean SD
White coat hypertension 39w+4d 0.382 3300 1.987 1.7 1.481 1.5 1.912
Gestational hypertension 3d38+w 1.281 2900 1.754 4.2 1.658 5.9 2.156
Normal blood pressure 39w+3d 0.3101 3350 1.645 1.2 2.893 1.2 2.893
P-value 0.01 0.004 0.01 0.0003

Table 2. Comparison of the rout of delivery in pregnant women

Normal vaginal
Group Cesarean (%) Inductive P-value
delivery
White coat HTN 45.7 48.6 5.7

Gestational HTN 40 48.6 11.4 0.012

Normal blood pressure 11.4 82.9 5.7

Table 3. Comparison of the incidence of pre eclampsia, eclampsia, preterm labor, low birth weight, intrauterine fetal death, reduced platelet, increased
Keratin abnormal liver function test, urinary aluminum and preterm delivery in pregnant women studied

Pre-eclampsia Eclampsia Preterm Low birth Intrauterine Reduced Increased Abnormal Urinary
Group
(%) (%) labor weight fetal death platelet Keratin liver test aluminum

White coat HTN 5.7 0 0 0 0 0 0 0 0

Gestational HTN 60 2.9 14.3 14.3 5.7 14.3 25.7 60 57.1

Normal blood pressure 8.5 0 0 0 0 0 0 0 0

P-value 0.0001 0.0001 0.005 0.005 0.13 0.005 0.0001 0.0001 0.0001

http://www.jnephropharmacology.com Journal of Nephropharmacology, Volume 2, Number 1, January 2013 7

Shahbazian N et al.

In our study, the abnormal laboratory results, including pregnant women and encourage them to come for more follow
reducing the number of platelets, increased creatinine, the up visits during pregnancy.
abnormal liver function tests and albumin in the random
urine of pregnant women with gestational hypertension were Authors’ contributions
observed, however, the impaired laboratory results were not Main draft write up and editing by MM. Important intellectual
observed in people with white coat hypertension and the content and critical revision by NS, RM and HS.
pregnant women with normal blood pressure. Similar results
were also obtained in other studies, including the study of Conflict of interests
Bellomo et al. (20). Also abnormal results were not observed in The authors declared no competing interests.
the laboratory examinations of white coat hypertension in the
study conducted by Hodgkinson et al. (7). Ethical consideration
The impaired liver enzymes, platelet count, and creatinine Ethical issues (including plagiarism, misconduct, data
were not observed in the laboratory examinations in the study fabrication, informed consent, double publication) have been
of Mark et al. on the white coat hypertension (15). Our study completely observed by the authors.
showed that, risks of preeclampsia and eclampsia were higher in
pregnant women with gestational HTN than pregnant women Funding/Support
with white coat hypertension or pregnant women with normal This paper has been derived from the residential thesis of this
blood pressure. Additionally, the duration of the pregnancy study was granted by Ahvaz Jundishapur university of medical
and duration of the mother’s hospitalization and preterm sciences and department of Gynecology and Obstetrics,
labor was more common in the gestational hypertension fertility and perinatology research center, Ahvaz Jundishapur
group than other groups. In the study of Bellomo et al. on university of medical sciences and research consultation
maternal results of the white coat hypertension, the risks of center.
preeclampsia and eclampsia in white coat hypertension group
were significantly less than gestational hypertension group Acknowledgements
(20). Jose et al. studied the adverse maternal outcomes such Hereby we would sincerely appreciate the Holter monitoring
as preeclampsia and eclampsia in white coat hypertension Center, Imam Khomeini Hospital, and patients participating
and observed that they were significantly lower in gestational in this study and all the ones who helped us in this study.
hypertension group (11). The authors also, appreciate and thank the Research Deputy
In analyzing the neonatal results in our study, low birth vice-chancellor for research affairs of the Ahvaz Jundishapur
weight and the hospitalization duration of newborns in the University of Medical Sciences, particularly the Research
hospital in the gestational hypertension group was more than Consultation Center (RCC) for technical support.
the other two groups. In this study, we have shown that the
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