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So good, so good, so good. New fall arrivals are at Nordstrom Rack stores. Now. Get ready to save big with up to 60% off. Vince, Kurt, Geiger London and more. How did I not know Rack has Adidas? Cause there's always something new. Join the Nordy Club at Nordstrom Rack to unlock exclusive discounts on your favorite brands. Shop new arrivals first and more. Plus get an extra 5% off every rack purchase with a Nordstrom credit card. Great brands, great prices. That's why you Rack. It's great when we have set protocols for things, maybe a bundle like we have for PPH or for preeclampsia, hypertensive disorders or pregnancy. But there's some things in medicine where we have to balance the risks of potential intervention versus the risks of doing nothing and doing expected management, right? I mean, there's some things that are kind of gray and we have set protocols for. So let me explain this very common situation which actually happened to us just last week when we were on call. So we had a patient who kept coming into labor and delivery. Now mind you, she was 37 weeks in a few days in 37 and three, 37 and four. And she keeps coming into labor and delivery for quote, decreased fetal movement. Now we know what to do with that, right? I mean that's a non stress test. In addition to an evaluation for fluids, we do the modified and there's a protocol for that that makes sense. Even though NST is okay as a type of endopartum fetal surveillance for decreased fetal movement, it would be most beneficial to add a fluid check as a maximal vertical pocket for patients with decreased fetal movement to make sure that it's not a fetal space issue. Okay? So we do NST and a modified and a maximal vertical pocket as a modified biophysical profile for our assessment of decreased fetal movement. Now this patient was otherwise low risk, no growth restriction. She did not have GEST or pre existing diabetes, no hypertension, just decreased fetal movement. Now, decreased fetal movement is a flag, right? We have to do something that is actionable because based on observational data, persistent decreased fetal movement is a flag and depends on who you read anywhere from a risk ratio of 2 up to like 3 or 4 for some adverse perinatal outcome. And so we did the same thing. We did the NST which was textbook reactive. We looked at the maximum vertical pocket and the MVP was stone cold normal. We kept doing this though. She had recurrent visits to labor and delivery. So here's the question. In a patient who does not have a growth restricted Baby okay? Baby's growing fine and is otherwise low risk and is at 37 weeks or above, but less than 39. Y' all get me right? So early term, not full term, because full term you don't even need to raise and just get out. I mean, as long as you're full term, you're good to go. But. But she kept coming in at 37 weeks and days with decreased fetal movement. And the assessments are stone cold normal. I mean, a good tracing and the maximum vertical pocket is normal. So the modified is good, which really does lower the possibility of an adverse issue over, let's say just the non stress test alone. Because according to the data, the rate of stillbirth with a reactive non stress test is about 1.8 per thousand. So it's still pretty good. I mean, it's very low. But if you add a maximal vertical pocket, you actually cut that to about half. So that the rate of stillbirth after a modified biophysical well, and a full biophysical at that point as well, because they're the same rate, is 0.8 per thousand. Right. So whether it's a modified or a full BPP, the rate of stillbirth after reassurance is still 0.8 per thousand. So we told this patient, look, I know this is your third time back here and we keep doing this evaluation, you got to keep coming. You got every time the field baby doesn't move as well, you've got to keep coming because we got to keep doing the evaluation. But it's not an indication to have early induction. It just isn't. There is no evidence that intervention just for decreased feta movement in an otherwise low risk pregnancy that that improves perinatal outcomes under 39 weeks. So, of course, the patient, very confused and a little frustrated, said, you know, the following. Well, now what the hell am I supposed to do? Yeah, that's a good question. Except that was Will Ferrell. That was a dude and not a lady. But still, I mean, so now what are we supposed to do? So we have to be very clear, because at some point, at some point, we do need to stick to our guns and do the right thing. Or do we just go, well, hell, let's just get out and be done, even though you're not 39 weeks yet. So to be very clear, decreased feet of movement is an absolute indication to decrease. Do something. Put the baby on the monitor, check the amount of fluid, make sure everything's okay. You've got to do something. However, routine induction of labor as of right now we're doing this at the end of September 2025. That is not an indication for, for induction of labor in and of itself if you are under 39 weeks. Now remember, if you're at or above 39, well, hell, you don't need to reason anyway that that's all fine and elective since the data from the ARRIVE trial, even though people are walking that back, you know, saying, look at the good use, make it a good use of resources, check the cervix, make sure it's her wishes so that you don't want to do a 39 week and zero induction and a nolip just because the ARRIVE trial