Laks MP, Cohen T. Noninvasive diagnosis of fetal anemia by Doppler ultrasonography. var alS = 2002 % 1000; There was no between-study heterogeneity due to threshold effect. Br J Obstet Gynaecol. All women underwent UtA Doppler US at 20 to 24 weeks of gestation; 8 of the 262 women (3.0 %) developed late-onset PE. Antepartum fetal surveillance is used to assess the risk of adverse perinatal outcome associated with utero-placental insufficiency, and is recommended for pregnancies that are at risk for hypoxia and stillbirth. 2018;127:19-23. Abnormal flow velocity waveforms have been correlated histopathologically with small-artery obliteration in placental tertiary villi and functionally with fetal hypoxia and acidosis, as well as with perinatal morbidity and mortality. } Pregnancy related E/M office visits must not be billed in conjunction with code, 59425 or 59426 by the same provider for the same beneficiary, during the same. CPT code 59025 can be conducted as many times as medically necessary. Obstet Gynecol. Still snag [], Bust 3 Myths to Increase Pay Without Raising a Red Flag, Youre most likely to use modifier 22 in these situations. Sound can also be used to induce acceleration of the heart rate of the fetus. Billing for non-global OB or Partial care may occur under the following circumstances. 1996;42(4):101-104. Ceska Gynekol. Abnormal fetal cerebral and umbilical Doppler measurements in fetuses with intrauterine growth restriction predicts the severity of perinatal morbidity. After adjusting for confounding variables, only PMDV remained statistically significant (p<0.001), with an area under the receiver-operating characteristics curve (AUC) of 0.73. These investigatorssearched the Cochrane Pregnancy and Childbirth Group Trials Register (May 2010). For example, your ob-gyn sees a patient at 31 weeks gestation who complains that her fetus has not been moving much in the past few weeks. Billing guidelines . A total of 7ophthalmic artery Doppler parameters, in addition to uterine artery (UtA) Doppler and clinical variables, were examined for their prognostic value with respect to PE. 1992;340:936-940. American College of Obstetricians and Gynecologists (ACOG), Committee on Practice Bulletins -- Obstetrics. PDF OB Coding - The Global Package & Beyond - AAPC The clinical utility of these tests remains unclear. Start . 99203 Medicare and e codes. Indiana Medicaid: Providers: Code Sets Critical appraisal of the use of umbilical artery Doppler ultrasound in high-risk pregnancies: Use of meta-analyses in evidence-based obstetrics. The important factor here is that the ob-gyn did not admit the patient for delivery. Society for Maternal-Fetal Medicine (SMFM), Norton ME, Chauhan SP, Dashe JS. Copayments; Fee-for-Service. Some advocate liberal or primary use of fetal blood sampling, while others promote the use of non-invasive ultrasonography and Doppler assessment of umbilical venous and middle cerebral artery peak systolic velocity (MCA PSV). Second, most of the included studies were hampered by lack of blinding of the UAD measurements. Additionally, the Cochrane Library, organizational guidelines, and studies identified through review of the above were utilized to identify relevant articles. American College of Obstetricians and Gynecologists (ACOG), Committee on Practice Bulletins -- Obstetrics. The review concluded: "At this time, the evidence does not support routine screening with uterine artery Doppler in any particular group of patients. 2007;72(3):175-180. Tip: Make sure you include labor checks in the global ob codeDo you want to code fetal non-stress test (NST) using 59025? var ffid = 2; If the baby's heart rate still does not accelerate, the ob-gyn will determine this to be a -nonreactive- NST. Clinical payment and coding policies are based on criteria developed by specialized professional societies, national guidelines (e.g. However, in the United Kingdom, the National Institute for Health and Care Excellence suggests offering PlGF-based testing to help rule out (but not rule in) preeclampsia in women presenting with suspected preeclampsia up to 35 weeks of gestation [citing NICE, 2019]. list-style-type: lower-alpha; Waltham, MA: UpToDate;reviewed November 2015; February 2021. Therefore, you would not report a separate NST.Note: For a free PDF of an outpatient fetal monitoring template you can put to use in your practice, e-mail [email protected]. The mother marks the strip when she feels movement throughout the 30-40 minutes of the test. However, because of its limited