Îngrijirea digitală personalizată în obstetrică: impactul aplicației Heart4Mom® în detectarea și managementul preeclampsiei severe

Introduction

Preeclampsia, pure or superimposed upon preexisting hypertension, increases the risk of both maternal and perinatal morbidity and mortality. Early recognition of high-risk factors and biomarkers for preeclampsia are critical to prevent maternal and fetal morbidity/mortality.

Preeclampsia is defined by the appearance of hypertension and proteinuria during gestation, and it affects 5% of pregnancies⁽¹⁾. Complications constitute a major issue encountered in cases of preeclampsia, with an 8% complication rate described in the Western world, rendering preeclampsia a major factor of maternal and fetal mortality worldwide^(2,3). Approximately 16-18% of maternal perinatal deaths and up to 40% of fetal and neonatal deaths are attributed to cases of preeclampsia⁽⁴⁾. 

Intrauterine or fetal growth restriction (IUGR/FGR) is a pathological condition in which the fetus fails to grow to its biological potential, primarily because of poor placental function. Early-onset fetal growth restriction (FGR) is most often diagnosed based on a finding of a small-for-gestational-age (SGA) fetus with abnormal blood flow in the umbilical artery recorded by Doppler ultrasound.

There is a strong but complex relationship between fetal growth restriction and preeclampsia. According to the International Society for the Study of Hypertension in Pregnancy, the coexistence of gestational hypertension and fetal growth restriction identifies preeclampsia with no need for other signs of maternal organ impairment⁽¹⁴⁾. While early-onset fetal growth restriction and preeclampsia are often strictly associated, such association becomes looser in the late preterm and term periods.

This case highlights the valuable role of remote monitoring in managing high-risk pregnancies, allowing for timely interventions and improved outcomes. It underscores the importance of early detection and proactive successful management to enhance both maternal and fetal health.

This paper aims to provide data regarding a rare case report of a patient with symptoms of early-onset severe FGR and preeclampsia during a singleton pregnancy at 23 weeks of gestation. The patient had a history of severe preeclampsia, complicated by severe FGR, that imposed delivery at 27 weeks of gestation.

This current pregnancy was managed from the beginning with appropriate treatment in order to avoid complications and clinical symptoms related to preeclampsia. Despite the absence of proteinuria and adequate treatment of the hypertension, severe FGR was revealed at 23 weeks of gestation. The patient was enrolled in a telemonitoring program using the Heart4Mom® application from the first trimester. Blood pressure trends were continuously observed, and abnormal values were promptly identified. The clinical management included multidisciplinary involvement with cardiology evaluation, 24-hour ambulatory BP monitoring, echocardiography, and advanced obstetric surveillance. This case underscores the critical role of telemonitoring in improving maternal and fetal outcomes in high-risk pregnancies.

Case report description

A 42-year-old, Caucasian woman, gravida three, parity secundum (GIII, PII), was referred to our clinic at 8 weeks of gestation.

Patient’s Body Mass Index (BMI) was 27 kg/m², and her medical history was marked by severe preeclampsia developed at first pregnancy; the patient was under treatment for autoimmune thyroiditis, free of smoking, infections, sexually transmitted diseases, and diabetes mellitus. Her familiar medical history included maternal hypertensive disorder, but free of pregnancy hypertensive disorders, including preeclampsia.

Her previous pregnancy was marked by severe early-onset preeclampsia, developed from the first trimester, and delivery was imposed at 27 weeks of gestation due to maternal and fetal complications. Prematurity complications led to perinatal death after three weeks.

Priorly, the woman was subjected to extensive clinical and biochemical investigation, cardiologic examination, eye fundus examination, in the context of screening for any possible underlying pathologies, as certain conditions are typically evaluated before proceeding to a new pregnancy. Following examination, no signs of chronic hypertension, retinal abnormalities, diabetes mellitus, antiphospholipid syndrome, thrombophilia or any other thrombophilic disorder were noted.

Four weeks following patient’s last menstruation, a transvaginal ultrasound (TVUS) was performed, revealing the existence of one sonolucent sac surrounded by an echogenic ring of chorionic villi, indicating intrauterine pregnancy.

Two weeks later, at the end of the sixth week, clinical pregnancy was confirmed via TVUS, indicating a single gestational sac with fetal heartbeat.

Concurrently, the patient was enrolled in a telemonitoring program using Heart4Mom®, a mobile application that facilitated home-based blood pressure measurement twice daily. A validated blood pressure monitor was provided. Measurements were automatically uploaded to a centralized system. The patient received education on optimal blood pressure measurement techniques, and she was regularly contacted for follow-up.

Following the confirmation of clinical pregnancy and until the 12^th week mark, the pregnancy progressed normally, without any complications.