said to do that. So it's kind of been walked back. That was ACOG's last publication in January of 2025. Right? Induction of labor and nulla pairs patient at term. And it's okay to wait. It's okay to wait if you're still in the full term bucket of 39 and 0 up to 40 and 6. And we've talked about that. But what happens when you're under that and you have a patient with this complaint of decreased fetal movement? So I'll be very clear, do something. Don't ignore that. But as of right now, there is no data that induction just for routine intervention for decreased fetal movement prior to 39 weeks, that has not been demonstrated to improve perinatal outcomes. And all it does is increase potentially respiratory distress and maybe some NICU admission because of the respiratory issue under 39 weeks. So as of right now, patients who present with decreased fetal movement in an otherwise low risk pregnancy under 39 is an absolute indication for surveillance, but not an indication to intervene. Okay, so look for a reason. There's something else, another reason that you can be out. But decreased feed movement in and of itself is just way too subjective. And there's no national guidance that says that that's an indication for delivery. So we're stuck, right? That's a conundrum. Ah, but this is where our topic for today comes in. And this is perfectly confusing. Now, first of all, I'm kind of excited because we are going to present something out of a brand new journal that got launched yesterday through the Lancet. Now, the Lancet is obviously not you. The Lancet is older than dirt. I mean, Lancet's been around for a long time, but there is this new publication through the Lancet that is just making its debris. It's. What the hell was that word making its debut for? For women's health. And so, and this is what we're covering, the article that we're going to cover is cerebro placental ratio. That's known as cpr. Cerebral placental ratio based management versus care as usual in non small for gestational age fetuses. In other words, appropriately grown at term with maternal perceived reduced fetal movements. This is a multicenter cluster randomized controlled trial. That's a lot of words. Okay, that's a big title. Let me explain. First of all, if you haven't heard of cpr, it's a big thing abroad. They love it, especially the Netherlands. They love this. And we're going to talk about this. However, here's the big catch. Cerebral placental ratio, cpr, which uses the positivity index of the middle cerebral artery, in other words the cerebrum, and the positivity index through the umbilical artery as a surrogate for placental flow. There is a ratio that is published and that's well recognized internationally and it's even in the ultrasound and obstetrics and gynecology guidance for this that came out January 2025, the start of this year. That is in the journal Ultrasounds and Obstetrics and Gynecology and the title is the Cerebral Placental ratio A useful marker, but should it be used as a screening test? And the answer is no. Screening test for what will for some kind of placental dysfunction. So there is international bodies and some that go, oh yeah, the cerebral placental ratio, the ratio of the pulsativity index of the middle cerebral artery and the umbilical artery, that's phenomenal. Not us. So here's the catch. This is where I'm going. This brand new journal publication through this brand new journal, which is through the Lancet, is covering this. Now this, this new journal, this new flavor of the Lancet is Obstetrics, Gynecology and Women's Health. This is volume one, September 2025. All right, so the good news is this is Free Press, it's available online, but this is Lancet Obstetric Gynecology and Women's Health, Volume 1, September 2025. Now, I'm not going to get into all the details of what, what the CPRA trial was. SEPRA is C E P R A, that stands for cerebral placent ratio based assessment. So cepra C E P R A cerebral placental ratio based management versus care as usual in non for gestational and non small for gestational age fetuses at term with maternal perceived reduced fetal movements. Boy, there's a lot There. Short answer is this is called Cepra. And if somebody asks you, like our patient did, is there anything else that you can do? Well, look, we looked at your baby. It's growing well, you're not ruptured, your blood pressure is good, you pass your diabetes test, your NST is great, the amount of fluid around the baby is great. We gotta keep going. I can't intervene. But I tell you what, if you're more comfortable, let's just, why don't you come in every other day and we'll put you on the monitor three times a week? Why not? We can do that. Just make sure we're not missing anything. But I can't induce you just for that. Under 39 weeks. So potentially. So if, let's say you're getting ready to do your oral boards and they ask, is there anything else you could do? Absolutely. We could do a cpr, a cerebral placental ratio based on ultrasound. The problem is this isn't really done in the US now. So. Hold on, because I know what you're thinking. Why are we talking about this? I'm talking about this because it's actually a very well done study. Multi center cluster, randomized, and we're getting into the details very briefly. There was a group that was the revealed group. In other words, they told them what the ratios were versus the concealed group. In other words, they did the ultrasound, found the ratio, but they didn't tell the providers that was the