Article | Published:

Blood pressure in early and mid-pregnancy and the risk of small-for-gestational-age birth: findings of a large cohort study in China


The influences of blood pressure in early to mid-pregnancy on the risk of small-for-gestational-age (SGA) birth are not clear. Our objective was to examine the associations of the blood pressure levels at 10 and 18 gestational weeks with the risk of SGA birth. Data were obtained from the Chinese Maternal and Newborn’s Health Monitoring System (MNHMS). In total, 50745 Chinese women who delivered a single live infant at a gestational age of between 28 and 42 weeks were included in this analysis. Blood pressure, birth outcome and other related information were obtained during antenatal visits by obstetricians. Logistic regression models were used to examine the associations, adjusting for potential confounders. The total incidence of SGA birth was 8.9%. High blood pressure levels at 10 gestational weeks significantly increased the risk of SGA birth (SBP: RR = 1.32, 95% CI: 1.11–1.56; DBP: RR = 1.10, 95% CI: 1.05–1.14). The incidence of SGA birth was not associated with the DBP at 18 gestational weeks but showed a U-shaped relationship with SBP. A decrease in blood pressure from 10 to 18 gestational weeks was associated with an increased risk of SGA birth (SBP: RR = 1.03, 95% CI: 1.00–1.07; DBP: RR = 1.05, 95% CI: 1.02–1.09). Our results provide evidence on the relationship of blood pressure in early and mid-pregnancy with SGA birth. Higher blood pressures during early pregnancy and greater decreases in blood pressure from early to mid-pregnancy increased the risk of SGA birth, indicating a continuum of risk for SGA birth based on blood pressure starting during early pregnancy.

Access optionsAccess options

Rent or Buy article

Get time limited or full article access on ReadCube.


All prices are NET prices.


  1. 1.

    Lee AC, Katz J, Blencowe H, Cousens S, Kozuki N, Vogel JP, et al. National and regional estimates of term and preterm babies born small for gestational age in 138 low-income and middle-income countries in 2010. Lancet Glob Health. 2013;1:e26–36.

  2. 2.

    Katz J, Lee AC, Kozuki N, Lawn JE, Cousens S, Blencowe H, et al. Mortality risk in preterm and small-for-gestational-age infants in low-income and middle-income countries: a pooled country analysis. Lancet. 2013;382:417–25.

  3. 3.

    Ray JG, Park AL, Fell DB. Mortality in infants affected by preterm birth and severe small-for-gestational age birth weight. Pediatrics. 2017;140:e20171881.

  4. 4.

    Huang Y-T, Lin H-Y, Wang C-H, Su B-H, Lin C-C. Association of preterm birth and small for gestational age with metabolic outcomes in children and adolescents: a population-based cohort study from Taiwan. Pediatr & Neonatol. 2018;59:147–53.

  5. 5.

    Mericq V, Martinez-Aguayo A, Uauy R, Iniguez G, Van der Steen M, Hokken-Koelega A. Long-term metabolic risk among children born premature or small for gestational age. Nat Rev Endocrinol. 2017;13:50–62.

  6. 6.

    Physical status: the use and interpretation of anthropometry. Report of a WHO Expert Committee. World Health Organ Tech Rep Ser. 1995;854:1–452.

  7. 7.

    Allen VM, Joseph K, Murphy KE, Magee LA, Ohlsson A. The effect of hypertensive disorders in pregnancy on small for gestational age and stillbirth: a population based study. BMC Pregnancy Childbirth. 2004;4:17.

  8. 8.

    Wikstrom AK, Gunnarsdottir J, Nelander M, Simic M, Stephansson O, Cnattingius S. Prehypertension in pregnancy and risks of small for gestational age infant and stillbirth. Hypertens. 2016;67:640–6.

  9. 9.

    Macdonald-Wallis C, Silverwood RJ, de Stavola BL, Inskip H, Cooper C, Godfrey KM, et al. Antenatal blood pressure for prediction of pre-eclampsia, preterm birth, and small for gestational age babies: development and validation in two general population cohorts. BMJ. 2015;351:h5948.

  10. 10.

    Macdonald-Wallis C, Tilling K, Fraser A, Nelson SM, Lawlor DA. Associations of blood pressure change in pregnancy with fetal growth and gestational age at delivery: findings from a prospective cohort. Hypertens. 2014;64:36–44.

  11. 11.

    Bakker R, Steegers EA, Hofman A, Jaddoe VW. Blood pressure in different gestational trimesters, fetal growth, and the risk of adverse birth outcomes: the generation R study. Am J Epidemiol. 2011;174:797–806.

  12. 12.

