The impact of a remote monitoring program on the prenatal follow-up of women with gestational hypertensive disorders

Exploring the impact of integrating telehealth in obstetric care: A scoping review

BACKGROUND

The use of telemedicine has spread to all areas of medicine, including obstetrics, over the last few decades.

OBJECTIVE

To identify and map the diversity and applicability of telemedicine in the obstetric literature, in the antenatal, intrapartum or postnatal period. To assess patient satisfaction and possible areas for future development.

METHODS

This scoping review was conducted following the Joanna Briggs Institute (JBI) methodological guidelines for scoping reviews and reported according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) and its extension for scoping reviews (PRISMA-ScR). We searched the databases PubMed (Medline), CINAHL, CENTRAL (Cochrane Library), EMBASE Ovid and Scopus. We also searched Google Scholar, clinicaltrial.gov, the WHO International Clinical Trials Registry Platform (ICTRP-WHO) and the reference lists of the included studies. We included any primary study design that focused on a population of women in the antenatal, intrapartum or postnatal period. Studies selection and data extraction were performed blindly and independently by two authors. We summarised the results narratively and used graphs and tables to present key concepts thematically.

RESULTS

We included 66 studies. We categorised the studies according to population, type of intervention, outcomes and user satisfaction. Most of the studies involved pathological (36%) and physiological (30%) pregnancy management, the type of intervention was mainly divided into televisits or video calls with professionals (43%) and the use of specific apps or devices (40%). The maternal outcomes studied were mainly quantitative, i.e., improvement in blood chemistry tests or vital parameters (65%) and treatment adherence (frequency of follow-up visits or keeping appointments, 27%). Patient satisfaction was positive in the majority of cases.

CONCLUSIONS

There is still little international agreement on the concept and possible applications of telemedicine in obstetrics, although it is increasingly being used in clinical practice. Studies have shown positive results in terms of improved care, particularly in terms of treatment adherence and as an alternative strategy in the management of pregnancy, postpartum and abortion care. Both patients and health professionals were satisfied with it, especially when offered as a complement or alternative to the traditional method of face-to-face visits. Future developments seem to be the time and cost-saving potential of telemedicine and its application to couples' infertility.

Experience Counts: Unveiling Patients' Willingness to Pay for Remote Monitoring and Patient Self-Measurement

OBJECTIVES

This study aimed to (1) estimate patients' willingness to pay (WTP) for remote monitoring (RM) and patient self-measurement (PSM) for pregnant women at risk of gestational hypertensive disorders, (2) assess the impact of experience with these technologies on WTP, and (3) determine their impact on health-related quality of life (HRQoL).

METHODS

Data collection was part of a multicentric randomized controlled trial, Pregnancy Remote Monitoring II, with 2 interventions: RM and PSM. A contingent valuation survey, combining a payment card and open-ended question, was completed twice by 199 participants. Two-part models analyze the impact of experience on WTP, regression models estimated using ordinary least squares the impact of RM and PSM on HRQoL.

RESULTS

The mean WTP amount was approximately €120 for RM and €80 for PSM. Compared with having no experience, WTP RM was €63 higher after a long-term exposure to RM (P = .01) and WTP PSM was €26 lower after a short-term exposure to RM (P = .07). No significant impact of RM or PSM on HRQoL was found.

CONCLUSIONS

This study contributes to the discussion on the impact of experience on WTP. Those who had a long-term experience with RM, were willing to pay more for RM than those without experience. This confirms our hypothesis that involving patients without experience with the valued treatment, possibly underestimates WTP. A long-term experience has, however, no impact on the WTP for technologies for which the potential benefits are apparent without experiencing them, such as PSM.

Changes in Intrapersonal Factors of Participants in the Pregnancy Remote Monitoring Study Who Are at Risk for Pregnancy-Induced Hypertension: Descriptive Quantitative Study

BACKGROUND

The peripartum period, defined as the period from the beginning of the gestation until 1 year after the delivery, has long been shown to be potentially associated with increased levels of stress and anxiety with regard to one's transition to the status of parent and the accompanying parental tasks. Yet, no research to date has investigated changes in intrapersonal factors during the peripartum period in women at risk for pregnancy-induced hypertension (PIH).

OBJECTIVE

The aim of this study is to explore and describe changes in intrapersonal factors in participants at risk for PIH.

METHODS

We used an explorative design in which 3 questionnaires were sent by email to 110 participants the day following enrollment in the Pregnancy Remote Monitoring program for pregnant women at risk for PIH. Women were invited to complete the questionnaires at the beginning of their participation in the Pregnancy Remote Monitoring project (mostly at 14 weeks of gestation) and after approaching 32 weeks of gestational age (GA). The Generalized Anxiety Disorder-7 Scale (GAD-7) and the Patient Health Questionnaire-9 were used to assess anxiety and depression, and adaptation of the Pain Catastrophizing Scale was used to measure trait pain catastrophizing.

RESULTS

Scores were significantly higher at 32 weeks of GA than at the moment of enrollment (GAD-7 score=7, range 4-11 vs 5, range 3-8; P=.01; and Patient Health Questionnaire-9 score=6, range 4-10 vs 4, range 2-7; P<.001). The subscale scores of the Pain Catastrophizing Scale were all lower at 32 weeks of GA compared with 14 weeks of GA (rumination: 4, range 1-6 vs 5, range 2-9.5; P=.11; magnification: 3, range 1-5.5 vs 4, range 3-7; P=.04; and helplessness: 5, range 2-9 vs 6, range 3.5-12; P=.06). The proportion of women with a risk for depression (GAD-7 score >10) was 13.3% (10/75) at enrollment and had increased to 35.6% (26/75) at 32 weeks of GA.

CONCLUSIONS

This study shows that pregnant women at risk for PIH have higher levels of stress and anxiety at 32 weeks of GA than at the moment of enrollment. Further research is recommended to investigate potential strategies to help pregnant women at risk for PIH manage feelings of stress and anxiety.

TRIAL REGISTRATION

ClinicalTrials.gov NCT03246737; https://clinicaltrials.gov/study/NCT03246737.

An evaluation of the efficacy and the safety of home blood pressure monitoring in the control of hypertensive disorders of pregnancy in both pre and postpartum periods: a systematic review and meta-analysis

BACKGROUND

Hypertensive disorders of pregnancy (HDP) can significantly impact maternal, neonatal, and fetal health. For controlling these disorders, frequent blood pressure measurements are required. Home blood pressure monitoring (HBPM) is a suggested alternative to conventional office monitoring that requires frequent visits. This systematic review was conducted to evaluate the efficacy and safety of HBPM in the control of HDP.

