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Objective A single course of antenatal corticosteroids (ACS) is associated with a reduction in respiratory distress syndrome and neonatal death. Multiple Courses of Antenatal Corticosteroids Study (MACS), a study involving 1858 women, was a multicentre randomized placebo-controlled trial of multiple courses of ACS, given every 14 days until 33+6 weeks or birth, whichever came first. The primary outcome of the study, a composite of neonatal mortality and morbidity, was similar for the multiple ACS and placebo groups (12.9% vs. 12.5%), but infants exposed to multiple courses of ACS weighed less, were shorter, and had smaller head circumferences. Thus for women who remain at increased risk of preterm birth, multiple courses of ACS (every 14 days) are not recommended. Chronic use of corticosteroids is associated with numerous side effects including weight gain and depression The aim of this postpartum assessment was to ascertain if multiple courses of ACS were associated with maternal side effects. Methods Three months postpartum, women who participated in MACS were asked to complete a structured questionnaire that asked about maternal side effects of corticosteroid use during MACS and included the Edinburgh Postnatal Depression Scale Women were also asked to evaluate their study participation Results Of the 1858 women randomized, 1712 (92.1%) completed the postpartum questionnaire. There were no significant differences in the risk of maternal side effects between the two groups. Large numbers of women met the criteria for postpartum depression (14.1% in the ACS vs. 16.0% in the placebo group). Most women (94.1%) responded that they would participate in the trial again. Conclusion In pregnancy, corticosteroids are given to women for fetal lung maturation and for the treatment of various maternal diseases. In this international multicentre randomized controlled trial, multiple courses of ACS (every 14 days) were not associated with maternal side effects, and the majority of women responded that they would participate in such a study again.

OBJECTIVE: The aim of this study was to determine the effects of repeated courses of prenatal corticosteroid therapy versus placebo on death or neurologic impairment among the children enrolled in the Multiple Courses of Antenatal Corticosteroids for Preterm Birth Study, at 18 to 24 months of age. METHODS: A total of 2305 infants were eligible for follow-up evaluation; 2104 infants (1069 in the prenatal corticosteroid therapy group and 1035 in the placebo group) were monitored. The primary outcome was death or neurologic impairment, defined as either cerebral palsy or cognitive delay, at 18 to 24 months of age. The secondary outcomes were measurements of growth (height, weight, and head circumference). RESULTS: Children exposed to multiple courses of prenatal corticosteroid therapy had similar rates of death or neurologic impairment, compared with children exposed to placebo (148 children [13.8%] vs 142 children [13.7%]; odds ratio: 1.001[95% confidence interval: 0.75–1.30]; P = .95). They had a mean weight of 11.94 kg, compared with 12.14 kg in the placebo group (P = .04), a mean height of 85.51 cm, compared with 85.46 cm (P = .87), and a mean head circumference of 48.18 cm, compared with 48.25 cm (P = .45). CONCLUSIONS: Multiple courses of prenatal corticosteroid therapy, given every 14 days, did not increase or decrease the risk of death or neurologic impairment at 18 to 24 months of age, compared with a single course of prenatal corticosteroid therapy. Continued follow-up monitoring of these children is necessary to assess neurobehavioral function, school performance, and possible susceptibility to disease.

Objective The purpose of this study was to determine whether planned cesarean delivery for the singleton fetus in breech presentation at term reduces the risk of death or neurodevelopmental delay at 2 years of age. Study design In selected centers in the Term Breech Trial, children were screened for abnormalities at ≥2 years of age with the Ages and Stages Questionnaire, followed by a neurodevelopmental assessment if the Ages and Stages Questionnaire score was abnormal. Results A total of 923 of 1159 children (79.6%) from 85 centers were followed to 2 years of age. The risk of death or neurodevelopmental delay was no different for the planned cesarean than for the planned vaginal birth groups (14 children [3.1%] vs 13 children [2.8%]; relative risk, 1.09; 95% CI, 0.52- 2.30; P =.85; risk difference, +0.3%; 95% CI, −1.9%, +2.4%). Conclusion Planned cesarean delivery is not associated with a reduction in risk of death or neurodevelopmental delay in children at 2 years of age.