usual care and then tracked outcomes. So, so I, I, I want you to know what this is. This is cpr. And unless you go to these MFM meetings, you're like, what? We, we don't do that. No. And we really don't. We're very comfortable with umbilical artery droppers by themselves. We're very comfortable with middle cerebral artery dopplers, especially in the setting of fetal anemia or hydropes. But this issue of cerebral placental ratio, the pulsativity ratio of the middle cerebral artery on top over the pulsativity index of the umbilical artery, the US says it's kind of hokey. SMFM doesn't endorse it. ACOG doesn't endorse it. I'm just bringing this up because our job on the podcast lets you know it's hot in print. And there's nothing more hot than a brand new journal called the Lancet. Obstetrics, Gynecology and Women's Health that is in volume one, September 2025. And this is the SEPRA trial. S E P R a cerebral placental ratio based management versus care as usual in non small for gestational age fetuses. That term with maternal perceived reduced fetal movement. That's a lot. So when I first read this I thought wait at term, like full term? I mean, why are you even doing this? Just be out? Well, it's not. It's in those between 37 and 39, which is. Right. Like our patient in that gray zone. And what to do? I don't see us doing this. Let me just say right now, as of September 2025, ACOG has never endorsed this, neither has SMFM. But again, this is a very, this is an international thing. Other people do do this and they're very comfortable with this. This is not the first article that touches on cpr. There are others. And the results on its ability to find early utero placental insufficiency is extremely mixed right now. Guys, in the U.S. how do we define placental insufficiency? Not in labor. In other words, antepartum. Two ways, right? It's either a baby that's not growing, that's FGR or oligo, ruling out that the patient's not ruptured or baby doesn't have some kind of a renal anomaly. Those are the two ways. It's the end result of what the placenta potentially is doing wrong, right? So we use FGR and then potentially oligo as a marker of placental insufficiency. So this is a way to say maybe we can get ahead of that and look at the blood flow in the brain. Compare that to the blood flow in the umbilical artery and take this ratio, that is the cpr. Now let me just say very quickly they'll get into, into the, out of the intro. A normal CPR in general has a ratio of about one, right? Just call it. They're about equally matched. Actually normal is about 1.1 to 1.2. Because middle cerebral artery tends to have a better indices than the placental than the umbilical artery. But in general, let's just call it one. But if that pulsativity index of the middle cerebral artery starts to become smaller, okay, if it becomes reduced because of increased resistance, then the ratio drops under one. And that's the catch. A CPR cerebral placental ratio under 1 or 1.1, if it's smaller than that, potentially that reflects fetal redistribution of blood. In other words, the brain is having some increased resistance so that there's more blood flow in the umbilical cord than in, in the Middle cerebral artery that potentially is a flag of very early placental dysfunction. So this study said, let's, let's get these patients who are between 37 and 39 and otherwise low risk babies growing. Well, remember, these babies are not sga and do this test and then we're going to reveal the results to one group, we're going to blind the results from the other, which are the practitioners, and see what happens. Okay, now let me just give you a spoiler alert because even though I've introduced the concept of cerebral placental ratio cpr, there was no change in stillbirth rate. Isn't that what we're trying to do here? The whole reason that we do endopartum fetal surveillance, guys, is to reduce stillbirth. And I'm telling you, according to this study, quote, no stillbirths were recorded. So that's great. Now if you're thinking, well, what about neonatal death, maybe it picks it up later on down the road. Well, there was one neonatal death in each group, so I'm not that impressed, which is why the US doesn't do this. So I want to be very clear the whole reason why I'm doing this. Let me give you the three reasons why we're. Why I'm bringing up a procedure that we don't really do in the U.S. number one, I want to let you know what's new and hot in print. And this is a brand new journal. This is the inaugural journal through the Lancet called Gynecology. I'm sorry, Obstetrics, Gynecology and Women's Health. Two, I want you to know, if somebody asks you what about the cerebral placental ratio? You say, got it. Mainly an international thing. US ACOG and SMFM doesn't really use that because we feel very comfortable doing what we do with antpartum surveillance and then using Dopplers in the setting of fetal growth restriction, not without fetal growth restrictions to try to predict bad things. It's just not that clear and it's very controversial. And then number three, to tell you that just because something is in print, this is our third reason, guys, you got to read it very carefully because they say, wow, we had a reduction. Our relative risk of bad things happening as a composite perinatal morbidity was actually 0.78. Okay, it's not bad, but that means it's a 22% reduction, which is good, but it's not great. And there was no stillbirth difference in either group, and there was no difference in