Hans van den Heuvel

The SAFE@HOME group consisted of women, who presented with one of the fore-mentioned risk factors between October 2017 and December 2018 in our clinics. Eligible candidates for the prospective study were >18 years of age, had access to a smartphone or tablet with Internet connection and could understand Dutch or English language. Kidney transplant patients and arm circumference >42 cm (as prescribed by the instructions of the monitor) were considered an exclusion criterion. The control group consisted of retrospectively selected women with one of the aforementioned four risk factors at start of pregnancy. After database search for these risk factors amongst all deliveries between 1-1-2015 and 31-12-2016, patients were included in this control group only if they received antenatal care from intake to delivery in the same centre. Exclusion criteria were maternal age <18 years and kidney transplant. Antenatal care in the control group was based on the Dutch guideline on hypertensive disorders of pregnancy, without use of home blood pressure measurements. 13 Follow-up visits were planned once per two weeks, with increased frequency if indicated by their care provider, depending on the patient’s condition, BP or medication use. Antihypertensive medication was generally prescribed in case of blood pressure >160/>110 mmHg. Hospitalization was recommended in case of preeclampsia, or fetal growth restriction with indication for daily cardiotocography (pulsatility index of the umbilical artery >95th centile). Intervention The digital health platform consisted of the Luscii platform (by Focuscura, the Netherlands, in collaborationwith UMC Utrecht) and the iHealth Track automated blood pressuremonitor, validated for use in pregnancy. 14 Development of the platform was described before and its use was found feasible in our hospital setting in a low risk pregnant population. 12 This study showed good participant compliance and high accuracy of the alarm system. 12 Subsequently, telemonitoring with the platform was offered to patients at risk of preeclampsia from October 2017 onwards. As part of this novel strategy, a uniform care path was predefined (Figure 1). We organized 4 multidisciplinary meetings with obstetricians, internists, cardiologists and nephrologists, nurses and patients for the development of the schedule. Considering the home- measurements and symptom scores, they discussed the desired structure of care, outcome measures of interest and the objective of each planned clinic and ultrasound visit. Before start of the study, a local telemonitoring team was set up. Nurses and midwives of these teams were trained in a 1-h course to 1) register and instruct new participants to use the monitor and platform and 2) perform daily monitoring of alerts and subsequent actions. Obstetricians (in training) were trained how to access the home measurements and to plan future appointments using the predefined schedule. CHAPTER 5 70