Hans van den Heuvel

2 are notoriously difficult in lifestyle studies. Smartphone technologies provide features to overcome these obstacles. Results from feasibility studies show good acceptability, adherence and engagement for e-health interventions for healthy gestational weight gain and physical activity, favoring an app over a website. 33,34 Physical activity trials with tailored SMS services resulted in an increase in step count up to four times more than in the control group. Also, e-health interventions resulted in better-perceived health in pregnancy and lower, healthier gestational weight gain in both non-obese (7.8 kg versus 9.7 kg) and obese women (6.65 kg versus 9.74 kg). 35-37 Dietary apps directed at healthy gestational weight gain are still in developmental and experimental phase. 27,38,39 Smoking during pregnancy increases the risk of unfavorable pregnancy outcomes. In 2010, approximately 10% of the women smoked cigarettes during pregnancy, especially younger, non-Caucasian mothers of a lower social economic status 40,41 The 2016 review by Heminger et al. summarizes the studies performed on short message service programs and mobile applications for smoking cessation in pregnancy. 42 Women participating in SMS cessation programs report relatively high abstinence of 38% in the first week, and 54% in the second week (n=20). Biochemically confirmed abstinence rates were 12.5% in participants compared to 7.8% in controls (n=207). Mobile applications were preferred over SMS-driven programs, as seen in over 10.000 installations of apps compared to 20-800 registrations in SMS programs. Gestational Diabetes About 5-7% of all pregnancies are complicated by Gestational Diabetes Mellitus (GDM) in the United Kingdom and United States (range 1-25%). 43 Pregnancies with GDM are associated with perinatal complications such as caesarean section, shoulder dystocia and neonatal hypoglycemia. Extensive glucose monitoring during pregnancy is a burden for both patients and health care budgets. E-health in GDM care has evolved most notably of all perinatal applications of e-health the last three years. 44 We found 13 studies on this topic, including two systematic reviews (Table 2). Developments involve smartphone facilitated remote blood glucose monitoring, management of medication schedules through web-based or SMS-facilitated feedback systems and telephone review service to support and supervise glycemic control. 45-51 Overall, studies showed a decrease in planned and unplanned visits by 50-66%, while no unfavorable differences in glycemic control, maternal and neonatal outcomes occurred .47-49,52 Two recent systematic reviews with meta-analysis confirms these results. 53,54 No cost–effectiveness analysis was performed due to insufficient data. There is also increasing evidence of GDM as a risk factor for type two diabetes later in life .55 E-health programs for follow up of women with a history of GDM are being developed, but need to be examined more thoroughly. 45 LITERATURE OVERVIEW OF E-HEALTH IN PERINATAL CARE 23