On the 12^th week of gestation, the patient underwent first-trimester nuchal translucency transabdominal scan, revealing a single pregnancy with measurements consistent with the gestational age estimated at the time. The embryo presented with normal crown rump length (CRL), as well as normal nuchal translucency (NT) measurements^(5,6). A visible nasal bone was observed. There was no evidence or signs of any anatomical defects for the fetus. Doppler ultrasound of the uterine artery was also performed, indicating mean uterine artery PI (UTPI) equal to 2.2 (1.539 MoM).

In addition to maternal characteristics and uterine artery Doppler indices, biomarkers such as placental growth factor (PLGF) can improve the accuracy of preeclampsia risk prediction. In the case presented, a PLGF level of 38 pg/mL (below the 5^th percentile for gestational age) was recorded, indicating a high risk for preeclampsia. Based on these evaluations, the patient was classified as being at an increased risk for developing early-onset preeclampsia. According to the Obstetrics and Gynecology Society Guidelines and Fetal Medicine Foundation (ASPRE Study) for preeclampsia prophylaxis, a low dose of aspirin (150 mg per day at the bedtime) was prescribed from that point onwards.

At the same time, a double marker test was also performed for the evaluation of serum PAPP-A levels, as well as of serum free beta-hCG levels, and the result was that the fetus had a risk of 1/72 for Down’s syndrome and 1/33 for Patau’s syndrome. The patient proceeded with noninvasive prenatal diagnosis testing, which did not detect an increased risk for aneuploidy for the embryo.

Following that, diagnostic amniocentesis was performed, and the result revealed a normal karyotype.

During the course of the pregnancy, under clear guidance and consultation, the patient’s blood pressure readings logged via Heart4Mom® averaged was constantly 120/70 mmHg. Urine analysis revealed normal proteinuria.

Transabdominal ultrasonography was performed, indicating that the fetus was consistent to the gestational age.

During the 21^st week of gestation (21 weeks and 4 days), a subtle but progressive increase in BP values (140-145/95 mmHg) was noted. The trend was flagged via Heart4Mom® alerts, and the patient was referred to our hospital for evaluation. The laboratory exams, the complete blood count, clotting, and liver function (SGOT 25 U/L and SGPT 55 U/L) were normal. Renal function was normal, and the patient’s 24-hour urine protein was 0.35 g/day. Regarding the clinical evaluation and based on guidelines for preeclampsia management, the patient started the treatment for hypertension, including labetalol 200 mg/day.

During the same gestational week, a transabdominal pregnancy scan of the fetus was also performed. Ultrasound revealed oligohydramnios, with an estimated weight of 220 g (<3^rd centile Hadlock). Close monitoring of the clinical and biochemical status of the patient was undertaken. The patient underwent serial ultrasound scans.

During the 22^nd week of gestation, the blood pressure monitorization by Heart4Mom® application revealed BP values of 150/95 mmHg, under the treatment. The patient was admitted in the hospital. A multidisciplinary evaluation was conducted. Cardiology consultation included 24-hour blood pressure monitoring, which confirmed a non-dipping pattern and nocturnal hypertension. The echocardiography revealed several subtle yet clinically significant changes: subtle left ventricular hypertrophy with increase in left ventricular mass index, along with increased relative wall thickness, confirming the presence of concentric remodeling; a normal ejection fraction with diastolic function pattern consistent with abnormal relaxation and a preserved systolic function.

The antihypertensive treatment was adjusted, and methyldopa 750 mg/day was included along with labetalol 200 mg/day.

Repeated laboratory tests, including the complete blood count, coagulation, liver and renal function, were in the normal limits.

The specialized ultrasound scan revealed normal fetal morphology and a fetal growth chart under the 3^rd percentile Hadlock.

At 23 weeks of gestation, ultrasound revealed absent end diastolic flow in umbilical artery and normal pulsatility index for middle-cerebral artery. Following the Fetal Medicine Foundation and Fetal Medicine Barcelona’s Guidelines recommendation, weekly serial monitorization were performed. It was explained to the patient that the pregnancy was classified at high fetal risk. Although hospitalization was recommended due to the diagnosis of early-onset preeclampsia with fetal growth restriction and abnormal Doppler findings, the patient declined admission after extensive counseling. She was thoroughly informed regarding the maternal and fetal risks, including the potential for rapid deterioration and the need for emergency intervention. The patient expressed a clear understanding of these risks, and signed an informed refusal for inpatient care. She opted to continue monitoring at home using the Heart4Mom® application, with close remote supervision by the medical team and scheduled in-person evaluations.

At 30 weeks of gestation, we decided to perform the fetal lung maturation with betamethasone 12 mg/day, two doses. The IUGR maintained, and ultrasonography revealed a fetus with an estimated weight of 500 g (<1^st centile Hadlock), with negative end diastolic flow in umbilical artery with decreased pulsatility index on middle cerebral artery and absent or reversed ductus venosus a-wave.

