Hans van den Heuvel

9 INTRODUCTION Pregnancies with complications need close antenatal surveillance. While 7 to 10 antenatal consultations are recommended in uncomplicated pregnancies, complications result in recurrent outpatient visits or hospital admission. 1 These complications include, amongst others, fetal growth restriction (prevalence 3-7%), preeclampsia (prevalence 1-3%), and preterm prelabor rupture of membranes (prevalence 1-5%). 2-4 Daily monitoring with cardiotocography (CTG), blood pressure measurements and/or urine and blood analysis is recommended in international guidelines to assess maternal and fetal condition in high- risk pregnancy. 5-7 Ultimately, hospitalization is indicated in up to 11% of all pregnancies and usually extends to delivery and the postpartum period. 5-7 Antenatal admissions pose psychological stress to pregnant women because of separation from family and home, lack of activity and feelings of uncertainty. 8,9 In addition, hospital admissions are a burden on health care costs and workload, also in high income countries, already experiencing difficulties as a result of shortage of professional staff. 10 From 1990 onwards, obstetric departments in the Netherlands are providing domiciliary care or “home monitoring” to women with high-risk pregnancies. As an alternative to clinical admission, home monitoring involves hospital-employed midwives or nurses visiting pregnant women with complications at home, on a daily basis. Medical tests, including CTG, are performed at home and the results are discussed with a supervising gynecologist (Fig 1a). Multiple randomized trials have proved that home monitoring with home visits is feasible and safe regarding perinatal outcome. 11-14 These trials demonstrated satisfactory outcomes for both mother and child but also that daily visits are time consuming and therefore expensive. The use of digital health for remote monitoring in pregnancy care is increasingly popular, as pregnant women are frequent users of smartphones, internet and health related apps. 15 As an alternative to hospital admission or home monitoring with prenatal home visits, as described above, telemonitoring is a relatively new approach in high-risk pregnancy. After training of participants, daily measurements of blood pressure and CTG are self-recorded by the patient at home, and sent with Bluetooth or wifi to a secured digital platform. Using Internet connection, the data are integrated in the electronic patient file (Fig 1b). Patients are contacted by their clinician on a daily basis, to discuss presence of symptoms, results of the tests and future management. Multiple telemonitoring platforms for remote cardiotocography have been evaluated in prospective studies to prove their feasibility, including usability, accuracy of tracings and acceptability of patients and clinicians. 15 In general, digital health has the potential to improve access to care, disease monitoring and patient satisfaction while reducing healthcare costs due to a reduction in visits and admissions. At this moment, only scarce clinical evidence is available for telemonitoring CURRENT PRACTICE OF HOME-BASED TELEMONITORING IN THE NETHERLANDS 145