METHODS

We systematically conducted databases search for relevant studies in June 2022. The relevant studies were identified, and qualitative synthesis was performed. An inverse variance quantitative synthesis was conducted using RevMan software. Continuous outcome data were pooled as means differences, whereas dichotomous ones were summarized as risk ratios. The 95% confidence interval was the measure of variance.

RESULTS

Fifteen studies were included in our review (n = 5335). Our analysis revealed a superiority of HBPM in reducing the risk of induction of labor, and postpartum readmission (P = 0.02, and 0.01 respectively). Moreover, the comparison of birth weights showed a significant variation in favor of HBPM (P = 0.02). In the analysis of other outcomes, HBPM was equally effective as office monitoring. Furthermore, HBPM did not result in an elevated risk of maternal, neonatal, and fetal adverse outcomes.

CONCLUSION

Home monitoring of blood pressure showed superiority over office monitoring in some outcomes and equal efficacy in other outcomes.

Remote blood pressure monitoring in high risk pregnancy - study protocol for a randomised controlled trial (REMOTE CONTROL trial)

BACKGROUND

Pregnant women at high risk for developing a hypertensive disorder of pregnancy require frequent antenatal assessments, especially of their blood pressure. This expends significant resources for both the patient and healthcare system. An alternative to in-clinic assessments is a remote blood pressure monitoring strategy, in which patients self-record their blood pressure at home using a validated blood pressure machine. This has the potential to be cost-effective, increase patient satisfaction, and reduce outpatient visits, and has had widespread uptake recently given the increased need for remote care during the ongoing COVID-19 pandemic. However robust evidence supporting this approach over a traditional face-to-face approach is lacking, and the impact on maternal and foetal outcomes has not yet been reported. Thus, there is an urgent need to assess the efficacy of remote monitoring in pregnant women at high risk of developing a hypertensive disorder of pregnancy.

METHODS

The REMOTE CONTROL trial is a pragmatic, unblinded, randomised controlled trial, which aims to compare remote blood pressure monitoring in high-risk pregnant women with conventional face-to-face clinic monitoring, in a 1:1 allocation ratio. The study will recruit patients across 3 metropolitan Australian teaching hospitals and will evaluate the safety, cost-effectiveness, impact on healthcare utilisation and end-user satisfaction of remote blood pressure monitoring.

DISCUSSION

Remote blood pressure monitoring is garnering interest worldwide and has been increasingly implemented following the COVID-19 pandemic. However, robust data regarding its safety for maternofoetal outcomes is lacking. The REMOTE CONTROL trial is amongst the first randomised controlled trials currently underway, powered to evaluate maternal and foetal outcomes. If proven to be as safe as conventional clinic monitoring, major potential benefits include reducing clinic visits, waiting times, travel costs, and improving delivery of care to vulnerable populations in rural and remote communities.

TRIAL REGISTRATION

The trial has been prospectively registered with the Australian and New Zealand Clinical Trials Registry (ACTRN12620001049965p, on October 11th, 2020).

Use of Cellular-Enabled Remote Patient Monitoring Device for Hypertension Management in Pregnant Women: A Feasibility Study

INTRODUCTION

Hypertension affects 5-10% of pregnancies in the United States. Chronic hypertension during pregnancy can have a significant impact on maternal and neonatal outcomes, especially in rural populations. Pregnancies complicated by hypertension are currently managed through frequent clinic visits or extended hospital stays. Cellular-enabled remote patient monitoring devices provide an alternative treatment method for women in rural areas.

RESEARCH AIM

This study aimed to measure the feasibility of and patient satisfaction with using an integrated model of cellular-enabled remote patient monitoring devices for blood pressure supported by a 24/7 nurse call center.

METHODS

In a mixed methods pilot study, twelve women with chronic hypertension during pregnancy were given cellular-enabled BodyTrace^™ blood pressure cuffs and weight scales. Participants' blood pressures were continuously monitored by a nurse call center. Participants completed a survey and a brief semi-structured interview after two weeks.

RESULTS

Participants scored low on stress and anxiety with mean scores of 5.45 (SD = 3.56) and 8.09 (SD 3.62), respectively. Participants scored high on behavioral intention, system usability, and perceived benefits with mean scores of 8.73 (SD = 2.53), 75.91 (SD = 23.70), and 19.64 (SD = 5.92), respectively. Participants perceived benefits to using the device, including increased monitoring by health professionals, increased self-awareness, decreased number of clinic visits, and convenience of use. Perceived disadvantages included higher readings when compared to clinical readings.

DISCUSSION

Cellular-enabled remote patient monitoring devices for blood pressure are a valuable tool for managing treatment of pregnancies complicated by hypertension.

Beat-to-beat fetal heart rate analysis using portable medical device and wavelet transformation technique

Objective: Beat-to-beat tele-fetal monitoring and comparison with clinical data are studied with a wavelet transformation approach. Tele-fetal monitoring is a big progress toward a wearable medical device for pregnant women capable of obtaining prenatal care at home. Study Design: We apply a wavelet transformation algorithm for fetal cardiac monitoring using a portable fetal Doppler medical device. After an investigation of 85 different mother wavelets, a bio-orthogonal 2.2 mother wavelet in level 4 of decomposition is chosen. The efficiency of the proposed method is evaluated using two data sets including public and clinical. Results: From publicly available data on PhysioBank, and simultaneous clinical measurement, we prove that the comparison between obtained fetal heart rate by the algorithm and the baselines yields a promising accuracy beyond 95%. Conclusion: Finally, we conclude that the proposed algorithm would be a robust technique for any similar tele-fetal monitoring approach.

Preeclampsia prediction with blood pressure measurements: A global external validation of the ALSPAC models

OBJECTIVE

The prediction of preeclampsia in pregnancy has resulted in a plethora of prognostic models. Yet, very few make it past the development stage and most fail to influence clinical practice. The timely identification of high-risk pregnant women could deliver a tailored antenatal care regimen, particularly in low-resource settings. This study externally validated and calibrated previously published models that predicted the risk of preeclampsia, based on blood pressure (BP) at multiple time points in pregnancy, in a geographically diverse population.

