Research

www. AJOG.org

OBSTETRICS

Elective delivery at 340/7 to 366/7 weeks gestation

and its impact on neonatal outcomes in women
with stable mild gestational hypertension
John R. Barton, MD; Lucy A. Barton, BS; Niki B. Istwan, RN; Cheryl N. Desch, MS;
Debbie J. Rhea, MPH; Gary J. Stanziano, MD; Baha M. Sibai, MD
OBJECTIVE: To examine the frequency of elective delivery and neonatal

outcomes in women with stable mild gestational hypertension delivering late preterm.
STUDY DESIGN: The frequency of elective delivery between 1995 and
2007 at gestational age of 340/7366/7 weeks (late preterm), 370/7
376/7 weeks, and 380/7 weeks, as well as neonatal outcomes, were
studied in singleton gestation with mild gestational hypertension without proteinuria from a large national database.
RESULTS: One thousand eight hundred fifty-eight patients were stud-

ied: 607 (33%) were delivered for maternal/fetal reasons and 1251
(67%) were electively delivered. Among the 1251 women delivered

electively, 25.5% were late preterm, 24.4% at 370/7376/7 weeks and

50.1% at 380/7 weeks gestation. Neonatal intensive care unit admission, ventilatory assistance, and respiratory distress syndrome were
more common in late-preterm infants. There was no maternal/perinatal
mortality.
CONCLUSION: We found that 25.5% of patients with stable mild gesta-

tional hypertension, without any maternal or fetal complication, had iatrogenic elective late-preterm delivery. This practice also was associated with
increased rates of neonatal complications and neonatal length of stay.
Key words: late-preterm birth, mild gestational hypertension,
neonatal outcomes

Cite this article as: Barton JR, Barton LA, Istwan NB, et al. Elective delivery at 340/7 to 366/7 weeks gestation and its impact on neonatal outcomes in women with
stable mild gestational hypertension. Am J Obstet Gynecol 2011;204:44.e1-5.

early 13% of infants in the United

States are born preterm, and more
than 70% of these births occur in the
late-preterm period defined as 340/7
through 366/7 weeks of gestation.1 The
From the Perinatal Diagnostic Center (Dr
Barton), Central Baptist Hospital,
Lexington, KY; Division of Maternal-Fetal
Medicine, Department of Obstetrics and
Gynecology (Ms Barton), University of the
South, Sewanee, TN; the Department of
Clinical Research (Ms Istwan, Ms Desch, Ms
Rhea, and Dr Stanziano), Alere Womens
and Childrens Health, Atlanta, GA; and the
Department of Obstetrics and Gynecology
(Dr Sibai), University of Cincinnati School
of Medicine, Cincinnati, OH.
Presented at the 29th Annual Meeting of the
Society for Maternal-Fetal Medicine, San
Diego, CA, Jan. 26-31, 2009.
Received March 4, 2010; revised June 1,
2010; accepted Aug. 18, 2010.
Reprints not available from the authors.
B.M.S. is a consultant for Alere; J.R.B. is a
speaker.
0002-9378/$36.00
2011 Mosby, Inc. All rights reserved.
doi: 10.1016/j.ajog.2010.08.030

44.e1

number of late-preterm births has increased 25% since 1990.1 Late-preterm

birth accounts for the majority of the
overall increase in the preterm birth rate
in the United States and is now recognized as a topic of concern by the March
of Dimes and other womens health organizations.2 Infants delivered late preterm have a higher risk for both acute
and long-term morbidities compared
with infants born at term.3 Although it is
believed that the majority of late-preterm deliveries are related to maternal or
fetal conditions necessitating intervention, patient management strategies providing close surveillance and promoting continued pregnancy prolongation
could potentially impact the nations
preterm birth rate and reduce costs related to newborn care.
According to a recent American College of Obstetricians and Gynecologists
(ACOG) Committee Opinion, late-preterm delivery should occur only when an
accepted maternal or fetal indication for
delivery exists. These accepted indications for preterm delivery include nonreassuring fetal status or a maternal con-