Background The Multiple Courses of Antenatal Corticosteroids for Preterm Birth Study (MACS) showed no benefit in the reduction of major neonatal mortality/morbidity or neurodevelopment at 2 and 5 years of age. Using the data from the randomized controlled trial and its follow-up, the aim of this study was to evaluate the association between gestational ages at birth in children exposed to single versus multiple courses of antenatal corticosteroid (ACS) therapy in utero and outcomes at 5 years of age. Method A total of 1719 children, with the breakdown into groupings of

Importance A single course of antenatal corticosteroid therapy is recommended for pregnant women at risk of preterm birth between 24 and 33 weeks’ gestational age. However, 50% of women remain pregnant 7 to 14 days later, leading to the question of whether additional courses should be given to women remaining at risk for preterm birth. The Multiple Courses of Antenatal Corticosteroids for Preterm Birth Study (MACS) was an international randomized clinical trial that compared multiple courses of antenatal corticosteroids with a single course in women at risk of preterm birth. Objective To determine the effects of single vs multiple courses of antenatal corticosteroid therapy on death or neurodevelopmental disability (neuromotor, neurosensory, or neurocognitive/neurobehavioral function) at 5 years of age in children whose mothers participated in MACS. Our secondary aims were to determine the effect on height, weight, head circumference, blood pressure, intelligence, and specific cognitive (visual, spatial, and language) skills. Design, Setting, and Participants Cohort follow-up study of children seen between June 2006 and May 2012 at 55 centers. In total, 1724 women (2141 children) were eligible for the study, of whom 1728 children (80.7% of the 2141 eligible children) participated and 1719 children contributed to the primary outcome. Intervention Single and multiple courses of antenatal corticosteroid therapy. Main Outcomes and Measures The primary outcome was death or survival with a neurodevelopmental disability in 1 of the following domains: neuromotor (nonambulatory cerebral palsy), neurosensory (blindness, deafness, or need for visual/hearing aids), or neurocognitive/neurobehavioral function (abnormal attention, memory, or behavior). Results There was no significant difference between the groups in the risk of death or neurodevelopmental disability: 217 of 871 children (24.9%) in the multiple-courses group vs 210 of 848 children (24.8%) in the single-course group (odds ratio, 1.02 [95% CI, 0.81 to 1.29]; P = .84). Conclusions and Relevance Multiple courses, compared with a single course, of antenatal corticosteroid therapy did not increase or decrease the risk of death or disability at 5 years of age. Because of a lack of strong conclusive evidence of short-term or long-term benefits, it remains our opinion that multiple courses not be recommended in women with ongoing risk of preterm birth. Trial Registration clinicaltrials.gov Identifier:NCT00187382

A single course of antenatal corticosteroids (ACS) is associated with a reduction in respiratory distress syndrome and neonatal death. Multiple Courses of Antenatal Corticosteroids Study (MACS), a study involving 1858 women, was a multicentre randomized placebo-controlled trial of multiple courses of ACS, given every 14 days until 33+6 weeks or birth, whichever came first. The primary outcome of the study, a composite of neonatal mortality and morbidity, was similar for the multiple ACS and placebo groups (12.9% vs. 12.5%), but infants exposed to multiple courses of ACS weighed less, were shorter, and had smaller head circumferences. Thus for women who remain at increased risk of preterm birth, multiple courses of ACS (every 14 days) are not recommended. Chronic use of corticosteroids is associated with numerous side effects including weight gain and depression. The aim of this postpartum assessment was to ascertain if multiple courses of ACS were associated with maternal side effects.Three months postpartum, women who participated in MACS were asked to complete a structured questionnaire that asked about maternal side effects of corticosteroid use during MACS and included the Edinburgh Postnatal Depression Scale. Women were also asked to evaluate their study participation.Of the 1858 women randomized, 1712 (92.1%) completed the postpartum questionnaire. There were no significant differences in the risk of maternal side effects between the two groups. Large numbers of women met the criteria for postpartum depression (14.1% in the ACS vs. 16.0% in the placebo group). Most women (94.1%) responded that they would participate in the trial again.In pregnancy, corticosteroids are given to women for fetal lung maturation and for the treatment of various maternal diseases. In this international multicentre randomized controlled trial, multiple courses of ACS (every 14 days) were not associated with maternal side effects, and the majority of women responded that they would participate in such a study again.