According to the guidelines, we decided that delivery was imposed, after the administration of steroids and magnesium sulphate. Despite the severe early IUGR diagnosis, increased fetal risk and the recommendation for delivery, the patient denied recommendation and persisted on maintaining the pregnancy until 32 weeks of gestation, based on her pregnancy history.

The patient was thoroughly informed regarding the medical indication for delivery, necessitated by the fetal condition. A detailed explanation was provided regarding the maternal and fetal risks associated with postponing the intervention. The patient acknowledged that she understood the information presented, accepted the associated risks, yet explicitly refused the proposed delivery at this time.

During the outpatient management period, the patient underwent serial ultrasonographic evaluations every 24 hours, which included fetal biometry, amniotic fluid assessment and Doppler velocimetry of the umbilical artery, middle cerebral artery and ductus venosus. Concurrently, she continued to monitor her blood pressure at home using the Heart4Mom® application, under close medical supervision.

On the third day of surveillance, the application recorded a severe hypertensive episode, with a systolic blood pressure of 200 mmHg. The patient was urgently referred to the hospital. Upon admission, she reported significantly reduced fetal movements, and ultrasonography revealed reversed a-wave in the ductus venosus, alongside worsening fetal growth parameters. Clinical assessment and laboratory tests to assess maternal well-being were performed, and showed an increased level of uric acid (6.4 mg/dL), normal complete blood count, coagulation, and in range liver and renal values.

In the context of severe early-onset preeclampsia with uncontrolled blood pressure values under treatment, that have been shown after blood pressure close monitorization via Heart4Mom® application, and evidence of imminent fetal decompensation, at 31 weeks of gestation (31 weeks and 1 day), an emergency caesarean section was performed. A female neonate weighing 852 grams was delivered, with signs of extreme prematurity and significant growth restriction.

The initial neonatal adaptation was challenging, requiring respiratory support, thermoregulation, and parenteral nutrition in the neonatal intensive care unit (NICU). Despite the high risk of morbidity associated with extreme low birth weight, the clinical course progressively improved. After an eight-week NICU stay, the infant was discharged in stable condition alongside the mother.

Post-discharge follow-up confirmed a favorable outcome, with satisfactory weight gain and neurodevelopmental parameters appropriate for corrected gestational age.

Following delivery, the patient continued to be monitored through the Heart4Mom® application during the postpartum period. Blood pressure measurements were recorded daily, allowing for close remote surveillance and timely adjustment of antihypertensive therapy as needed.

In addition to hemodynamic monitoring, the patient completed the in-app standardized screening questionnaire for postpartum depression (based on the Edinburgh Postnatal Depression Scale). This integrated feature enabled early a comprehensive evaluation of the psychological and medical status that was performed by a specialist, and ensured holistic postpartum care, addressing both physical and emotional recovery. The patient was subjected to hypertensive medication for maintaining normal values of arterial tension, following the cardiologist recommendations, and long-term monitorization of the blood pressure via Heart4Mom® application, due to the increased long-term cardiovascular risks.

The patient received extensive consultation during all stages of the decision-making process, and she provided oral as well as written informed consent concerning all medical interventions performed.

Moreover, the patient provided oral and written informed consent for her data to be employed for research purposes, authorizing the authors to collect all information related to this case report for further analysis. In addition, the patient, acknowledging the scientific merit of the case’s publication, following consultation, provided the oral and written informed consent, and she approved the publication of this case.

Discussion

The definition of preeclampsia has been thoroughly described and established in literature. In clinical practice, the early onset of preeclampsia is considered an extremely critical condition. Certain international guidelines on the recommended therapeutic approach have been proposed for clinicians and for an efficient management of such cases^(7-9). On the contrary, when diagnosed prior to the 20^th week mark, early-onset preeclampsia requires empirical management on behalf of the clinicians.

There is a strong but complex relationship between fetal growth restriction and preeclampsia. According to the International Society for the Study of Hypertension in Pregnancy, the coexistence of gestational hypertension and fetal growth restriction identifies preeclampsia with no need for other signs of maternal organ impairment. While early-onset fetal growth restriction and preeclampsia are often strictly associated, such association becomes looser in the late preterm and term periods.

Different placental and cardiovascular mechanism underlie this trend: isolated fetal growth restriction has less frequent placental vascular lesions than fetal growth restriction associated with preeclampsia; moreover, late preterm and term fetal growth restriction show different patterns of maternal cardiac output and peripheral vascular resistance compared with preeclampsia.