American Journal of Obstetrics & Gynecology JANUARY 2011

dition that is likely to be improved by

delivery.2 Hypertensive disorders are
common in pregnancy and contribute to
both maternal and neonatal morbidity
and mortality. Optimal management of
patients with hypertensive conditions
during pregnancy includes avoiding
eclampsia and other severe maternal
complications while balancing the need
for maintaining fetal well-being and
achieving in utero fetal maturation.
Although some would argue that gestational hypertension meets the ACOG
criteria as a maternal condition that is
likely to improve with delivery, there are
few guidelines addressing the optimal
timing for delivery in women with mild
gestational hypertension who remain in
stable condition and are not yet term.
We are unaware of any guidelines recommending delivery 37 weeks gestation in a stable patient with mild gestational hypertension. All guidelines in
existence at the time of our study recommend that women with stable mild gestational hypertension be followed to
term or the onset of labor in the absence
of maternal or fetal indications for deliv-

Obstetrics

www.AJOG.org
ery with the option for delivery at 37
weeks with a favorable Bishop score.4
The purpose of this analysis was to examine the frequency of elective deliveries
and neonatal outcomes in women with
stable mild gestational hypertension delivering in the late-preterm period.

M ATERIALS AND M ETHODS

The study population was identified retrospectively from a large national database containing clinical data collected
prospectively from high-risk pregnant
women receiving outpatient perinatal
nursing services from Alere (Atlanta,
GA; formerly Matria Healthcare).5
These services provide comprehensive
outpatient services for conditions that
place a pregnancy at risk for adverse outcomes. The population consisted of both
commercially insured and Medicaid patients receiving care from obstetricians
in either academic or community
settings.
Each patients individual health care
provider determined patient diagnoses,
referral for outpatient services, timing,
and method of delivery. Outpatient perinatal nursing services were provided in
addition to care through the physicians
office. Consent for the use of each patients deidentified clinical data for research and reporting purposes is received during the enrollment process.
The institutional review board of Central
Baptist Hospital approved the analysis of
this data. All data were collected using
standardized definitions, policies, procedures, forms, and computer systems.5
The outpatient hypertension surveillance program included an initial education session conducted by an experienced perinatal nurse in the patients
home. Verbal instructions and written
educational materials specific to the condition of gestational hypertension, as
well as clinical signs and symptoms of
a worsening condition, were provided.
Each patient was instructed on self-care
procedures, including use of equipment
for collection of biometric clinical data.
Patients were required to measure blood
pressure using an automated device a
minimum of twice daily. Urine protein
testing was performed daily via dipstick.

Maternal weight was measured daily. Fetal movement counts were performed
daily and as needed. Patients received
antenatal testing with nonstress test
and/or biophysical profile evaluations 1
to 2 times per week at the discretion of
their obstetric provider. Nursing staff
contacted the patient per telephone at
least 1 time per day to assess clinical data
and question the patient about subjective maternal signs and symptoms
(headache, visual changes, epigastric
pain, and edema). Written and verbal reports were provided to the prescribing
physician and case manager weekly or
emergently as needed. As part of the program, 24/7 perinatal nursing support
was available for patient questions or
concerns.5
Medical records of women with a singleton pregnancy enrolled in outpatient
hypertension surveillance program between 1995 and 2007 were studied. Included for analysis were records from
women with a diagnosis of mild gestational hypertension, no prior history of
chronic hypertension, and documented
pregnancy outcome at 34 weeks of gestation. Mild gestational hypertension
was defined as systolic blood pressure
(SBP) 140 mmHg but 160 mmHg
and/or diastolic blood pressure (DBP)
90 mmHg but 110 mmHg on at least
2 occasions 6 hours apart without the
presence of proteinuria by urine dipstick
analysis, without maternal symptoms of
severe disease and with normal complete
blood count and liver function tests.4
Information regarding the patients
medical and obstetric history, current
pregnancy risk factors, diagnoses, medical and pharmacologic treatments and
interventions, daily clinical assessments,
and pregnancy outcome are collected
from the patient and/or her healthcare
provider and maintained in a relational
database. Policies and procedures,
forms, questionnaires, and a standardized electronic medical record are used at
all patient care locations, contributing to
homogeneity of data. Continuous quality improvement measures on a centralized basis and at all nursing call centers
allows for monitoring of data integrity
and nursing compliance.5