METHODS

The prospective INTERBIO-21st Fetal Study included 3,391 singleton pregnancies from Brazil, Kenya, Pakistan, South Africa, Thailand and the UK, 2012-2018. Preeclampsia prediction was based on baseline characteristics, BP and deviation from the expected BP trajectory at multiple time points in pregnancy. The prediction rules from the Avon Longitudinal Study of Parents and Children (ALSPAC) were implemented in the INTERBIO-21st cohort.

RESULTS

Model discrimination was similar to the development cohort. Performance was best with baseline characteristics and a BP measurement at 34 weeks' gestation (AUC 0.85, 95 % CI 0.80-0.90). The ALSPAC models largely overestimated the true risk of preeclampsia incidence in the INTERBIO-21st cohort.

CONCLUSIONS

After recalibration, these prediction models could potentially serve as a risk stratifying tool to help identify women who might benefit from increased surveillance during pregnancy.

Telehealth Strategies for the Delivery of Maternal Health Care : A Rapid Review

BACKGROUND

Telehealth strategies to supplement or replace in-person maternity care may affect maternal health outcomes.

PURPOSE

To conduct a rapid review of the effectiveness and harms of telehealth strategies for maternal health care given the recent expansion of telehealth arising from the COVID-19 pandemic, and to produce an evidence map.

DATA SOURCES

Systematic searches of MEDLINE, the Cochrane Library, CINAHL, Embase, and Scopus for English-language studies (January 2015 to April 2022).

STUDY SELECTION

Randomized controlled trials (RCTs) and observational studies of maternal care telehealth strategies versus usual care.

DATA EXTRACTION

Dual data extraction and risk-of-bias assessment of studies, with disagreements resolved through consensus.

DATA SYNTHESIS

28 RCTs and 14 observational studies (n = 44 894) were included. Maternal telehealth interventions supplemented in-person care for most studies of mental health and diabetes during pregnancy, primarily resulting in similar, and sometimes better, clinical and patient-reported outcomes versus usual care. Supplementing in-person mental health care with phone- or web-based platforms or mobile applications resulted in similar or better mental health outcomes versus in-person care. A reduced-visit prenatal care schedule using telehealth to replace in-person general maternity care for low-risk pregnancies resulted in similar clinical outcomes and higher patient satisfaction versus usual care. Overall, telehealth strategies were heterogeneous and resulted in similar obstetric and patient satisfaction outcomes. Few studies addressed disparities, health equity, or harms.

LIMITATIONS

Interventions varied, and evidence was inadequate for some clinical outcomes.

CONCLUSION

Replacing or supplementing in-person maternal care with telehealth generally results in similar, and sometimes better, clinical outcomes and patient satisfaction compared with in-person care. The effect on access to care, health equity, and harms is unclear.

PRIMARY FUNDING SOURCE

Patient-Centered Outcomes Research Institute. (PROSPERO: CRD42021276347).

Self-monitoring of blood pressure among women with hypertensive disorders of pregnancy: a systematic review

BACKGROUND

The World Health Organization (WHO) recommends self-monitoring of blood pressure (SMBP) for hypertension management. In addition, during the COVID-19 response, WHO guidance also recommends SMBP supported by health workers although more evidence is needed on whether SMBP of pregnant individuals with hypertension (gestational hypertension, chronic hypertension, or pre-eclampsia) may assist in early detection of pre-eclampsia, increase end-user autonomy and empowerment, and reduce health system burden. To expand the evidence base for WHO guideline on self-care interventions, we conducted a systematic review of SMBP during pregnancy on maternal and neonatal outcomes.

METHODS

We searched for publications that compared SMBP with clinic-based monitoring during antenatal care. We included studies measuring any of the following outcomes: maternal mortality, pre-eclampsia, long-term risk and complications, autonomy, HELLP syndrome, C-section, antenatal hospital admission, adverse pregnancy outcomes, device-related issues, follow-up care with appropriate management, mental health and well-being, social harms, stillbirth or perinatal death, birthweight/size for gestational age, and Apgar score. After abstract screening and full-text review, we extracted data using standardized forms and summarized findings. We also reviewed studies assessing values and preferences as well as costs of SMBP.

RESULTS

We identified 6 studies meeting inclusion criteria for the effectiveness of SMBP, 6 studies on values and preferences, and 1 study on costs. All were from high-income countries. Overall, when comparing SMBP with clinic-monitoring, there was no difference in the risks for most of the outcomes for which data were available, though there was some evidence of increased risk of C-section among pregnant women with chronic hypertension. Most end-users and providers supported SMBP, motivated by ease of use, convenience, self-empowerment and reduced anxiety. One study found SMBP would lower health sector costs.

CONCLUSION

Limited evidence suggests that SMBP during pregnancy is feasible and acceptable, and generally associated with maternal and neonatal health outcomes similar to clinic-based monitoring. However, more research is needed in resource-limited settings.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42021233839 .

Triage of antenatal care through telehealth during COVID-19 pandemic in a tertiary care centre of North India

Background:

Telemedicine facilitates patient care in various fields including antenatal care. Its application and usefulness need objectification and can be a guide to using this service in the care of pregnant women.

Material and Methods:

This was a prospective observational study conducted from May 2020 to December 2020. Following the telemedicine practice guideline of the country, 3,360 teleconsultations were sought by 862 antenatal patients. The duration of each call, an indication of referral and pregnancy risk stratification were noted. Further management was classified into three categories depending upon the need for an immediate hospital visit, no hospital visit or scheduled visit after at least 48 h after the first contact.

Results:

The antenatal cases were referred for either maternal, foetal or both indications in 24.7, 54.8 and 20.5% of the cases, respectively. Women were classified as low risk (61.6%), high risk (35.7%) and severe risk (2.7%). In 1.4% of the patients, history and review of the records could not be done through telemedicine. The average time spent was 16.6 min for the first contact and 3.1 min for subsequent contacts. Further management was done with immediate visits in 385 (45.3%), scheduled hospital visits in 292 (34.3%) women and no tertiary care hospital visit in 173 (20.4%).

Discussion:

Women (20.4%) not called to the maternal-foetal medicine department of the institute were managed along with the treating obstetrician and no difference in pregnancy outcome was noted.

Conclusion:

Antenatal care can be provided following triage over teleconsultation and 1.4% of the women may not be able to use telehealth.

[Smart sensors in pregnancy: Narrative review on the use of smart home technology in routine prenatal care]

INTRODUCTION

Today's routine prenatal care in Germany includes regular in-person appointments of pregnant women with doctors or midwives. Considering an increasing digitalization of the health care sector and in view of the global COVID-19 pandemic, the frequency of in-person visits could be reduced by remote monitoring using smart sensor technology. We aim to give an overview of the current international research on the use of smart sensors in prenatal care and its benefits, costs and resource consumption.

