Podcast Summary: Dr. Chapa’s Clinical Pearls

Episode: “CPR” For Decreased Fetal Movement? The CEPRA Trial
Date: September 23, 2025
Host: Dr. Chapa

Episode Overview

This episode addresses the clinical challenge of managing patients with decreased fetal movement (DFM) in otherwise low-risk pregnancies at 37–39 weeks, focusing on the role (and relevance) of the cerebral placental ratio (CPR) as per the new international CEPRA trial. Dr. Chapa emphasizes evidence-based, pragmatic care, discusses why DFM is actionable but not an automatic reason for labor induction, and breaks down the findings and implications of the CEPRA trial, recently published in the inaugural issue of Lancet Obstetrics, Gynecology and Women’s Health.

Key Discussion Points & Insights

1. Clinical Management Dilemma: Decreased Fetal Movement (DFM)

• There are clear protocols for some complications (e.g., postpartum hemorrhage, preeclampsia), but DFM remains a gray area in otherwise low-risk pregnancies, particularly between 37 and 39 weeks (02:00).
• Standard protocol:
  • Non-stress test (NST)
  • Assessment of amniotic fluid (maximum vertical pocket, MVP) as part of a modified biophysical profile
• Dr. Chapa:

  "Decreased fetal movement is a flag, right? We have to do something that is actionable." (04:06)

2. Risk Assessment and Indication for Intervention

• Persistent DFM raises relative risk for adverse perinatal outcomes.
• NST and normal MVP (modified BPP) substantially lower risk of stillbirth:
  • NST alone: ~1.8 per 1000
  • Modified BPP: ~0.8 per 1000 (07:35)
• Key message:
  • Do not induce labor solely for DFM in low-risk pregnancies under 39 weeks unless another indication is present (08:40).
• Clarification post-ARRIVE and ACOG guidance:
  • Elective induction at 39 weeks is reasonable, but under 39 weeks, intervention solely for DFM is not supported by evidence (11:30).

3. Introducing the CEPRA Trial & CPR Measurement

• CPR (Cerebro-Placental Ratio): Ratio of the pulsatility index of the middle cerebral artery (MCA) to the umbilical artery (UA); used internationally as a marker for early placental dysfunction.
• CEPRA Trial:
  • Newly published multicenter, cluster-randomized trial (Netherlands, Australia).
  • Compared CPR-based management versus standard care in term, appropriately grown fetuses with maternal perception of reduced fetal movement (16:40–18:55).
• Journal Highlight:
  • Inaugural issue of Lancet Obstetrics, Gynecology and Women’s Health (18:05).
• Dr. Chapa:

  "If somebody asks you, 'Is there anything else you could do?' Absolutely, we could do a CPR... The problem is this isn’t really done in the US." (21:10)

4. US vs. International Practice

• US guidelines (ACOG, SMFM) do not support routine use of CPR in the absence of fetal growth restriction (FGR) or oligohydramnios.
• International societies (especially in Europe) are more enthusiastic, but data remain mixed.
• In the US, placental insufficiency is typically defined by:
  • FGR (growth <10th, notably <3rd percentile)
  • Oligohydramnios (after ruptured membranes/renal anomaly ruled out)
• Rationale:
  • Use of Dopplers: only for FGR, not routine DFM surveillance (25:30)

5. CEPRA Trial Results: What Did They Actually Find?

• Primary Outcome: Composite of adverse perinatal outcomes (stillbirth, neonatal mortality <28 days, 5-min Apgar <7, UA pH <7.1, emergency birth for fetal distress, severe neonatal morbidity) (41:50).
• Key Data:
  • 1684 cases assessed; only 61 (4%) had abnormal CPR (<1.1)
  • Composite adverse outcome:
    • CPR-based management: 12%
    • Usual care: 15%
  • Stillbirths: None in either group
  • Neonatal Deaths: One in each group
• Dr. Chapa’s take:

  "It didn’t really have that great of results. Even though the conclusion was, 'This is better than sliced bread.' ... when I read it, I’m like, huh, it’s not that great. No offense to the Dutch sites that did this..." (35:16)

6. Interpreting the Composite Outcome

• While composite outcomes were lower with CPR-based management (risk reduction ~22%), the driving factors were "softer" outcomes (e.g., lower UA pH thresholds) rather than hard endpoints like stillbirth or neonatal death.
• Number needed to treat (NNT) to improve composite: 1 in 27, but the clinical significance is debated (54:20).
• Limitations Identified:
  • Only 4% abnormal CPR, limiting impact
  • No difference in stillbirths or neonatal deaths
• Comparison: Other trials (e.g., DIGITAT) also failed to demonstrate benefit in high-risk groups (SGA fetuses) (56:00).

7. Practice Implications and Clinical Advice

• Take-home:
  • Always evaluate DFM with surveillance—believe and act, but don’t intervene (i.e., induce labor) under 39 weeks in low-risk, non-FGR, non-oligo patients if everything is otherwise normal.
  • CPR measurement is used internationally but not adopted in the US guidelines; current evidence, including the CEPRA trial, does not support routine use to improve meaningful perinatal outcomes.
• Dr. Chapa's summary advice:

  "Do something for decreased freedom movement. Believe them, do surveillance, but don’t induce them just because they have decreased fetal movement if everything else is normal under 39 weeks." (01:02:20)

Notable Quotes & Memorable Moments

• On patient anxiety:

  “So the patient, very confused and a little frustrated, said, ‘Well, now what the hell am I supposed to do?’ … So now what are we supposed to do?” (09:00)

• Evidence summary:

  “Just because something is in print … you gotta read it very carefully … there was no stillbirth difference in either group, and there was no difference in perinatal death in either group. So not all that helpful.” (33:04)

• On U.S. guideline philosophy:

  “We use FGR and then potentially oligo as a marker of placental insufficiency … we’re very comfortable with umbilical artery Dopplers by themselves ... but this issue of cerebral placental ratio ... the US says it’s kind of hokey. SMFM doesn’t endorse it. ACOG doesn’t endorse it.” (26:10)

• Clinical bottom line:

  “As of now, there has been no high-quality evidence from either randomized or even observational studies that intervention just for persistent decreased fetal movement improves perinatal outcomes because the positive predictive value of that complaint is very small, especially in the otherwise low-risk pregnancies.” (01:01:34)

Timestamps for Important Segments

• Clinical scenario explanation – 01:20–07:00
• Risk assessment statistics – 07:30–09:00
• Discussion on induction and ARRIVE/ACOG – 11:30–14:00
• Introduction to CPR and CEPRA trial – 16:40–21:55
• International vs. US practice – 25:20–27:30
• CEPRA trial design and abnormal CPR rates – 32:10–35:20
• CEPRA primary outcomes/results and context – 41:50–48:50
• Comparison to other trials (DIGITAT) – 56:00–57:10
• Key clinical takeaways and wrap-up – 01:01:34–01:03:00

Conclusion & Clinical Pearls

• For decreased fetal movement in otherwise low-risk pregnancies under 39 weeks:
  • Act and surveil (NST and fluid assessment), do not ignore
  • Do not induce solely for DFM if evaluations are reassuring
• CPR measurement:
  • Interesting international research direction, but currently not recommended or practiced in the US for non-FGR/SGA pregnancies; little impact on stillbirth/neonatal death demonstrated
• Counseling tip for patients/providers:
  • “We do everything to make sure there’s not another hidden issue. If all tests are reassuring, we continue careful monitoring.”

Summary prepared for clinicians, learners, and anyone seeking a clear, evidence-based guide to the complex topic of decreased fetal movement and the relevance of the latest international trial in everyday obstetric practice.