Objective This study was undertaken to compare maternal outcomes at 2 years postpartum after planned cesarean section and planned vaginal birth for the singleton fetus in breech presentation at term. Study design In selected centers in the Term Breech Trial, mothers completed a structured questionnaire at 2 or more years postpartum to determine their health in the previous 3 to 6 months. Results A total of 917 of 1159 (79.1%) mothers from 85 centers completed a follow-up questionnaire at 2 years postpartum. There were no differences between groups in breast feeding, relationship with child or partner, pain, subsequent pregnancy, incontinence, depression, urinary, menstrual or sexual problems, fatigue, or distressing memories of the birth experience. Planned cesarean section was associated with a higher risk of constipation ( P =.02). Conclusion Maternal outcomes at 2 years postpartum are similar after planned cesarean section and planned vaginal birth for the singleton breech fetus at term.

Although a single course of antenatal corticosteroids for women at risk of preterm birth reduces the risk of respiratory distress syndrome (RDS), neonatal mortality and morbidity, the benefits may diminish over time. The effects of weekly doses have been investigated but the benefits are unclear, and there is evidence of decreased fetal growth and other short-term and long-term adverse effects. MACS is an international, multicenter, double-blind, randomized controlled trial designed to determine whether multiple courses of antenatal corticosteroids provide short-term respiratory benefits and minimize the risk of neonatal morbidity and mortality. This trial enrolled 1858 women at 25 to 32 weeks' gestation who had not delivered 14 to 21 days after an initial course of antenatal corticosteroids and remained at high risk for preterm birth. The study was conducted at 80 centers in 20 countries. The study subjects were randomized to receive either antenatal corticosteroids (n = 937) or placebo (n = 921), every 14 days until week 33 or delivery, whichever came first. The primary study outcome was a composite of perinatal or neonatal mortality, or clinically significant neonatal morbidity, which was defined as severe RDS, bronchopulmonary dysplasia intraventricular hemorrhage grade III or IV, cystic periventricular leucomalacia, or necrotizing enterocolitis. All patients and caregivers were blinded as to the treatment given. No difference in primary outcomes of morbidity and mortality was found between infants receiving multiple courses of antenatal corticosteroids or placebo (150 [12.9%] vs. 143 [12.5%], P = 0.83). At birth, in comparison to the placebo, infants who received multiple courses of antenatal corticosteroids weighed less (2216 vs. 2330 g, P < 0.0026), were shorter (44.5 vs. 45.4 cm, P < 0.001), and had a smaller head circumference (31.1 vs. 31.7 cm, P < 0.001). These data show that multiple courses of antenatal corticosteroids given every 14 days are associated with decreased growth in utero and provide no neonatal benefits compared with 1 course of antenatal corticosteroids. The investigators conclude from these findings that multiple courses every 14 days are not recommended.