METHODS

For this narrative review, PubMed and Science Direct were searched for clinical trials using smart sensors in prenatal care published in English or German language from 1/2016 to 12/2020. We included studies which addressed the benefits, costs and resource consumption of this innovative technology.

RESULTS

We identified 13 projects using smart sensors in the fields of basic prenatal care, prenatal care for patients with hypertensive disease in pregnancy and prenatal care for women with gestational diabetes. The projects detected positive effects of smart sensors on health care costs and resource consumption and at least equal benefits for the pregnant women.

DISCUSSION AND CONCLUSIONS

The current COVID-19 pandemic underlines the need for the introduction of smart sensor technology into German prenatal care routine. Remote monitoring could easily reduce the frequency of in-person visits by half. Smart sensor concepts could be approved as digital health applications in Germany. In order to increase user acceptance, there should not be any additional costs for pregnant women and health care professionals using modern health care apps. However, health insurance providers need to invest in smart sensor technology in order to eventually benefit from it.

SAFE@HOME: Cost analysis of a new care pathway including a digital health platform for women at increased risk of preeclampsia

OBJECTIVE

To perform a cost analysis of the use of a new care pathway with a digital health platform for blood pressure telemonitoring for women at risk of preeclampsia.

STUDY DESIGN

This is a cost analysis of a case-control study with women with chronic hypertension, history of preeclampsia, maternal cardiac or kidney disease at intake of pregnancy. Antenatal care with a reduced visit schedule and a digital health platform (SAFE@HOME, n = 97) was compared to a retrospective control group (n = 133) with usual care without self-monitoring.

MAIN OUTCOME MEASURES

Costs per pregnancy (€) of healthcare consumption of antenatal clinic visits, ultrasound assessments, antenatal admissions, laboratory and other diagnostic tests, and societal costs such as traveling and work absence.

RESULTS

Baseline characteristics and perinatal outcomes were similar between both groups. A significant reduction of antenatal visits, ultrasounds and hypertension-related admissions was associated with use of the digital platform. In the SAFE@HOME group, costs of antenatal care, including the costs of the digital platform, were 19.7% lower compared to the control group (median €3616 [IQR 3071 - 5329] vs €4504 [IQR 3515-6923], p = 0.001). Total costs per pregnancy, including societal costs, were also reduced (€7485 [IQR 6338-10,173] vs €9150, [IQR 7546-12,286] p < 0.001). Each euro invested in the platform saved on average €8 of antenatal care resources.

CONCLUSION

The use of a digital platform for blood pressure and symptom monitoring in antenatal care for high-risk women is associated with lower costs compared to conventional care, while observed maternal and neonatal outcomes are similar.

[Ambulatory and Home Blood Pressure Measurement in Hypertensive Pregnant Women]

The prevalence of hypertensive disorders in pregnancy (HDP) is 6-8%. Blood pressure measurement (BPM) remains the cornerstone of diagnosis and should be performed in a standardised manner using automated devices. Office BPM represents only a spotty reading in an "artificial" environment failing to diagnose white coat hypertension (WCH). Ambulatory and home blood pressure measurement (ABPM/HBPM) are recommended for the diagnosis and differentiation of hypertension as well as for blood pressure and therapy control in women with HDP. Patient compliance is crucial for the use of both methods. ABPM is an appropriate method for the early identification of WCH and masked hypertension as well as for differentiating WCH from chronic hypertension < 20 week's gestation. HBPM has been shown to reduce the number of antenatal visits and hospital admissions compared to office blood pressure measurement without compromising maternal and fetal outcomes; it also avoids unnecessary antihypertensive medications and reduces the rate of labour inductions and false diagnosis of "preeclampsia". Problems associated with ABPM are its limited availability and inconvenience to patients due to sleep disturbances. Disadvantages of HBPM are the need for patient training, potential measurement errors, and the lack of evidence-based BP thresholds. The widespread use especially of HBPM may contribute to a reduction in workload of obstetric staff in the hospital and may save hospital expense.

Design of the Pregnancy REmote MOnitoring II study (PREMOM II): a multicenter, randomized controlled trial of remote monitoring for gestational hypertensive disorders

Background

Observational data from the retrospective, non-randomized Pregnancy REmote MOnitoring I (PREMOM I) study showed that remote monitoring (RM) may be beneficial for prenatal observation of women at risk for gestational hypertensive disorders (GHD) in terms of clinical outcomes, health economics, and stakeholder perceptions. PREMOM II is a prospective, randomized, multicenter follow-up study that was performed to explore these promising results.

Methods

After providing written consent, 3922 pregnant women aged ≥18 years who are at increased risk of developing GHD will be randomized (1:1:1 ratio) to (a) conventional care (control group), (b) a patient self-monitoring group, and (c) a midwife-assisted RM group. The women in each group will be further divided (1:1 ratio) to evaluate the outcomes of targeted or non-targeted (conventional) antihypertensive medication. Women will be recruited in five hospitals in Flanders, Belgium: Ziekenhuis Oost-Limburg, Universitaire Ziekenhuis Antwerpen, Universitaire Ziekenhuis Leuven, AZ Sint Jan Brugge–Oostende, and AZ Sint Lucas Brugge. The primary outcomes are: (1) numbers and types of prenatal visits; (2) maternal outcomes; (3) neonatal outcomes; (4) the applicability and performance of RM; and (5) compliance with RM and self-monitoring. The secondary outcomes are: (1) cost-effectiveness and willingness to pay; (2) patient-reported outcome measures (PROMS) questionnaires on the experiences of the participants; and (3) the maternal and perinatal outcomes according to the type of antihypertensive medication. Demographic, and maternal and neonatal outcomes are collected from the patients’ electronic records. Blood pressure and compliance rate will be obtained from an online digital coordination platform for remote data handling. Information about the healthcare-related costs will be obtained from the National Coordination Committee of Belgian Health Insurance Companies (Intermutualistisch Agentschap). PROMS will be assessed using validated questionnaires.

Discussion

To our knowledge, this is the first randomized trial comparing midwife-assisted RM and self-monitoring of prenatal blood pressure versus conventional management among women at increased risk of GHD. Positive results of this study may lead to a practical framework for caregivers, hospital management, and payers to introduce RM into the prenatal care programs of high-risk pregnancies.