Research

After delivery, maternal and neonatal

outcome data were collected by a perinatal nurse and recorded in the database.
For purposes of the study, we categorized each patient into 1 of 3 reason for
delivery groups; spontaneous preterm
delivery, maternal/fetal indications, or
elective/nonindicated delivery. We defined indicated delivery as the presence
of 1 of the following: (1) spontaneous
preterm labor, premature rupture of
membranes (PROM) or vaginal bleeding, (2) maternal/fetal indications including development of preeclampsia,
severe hypertension, hemolysis, elevated
liver enzymes and low platelets (HELLP)
syndrome or thrombocytopenia, diabetes, fetal growth restriction, or nonreassuring fetal testing. Elective delivery was
defined as any delivery predicated by induced labor or scheduled cesarean without documentation of any of the above
reasons for delivery. Maternal outcome
variables studied included the cesarean
section rate, gestational age at delivery,
and mortality. Selected neonatal outcome variables included admission to
the neonatal intensive care unit (NICU),
neonatal respiratory complications (including respiratory distress syndrome
[RDS] and need for ventilation such as
mechanical ventilator or continuous
positive airway pressure [CPAP]), presence of jaundice (need for phototherapy), and total neonatal hospital stay
(NICU, intermediate, and regular nursery
days). Decisions for admission to the
NICU and management of neonatal complications were at the discretion of the attending neonatologists.
Outcomes were compared among
those with nonindicated, elective delivery late-preterm vs 370/7 376/7 weeks
and 380/7 weeks using Student t,
Mann-Whitney U, or Pearsons 2 test
statistics. Two-sided P values .05 are
shown and were adjusted for multiple
comparisons (2 total groups vs control).

R ESULTS
During the study period, there were 1858
patients with mild gestational hypertension delivering 340/7 weeks: 607 (33%)
had maternal and/or fetal reasons for delivery whereas 1251 (67%) women had

JANUARY 2011 American Journal of Obstetrics & Gynecology

44.e2

Research

Obstetrics

www.AJOG.org

TABLE 1

Maternal characteristics of women with the diagnosis of mild gestational hypertension (n 1251)
340/7366/7 wks
(n 319)

GA at delivery groups
Maternal age, y

29 (16, 46)

370/7376/7 wks
(n 305)
29 (15, 44)

>380/7 wks
(n 627)

P value

29 (15, 46)

.591

................................................................................................................................................................................................................................................................................................................................................................................

Nulliparous

168 (52.7)

162 (53.1)

378 (60.3)

.030

Married

255 (79.9)

250 (82.0)

506 (80.7)

.809

Tobacco use

13 (4.1)

12 (3.9)

31 (4.9)

.722

DX of GHTN at 28 wks

36 (11.3)

29 (9.5)

54 (8.6)

.416

GA at start of outpatient
program, wks

33.4 (20.7, 36.4)

34.4 (20.7, 37.6) ( .002)

35.1 (20.4, 40.4) ( .002)

................................................................................................................................................................................................................................................................................................................................................................................
................................................................................................................................................................................................................................................................................................................................................................................
................................................................................................................................................................................................................................................................................................................................................................................
................................................................................................................................................................................................................................................................................................................................................................................
a
a

.001

................................................................................................................................................................................................................................................................................................................................................................................

Data presented as median (minimum, maximum), or n (%).

DX, diagnosis; GA, gestational age; GHTN, gestational hypertension.
a

Adjusted P vs 340 /7366 /7 weeks group.

Barton. Elective late-preterm delivery. Am J Obstet Gynecol 2011.

elective delivery. These later patients are

the subject of this study. Of those 1251
women with elective delivery, 319
(25.5%) were delivered at 340/7366/7
weeks, 305 (24.4%) at 370/7376/7 weeks,
and 627 (50.1%) were delivered at
380/7 weeks gestation. Maternal characteristics are presented in Table 1. Maternal age and marital status were similar
among the groups. Gestational age at
start of outpatient services was earlier for
the women with elective delivery among
340/7366/7 weeks, though rates of diagnosis of gestational hypertension at 28

weeks were similar among the groups.

The rate of cesarean delivery in the latepreterm group was significantly higher
as compared with those delivering at 370/
6/7
737
(51.4% vs 39.9%; P .05);
whereas it was not different from those
delivering 380/7 weeks (44.5%).
Neonatal outcomes are presented in
Table 2. The median gestational age at
delivery was at 36.0 weeks in the latepreterm group compared with 37.4
weeks in the 370/7376/7 week group
and 39.0 in the 380/7 week group. The
frequency of NICU admission, assisted

ventilation, low birthweight, small-forgestational age (SGA) infants, jaundice,

and RDS were highest for infants from
women with elective late-preterm delivery.
There was no maternal or perinatal
mortality.
Neonatal outcomes were further stratified by each week gestation (34, 35, and
36 weeks) and are presented in the Figure. Adverse neonatal outcomes are
shown to decrease with increasing gestational age at delivery. Further, the median nursery days decreased with increasing gestational age at delivery.

