Safe care from home for complicated pregnancies?

There is a move towards greater patient involvement in health care across the world, supported by rapid improvements in self-monitoring technology and widespread accessibility of devices that can be used in telemonitoring, such as smartphones. However, there is a need to understand how to integrate novel interventions into daily practice. Such organisational change can be difficult, and barriers include practical issues such as provision and management of equipment, and the costs of new technology, including reimbursement, with novel interventions sometimes not funded by the health-care service.1Wilson H Tucker KL Chisholm A et al.Self-monitoring of blood pressure in pregnancy: a mixed methods evaluation of a national roll-out in the context of a pandemic.Pregnancy Hypertens. 2022; 30: 7-12Crossref PubMed Scopus (1) Google Scholar Additionally, there is a need to ensure health equity with evidence that those from underserved groups (groups with a lower inclusion in research than expected for their disease burden or with differences in engagement in health care) might be less likely to be included in trials, when there is a need to ensure that interventions or health technology is effective for all.2Witham MD Anderson E Carroll C et al.Developing a roadmap to improve trial delivery for under-served groups: results from a UK multi-stakeholder process.Trials. 2020; 21: 694Crossref PubMed Scopus (64) Google Scholar In The Lancet Digital Health, Mireille N Bekker and colleagues3Bekker NM Koster MPH Keusters WR et al.Home telemonitoring versus hospital care in complicated pregnancies in the Netherlands: a randomised, controlled non-inferiority trial (HoTeL).Lancet Digit Health. 2023; 5: e116-e124Summary Full Text Full Text PDF Scopus (2) Google Scholar present the main results of the HoTeL study, a randomised, multicentre, non-inferiority trial including pregnant women with a range of antenatal morbidities, who required daily monitoring but were not expected to need intervention within 48 h. This was a very high risk population with an incidence of eclampsia perhaps a hundred times higher than that of the general antenatal population.4Knight M Ukoss Eclampsia in the United Kingdom 2005.BJOG. 2007; 114: 1072-1078Crossref PubMed Scopus (210) Google Scholar Participants were randomly assigned 1:1 to either hospital admission or telemonitoring (monitoring cardiotocography [with an internet portal], blood pressure, and temperature, and with daily midwife contact) and a composite primary outcome of adverse perinatal outcomes was assessed. Recruitment was halted after only 200 of a planned sample size of 416 were successfully randomly assigned because of poor recruitment and an interim analysis. The one-way non-inferiority margin was not breached and the telemonitoring group had fewer primary outcome events (31 [31%] of 100 participants in the telemonitoring group and 40 [40%] of 100 participants in the hospital admission group), suggesting that telemonitoring was at least as safe as hospital admission, albeit with a concern that had recruitment been complete, telemonitoring might have been convincingly different to hospital care. There were no significant differences to in-labour caesarean sections nor admissions to the neonatal intensive care unit; there were also no significant differences for any secondary outcomes but these were probably underpowered comparisons. There were no deaths among the women but three had eclampsia (one in the telemonitoring group, which was reported as a serious adverse event, and two in the hospital group). There were three neonatal deaths, two in the telemonitoring group and one in the hospital group. The women in the study required daily monitoring owing to pre-eclampsia, fetal growth restriction, fetal anomaly, preterm rupture of membranes, reduced fetal movements, or history of fetal death and so were at high risk of serious adverse events. This research adds confidence that these high-risk women might be able to safely be monitored as outpatients with the appropriate support. There were high degrees of satisfaction in the telemonitoring group and a reduction in cost, predominantly driven by a reduction in admission, despite an intensive intervention. Those at high risk, such as those in the study by Bekker and colleagues, require more intensive (and therefore costly) interventions. More generally in maternity care, many women are at lower risk of complications. Recent large trials have suggested that blood pressure self-monitoring is safe in hypertensive pregnancy but does not improve hypertension detection or blood pressure control.5Chappell LC Tucker KL Galal U et al.Effect of self-monitoring of blood pressure on blood pressure control in pregnant individuals with chronic or gestational hypertension: the BUMP 2 randomized clinical trial.JAMA. 2022; 327: 1666-1678Crossref PubMed Scopus (24) Google Scholar The evidence does suggest that telemonitoring can reduce the number of antenatal visits, with consequent reductions in cost, and is acceptable and valued by women.6Xydopoulos G Perry H Sheehan E Thilaganathan B Fordham R Khalil A Home blood-pressure monitoring in a hypertensive pregnant population: cost-minimization study.Ultrasound Obstet Gynecol. 