perinatal Death in either group. So not all that helpful. Okay, so I'm going to get into some of the details here. Plus I'm going to give you the exact absolute number of how many CPR ratios actually were abnormal in this cohort. Okay? In other words, if you can do this work, what is the percent chance that you're actually going to find something? I'm going to give you that percent that was actually abnormal in the entire cohort after the intro and let me just tell you it was. Shall I do it now, Mike? Let me just tell you next, before I forget, an abnormal cerebral placental ratio in this study in abnormal CPR in the. Let me find my number. Here it is. In the 1684 cases that were checked, okay. In the end of 1684, the number of abnormal CPR ratios was seen in 61. That's 61 out of 1684. The percentage of that guys is 4% overall. 4%. Not 50%, thankfully. Not 20%, not 10%. An abnormal CPR ratio was found in 61 out of 1684. That's 4%. So that's why us doesn't really do this. I'm simply bringing this up true to our formula to know it's hot in print. So if a patient asks you, is there anything else that we can do? Your answer is yes, there is. But we don't really use it in the US and it doesn't seem to be all that great because the two things we're trying to prevent here, guys, stillbirth and perinatal death, did not change by measuring the positivity index in the middle cerebral artery as a ratio over the positivity index in the umbilical artery. It didn't really have that great of results. Even though the conclusion was oh, this is better than sliced bread. I think we have discovered water. I think we have discovered fire. This is going to change. Upset? No, it doesn't say to that degree, but they are pretty excited about it. And when I read it I'm like, huh, it's not that great. No offense. No offense to the Dutch sites that did this out of the Netherlands and the one Australian site. No offense at all. But there's so much room here for how you inter beauties in the eye of the beholder. And this is why the US as of right now does not include CPRS cerebral placental ratios as an assessment for persistent decreased freedom movement. So the take home message number one is 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, there is no criteria and no guidance that said that we can do routine induction just for persistent decreased fetal movement under 39 weeks in the otherwise low risk, non growth restricted child. Does that make sense? Man, that is a long ass intro. I mean, this is like the whole podcast. So I'll tell you what, let's take a break. Let's get out of this intro. I think I've kind of set it up enough. But we're talking about cpr, cerebral placental ratio, not cardiopulmonary resuscitation. So you got to know what letters we're talking about when people say cpr. We're talking about cerebro plus central ratio, not cardiopulmonary resuscitation. All right, we're going to get into the CEPRA multicenter cluster randomized control trial. When we come back. Tired of all the spin in women's health education. Yeah, so are we. This is Dr. Chapa's OBGYN no Spin podcast. This is, excuse me, a damn fine cup of coffee podcast family. Unique to the Chop up podcast community, the Strong Coffee Company offers 20 discount to whatever you purchase online through the link in our show notes. That's right, it's unique to our podcast community. The Strong Coffee Company is not your routine cup of coffee. It is coffee 2.0 and it's coffee that works as hard as weed do. There are latte options. There's whole bean options as well. And this comes with collagen as well as L theanine and adaptogens to boost overall performance and mental acuity without the caffeine crash. 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A Hulu Original, swiped now streaming on Hulu and Hulu on Disney for bundle subscribers terms apply Your teen adjective used to describe an individual whose spirit is unyielding, unconstrained. One who navigates life on their own terms, effortlessly. They do not always show up on time, but when they arrive, you notice an individual confident in their contradictions. They know the rules, but behave as if they do not exist. The new fragrance by Miu Miu defined by you. Okay, so this is the Sepra trial C E P R A which stands for cerebral placental ratio based management versus care as usual in non small for gestational age fetuses at term with maternal perceived reduced fetal movements. Man, that's a mouthful. This is a multi center cluster randomized control trial. Again, this is out of the Netherlands and one site, one site out of Australia. So very quickly, the positive. Let's just go back just for a minute. The positive predictive value of decreased fetal movement for something bad happening. I'm talking about decrease, not absent fetal movement. Right. Absent fetal movement is a separate issue. But the positive predictive value for decreased fetal movement for an adverse issue is incredibly small. And so that's one of the issues here. It's actionable, but that's why we don't intervene just for that in the setting of reassuring evaluation. And it's okay if it still continues the next day to be decreased. You got to do it again and you got to keep doing it again. You got to keep doing surveillance and or patient education that there's no set amount of kicks or movements per hour. That is okay versus not okay. We don't do that anymore. I wouldn't do kick counts. That's the whole purpose of the affirm trial that was published years ago, that every