Furthermore, it has been voiced that early-onset preeclampsia is also associated with an increased risk of stillbirth, reporting 11.6 stillbirths per 1000 pregnancies in the 30^th week of gestation. However, the risk for stillbirth is significantly reduced as pregnancy advances⁽¹⁰⁾. Impressively, studies have demonstrated that incidents of preeclampsia could also appear as early as prior to the 20-week milestone during gestation⁽¹¹⁾. Nonetheless, only a few live births have been reported for cases where preeclampsia has been diagnosed prior to 20 weeks of gestation. Moreover, preeclampsia may be present despite the absence of any symptoms indicating proteinuria or hypertension⁽¹²⁾. In the occurrence of antiphospholipid syndrome or partial molar pregnancy with triploidy, along with the detection of early-onset preeclampsia, the term atypical preeclampsia is employed^(13-16). The cases where early onset preeclampsia prior to the 20^th week mark is diagnosed in the absence of the aforementioned disorders are extremely rare in literature, with only six cases published hitherto^{(17,18,19,20)}. It should be noted that none of the published studies has reported a live birth following the management of early-onset preeclampsia, indicating the knowledge gap in efficiently addressing and treating preeclampsia symptoms, while ascertaining a positive pregnancy outcome. This very fact renders this study timely and essential.

Regarding the management employed in the present case report and despite the lack of robust data indicating the appropriate management of early-onset preeclampsia in the 23^rd week mark, the clinical management and approach were strictly based on the guidelines set by the Romanian Society of Obstetrics and Gynecology and NICE guidelines regarding hypertension in pregnancy. Initially, a pharmaceutical regulation of hypertension was attempted by administering an appropriate scheme, while monitoring its efficacy in ameliorating patient’s symptoms. According to the NICE guidelines in 2019, labetalol constitutes the gold standard choice amongst antihypertensive drug for treating pregnant women with preeclampsia. Nifedipine has been proposed as an alternative option if administration of labetalol is not allowed⁽²⁰⁾. Additional to the NICE guidelines, further clinical data indicate that methyldopa may also be considered if labetalol and nifedipine are not considered suitable for prescription.

In addition, during the publication of the NICE guidelines in June of 2019, certain nifedipine trademarks were contraindicated in pregnancy by manufacturers, based on the summary of their product’s characteristics. Therefore, the coordinating physician and the clinic opted for administrating methyldopa as the optimal pharmaceutical line of treatment. Nonetheless, considering the mild antihypertensive effect of methyldopa, along with its delayed onset of action, additional actions for regulating patient’s blood pressure levels were required⁽²⁰⁾.

An efficient and safe strategy treatment outside the scope of empirical approaches remains the “Holy Grail” for pregnant women diagnosed with early-onset preeclampsia and severe FGR prior to 23 weeks of gestation.

This case highlights the critical role of continuous blood pressure telemonitoring in the management of high-risk pregnancies, particularly in patients at risk for preeclampsia and fetal growth restriction. The integration of the Heart4Mom® application into clinical care enabled daily remote assessment of maternal blood pressure, offering real-time data to the medical team.

Thanks to the use of the Heart4Mom® application, we were able to promptly detect the onset of preeclampsia. This allowed the early detection and the initiation of targeted antihypertensive therapy and close monitoring of blood pressure parameters, contributing to the timely management of the pregnancy.

Importantly, the application was instrumental in detecting a sudden and severe hypertensive episode (systolic BP ≥200 mmHg) during outpatient management. This alert, generated through home monitoring, prompted urgent referral and admission, where further evaluation revealed reversed a-wave in the ductus venosus and decreased fetal movements, criteria that necessitated immediate delivery. Without the continuous data provided by the Heart4Mom® platform, such a critical hypertensive spike may have gone unnoticed, delaying appropriate intervention and potentially leading to adverse maternal or fetal outcomes.

Beyond blood pressure surveillance, the application also supported postpartum follow-up, including ongoing hemodynamic monitoring and psychological screening using the Edinburgh Postnatal Depression Scale (EPDS), reflecting the comprehensive utility of digital tools in maternal care.

This case underscores the potential of telemonitoring platforms not only to detect early clinical deterioration, but also to empower patient engagement and enhance clinical decision-making.

Future studies are warranted to validate the efficacy of such tools in larger, prospective cohorts and to explore their role in reducing morbidity and improving outcomes in hypertensive disorders of pregnancy.

Incorporating the Heart4Mom® application into the routine care of high-risk pregnancies provided essential support for early detection and management of preeclampsia. The integration of digital BP monitoring, cardiology assessment, and obstetric surveillance enabled proactive decision-making, ultimately improving the maternal and neonatal outcomes. This case supports the broader implementation of telemedicine tools in modern obstetrics.   

Corresponding author: Alina-Alexandra Dîrlău E-mail: alina-alexandra.dirlau@drd.umfcd.ro

Conflict of interest: none declared.

Financial support: none declared.

This work is permanently accessible online free of charge and published under the CC-BY licence.