2019; 53: 496-502Crossref PubMed Scopus (36) Google Scholar The current study is timely as some forms of self-monitoring have perhaps moved ahead of the evidence. A UK-based survey suggested that about half of women with hypertension are already monitoring their own blood pressure in some way.7Tucker KL Hodgkinson J Wilson HM et al.Current prevalence of self-monitoring of blood pressure during pregnancy: the BUMP Survey.J Hypertens. 2021; 39: 994-1001Crossref PubMed Scopus (10) Google Scholar Only half of women who monitored had mentioned this to their health-care professional and many were not using equipment validated for use in pregnancy. Although not indicated in the current study, more general populations might monitor proteinuria as a key indicator of pre-eclampsia, alongside blood pressure and blood sugar for those with diabetes.8Jakubowski BE Stevens R Wilson H et al.Cross-sectional diagnostic accuracy study of self-testing for proteinuria during hypertensive pregnancies: the UDIP study.BJOG. 2022; 129: 2142-2148Crossref PubMed Scopus (2) Google Scholar, 9Mackillop L Hirst JE Bartlett KJ et al.Comparing the efficacy of a mobile phone-based blood glucose management system with standard clinic care in women with gestational diabetes: randomized controlled trial.JMIR Mhealth Uhealth. 2018; 6: e71Crossref PubMed Scopus (99) Google Scholar Self-testing for proteinuria has been shown to be accurate, and was offered by about half of UK maternity units during the pandemic.1Wilson H Tucker KL Chisholm A et al.Self-monitoring of blood pressure in pregnancy: a mixed methods evaluation of a national roll-out in the context of a pandemic.Pregnancy Hypertens. 2022; 30: 7-12Crossref PubMed Scopus (1) Google Scholar, 8Jakubowski BE Stevens R Wilson H et al.Cross-sectional diagnostic accuracy study of self-testing for proteinuria during hypertensive pregnancies: the UDIP study.BJOG. 2022; 129: 2142-2148Crossref PubMed Scopus (2) Google Scholar Such combinations of blood pressure, blood sugar (if relevant), and proteinuria self-monitoring have only been tested on a small scale to date.10Kalafat E Benlioglu C Thilaganathan B Khalil A Home blood pressure monitoring in the antenatal and postpartum period: a systematic review meta-analysis.Pregnancy Hypertens. 2020; 19: 44-51Crossref PubMed Scopus (40) Google Scholar Trials powered for adverse maternal and fatal events in lower risk populations might be impractically large, but there is an ongoing need to understand the place of telemonitoring more generally in antenatal care. The study by Bekker and colleagues provides important evidence that adds to the growing body of work on telemonitoring in pregnancy, showing that in pregnancies at high risk of serious adverse outcomes, telemonitoring appears to be safe, cost-effective, and acceptable. RJM reports fees from Omron paid to the University of Oxford for licensing of algorithms for telemonitoring interventions, and paid consultancy, as well as receipt of equiptment. RJM also reports occasional travel reimbursement and accommodation for speaking at conferences, most recently in 2019. Honoraria from Hypertension Canada and the Finnish Hypertension Society were paid to his institution. RJM is chair of the BP monitoring working party of the British and Irish Hypertension Society (unpaid). KLT chairs the data monitoring committee for the Parrot-2 trial, evaluating placental growth factor repeat sampling. The authors receive funding from the National Institute for Health and Care Research (NIHR) via the Applied Research collaboration Oxford and Thames Valley (ARC-OxTV) and a programme grant for applied research (NIHR203283). The views expressed in this publication are those of the authors and not necessarily those of the NHS, the NIHR, or the Department of Health and Social Care. Home telemonitoring versus hospital care in complicated pregnancies in the Netherlands: a randomised, controlled non-inferiority trial (HoTeL)This non-inferiority trial shows the first evidence that telemonitoring might be as safe as hospital admission for monitoring complicated pregnancies. Full-Text PDF Open Access