or gestational age at birth? A secondary analysis from the multiple courses of antenatal corticosteroids for preterm birth study (MACS) Kellie Murphy, Andrew Willan, Mary Hannah, Arne Ohlsson, Edmond Kelly, Stephen Matthews, Saroj Saigal, Elizabeth Asztalos, Sue Ross, Marie-France Delisle, Kofi Amankwah, Patricia Guselle, Amiram Gafni, Shoo Lee, Anthony Armson Mount Sinai Hospital, University of Toronto, Maternal Fetal Medicine, Toronto, ON, Canada, SickKids Research Institute, Child Health Evaluative Sciences, Toronto, ON, Canada, University of Toronto, Department of Obstetrics and Gynecology, Toronto, ON, Canada, University of Toronto, Department of Paediatrics, Toronto, ON, Canada, Paediatrics, Mount Sinai Hospital, Paediatrics, Toronto, ON, Canada, University of Toronto, Physiology, Toronto, ON, Canada, McMaster University, Paediatrics, Hamilton, ON, Canada, Sunnybrook Health Sciences Centre, Paediatrics, Toronto, ON, Canada, Foothills Medical Centre, Obstetrics and Gynecology, Calgary, AB, Canada, Children’s & Women’s Health Centre of British Columbia, Obstetrics and Gynecology, Vancouver, BC, Canada, York Central Hospital, Obstetrics and Gynecology, Richmond Hill, ON, Canada, Sunnybrook Research Institute, Centre for Mother, Infant and Child Research, Toronto, ON, Canada, McMaster University, Clinical Epidemilogy and Biostatistics, Hamilton, ON, Canada, University of Toronto, Pediatrics, Obstetrics and Gynecology and Physiology, Toronto, ON, Canada, IWK Health Centre, Obstetrics and Gynaecology, Halifax, NS, Canada OBJECTIVE: Multiple courses of Antenatal Corticosteroids for preterm birth Study (MACS) was an international multi-centered doubleblind randomized controlled trial of single vs. multiple courses of antenatal corticosteroids (ACS). Infants exposed to ACS experienced similar composite morbidity and mortality as compared to placebo (12.9 % ACS vs. 12.5% placebo) OR 1.04 (CI 0.77-1.39 p 0.83). Infants in the ACS group were smaller. They weighed less (2216 g vs. 2330 g, p 0.0026), were shorter (44.5 cm vs. 45.4 cm, p 0.001) and had a smaller head circumference (31.1 cm vs. 31.7 cm, p 0.001) vs. placebo. The objective of these secondary analyses was to determine the effect of multiple courses of ACS on infant size, controlling for gestational age at birth and other confounders, and to determine if there was a dose response relationship between infant size and number of courses of ACS. STUDY DESIGN: All women (n 1858) and infants (n 2304) enrolled in MACS were included. The gestational age at birth was compared between randomized groups. Multiple linear regression analyses were undertaken to estimate differences (SE) in birth weight, length and head circumference, for the ACS vs. placebo groups, controlling for gestational age at birth and other confounders. RESULTS: Compared to placebo, infants exposed to ACS were born earlier (estimated difference [SE]: 0.43 weeks [0.17], p 0.0098). Controlling for gestational age at birth and other known confounders, multiple courses of ACS were associated with a decrease in birth weight (-33.5 g [SE 16.7] p 0.045), length (-0.3 cm [SE 0.14] p 0.0187) and head circumference (-0.3 cm [SE 0.08] p 0.0003). Lastly, for each additional course of ACS, there was a trend towards an incremental decrease in birth weight, length and head circumference. CONCLUSION: Infants exposed to multiple courses of ACS were born earlier and were smaller. In addition, a dose response was noted between the increasing number of courses of ACS and a decrease in birth weight, length and head circumference. Therefore, administration of multiple courses of ACS, every 14 days, is not recommended. 499 Respiratory outcomes of early term birth Kobina Ghartey, Jaclyn Coletta, Liza Lizarraga, Elizabeth Murphy, Cande V. Ananth, Cynthia Gyamfi Columbia Presbyterian, Maternal Fetal Medicine, New York, NY, Columbia University Medical Center, Obstetrics and Gynecology, Division of Maternal Fetal Medicine, New York, NY, Columbia University Medical Center, Obstetrics and Gynecology, New York, NY, Columbia University Medical Center, Maternal Fetal Medicine, New York, NY, Columbia University Medical Center, OB/GYN, New York, NY OBJECTIVE: Respiratory morbidity at term is thought to decrease as gestational age approaches 39 weeks. However, the risk still persists. The purpose of this study was to evaluate the extent to which respiratory morbidity is higher for neonates delivered at 37-38 weeks gestation, defined as the early term period, in comparison to morbidity at 39 weeks gestation. STUDY DESIGN: We conducted a retrospective cohort study of term deliveries from 370/7 weeks to 396/7 weeks gestation from January to December 2010. Medical records were reviewed to determine baseline characteristics including maternal demographics, admission diagnosis, indication for delivery, mode of delivery, and prior antenatal corticosteroids. Neonatal outcomes were abstracted from infant charts. Our primary outcome was defined as a composite respiratory morbidity comprised of transient tachypnea of the newborn, respiratory distress syndrome, oxygen usage, CPAP, and intubation. RESULTS: Of 2,273 deliveries between 37-39 weeks, 51% (n 1,169) of women delivered in the early term period. There was a significant increase in adverse neonatal respiratory outcomes in those patients delivered in the early term period (Table). There was a significant decrease in the composite respiratory morbidity in those patients delivered at term as compared with the early term period (Figure). CONCLUSION: The two-fold increased risk of respiratory morbidity of infants in the early term period underscores the urgency for limiting non-indicated deliveries to 39 weeks gestation. Poster Session III Doppler Assessment, Fetus, Prematurity www.AJOG.org