Trial registration

This study was registered on clinicaltrials.gov, identification number NCT04031430. Registered 24 July 2019, https://clinicaltrials.gov/ct2/show/NCT04031430?cond=premom+ii&draw=2&rank=1.

Exploring perspectives, preferences and needs of a telemonitoring program for women at high risk for preeclampsia in a tertiary health facility of Karachi: a qualitative study protocol

Background

In Pakistan, deaths from preeclampsia/eclampsia (PE/E) represent one-third of maternal deaths reported at tertiary care hospitals. To reduce the morbidity and mortality associated with PE/E, an accessible strategy is to support pregnant women at high risk for preeclampsia (HRPE) by closely monitoring their blood pressures at home (i.e., telemonitoring) for the earliest signs of preeclampsia. This could lead to the earliest possible detection of high blood pressure, resulting in early intervention such as through medications, hospitalization, or delivery of the baby. The study aims to explore the perspectives, preferences and needs of telemonitoring (TM) for pregnant women at HRPE in Karachi, to inform future implementation strategies.

Methods

The study will employ an exploratory qualitative research design. The study will be conducted at the Jinnah Postgraduate Medical Centre (JPMC) hospital and Aga Khan University Hospital (AKUH) in Karachi, Sindh, Pakistan. Data will be collected through key-informant interviews (KIIs) and in-depth patient interviews (IDPIs). IDPIs will be conducted with the pregnant women at HRPE who are visiting the out-patient department/ antenatal clinics of JPMC hospital for antenatal check-ups and immunizations. KIIs will be conducted with the obstetricians, Maternal, neonatal and child health (MNCH) specialists and health care providers at JPMC, as well as TM experts from Karachi. Study data will be analyzed through conventional content analysis. Interviews are anticipated to begin in April 2020 and to be completed during the summer of 2020.

Discussion

This is the first study to explore the use of TM program for pregnant women at HRPE in a tertiary health facility in Karachi. The research will help explore perceived benefits associated with the use of a TM program alongside potential facilitators and barriers that may help inform the future implementation of a TM program for pregnant women at HRPE in Karachi.

SAFE@HOME: Digital health platform facilitating a new care path for women at increased risk of preeclampsia - A case-control study

OBJECTIVE

In women at risk of developing preeclampsia, we evaluated the use of a digital health platform for telemonitoring blood pressure and symptoms combined with a minimal antenatal visit schedule.

STUDY DESIGN

A case-control study for women with chronic hypertension, history of preeclampsia, or maternal cardiac or kidney disease. A care path was designed with reduced visits enhanced with a digital platform (SAFE@HOME) for daily blood pressure and symptom monitoring starting from 16 weeks of gestation. Home-measurements were monitored in-hospital by obstetric professionals, taking actions upon alarming results. This prospective SAFE@HOME group was compared to a retrospective control group managed without self-monitoring.

MAIN OUTCOME MEASURES

Primary: healthcare consumption (number of antenatal visits, ultrasounds, admissions and diagnostics), user experiences of the platform. Secondary: maternal and perinatal outcomes.

RESULTS

Baseline characteristics of the SAFE@HOME (n = 103) and control group (n = 133) were comparable. In the SAFE@HOME group, antenatal visits (mean 13.7 vs 16.0, p < 0.001) and ultrasounds (6.3 vs 7.4, p = 0.005) were lower compared to the control group. Admissions for hypertension or suspected preeclampsia were significantly fewer in the SAFE@HOME group (2.9% versus 13.5%, p = 0.004). Telemonitoring participants were highly satisfied using the platform. No differences were observed for maternal and perinatal outcomes.

CONCLUSIONS

Our care path including blood pressure telemonitoring for women at risk of preeclampsia allows fewer antenatal visits, ultrasounds and hypertension-related admissions. We observed no differences in perinatal outcomes. These results suggest that telemonitoring of blood pressure is feasible in a high-risk pregnant population and has the potential to profoundly change antenatal care.

Using mHealth in postpartum women with pre-eclampsia: Lessons learned from a qualitative study

OBJECTIVE

To explore perceptions and attitudes of postpartum women with pre-eclampsia towards remote monitoring (mHealth) and communication with the call center.

METHODS

A non-randomized cohort study was conducted in postpartum hypertensive women, recruited from a tertiary hospital between October 2015 and February 2016. Participants were categorized into users (using mHealth) and non-users (not using mHealth) to monitor vital signs at home over a 2-week period after discharge. Non-users were informed about functionality of mHealth. Both groups participated in a 30-minute phone interview at the end of the study. Directed content analysis of interview transcripts was conducted.

RESULTS

In total, 21 users and 16 non-users participated in the interview. Both groups perceived that mHealth helped manage their condition. However, non-users were concerned about the challenge of incorporating mHealth into their routine, whereas users mentioned that they liked using mHealth on a daily basis. They also stated that communication with nurses in the call center was helpful. Barriers identified by users included size of the blood pressure cuffs, size of the equipment set, wireless connection, and stress associated with mHealth monitoring. Users stated that they would have preferred using mHealth during pregnancy.

CONCLUSION

The findings provide useful insights to inform a successful remote monitoring program among perinatal and postpartum women.

Telemedicine in High-Risk Obstetrics

Telemedicine involves the use of technology to provide services to patients and share medical information. Telemedicine's use has increased as technology has advanced. It allows for medicine to be practiced from a distance to reach patients in rural or underserved areas. Telemedicine has widespread uses in high-risk obstetrics, including management of diabetes, diagnosis and management of hypertensive disorders of pregnancy, screening for fetal malformations with teleultrasound, delivering care to underserved areas, and more. The use of telemedicine to provide care to patients and information to health care providers at a distance has been well accepted by the patients and providers.

Exploring the Use of Telemonitoring for Patients at High Risk for Hypertensive Disorders of Pregnancy in the Antepartum and Postpartum Periods: Scoping Review

Background

High blood pressure complicates 2% to 8% of pregnancies, and its complications are present in the antepartum and postpartum periods. Blood pressure during and after pregnancy is routinely monitored during clinic visits. Some guidelines recommend using home blood pressure measurements for the management and treatment of hypertension, with increased frequency of monitoring for high-risk pregnancies. Blood pressure self-monitoring may have a role in identifying those in this high-risk group. Therefore, this high-risk pregnancy group may be well suited for telemonitoring interventions.