predictive ability as a stand-alone test, UAD should be used in combination with other tests to guide clinical decisions. The ACOG guidelines on intrauterine growth restriction (2000) state that umbilical artery ultrasounds may be useful in the evaluation of the growth restricted fetus; however, these guidelines indicate no particular role for uterine artery Doppler ultrasound in the evaluation and management of intrauterine growth restriction pregnancies. Find out, Learn These In-House Lab Codes And Lasso Reimbursement, Tests with different names don't always mean different codes, See How Your Hysterectomy Responses Measure Up. Management of prolonged pregnancy. Harrington K, Carpenter RG, Goldfrad C, et al. Billing and Claims. August P, Sibai BM. Services Included in Global Obstetrical Package. This button displays the currently selected search type. Red flag: If the patient does deliver within 24 hours of admission, you should consider the labor check part of the global. window.ezoSTPixelAdd(slotId, 'adsensetype', 1); 1997;9:6-13. The positive likelihood ratio was 3.5 (95 % CI: 2.3 to 5.5) and negative likelihood ratio 0.43 (95 % CI: 0.22 to 0.85); the diagnostic OR was 8.3 (95 % CI: 3 to 22.4). 1998;105:422-429. Modifier 59 should be used when the injection is a separate service from other treatments. (If used in this setting, accepted guidelines indicate that decisions regarding timing of delivery should be made using a combination of information from the Doppler ultrasonography and other tests of fetal well being, along with careful monitoring of maternal status.). Arch Gynecol Obstet. OB GYN Reimbursement Rate Methodology White Paper. Cochrane Database Syst Rev. Pedrosa AC, Matias A. The overall estimates of IMA in detecting PE were pooled sensitivity; 0.80 (95 % CI: 0.73 to 0.86), pooled specificity; 0.76 (95 % CI: 0.70 to 0.81), DOR; 14.32 (95 % CI: 5.06 to 40.57), and area under curve (AUC); 0.860. Goetzinger et al (2013) estimated the efficiency of first trimester Ut-A Doppler, ADAM12, PAPP-A, and maternal characteristics in the prediction of PE. Example: -You might use the decreased fetal movement code (655.73) because the ob-gyn is monitoring the baby,- says Deanna Sherland, CPC, billing/surgery clerk at Midwest Women's Care in Belleville, Ill. Prediction of preeclampsia. To separately bill this service with 59025 (Fetal nonstress test), your ob-gyn must document a clear indication for doing the NST (for instance, to measure fetal wellbeing).You must have a report with the findings and a recommendation for further testing or treatment. Cochrane DatabaseSyst Rev. In a prospective, cohort study, Gybel-Brask et al (2014) examined if serum YKL-40 is increased in women developing pre-eclampsia or small-for-gestational age fetuses. Policies, Guidelines & Manuals. Fetal middle cerebral artery Doppler waveforms in twin-twin transfusion syndrome. The ob-gyn interprets the strip and writes (or dictates) a report that he must include in the patient's record. 2020;55(5):575-585. Middle cerebral artery flow velocity waveforms in normal and small-for-gestational-age fetuses. Uterine artery Doppler flow studies in obstetric practice. The rate of PE was 2.5 % (13/528); 4 (0.8 %) had severe PE. The following CPT codes are for delivery services only: Vaginal delivery only (with or without episiotomy and/or, Vaginal delivery only, after previous cesarean delivery (with or without episiotomy and/or forceps), Cesarean delivery only, following attempted vaginal delivery after previous cesarean delivery, Based on CPT and ACOG guidelines, the following items are included in the delivery service codes and should not be reported separately, The admission history and physical examination, Management of uncomplicated labor, vaginal delivery (with or without, episiotomy, with or without forceps), or cesarean delivery, external and internal, fetal monitoring provided by the attending physician, Intravenous induction of labor via oxytocin (CPT code 96365-96367), Repair of first or second degree lacerations*, Insertion of cervical dilator (CPT 59200) to be included if performed on the same, If the physician or group physician provide the delivery and postpartum care only, there are CPT codes that encompass both of these services. 