Comment on “Cerebroplacental Ratio-based Management Versus Care as Usual in Non–Small-for-Gestational-Age Fetuses At Term With Maternal Perceived Reduced Fetal Movements (CEPRA): A Multicentre, Cluster-randomized Controlled Trial”

Up to 15% of pregnant people perceive reduced movements of their fetuses. While this is a subjective perception, reduced fetal movements can be an early warning sign of placental dysfunction. Reduced fetal movements increase the risk of stillbirth and other adverse outcomes, including asphyxia and adverse neurodevelopmental outcomes. Currently, there is a wide variation in how providers respond to reports of reduced fetal movement. Doppler ultrasound and serum biomarkers that assess placental function may help identify at-risk fetuses. The cerebroplacental ratio is a measure that looks at how blood is shared between the baby’s brain and placenta. A reduced cerebroplacental ratio may indicate placental dysfunction, so that a redistribution of fetal circulation is necessary as a compensatory response. While a low cerebroplacental ratio has been associated with adverse outcomes in small-for-gestational-age (SGA) fetuses, non-SGA fetuses are an understudied group. The aim of this study was to evaluate whether the cerebroplacental ratio improves perinatal outcomes in uncomplicated, at-term, non-SGA pregnancies with reduced fetal movements. This was a cluster-randomized controlled trial conducted at 22 Dutch hospitals and 1 Australian hospital between July 1, 2020 and September 3, 2024. Included were uncomplicated, at-term, singleton pregnancies with perceived reduced fetal movements, with an estimated fetal weight ≥10th percentile and no reasons for delivery within 4 days. Excluded were people who were younger than 18 years of age, could not give informed consent, or had an abnormal ultrasound indicating fetal compromise, major congenital malformation, or chromosomal abnormality. Clusters of hospitals were randomly assigned 1:1 to either usual care (concealed group) or cerebroplacental ratio-based management (revealed group). The revealed group knew the cerebroplacental ratio and used it to manage a pregnancy, with either expedited birth when the ratio was <1.1 or expectant management when the ratio was ≥1.1. The ratio was not revealed to the obstetric providers in the concealed group. The primary outcome was a composite of adverse perinatal outcomes, which included stillbirth, neonatal mortality (<28 d), 5-minute Apgar score <7, umbilical artery pH <7.10, emergency birth due to fetal distress, and severe neonatal morbidity. A total of 1684 women were included in the intention-to-treat analysis. The primary outcome was observed in 12% of women in the revealed group versus 15% of those in the concealed group [relative risk (RR), 0.76, 95% CI, 0.58-0.99]. Of note, 3% of patients in the revealed group had a CPR <1.1, whereas 5% in the concealed group did. There were no stillbirths, one neonatal death in each group, as well as 12 non-study-related serious events in the revealed group and 14 in the concealed group. In conclusion, cerebroplacental-ratio management of uncomplicated, at-term, non-SGA pregnancies with perceived reduced fetal movements had fewer adverse perinatal outcomes than pregnancies in which the ratio was unknown. (Summarized from Lens LA, Posthuma S, Damhuis SE, et al. Cerebroplacental ratio-based management versus care as usual in non-small-for-gestational-age fetuses at term with maternal perceived reduced fetal movements (CEPRA): A multicentre, cluster-randomised controlled trial. Lancet Obstet Gynaecol Womens Health 2025;1:e19–27. doi: https://doi.org/10.1016/j.lanogw.2025.100002)