Objective

The aim of this study was to explore the use of telemonitoring in patients at high risk for hypertensive disorders of pregnancy (HDP) during the antepartum and postpartum periods. This paper aims to answer the following question: What is the current knowledge base related to the use of telemonitoring interventions for the management of patients at high risk for HDP?

Methods

A literature review following the methodological framework described by Arksey et al and Levac et al was conducted to analyze studies describing the telemonitoring of patients at high risk for HDP. A qualitative study, observational studies, and randomized controlled trials were included in this scoping review.

Results

Of the 3904 articles initially identified, 20 met the inclusion criteria. Most of the studies (13/20, 65%) were published between 2017 and 2018. In total, there were 16 unique interventions described in the 20 articles, all of which provide clinical decision support and 12 of which are also used to facilitate the self-management of HDP. Each intervention’s design and process of implementation varied. Overall, telemonitoring interventions for the management of HDP were found to be feasible and convenient, and they were used to facilitate access to health services. Two unique studies reported significant findings for the telemonitoring group, namely, spontaneous deliveries were more likely, and one study, reported in two papers, described inductions as being less likely to occur compared with the control group. However, the small study sample sizes, nonrandomized groups, and short study durations limit the findings from the included articles.

Conclusions

Although current evidence suggests that telemonitoring could provide benefits for managing patients at high risk for HDP, more research is needed to prove its safety and effectiveness. This review proposes four recommendations for future research: (1) the implementation of large prospective studies to establish the safety and effectiveness of telemonitoring interventions; (2) additional research to determine the context-specific requirements and patient suitability to enhance accessibility to healthcare services for remote regions and underserved populations; (3) the inclusion of privacy and security considerations for telemonitoring interventions to better comply with healthcare information regulations and guidelines; and (4) the implementation of studies to better understand the effective components of telemonitoring interventions.

Mobile Health Applications for Prenatal Assessment and Monitoring

BACKGROUND

A mobile health application is an exciting, fast-paced domain that is likely to improve prenatal care.

METHODS

In this narrative review, we summarise the use of mobile health applications in this setting with a special emphasis on both the benefits of remote monitoring devices and the potential pitfalls of their use, highlighting the need for robust regulations and guidelines before their widespread introduction into prenatal care.

RESULTS

Remote monitoring devices for four areas of prenatal care are reported: (1) cardio-tocography; (2) blood glucose levels; (3) blood pressure; and (4) prenatal ultrasound. The majority of publications are pilot projects on remote consultation, education, coaching, screening, monitoring and selective booking, mostly reporting potential medical and/or economic benefits by mobile health applications over conventional care for very specific situations, indications and locations, but not always generalizable.

CONCLUSIONS

Despite the potential advantages of these devices, some caution must be taken when implementing this technology into routine daily practice. To date, the majority of published research on mobile health in the prenatal setting consists of observational studies and there is a need for high-quality randomized controlled trials to confirm the reported clinical and economic benefits as well as the safety of this technology. There is also a need for guidance and governance on the development and validation of new apps and devices and for the implementation of mobile health technology into healthcare systems in both high and low-income settings. Finally, digital communication technologies offer perspectives towards exploration and development of the very new domain of tele-pharmacology.

Home blood pressure monitoring in the antenatal and postpartum period: A systematic review meta-analysis

Recent evidence suggests that home blood pressure monitoring (HBPM) is an effective way of managing women with hypertensive disorders of pregnancy (HDP) without increasing adverse outcomes. The aim of this systematic review and meta-analysis was to investigate the safety and efficacy of HBPM during pregnancy. Medline, EMBASE and the Cochrane library databases were searched electronically in November 2018. Studies were included from which data could be extracted on the pregnancy outcomes and included pregnancies with HDP or at increased risk of developing HDP. Data from nine studies were included in the meta-analysis. The use of HBPM during the antenatal period was associated with reduced risk of induction of labor (OR: 0.55, 95% CI: 0.36-0.82, 444 women, I² = 0%), prenatal hospital admissions (OR: 0.31, 95% CI: 0.19-0.49, 416 women, I² = 0%) and diagnosis of preeclampsia (OR: 0.50, 95% CI: 0.31-0.81, 725 women, I² = 37%). The number of antenatal visits was significantly less in the HBPM group (standard mean difference: -0.49, 95% CI: -0.82 to -0.16, 738 women, I² = 75%). There were no significant differences between HBPM and conventional care regarding composite maternal, fetal or neonatal outcomes when used during the antenatal period. There were no significant differences between the groups who had HBPM compared to those who had conventional care regarding postpartum readmissions and obtaining a blood pressure measurement within 10 days of delivery after discharge. The significant clinical heterogeneity and low quality of evidence are the main limitations, and therefore, more high quality studies are needed.

Experiences of women receiving mhealth-supported antenatal care in the village from community health workers in rural Burkina Faso, Africa

Objective

This qualitative study explored the experiences of women receiving mhealth-supported antenatal care in a village, from community health workers (CHWs) in rural Burkina Faso, Africa.

Intervention

CHWs entered patient clinical data manually in their smartphone during their home visits. All wireless transferred data was monitored by the midwives in the community clinic for arising medical complications.

Methods

Semi-structured interviews were conducted with 19 pregnant women, who were housewives, married and their age ranged from 18 to 39 years. None had completed their formal education. Depending on the weeks of gestation during their first antenatal care visit, length of enrollment in the project varied between three and eight months. Transcripts were content-analyzed.

Results

Despite the fact that mhealth was a novel service for all participants, they expressed appreciation for these interventions, which they found beneficial on three levels: 1) it allowed for early detection of pregnancy-related complications, 2) it was perceived as promoting collaboration between CHWs and midwives, and 3) it was a source of reassurance during a time when they are concerned about their health. Although not unanimous, certain participants said their husbands were more interested in their antenatal care as a result of these services.

Conclusion

Findings suggested that mhealth-supported visits of the CHWs have the potential to increase mothers’ knowledge about their pregnancy and, as such, motivate them to attend more ANC visits. In response to this increased patient engagement, midwives approached women differently, which led to the mothers’ perception of improvement in the patient–provider relationship. Results also indicated that mhealth may increase spousal involvement, as services are offered at home, which is an environment where spouses feel more comfortable.