2014 Advanced MIS amp SILS Medicare Reimbursement Coding Guide. The LHD can bill 59430, S0281 and codes for the contraceptive device and insertion. Ob/Gyn Coding Guidelines 2022 There was no available evidence to assess the effect on substantive long-term outcomes such as childhood neurodevelopment and no data to assess maternal outcomes, particularly maternal satisfaction. CPT code 59025 can be conducted as many times as medically necessary. Lalor JG, Fawole B, Alfirevic Z, Devane D. Biophysical profile for fetal assessment in high risk pregnancies. be reported using code 59025 with additional tests for the each additional fetus reported using code 59025 with modifier 76 Repeat Procedure or Service by Same Physician. Gurgel Alves JA, Praciano de Sousa PC, Bezerra Maia E, et al. 1997;104(6):674-681. Individual patient data were obtained for all 3 included studies. 99214 - Office or other outpatient visit for the evaluation and management of an established patient, which requires a medically appropriate history and/or examination and . Although Doppler studies of the ductus venous, middle cerebral artery, and other vessels have some prognostic value for IUGR fetuses, currently there is a lack of randomized trials showing benefit. To learn more about using ProviderOne to file your claims, use our ProviderOne resources section. Medicare Reimbursement Rates By Cpt Code 99080 PDF ePub. London, UK: NICE; June 2019. var container = document.getElementById(slotId); Moreover, these researchers stated that further studies are needed to evaluate the usefulness of the combined screening test in low-risk populations. 134: Fetal growth restriction. In: The Cochrane Library, Issue 1, 2003. Billing for Non-Global or Partial OB Services 1998;77(5):527-531. (Monday through Friday, 8:30 a.m. to 5 p.m. See alsoCPB 0106 - Fetal Echocardiography and Magnetocardiography and CPB 0127 - Home Uterine Activity Monitoring. The more accurate one of Doppler parameters was MCA, with sensitivity and specificity values of 85.7 % and 77.9 %, respectively, for the cut-off value delta MCA 25 %. All E/M services provided on the same day as a procedure are part of the procedure and Medicare only . An MUE for a Healthcare Common Procedure Coding System (HCPCS) / Current Procedural Terminology (CPT) code is the maximum units of service that a provider would . Non-invasive 20-40 minutes to perform, fetus can be American College of Obstetricians and Gynecologists (ACOG), Committee on Obstetric Practice. 1997;9(4):271-286. 21. Otherwise, count the fetal monitoring as routine. Gudmundsson S, Marsal K. Umbilical and uteroplacental blood flow velocity waveforms in pregnancies with fetal growth retardation. PDF Obstetrical Services Policy, Professional - UHCprovider.com . It may also include the skull, neck and tailbone. window.ezoSTPixelAdd(slotId, 'stat_source_id', 44); list-style-type: decimal; padding-bottom: 4px; For Vaginal Deliveries Bill vaginal deliveries for multiples using the guidelines outlined below: For the first infant (Baby A): .headerBar { SGA of less than fifth centile was significantly associated with low PlGF (p< 0.001 ; DR 57 %, AUC 0.73, 95 % CI: 0.65 to 0.80). You would report this service with 59025 because the ob-gyn is using the NST to determine fetal status. Newnham JP, O'Dea MR, Reid KP, Diepeveen DA. Aetna Inc. and its subsidiary companies are not responsible or liable for the content, accuracy, or privacy practices of linked sites, or for products or services described on these sites. 2021;137(1):72-81. 2001;29(3):146-151. This section of the Manual contains billing guidelines for various provider types. The role of laser surgery in dissecting the etiology of absent or reverse end-diastolic velocity in the umbilical artery of the donor twin in twin-twin transfusion syndrome. 1997;24(2):79-81. Ischemia-modified albumin in preterm infants born to mothers with pre-eclampsia. 2008;(1):CD000038. 1998;178(4):698-706. UA had sensitivity and specificity 70 % and 47.8 %, respectively, for most suitable cut-off value delta UA 16.7 %. Chitotriosidase and YKL-40 in normal and pre-eclamptic pregnancies. The authors concluded that it is possible to predict the discordant twins birth using MCA Doppler velocimetry, but the EFW assessment remains the most accurate method. Endometrial malignancy was diagnosed in 24 of the patients (22.7 %). 