baby is different. That's why it's just overall perception of normality for that woman and her child. Whatever is normal for that pair, then that's normal for them. Because for some, normal movement could be 30 movements per hour. For some it's 15 movements. Whatever. I mean, the point is, is that every child is different. So we don't do a strict number of kick counts. That was proven by the affirm trial. All right? Not the arrive trial. That was induction and no lips at 39 weeks electively. This is the affirm trial, which we have covered many times before that that detailed kick counts versus overall just awareness of fetal movement. The amount of stillbirth were the same in each. Okay, so the positive predictive value of decreased fetal movement for something really bad happening is actually pretty small. That's why we don't induce just for that. We, we evaluate for that, but it's not enough to induce just for that. Now, maybe in the serial evaluations we find something or we say, ah, now we can intervene because xyz, but now it's no longer elective. Okay. Otherwise you really do want to try to wait, of course, until around 39 weeks where you don't even need a reason. So in general, this is where we're going to go very quickly. This was a very complicated study. It's actually pretty voluminous in the pages. But it's taken this cpr, this cerebral placental ratio, which I've already discussed, it's measuring the positivity index in the fetal middle cerebral artery and the positivity index in the umbilical artery as a ratio. And normal is basically one or just over one. Anything that was less than one, the thought is that's potential some kind of redistribution of blood and that's a flag for very early maybe placental dysfunction. Right. So if the number is getting smaller, that means that the bottom number is getting bigger. The top number is reducing. All right, so you get a reduce in the positivity index in the middle cerebral artery over a normal umbilical artery positivity index so that the ratio drops. So in this publication, what was considered abnormal for the CPR for the cerebral placental ratio, not. Remember, not cardiopulmonary resuscitation, but for this CPR, it is anything less than 1.1. All right, now, very quickly, I'm just going to give you the results because I've kind of belabored this already, that we don't do this here in the US for a lot of reasons. And the data, even internationally is gray. The data for this is gray. Although the International Society for Ultrasound and gyn, they do endorse this. Okay. So there are societies that say maybe this is a thing, although it's too non specific to use as a screening test. But maybe in those that are growth restricted, it's another tool to investigate. We don't use this, right. Growth restricted. We use right now the umbilical artery dopplers and act on them. That's the only thing that tells us when to get out. Outside of extra a very small fetal growth like under 3%. Right. So if there's normal dopplers, but. But less than 3% fetal growth, that's an indication to intervene. But potentially we still do that at about 37 weeks. And then if there is an increase in SD ratio in the umbilical middle. Oh my goodness. In the umbilical artery, that's 37 weeks. If there's absence of flow, you could do that as early as 34 weeks, 33 to 34 weeks. And then if it's reversal of flow in FGR cases, remember you can get out as early as 30 weeks. Right. So that's all in the medically indicated late preterm early term delivery in the growth restricted child. So we know what to do with that. We use umbilical artery dopplers, but internationally they use that and the CPR cerebral placental ratio we do not. So to be very clear, if somebody asks you on your oral boards for persistent fetal movement, is that an indication to intervene? No, it's an indication to observe, to surveil, to see what's going on, to make sure there's no other reason to get out. But if there isn't, you got to just keep doing surveillance. Although there is something called CPR cerebral placental ratio, which internationally is done, but the data is very gray and not that awe inspiring. This was a multi center cluster randomized trial at 22 Dutch hospitals and one Australian hospital. Boy, that was a terrible Australian. Australian hospital. Let me give you the results and then we're going to be done because I already told you that it possibly could help. But the results weren't all that impressive when you consider that the whole reason we surveil is to prevent stillbirth and to prevent perinatal death. Not just an umbilical cord pH less than 7.1, which is 1 of the things that they use as part of their composite. I don't care if their pH is 7.09 in general or 7.08, because the definition in the US for metabolic acidemia is less than or equal to 7.00 and a base excess greater than or equal to minus 12. Okay, that's the definition. So their primary outcome. These are all patients who presented. Hey, I'm over 37, baby's not moving as much. Great, then let's get randomized. We're going to do the CPR and we're going to tell you the results to the providers, or you're randomized to doing the CPR but not tell you the results to the providers. That's called the usual care. Then we're going to see what happens. Okay, so here was their primary outcome. Quote, the primary outcome was a composite, so it's not just one thing. Right. So to be very clear, and these are. This is fine. It's okay to have a composite score, but there's a lot of things thrown in there. It was a composite of adverse perinatal outcomes. Stillbirth, neonatal mortality at less than 28 days, 5 minute Apgar score less than 7, umbilical artery pH less than 7.10. Again. Okay, whatever. 