A Vendor-Independent Mobile Health Monitoring Platform for Digital Health Studies: Development and Usability Study

Background

Medical smartphone apps and mobile health devices are rapidly entering mainstream use because of the rising number of smartphone users. Consequently, a large amount of consumer-generated data is being collected. Technological advances in innovative sensory systems have enabled data connectivity and aggregation to become cornerstones in developing workable solutions for remote monitoring systems in clinical practice. However, few systems are currently available to handle such data, especially for clinical use.

Objective

The aim of this study was to develop and implement the digital health research platform for mobile health (DHARMA) that combines data saved in different formats from a variety of sources into a single integrated digital platform suitable for mobile remote monitoring studies.

Methods

DHARMA comprises a smartphone app, a Web-based platform, and custom middleware and has been developed to collect, store, process, and visualize data from different vendor-specific sensors. The middleware is a component-based system with independent building blocks for user authentication, study and patient administration, data handling, questionnaire management, patient files, and reporting.

Results

A prototype version of the research platform has been tested and deployed in multiple clinical studies. In this study, we used the platform for the follow-up of pregnant women at risk of developing pre-eclampsia. The patients’ blood pressure, weight, and activity were semi-automatically captured at home using different devices. DHARMA automatically collected and stored data from each source and enabled data processing for the end users in terms of study-specific parameters, thresholds, and visualization.

Conclusions

The increasing use of mobile health apps and connected medical devices is leading to a large amount of data for collection. There has been limited investment in handling and aggregating data from different sources for use in academic and clinical research focusing on remote monitoring studies. In this study, we created a modular mobile health research platform to collect and integrate data from a variety of third-party devices in several patient populations. The functionality of the platform was demonstrated in a real-life setting among women with high-risk pregnancies.

Being 'A Google Mom' or securely monitored at home: Perceptions of remote monitoring in maternity care

AIMS

To understand the perspectives of both healthcare professionals in maternity care and pregnant women with higher risk pregnancies about remote monitoring in maternity care.

DESIGN

Qualitative descriptive design.

METHODS

Individual and focus group interviews were conducted in public maternity care and in a level III hospital in Finland during April-May 2018. The sample consisted of healthcare professionals working in the primary care and at the hospital and hospitalized pregnant women. Altogether, 17 healthcare professionals and 4 pregnant women participated in the study. The data were analysed using inductive thematic network analysis.

RESULTS

Many possibilities - and an equal number of concerns - were identified regarding remote monitoring in pregnancy, depending on the respondent's viewpoint from holistic to symptom-centred care. Healthcare staff had reservations about technology due to previous negative experiences and difficulties trusting technology. The pregnant women thought that monitoring would ease the staff's workload if the latter had enough technological skills. Remote monitoring could increase security in pregnancy care but create a feeling of false security if the women ignored their subjective symptoms. Face-to-face visits and the uniqueness of human contact were strongly favoured. Pregnant women wished to use monitoring as a confirmation of their subjective feelings.

CONCLUSION

Remote monitoring could be used as a supplementary system in pregnancy care, although it could replace only some healthcare visits. Pregnant women identified more possibilities for remote monitoring compared with the staff members both in primary care and the hospital.

IMPACT

A comprehensive understanding of pregnant women's and healthcare professionals' perceptions of remote monitoring in pregnancy was built to be able to develop new technologies in maternity care. In certain cases, remote monitoring would supplement traditional pregnancy follow-ups. Staff in primary and specialized care, and healthcare managers, should support teamwork to be able to understand different approaches to pregnancy care.

Relationship Between Adherence to Remote Monitoring and Patient Characteristics: Observational Study in Women With Pregnancy-Induced Hypertension

Background

Pregnancy-induced hypertension (PIH) is associated with high levels of morbidity and mortality in mothers, fetuses, and newborns. New technologies, such as remote monitoring (RM), were introduced in 2015 into the care of patients at risk of PIH in Ziekenhuis Oost-Limburg (Genk, Belgium) to improve both maternal and neonatal outcomes. In developing new strategies for obstetric care in pregnant women, including RM, it is important to understand the psychosocial characteristics associated with adherence to RM to optimize care.

Objective

The aim of this study was to explore the role of patients’ psychosocial characteristics (severity of depression or anxiety, cognitive factors, attachment styles, and personality traits) in their adherence to RM.

Methods

Questionnaires were sent by email to 108 mothers the day after they entered an RM program for pregnant women at risk of PIH. The Generalized Anxiety Disorder Assessment-7 and Patient Health Questionnaire-9 (PHQ-9) were used to assess anxiety and the severity of depression, respectively; an adaptation of the Pain Catastrophizing Scale was used to assess cognitive factors; and attachment and personality were measured with the Experiences in Close Relationships-Revised Scale (ECR-R), the Depressive Experiences Questionnaire, and the Multidimensional Perfectionism Scale, respectively.

Results

The moderate adherence group showed significantly higher levels of anxiety and depression, negative cognitions, and insecure attachment styles, especially compared with the over adherence group. The low adherence group scored significantly higher than the other groups on other-oriented perfectionism. There were no significant differences between the good and over adherence groups. Single linear regression showed that the answers on the PHQ-9 and ECR-R questionnaires were significantly related to the adherence rate.

Conclusions

This study demonstrates the relationships between adherence to RM and patient characteristics in women at risk of PIH. Alertness toward the group of women who show less than optimal adherence is essential. These findings call for further research on the management of PIH and the importance of individual tailoring of RM in this patient group.

Trial Registration

ClinicalTrials.gov NCT03509272; https://clinicaltrials.gov/ct2/show/NCT03509272

Telemonitoring for hypertensive disease in pregnancy

Introduction: Telemonitoring of hypertension in pregnancy is becoming increasingly common. Several small studies have described the potential benefits of patient-led remote monitoring, including fewer hospital visits, better blood pressure control, and cost savings. Areas covered: This review summarises the principles of prenatal remote monitoring of hypertension as well as the types of devices and applications currently in use. We summarise current evidence regarding the potential benefits and pitfalls with respect to outcomes for mothers, neonates and wider population health. Core topics for ongoing and future research are discussed, with special emphasis on feasibility and validation of technologies, methodological standardization, patient safety, privacy and acceptability, and health economics and governance. Expert opinion: Telemonitoring of hypertension in pregnancy is likely to become commonplace in the next five to ten years and research now must be directed to ensure it is used in the safest way before its general introduction into daily clinical practice can be recommended. Raising women's awareness of their health condition could improve both pregnancy and long-term health outcomes.

Pregnancy outcomes following home blood pressure monitoring in gestational hypertension

OBJECTIVES

To assess the safety and efficacy of home blood pressure monitoring (HBPM) and office (traditional) blood pressure measurements in a cohort of pregnant women with gestational hypertension (GH).