1998;12(1):39-44. Although UAD is more accurate in the second trimester,these investigatorsfound encouraging results for first-trimester screening when it was combined with other markers. At least3 randomized clinical trials (RCTs) have evaluated the utility of umbilical artery Doppler velocimetry as a technique of antepartum fetal surveillance in pregnancies complicated by suspected intrauterine growth restriction. Serum YKL-40 and uterine artery Doppler -- a prospective cohort study, with focus on preeclampsia and small-for-gestational-age. Reference ranges for Doppler indices of umbilical and fetal middle cerebral arteries and cerebroplacental ratio: Systematic review. Serum YKL-40 increased from 12 to 20 weeks and decreased from 20 to 25 and 25 to 32 weeks of gestation. London, UK: NICE; May 11, 2016. How and When to Use the 96372 CPT Code - My Clients Plus Banta DH, Thacker SB. Abnormal uterine artery Doppler studies in the first and second trimester have been associated with subsequent adverse pregnancy outcomes including preeclampsia, fetal growth restriction, and perinatal mortality. Ott WJ, Mora G, Arias F, et al. The procedure is noninvasive and typically takes 20 to 40 minutes to perform. Outpatient Hospital Fee Schedule Frequently Asked Questions (FAQs) Screening for pre-eclampsia: A systematic review of tests combining uterine artery Doppler with other markers. Question: What do fetal non-stress tests (NSTs) entail? National Institute for Health and Care Excellence (NICE). Statistically, uterine artery PI, RI, radial artery PI, spiral artery PI, and RI were also significantly lower in patients with malign histopathology. Evaluation of 7 serum biomarkers and uterine artery Doppler ultrasound for first-trimester prediction of preeclampsia: A systematic review. Home; About Us. The authors concluded that serum IMA in addition to the prevalence of SGA were significantly increased in the PE group; thus, cord blood IMA might be a predictive biomarker for SGA in PE pregnancies. CAPC Billing Series) with Andy Esch, MD, MBA and Phillip Rodgers, MD, FAAHPM Wed, August 28 at 12:30pm ET Virtual Office Hours: - Billing for Community Palliative Care with Anne Monroe, MHA Wed, June 19 at 2:00pm ET - Billing and RVUs in Hospital-Based Palliative Care with Julie Pipke, CPC Fri, June 21 at 12:30pm ET Resources: "Tests for measurement of angiogenic factors are commercially available in some countries (not the United States) but are generally still considered investigational. In a systematic review and meta-analysis, Kalafat and colleagues (2018) determined the accuracy of ophthalmic artery Doppler in pregnancy for the prediction of PE. To know more about our billing and coding services you can contact us at 888-357-3226 / [email protected] Reference: CPT CODE 99214 Posted by Medical Billers and Coders February 26, 2020 Medical Billing Services Cochrane Database Syst Rev. 1993;100:733-741. Normal Doppler studies could potentially lead to a reduction in such testing and interventions. Medicaid Obstetrical and Maternal Services MOMS Billing Guidelines Ultrasound Obstet Gynecol. 90791 90792 . 95004 95017 95028 95044. Obstet Gynecol. Mean arterial pressure (MAP) and maternal weight (p=0.001) were significantly associated with PIH (DR 48 %, AUC 0.76, 95 % CI: 0.65 to 0.86). 32 CFR 199 (DHA Version), December 2016 (for use with 2015 (T-2017) Manuals) DoD Women, Infants, and Children (WIC) Overseas Program Policy Manual, July 2017 2014;44(4):419-426. These researchers examined the association between the concentrations of maternal serum PLGF, PAPPA, free beta-hCG, and AFP and the development of PE early in the second trimester. } Here's What You Need to Report 59025 : READER QUESTIONS - AAPC cursor: pointer; Aetna considers Doppler studies of ductus venosus and vessels other than the middle cerebral artery andumbilical arteryfor fetal surveillance of impaired fetal growth experimental and investigational because their effectiveness for these indications has not been established. J Perinat Med. 7. Relevant documents were identified using PubMed (US National Library of Medicine, 1983 through 2011) publications, written in English, which describe the peri-partum outcomes of IUGR according to Doppler assessment of umbilical arterial, middle cerebral artery, and ductus venosus. Doppler ultrasonography in suspected intrauterine growth retardation: A randomized clinical trial. Hypertens Pregnancy. Mariel Gonzalez-Perez on LinkedIn: Very proud to be part of this The authors stated that this study had several drawbacks. Increasing serum YKL-40 was related to maternal age, BMI and small-for-gestational age and may reflect an exaggerated inflammatory response. Furthermore, critical appraisal of the very few prospective studies is hampered by limitations in design or insufficient data given by the authors. Angiogenic marker prognostic models in pregnant women with hypertension. Am J Obstet Gynecol. This prospective cohort study included 262 pregnant