TABLE 2

Neonatal outcomes for women with mild gestational hypertension and elective delivery (n 1251)
Outcomes

340/7366/7 wks
(n 319)

GA at delivery, wks

36.0 (34.0, 36.9)

370/7376/7 wks
(n 305)
37.4 (37.0, 37.9)a ( .002)

>380/7 wks
(n 627)
38.9 (38.0, 41.9)a ( .002)

P value
.001

................................................................................................................................................................................................................................................................................................................................................................................
a

Cesarean delivery

164 (51.4)

120 (39.3) (.004)

279 (44.5)

.010

................................................................................................................................................................................................................................................................................................................................................................................
a
a

2698 553

3045 423 ( .001)

3458 486 ( .001)

.001

119 (37.3)

24 (7.9) ( .002)

11 (1.8) ( .002)

.001

SGA

71 (22.3)

27 (8.9) ( .002)

41 (6.4) ( .002)

.001

NICU admission

87 (27.3)

31 (10.2) ( .002)

33 (5.3) ( .002)

.001

Birthweight, g

................................................................................................................................................................................................................................................................................................................................................................................
a
a

LBW (2500 g)

................................................................................................................................................................................................................................................................................................................................................................................
a
a
................................................................................................................................................................................................................................................................................................................................................................................
a
a
................................................................................................................................................................................................................................................................................................................................................................................
a

Days in NICU

7 (1, 35)

7 (1, 22)

4 (1, 31)

Total nursery days

3 (1, 35)

3 (1, 22) ( .002)

2 (1, 31) ( .002)

.001

.003

3 (0.5) ( .002)

.001

................................................................................................................................................................................................................................................................................................................................................................................
a
a
................................................................................................................................................................................................................................................................................................................................................................................
a

Assisted ventilation

22 (6.9)

12 (3.9)

Jaundice

59 (18.5)

28 (9.2) (.002)

59 (9.4) ( .002)

.001

RDS

19 (6.0)

7 (2.3) (.044)

6 (1.0) ( .002)

.001

................................................................................................................................................................................................................................................................................................................................................................................
a
a
................................................................................................................................................................................................................................................................................................................................................................................
a
a
................................................................................................................................................................................................................................................................................................................................................................................

Data presented as mean SD, n (%), or median (minimum, maximum).

GA, gestational age; LBW, low birthweight; NICU, neonatal intensive care unit; RDS, respiratory distress syndrome; SGA, small for gestational age.
a

Adjusted P .05 vs 340 /736 6 /7 wks.

Barton. Elective late-preterm delivery. Am J Obstet Gynecol 2011.

44.e3

American Journal of Obstetrics & Gynecology JANUARY 2011

Obstetrics

www.AJOG.org

FIGURE

Neonatal outcome by week of elective delivery

60.0%

56.4%

50.0%

34 wks
35 wks

40.0%

37.8%

36 wks

30.8%
30.0%
23.5%
20.0%
15.4%
13.2%
10.3%

10.0%

9.2%

7.7%
4.9%

6.1% 5.5%

0.0%
NICU admission

Asst ventilation

RDS

Jaundice

Barton. Elective late-preterm delivery. Am J Obstet Gynecol 2011.

C OMMENT
In the population studied, we found that
25.5% of patients with stable mild gestational hypertension without proteinuria
had elective delivery late preterm. To our
knowledge, this is the first study to provide data on this subject from community practices from across the United
States. We also found elective delivery in
women with stable mild gestational hypertension was also associated with increased rates of cesarean section as well
as neonatal complications and neonatal
length of hospital stay that is in agreement with the findings reported by other
investigators.6,7
Until recently, there have been few
data regarding the neonatal outcomes of
late preterm infants. In fact, it was not
until December 2007 that the American
Academy of Pediatrics reported a definition of the late-preterm gestation.8 As
a follow-up of these findings, a recent
commentary questioned the justification
for late-preterm delivery, stating that the
risks and benefits of immediate delivery vs
postponing need to be closely assessed.
Obstetricians need to avoid delivery of infants in late-preterm pregnancy when it is
not medically indicated.9
In managing a patient with mild stable
gestational hypertension at 37 weeks