STUDY DESIGN

This was a cohort study at St. George's Hospital, University of London conducted between December 2013 and August 2018. The inclusion criteria was pregnant women with a diagnosis of GH. Eligible patients were counseled and trained by a specialist midwife and were provided with an automated Microlife® "WatchBP Home" BP machine. Each patient followed an individualised schedule of hospital visits and BP measurements based on the HBPM pathway or standard hospital protocol which was based on the National Institute of Health and Care Excellence (NICE) guideline.

MAIN OUTCOME MEASURES

Adverse fetal, neonatal and maternal outcomes as well as number of antenatal hospital visits were recorded and compared between HBPM and office (traditional) pathways.

RESULTS

143 women with GH were included in the study (80 HBPM vs 63 standard care). There were no significant difference between the two groups in maternal high-dependency unit admission (P = 0.999), birth weight centile (P = 0.803), fetal growth restriction (p = 0.999), neonatal intensive care unit admissions (p = 0.507) and composite neonatal (p = 0.654), maternal (p = 0.999) or fetal adverse outcomes (p = 0.999). The number of Day Assessment Unit (DAU) visits was significantly lower in the HBPM group than the traditional pathway (median 4.0 vs. 5.0, P = 0.009). The difference was greater when the number of visits were adjusted for the duration of monitoring in weeks (median: 1.0 vs 1.5, P < 0.001). There were no significant difference between the two groups in the total number of outpatient (P = 0.357) and triage visits (p = 0.237). However, the total number of antenatal visits adjusted for the duration of monitoring was significantly lower for the HBPM group compared to the traditional pathway (median 1.4 vs 1.8, P = 0.020).

CONCLUSIONS

HBPM in women with GH results in significantly less antenatal visits compared to women on a standard pathway of care. The two groups had comparable fetal, neonatal and maternal adverse outcomes. Large multicentre studies are needed to ascertain the safety of rare adverse pregnancy outcomes.

SAFE@HOME - Feasibility study of a telemonitoring platform combining blood pressure and preeclampsia symptoms in pregnancy care

OBJECTIVE

To study the feasibility of a telemonitoring platform for hypertensive disease in pregnancy, consisting of a wireless blood pressure monitor and an app in combination with an integrated preeclampsia symptom checklist.

STUDY DESIGN

Prospective observational study with 14 pregnant women during a 15 weekday study period. For feasibility purposes, compliance was measured by evaluating the number of entered BP and symptom checklists. Comparing all the entered values with the threshold values checked the accuracy of the automatic alerts. Usability and patient satisfaction were measured using questionnaires.

RESULTS

Compliance rates for blood pressure and symptom checklist were 93% and 85% respectively. No false positive or missing alerts were found in the alarm system. The telemonitoring system alarmed 7 times for BP thresholds (3.8% of all received values), Of 167 returned symptom checklists, 93% of symptom alarms could be handled with expectant management because of concurrent normal blood pressure. The majority of participants were satisfied with the system.

CONCLUSIONS

This is the first feasibility study of a telemonitoring platform, combining remote monitoring of BP with preeclampsia symptoms in pregnancy care. Action from health care providers during telemonitoring is only needed in case of alarming combinations of results. This system is potentially very useful in care for women at risk for hypertensive disorders during pregnancy.

Development of a biophysical screening model for gestational hypertensive diseases

Background

To investigate the possibility of using maternal biophysical parameters only in screening for the different types of gestational hypertensive diseases.

Methods

A total of 969 pregnant women were randomly screened in first and second trimester, of which 8 developed Early-onset Preeclampsia, 29 Late-onset Preeclampsia, 35 Gestational Hypertension and 897 women had a normal outcome. An observational maternal hemodynamics assessment was done via standardized electrocardiogram-Doppler ultrasonography, Impedance Cardiography and bio-impedance, acquiring functional information on heart, arteries, veins and body fluid. Preliminary prediction models were developed to test the screening potential for early preeclampsia, late preeclampsia and gestational hypertension using a Partial Least Square Discriminant Analysis.

Results

A combined model using maternal characteristics with cardiovascular parameters in first and second trimester offers high screening performance with Area Under the Curve of 99,9% for Early-onset Preeclampsia, 95,3% for Late-onset Preeclampsia and 94% for Gestational Hypertension.

Conclusions

Using biophysical parameters as fundament for a new prediction model, without the need of biochemical parameters, seems feasible. However, validation in a large prospective study will reveal its true potential.

Midwives', Obstetricians', and Recently Delivered Mothers' Perceptions of Remote Monitoring for Prenatal Care: Retrospective Survey

BACKGROUND

The Pregnancy Remote Monitoring (PREMOM) study enrolled pregnant women at increased risk of developing hypertensive disorders of pregnancy and investigated the effect of remote monitoring in addition to their prenatal follow-up.

OBJECTIVE

The objective of this study was to investigate the perceptions and experiences of remote monitoring among mothers, midwives, and obstetricians who participated in the PREMOM study.

METHODS

We developed specific questionnaires for the mothers, midwives, and obstetricians addressing 5 domains: (1) prior knowledge and experience of remote monitoring, (2) reactions to abnormal values, (3) privacy, (4) quality and patient safety, and (5) financial aspects. We also questioned the health care providers about which issues they considered important when implementing remote monitoring. We used a 5-point Likert scale to provide objective scores. It was possible to add free-text feedback at every question.

RESULTS

A total of 91 participants completed the questionnaires. The mothers, midwives, and obstetricians reported positive experiences and perceptions of remote monitoring, although most of them had no or little prior experience with this technology. They supported a further rollout of remote monitoring in Belgium. Nearly three-quarters of the mothers (34/47, 72%) did not report any problems with taking the measurements at the required times. Almost half of the mothers (19/47, 40%) wanted to be contacted within 3 to 12 hours after abnormal measurement values, preferably by telephone.

CONCLUSIONS

Although most of midwives and obstetricians had no or very little experience with remote monitoring before enrolling in the PREMOM study, they reported, based on their one-year experience, that remote monitoring was an important component in the follow-up of high-risk pregnancies and would recommend it to their colleagues and pregnant patients.

TRIAL REGISTRATION

ClinicalTrials.gov NCT03246737; https://clinicaltrials.gov/ct2/show/NCT03246737 (Archived by WebCite at http://www.webcitation.org/76KVnHSYY).