women with a low risk of PE. The overall test performance was summarized using summary receiver operating characteristic (SROC) curve analysis. Doppler investigation identifies the fetal cardiovascular response to progressive hypoxia and acidosis and assists in discriminating small, but constitutionally normal, fetuses from those compromised by placental insufficiency". Reece EA, Hagay Z, Garofalo J, Hobbins JC. Fetal and umbilical Doppler ultrasound in normal pregnancy. Allen et al (2016) evaluated the predictive accuracy for stillbirth of second trimester UAD. var ins = document.createElement('ins'); Am J Obstet Gynecol. Answer: A NST is a discrete test that takes 20-40 minutes to complete and requires a notation of fetal movement as part of the test. color: blue It does not mention "multiple pregnancies" as an indication for UA Doppler velocimetry. The dates reported should be the range of time covered, E.g.If the patient had a total of 4-6 antepartum visits, then the physician should, report CPT code 59425 with the from and to dates for which the services, CPT 59425 and 59426 These codes must not be billed together by the same. Am J Obstet Gynecol. The CPT book describes the 59025 CPT code as: Fetal non-stress test.. Doppler assessment of the fetoplacental circulation in normal and growth-retarded fetuses. Kuc S, Wortelboer EJ, van Rijn BB, et al. The ob-gyn may perform the labor check, but as long as the patient does not deliver within 24 hours of admittance, you can include the reimbursement for the labor check in your codes for initial hospital care (99221-99223, Initial hospital care, per day, for the evaluation and management of a patient ). Helsinki, Finland: Duodecim Medical Publications Ltd.; April 3, 2000. Dildy GA. Next, the patient's back . 2019 53(4):465-472. They stated that future studies should be designed to address small changes in peri-natal outcome, and should focus on potentially preventable deaths. 2021;57(1):75-83. American College of Obstetricians and Gynecologists (ACOG). Way Revenue Code For 59025 - Mar 2023 Following an abnormal versus normal UAD assessment, the posterior risks for composite adverse perinatal outcome, admission to the neonatal intensive care unit (ICU), Cesarean section for intrapartum fetal compromise, 5-min Apgar score of less than 7, neonatal acidosis and perinatal death were: 52.3 % versus 20.2 %, 48.6 % versus 18.7 %, 23.1 % versus 15.2 %, 3.59 % versus 1.32 %, 9.15 % versus 5.12 % and 31.4 % versus 1.64 %, respectively. In a systematic review, Kuc et al (2011) examined the literature on the predictive potential of first-trimester serum markers and of UAD velocity waveform assessment (uterine artery [Ut-A] Doppler). Ultrasound scanning during pregnancy. 2011;39(6):619-635. This observation provides the rationale for fetal movement assessment by the mother ("kick counts") as a means of antepartum fetal surveillance. Br J Obstet Gynaecol. Billing and Reimbursement - Harvard Pilgrim Health Care The acoustic stimulation may be repeated up to 3 times, each time for progressively longer durations (up to 3 seconds), to elicit fetal heart rate accelerations. The most commonly interrogated vessels are the umbilical arteries. These investigators searched the Cochrane Pregnancy and Childbirth Group Trials Register (February 28, 2015) and reference lists of retrieved studies. The different performance of tests in screening for early versus late PE, and of low- versus high-risk populations, supports the concept that PE is a heterogeneous disease. analyst jobs in G T S Nagar, Delhi - in.indeed.com PDF Billing Guidelines Section - Florida Blue PMH Billing Scenario 3 Patient returns to LHD within 60 days of delivery for her postpartum visit.Patient has an IUD inserted at the postpartum visit in the FP Clinic. Overall summary of test accuracy was provided by the diagnostic odds ratio (OR). 