gestation, the burden is on the clinician to

weigh the possible benefit of prolonging a
late-preterm pregnancy against the risks of
continuing pregnancy such as progression
to severe gestational hypertension-preeclampsia, eclampsia, abruptio placentae,
HELLP syndrome, pulmonary edema,
periventricular leukomalacia, fetal growth
restriction, and fetal demise. Therefore,
any management of women with mild gestational hypertension must have well-defined maternal and fetal parameters for
delivery.
In a secondary analysis of data from
patients enrolled in the Calcium for Prevention of Preeclampsia (CPEP) trial, Habli et al7 reported neonatal outcomes in
1064 subjects with gestational hypertension/preeclampsia (both mild and severe). In this study, the authors found
that 11(1.0%) had elective induction at
350/7356/7 and 16 (1.5%) at 360/7366/7
weeks gestation. In this study conducted
at 7 medical centers in the United States
for patients with both mild and severe
gestational hypertension, only 2.5% had
elective delivery at 350/7366/7 weeks
gestation. In addition, 3 recent studies
conducted at university hospitals evaluating the causes of late-preterm birth in
their populations found that 9.417.5%10-12 were due to gestational hy-

Research

pertension/preeclampsia. These studies,

however, did not include data on the total number of women with mild gestational hypertension/preeclampsia during the study period to allow the
determination of a true incidence of latepreterm delivery with this pregnancy
complication. Nevertheless, the combined results of these studies suggest that
mild hypertension is an infrequent cause
of late-preterm birth in academic medical centers. In contrast, we found that,
among patients managed by community
providers, one-quarter of patients with
mild gestational hypertension delivered
late preterm. This suggests that there are
variations among practice patterns when
assessing the potential risks of continuing such pregnancies. This discrepancy
in practice might be due to the absence of
randomized trials addressing the risks vs
the benefits of expectant management of
mild gestational hypertension between
340/7370/7 weeks gestation. One can argue that the threshold of risk for stillbirth, severe hypertension, abruptio placentae, eclampsia, and fetal growth
restriction justifies the small newborn
risk from near term delivery. Further,
these patients are still at risk for preterm
labor and PROMs with expectant management that will also result in preterm
delivery.
Unlike severe preeclampsia where expectant management is associated with
substantial maternal and perinatal morbidity,13 the risk for complications in
women with mild gestational hypertension are generally low.5 For example, as
reviewed by Sibai,4 the risks with mild
gestational hypertension range from 0.30.5% for abruptio placentae, 1.5-13.8%
for SGA infants, and 0-0.8% for perinatal
death. These small risks, however, might
result in catastrophic maternal and/or
fetal outcome that has the potential for
significant medicolegal liability as well as
adverse consequences for the obstetric
provider (issues related to hospital privileges, credentialing, and medical licensing). In addition, in women whose disease progresses to severe disease, they
will require the use of intravenous antihypertensive agents, magnesium sulfate
prophylaxis, intensive monitoring during labor, and immediately postpartum

JANUARY 2011 American Journal of Obstetrics & Gynecology

44.e4

Research

Obstetrics

as well as prolonged hospital stay.14 Further, expectant management increases

the risk for fetal growth restriction. It is
well established that newborns with fetal
growth restriction have increased neonatal morbidity and neonatal length of
stay compared with an appropriately
grown infant.15
The strength of our study includes the
large sample size decreasing the possibility of type II error and the geographic
diversity of the women and their obstetric providers in the national database. In
addition, it is the first study to address
the rate of elective delivery in women
with mild stable gestational hypertension with prospective assessment. Limitations of our study include those inherent to any retrospective study. Data
regarding maternal race were not consistently available as women frequently decline to provide this information for the
outpatient record. Also, it is possible that
some maternal and fetal indications were
not well documented by the managing
physicians or reporting nurses. In addition, we did not collect data on amniocentesis for documentation of fetal lung
maturity or steroids for fetal lung maturity enhancement. Decisions for admission to the NICU and management of
neonatal complications were at the discretion of the attending neonatologists
that could have varied between centers
and over the study period of 12 years.
Further, we only evaluated short-term
infant outcomes. The length of the study
period (1995-2007), although allowing
for a larger patient sample, may also have
been a study weakness in that practice
patterns may change over time, rates of
elective delivery were 63.7% for deliveries before 2001 and 71.2% for deliveries
between 2001 and 2007.