7.10. An emergency birth for fetal distress or severe neonatal morbidities. So that was their outcome. Now remember the primary outcome. Okay, so that's good as a composite. Occurred in 12% of those who had management based in the cerebral placental ratio algorithm based on the CPR. But it occurred in 15% of those who had usual care. So 12% versus 15% as a composite. However. However, there was no stillbirth in either group. And though there was one neonatal death in each group, so it didn't make a difference. Meaning the big difference here in the 12% and 15% were stuff that I'm not sure really made that big deal. Does that make sense? Oh, there was less arterial ph less than 7.10. So we use less than 7.00. So my point is I'm not again, not trying to minimize this. It's very complicated. You know, dopplers are doing. You got to do the ratio. You gotta put in the formula. It didn't really change anything. There was no stillbirth recorded period. And there was one neonatal death in each camp. So again, it's weird because we don't do this. I just want to introduce this idea and the authors. Let me just give you the interpretation directly from this manuscript. Even though it didn't seem to any have any big reduction in death either immediately as a stillbirth or perinatally. Quote. Our study findings show that for women with perceived reduced fetal movements at term in non SGA fetuses, cerebral placental ratio based management, reduced adverse perinatal outcomes, end quote. Yeah, it did as a composite, but it didn't have any effect on stillbirth because no silbers were recorded, period. And there was one neonatal death which occurred in each group. So this is why, guys, this is why if you go visit in the Netherlands or you go to Australia, maybe observe this. I, I got, I've done time abroad. Done time. That's not like I was in the lockup, right? I've done my time, I've done time in the clink. No, never been in the clink. I mean I've done spend time abroad and I'm thankful, you know, there was a time in my young career you were doing a lot of FDA trials or going to as Visiting faculty. So I've been in different sites in the uk, both for some gynecological devices that I was asked to help PI, and even for some obstetrical stuff. We did stuff on adhesions and. And I saw. One time I saw somebody do this CPR ratio, and this was like, in what? Let me think 2012. And I was like, oh, well, we're not doing that, nor do I think we will do that. But they can use that to guide management as potentially. Potentially an early sign of placental dysfunction. But its specificity, guys, is not that good. Now, they say the number needed to treat here to prevent a composite. Remember, a composite of perinatal morbidity was 1 in 27, which is a good number. That's good. But the composite is not that impressive. Plus, there were other studies that have looked at this. There's one called the Digitat D R I G I T A T. That was Digitat. That was a separate trial that looked at doing something based on this abnormal cerebral placental ratio. And guess what? There was no reduction in adverse perinatal outcomes even in higher risk babies, which were sga. Okay, so this is. I'm not the only one saying, I don't know what to do with this. I mean, the Digitrat trial also came up with the same thing, which is even in SGA fetuses. Not fgr, but SGA fetuses. This didn't really help prevent or reduce adverse perinatal outcomes. All right, so as we get ready to wrap this up, guys, what did we cover? We covered a new inaugural article of a new inaugural journal, which is through the Lancet. This is a new journal coming out called Obstetrics, Gynecology and Women's Health. This is volume one, September 2025. And we have covered the CEPRA trial. CEPRA, that stands for Cerebral Placental Ratio Based Management versus CARE as usual in non small for gestational age fetuses at term with maternal perceived reduced fetal movements. A multicenter cluster randomized control trial. My goodness, that's a title. So I'll just say do something for decreased freedom movement. Don't induce just for that. Unless there's something else going on or you'll get a day at least. We do. We'll get a ding if it's under 39 weeks. That's. That's not a thing. But look for reasons. Look to see. And guys, we do our due diligence. I mean, we're like, look under the chassis. We, you know, we spin the tires, we look at the windshield wipers, we do everything as if the body's a car to find another reason to get out. But if there isn't, then discontinued surveillance because as of now there has been no high quality evidence from either randomized or even observational studies that intervention just for persistent decreased freedom movement improves perinatal outcomes because the positive predictive value of that complaint is very small, especially in the otherwise low risk pregnancies. All right. Boy, that seemed like a lot. Was that a lot? I think it was a lot. Podcast family, as always, we're thankful for you. We're glad you're part of our podcast community. And having said that, now that we've done all that, Podcast family, let's take it home. Podcast family, we're thankful for all the support that you've given us throughout the years. This has been the OBGYN no Spin podcast. We'll see you on the next episode.