Hans van den Heuvel

care with a new pregnancy in our university hospital (secondary and tertiary level obstetric care) with one of the following risk factors for preeclampsia: chronic hypertension, preeclampsia in a prior pregnancy, or concurrent maternal cardiac or kidney disease. The prospective group of women (SAFE@HOME group) consisted of women who presented with one of the four risk factors and, after written consent, used the platform in antenatal care. Other inclusion criteria were maternal age >18 years, access to a smartphone/tablet with Internet and knowledge of Dutch or English language. Exclusion criteria were kidney transplant and arm circumference >42 cm, due to technical requirements of the monitor. For the retrospectively selected control group, a database search was conducted to add women who received perinatal care in our centre for one the four mentioned risk factors at start of pregnancy. Those who delivered between 1-1-2015 and 31-12-2016 were included. Patients younger than 18 years and kidney transplants were excluded. Antenatal care in the control group was traditionally managed based on the Dutch guideline on hypertensive disorders of pregnancy, but without use of home blood pressure monitoring or a fixed antenatal visit scheme. 8 Intervention The intervention combined a digital health platform with a predefined (reduced) antenatal visit schedule. The digital health platform includes an app (Luscii, Focuscura, The Netherlands) and the iHealth Track automated blood pressure monitor, validated in a pregnant population. 9 Use of the platform for blood pressure measurements and symptom reporting was found feasible in our hospital setting prior to study start. 7 After informed consent, participants started telemonitoring from 16 weeks of gestation to delivery date, uploading a single blood pressure on Monday-Friday before 10 AM. In case of hypertension (BP >140/>90 mmHg) participants would answer an in-app symptom list with 10 yes/no questions regarding hypertension and pregnancy. Values exceeding set thresholds were visible as alerts for the telemonitoring team of our department, who reviewed the alerts at 10.30 AM. If needed, management was discussed with the consulting obstetrician to further inform or instruct participants at home or ask them to visit the hospital for additional observation or follow-up. All alerts in the dashboard had to be switched off manually after review. Alongside the use of the platform, a multidisciplinary team of obstetricians, cardiologists nephrologists and patients predefined a uniform antenatal visit schedule, including structure of the scheduled visits and ultrasound assessments (See Chapter 5, Figure 1). This new SAFE@HOME care-pathway, including access to the home-measurements, was embedded in our outpatient department with general visits being performed by hospital- based midwives, gynaecologists in training and supervising obstetricians. CHAPTER 6 88