Evidence map›Paper›PMID 33836690›Full record

ArticleBMC pregnancy and childbirth2021

The CErebro Placental RAtio as indicator for delivery following perception of reduced fetal movements, protocol for an international cluster randomised clinical trial; the CEPRA study.

Stefanie E Damhuis, Wessel Ganzevoort, Ruben G Duijnhoven, Henk Groen, Sailesh Kumar, Alexander E P Heazell, Asma Khalil, Sanne J Gordijn

Open access · goldAbstract readClinical Trial Protocol
PubMed Full text at PMC Publisher
In one paragraph

Article in BMC pregnancy and childbirth, 2021. The graph could read no effect estimate from its abstract, so it casts no vote on the map. Cited by 6 papers, 1 of them a synthesis that pooled it.

0numbers the graph read from it
0cells of the map it votes in
6citing papers in PubMed, 1 pooled it
1.9field-weighted citation impact, top 14% of its field
1 · What the graph read from it

What it found

Each row is one number read from the abstract, on the scale the paper reported it, with its interval. Left of the dashed line favours the treatment, right favours the comparator. Under each row is the sentence it came from. New to these charts? A ten-minute tutorial.

The abstract states no effect estimate the extractor could read, or names no intervention and outcome on the map, so this paper lights no cell and moves no belief. It is still indexed, cited and linked below.

2 · The registry

The trial behind it

Trials whose registry record cites this paper, or whose number appears in the abstract. A trial that started after this paper was published is citing it as background, not reporting it.

Neither the registry nor the abstract names a trial number. If this is a trial report, that itself is worth knowing.

3 · Its place in the literature

Who cites it

6 citing papers in PubMed, 1 synthesis or guideline pooled it, 17 citations in OpenAlex.

  1. Risk Factors for Adverse Pregnancy Outcomes in Reduced Fetal Movement: An IPD Meta-Analysis.BJOG : an international journal of obstetrics and gynaecology · 2025
    Pooled it
  2. Article
  3. Predictive value of fetal Doppler velocimetry, fetal growth trajectory and maternal serum biomarkers for short-term adverse perinatal outcome: secondary analysis of DRIGITAT study.Ultrasound in obstetrics & gynecology : the official journal of the International Society of Ultrasound in Obstetrics and Gynecology · 2025
    Observational
  4. Fetal movement trials: Where is the evidence in settings with a high burden of stillbirths?BJOG : an international journal of obstetrics and gynaecology · 2023
    Article
  5. Fetal Growth Restriction: Mechanisms, Epidemiology, and Management.Maternal-fetal medicine (Wolters Kluwer Health, Inc.) · 2022
    Review
  6. Review
4 · The record

Corrections and comments

PubMed lists nothing against this paper. Absence here is not a guarantee, only a check that was made.

5 · Who and what money

Authors and funding

8 authors at 5 institutions in 3 countries.

Stefanie E DamhuisDepartment of Obstetrics and Gynaecology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands. s.e.damhuis@umcg.nl.ORCID http://orcid.org/0000-0001-8411-2816
Wessel GanzevoortDepartment of Obstetrics and Gynaecology, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam, The Netherlands.
Ruben G DuijnhovenDepartment of Obstetrics and Gynaecology, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam, The Netherlands.
Henk GroenDepartment of Epidemiology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands.
Sailesh KumarDepartment of Obstetrics and Gynaecology, Mater Mothers' Hospital, Mater Research Institute, University of Queensland, Brisbane, QLD, Australia.
Alexander E P HeazellMaternal and Fetal Health Research Centre, Mary's Hospital, University of Manchester and Manchester University NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester, UK.
Asma KhalilFetal Medicine Unit, St George's University and St George's University Hospitals NHS Foundation Trust, London, UK.
Sanne J GordijnDepartment of Obstetrics and Gynaecology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands.
University Medical Center Groningen · NLAmsterdam University Medical Centers · NLManchester Academic Health Science Centre · GBSt George's, University of London · GBThe University of Queensland · AU

Funding

ZonMw 852002034
6 · The paper itself

Abstract

backgroundRoutine assessment in (near) term pregnancy is often inaccurate for the identification of fetuses who are mild to moderately compromised due to placental insufficiency and are at risk of adverse outcomes, especially when fetal size is seemingly within normal range for gestational age. Although biometric measurements and cardiotocography are frequently used, it is known that these techniques have low sensitivity and specificity. In clinical practice this diagnostic uncertainty results in considerable 'over treatment' of women with healthy fetuses whilst truly compromised fetuses remain unidentified. The CPR is the ratio of the umbilical artery pulsatility index over the middle cerebral artery pulsatility index. A low CPR reflects fetal redistribution and is thought to be indicative of placental insufficiency independent of actual fetal size, and a marker of adverse outcomes. Its utility as an indicator for delivery in women with reduced fetal movements (RFM) is unknown. The aim of this study is to assess whether expedited delivery of women with RFM identified as high risk on the basis of a low CPR improves neonatal outcomes. Secondary aims include childhood outcomes, maternal obstetric outcomes, and the predictive value of biomarkers for adverse outcomes.

methodsInternational multicentre cluster randomised trial of women with singleton pregnancies with RFM at term, randomised to either an open or concealed arm. Only women with an estimated fetal weight ≥ 10th centile, a fetus in cephalic presentation and normal cardiotocograph are eligible and after informed consent the CPR will be measured. Expedited delivery is recommended in women with a low CPR in the open arm. Women in the concealed arm will not have their CPR results revealed and will receive routine clinical care. The intended sample size based on the primary outcome is 2160 patients. The primary outcome is a composite of: stillbirth, neonatal mortality, Apgar score < 7 at 5 min, cord pH < 7.10, emergency delivery for fetal distress, and severe neonatal morbidity. DISCUSSION: The CEPRA trial will identify whether the CPR is a good indicator for delivery in women with perceived reduced fetal movements.

trial registrationDutch trial registry (NTR), trial NL7557 . Registered 25 February 2019.

Indexed as

AdultApgar ScoreClinical Decision-MakingFemaleFetal DistressFetal MovementFollow-Up StudiesHumansInfant, NewbornLabor, InducedMiddle Cerebral ArteryMulticenter Studies as TopicPerinatal MortalityPlacental InsufficiencyPractice Guidelines as TopicPredictive Value of TestsCerebroplacental ratioCPRDecreased fetal movementsFetal hypoxiaNeonatal morbidityPlacental insufficiencyReduced fetal movementsStillbirth

Identifiers

PMID33836690
PMCPMC8034072
OpenAlexW3145653442

What OpenQuestion holds

Textmetadata
LicenceCC BY
Read underepoch 390

Registered trials

None linked

Read under generation 80e0d062 · epoch 390. Bibliography from PubMed, PubMed Central and OpenAlex; grants from NIH RePORTER; trial links from ClinicalTrials.gov; estimates, votes and beliefs from the OpenQuestion graph.