2008;(3):CD006593. Billing Outpatient Observation Services HCPCS CODE G0378, G0379 No single marker had a test performance suitable for routine clinical use. Goffinet et al (1997) reviewed RCTs of umbilical artery Doppler velocimetry in average-risk pregnancies, and concluded that there is inadequate evidence to support its use in that clinical context: "There is no evidence that routine umbilical Doppler in a general or low-risk population leads to any improvement in the health of women or their infants. Mayer-Pickel et al (2018) stated that an imbalance of angiogenic placental factors such as endoglin, sFlt-1 and PlGF has been implicated in the pathophysiology of PE. Schiffer V, van Haren A, De Cubber L, et al. This association is not sufficiently strong to warrant changes in routine prenatal care, but the biomarkers have been used in risk prediction models". When you-re reporting 59025, you-d better be sure you-ve got supporting documentation--and the supporting diagnosis to justify this code. Because standards for the study technique, gestational age, and criteria for an abnormal test are lacking, uterine artery Doppler studies should not be considered to be a required medical practice in low or high risk populations.". Samples of maternal peripheral blood and umbilical venous blood were collected from 28 pre-eclamptic and 24 normotensive pregnant women and their newborns. "Antepartum care only codes" (CPT codes: 59425 or 59426) should be billed when the practitioner or practitioners of the same group, will not be performing all 3 components of global OB care (4 or more antepartum visits, delivery and postpartum care). To separately bill this service with 59025 (Fetal nonstress test), your ob-gyn must document a clear indication for doing the NST (for instance, to measure fetal wellbeing).You must have a report with the findings and a recommendation for further testing or treatment. UTI, Asthma) during antepartum, Additional E/M visits for complications or high risk monitoring resulting in greater than, However these E/M services should not be reported until after the patient, to identify these visits as separately identifiable from, Inpatient E/M services provided more than 24 hrs before delivery. 2017;75:6-15. A nurse will listen to and record the baby's heartbeat while the baby is resting and while the baby . Epidemiology of antepartum fetal testing. PDF CMS Manual System - Centers for Medicare & Medicaid Services For the comparison of a single Doppler assessment versus no Doppler, evidence for group differences in perinatal death was detected (RR 0.36, 95 % CI: 0.13 to 0.99; 1 study, 3,891 participants). Clinical and demographic data were recorded for both groups. YKL-40 concentration and chitotriosidase activity were determined by enzyme-linked immunoassay and fluorometry, respectively. Kingdom JC, Burrell SJ, Kaufmann P. Pathology and clinical implications of abnormal umbilical artery Doppler waveforms. Salamalekis E, Loghis C, Panayotopoulos N, et al. Manning F. Fetal assessment based on fetal biophysical profile scoring. ", CPT Code 0440T | Description & Clinical Information, CPT Code 26260 | Description & Clinical Information, CPT Code 78191 | Description & Clinical Information, CPT Code 72082 | Description & Clinical Information, CPT Codes For Remote Body And Limb Kinematic Measurement-Based Therapy, CPT Code 44140 | Description & Clinical Information. Fetal Diagn Ther. The fetal heart rate tracing is then evaluated for accelerations of the fetal heart rate corresponding with fetal movement. 2019;53(4):454-464. Ultrasound Obstet Gynecol. First, these researchers were yet to validate their findings in an external cohort; thus, they could not be certain that their model would perform as well in other populations. 28. 5. Mayer-Pickel K, Stern C, Eberhard K, et al. 1997;104:431-435. PDF Reimbursement Rate For Cpt Code 59000 Pdf ; Copy Clinical Guidelines, Standards & Quality of Care Permits, Licenses & Certification All Health Care Professionals & Patient Safety Health Topics A to Z Health Facilities Compare Health Care Providers Adult Care Facilities/Assisted Living Home Care & Hospice Hospitals & Clinics New York State Veterans Homes Nursing Homes School Based Health Centers ins.dataset.adChannel = cid; Procedure. Some providers give the female patient a buzzer and ask her to push it whenever she feels the fetus move. 1985;92:31-38. Physiol Meas. Services should be billed using Current Procedure Terminology (CPT) codes, Healthcare Common Procedure Coding System (HCPCS) codes and/or revenue codes. UpToDate [online serial]. Penning S, Garite TJ. Results for studies that were performed in the second trimester were pooled and summary estimates of sensitivity, specificity, likelihood ratios and their 95 % CIs were obtained. Some of our partners may process your data as a part of their legitimate business interest without asking for consent. This trial included women attending for a routine hospital visit at 19+1 to 23+3 weeks' gestation. Guidelines from the ACOG have concluded that uterine artery Doppler is not an effective method for identifying women at risk for eclampsia.
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