    Fukushima K, Morokuma S, Tsukimori K, Murata M, Wake N. Blood pressure measurements within the JNC7 pre-hypertensive range after 32 weeks of gestation are a risk factor for decreased fetal growth. Hypertens Res. 2012;35:128–30.

  13. 13.

    Gaillard R, Bakker R, Willemsen SP, Hofman A, Steegers EA, Jaddoe VW. Blood pressure tracking during pregnancy and the risk of gestational hypertensive disorders: the Generation R Study. Eur Heart J. 2011;32:3088–97.

  14. 14.

    Macdonald-Wallis C, Silverwood RJ, Fraser A, Nelson SM, Tilling K, Lawlor DA, et al. Gestational-age-specific reference ranges for blood pressure in pregnancy: findings from a prospective cohort. J Hypertens. 2015;33:96–105.

  15. 15.

    Macdonald-Wallis C, Tilling K, Fraser A, Nelson SM, Lawlor DA. Established preeclampsia risk factors are related to patterns of blood pressure change in normal term pregnancy: findings from the Avon Longitudinal Study of Parents and Children. J Hypertens. 2011;29:1703–11.

  16. 16.

    Huang A, Ji Z, Zhao W, Hu H, Yang Q, Chen D. Rate of gestational weight gain and preterm birth in relation to prepregnancy body mass indices and trimester: a follow-up study in China. Reprod Health. 2016;13:93.

  17. 17.

    Zhu LiZR, Shulian Zhang, Wenjing Shi, Weili Yan, Xiaoli Wang, et al. Chinese neonatal birth weight curve for different gestational age. Chin J Pediatr. 2015;53:97–103.

  18. 18.

    Brown MA, Lindheimer MD, de Swiet M, Van Assche A, Moutquin JM. The classification and diagnosis of the hypertensive disorders of pregnancy: statement from the International Society for the Study of Hypertension in Pregnancy (ISSHP). Hypertens Preg. 2001; 20:IX-XIV.

  19. 19.

    R Development Core Team. R: A Language and Environment for Statistical Computing. Vienna, Austria: the R Foundation for Statistical Computing; 2011.

  20. 20.

    Shen M, Tan H, Zhou S, Smith GN, Walker MC, Wen SW. Trajectory of blood pressure change during pregnancy and the role of pre-gravid blood pressure: a functional data analysis approach. Sci Rep. 2017;7:6227.

  21. 21.

    Steer PJ, Little MP, Kold-Jensen T, Chapple J, Elliott P. Maternal blood pressure in pregnancy, birth weight, and perinatal mortality in first births: prospective study. BMJ. 2004;329:1312.

  22. 22.

    Mayer C, Joseph KS. Fetal growth: a review of terms, concepts and issues relevant to obstetrics. Ultrasound Obstet Gynecol. 2013;41:136–45.

  23. 23.

    He D, Wu S, Zhao H, Zheng Z, Zhang W. High normal blood pressure in early pregnancy also contribute to early onset preeclampsia and severe preeclampsia. Clin Exp Hypertens. 2018;40:539–46.

  24. 24.

    Steegers EA, von Dadelszen P, Duvekot JJ, Pijnenborg R. Pre-eclampsia. Lancet. 2010;376:631–44.

  25. 25.

    Goulopoulou S, Davidge ST. Molecular mechanisms of maternal vascular dysfunction in preeclampsia. Trends Mol Med. 2015;21:88–97.

  26. 26.

    Mol BWJ, Roberts CT, Thangaratinam S, Magee LA, de Groot CJM, Hofmeyr GJ. Pre-eclampsia. Lancet. 2016;387:999–1011.

  27. 27.

    Kintiraki E, Papakatsika S, Kotronis G, Goulis DG, Kotsis V. Pregnancy-Induced hypertension. Hormones. 2015;14:211–23.

  28. 28.

    Roberts JM, Hubel CA. The two stage model of preeclampsia: variations on the theme. Placenta. 2009;30(Suppl A):S32–7.

  29. 29.

    Santillan MK, Santillan DA, Sigmund CD, Hunter SK. From molecules to medicine: a future cure for preeclampsia? Drug News Perspect. 2009;22:531–41.

  30. 30.

    Huang A, Wu K, Zhao W, Hu H, Yang Q, Chen D. Attendance at prenatal care and adverse birth outcomes in China: a follow-up study based on Maternal and Newborn’s Health Monitoring System. Midwifery. 2018;57:26–31.

Download references

Author information

Correspondence to Aiqun Huang or Dafang Chen.

Ethics declarations

Conflict of interest

The authors declare that they have no conflict of interest.

Additional information

Publisher’s note: Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Supplementary information

Figure S1

Table S1

Table S2

Supplemental Material

Rights and permissions

Reprints and Permissions

About this article

Verify currency and authenticity via CrossMark
Fig. 1