44.e5

www.AJOG.org
In summary, we found that 25.5% of
patients with mild stable gestational hypertension are delivered electively at
340/7366/7 weeks gestation. In addition,
we found that infants delivered at these
gestations had increased neonatal complications and increased neonatal
lengths of stay as compared with those
delivered at 37weeks. In the absence of
randomized trials, however, we do not
know whether attempting to prolong
pregnancy with mild stable gestational
hypertension until 37 weeks gestation is
safe to the mother and/or fetus. Further,
we currently do not have a biochemical
or biophysical marker to predict which
patient will develop an adverse pregnancy outcome.16 Therefore, we cannot
provide any recommendations whether
these adverse neonatal outcomes could
have been avoided. This question can
only be answered by a randomized trial
to evaluate the risks and benefits of
delivery vs expectant monitoring in
women with mild gestation hypertension at 340/7366/7 weeks (late-preterm)
gestation.
f
REFERENCES
1. Martin JA, Hamilton BE, Sutton PD, et al.
Births: final data for 2005. Nat Vital Stat Rep
2007;56:1-104.
2. American College of Obstetricians and Gynecologists. Late-preterm infants. ACOG committee opinion no. 404. Obstet Gynecol 2008;111:
1029-32.
3. Bastek JA, Sammel MD, Par E, et al. Adverse neonatal outcomes: examining the risks
between preterm, late preterm, and term infants. Am J Obstet Gynecol 2008;199:
367.e1-8
4. Sibai BM. Diagnosis and management of
gestational hypertension and preeclampsia.
Obstet Gynecol 2003;102:181-92.
5. Barton JR, OBrien JM, Bergauer NK,
Jacques DL, Sibai BM. Mild gestational hyper-

American Journal of Obstetrics & Gynecology JANUARY 2011

tension remote from term: progression and outcome. Am J Obstet Gynecol 2001;184:979-83.
6. Raju TN, Higgins RD, Stark AR, Leveno KJ.
Optimizing care and outcome for late-preterm
(near-term) gestations and for late-term infants:
a summary of the workshop sponsored the National Institute of Child Health and Human Development. Pediatrics 2006;118:1207-14.
7. Habli M, Levine RJ, Qian C, Sibai BM. Neonatal outcomes in pregnancies with preeclampsia or gestational hypertension and in normotensive pregnancies that delivered at 35, 36, or
37 weeks of gestation. Am J Obstet Gynecol
2007;197:406.e1-7
8. Engle WA, Tomashek KM, Wallman C. Late
preterm infants: a population at risk. Pediatrics
2007;120:1390-401.
9. Raju TN. Late-preterm births: challenges and
opportunities. Pediatrics 2008;121:402-3.
10. Lubow JM, How HY, Habli M, Maxwell R,
Sibai BM. Indications for delivery and shortterm neonatal outcomes in late preterm as
compared with term births. Am J Obstet Gynecol 2009;200:e30-3.
11. McIntire DD, Leveno KJ. Neonatal mortality
and morbidity rates in late preterm births compared with births at term. Obstet Gynecol
2008;111:35-41.
12. Holland MG, Refuerzo JS, Ramin SM,
Saade GR, Blackwell SC. Late preterm birth:
how often is it avoidable? Am J Obstet Gynecol
2009;201:400.e1-4.
13. Sibai BM, Barton JR. Expectant management of severe preeclampsia remote from term:
patient selection, treatment, and delivery indications. Am J Obstet Gynecol 2007;196:
514.e1-9.
14. Koopmans CM, Bijlenga D, Groen H, et al.
Induction of labour versus expectant monitoring
for gestational hypertension or mild preeclampsia after 36 weeks gestation (HYPITAT):
a multicentre, open-label randomised controlled trial. Lancet 2009;374:979-88.
15. Pallotto EK, Kilbride HW. Perinatal outcome
and later implications of intrauterine growth restriction. Clin Obstet Gynecol 2006;49:257-69.
16. Barton JR, Sibai BM. Prediction and prevention of recurrent preeclmpsia. Obstet Gynecol 2008;112:359-72.