COVID-19 in pregnancy

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COVID-19 in pregnancy
3d illustration of coronavius.png
Virtual model of coronavirus
Risk factors Severe infection
PreventionCovering cough, avoid interacting with sick people, cleaning hands with soap and water or sanitizer
Deaths2 [1]

The effect of COVID-19 infection on pregnancy is not completely known because of the lack of reliable data. [2] If there is increased risk to pregnant women and fetuses, so far it has not been readily detectable.


Predictions based on similar infections such as SARS and MERS suggest that pregnant women are at an increased risk of severe infection [3] [4] but findings from studies to date show that clinical characteristics of COVID-19 pneumonia in pregnant people were similar to those reported from non-pregnant adults. [5] [6]

There is no data suggesting an increased risk of miscarriage of pregnancy loss due to COVID-19 and studies with SARS and MERS do not demonstrate a relationship between infection and miscarriage or second trimester loss. [7]

It is unclear yet whether conditions arising during pregnancy including diabetes, cardiac failure, hypercoagulability or hypertension might represent additional risk factors for pregnant women as they do for non-pregnant women. [5]

From the limited data available, vertical transmission during the third trimester probably does not occur, or only occurs very rarely. There is no data yet on early pregnancy. [5]

Research about COVID-19 in pregnancy

Little evidence exists to permit any solid conclusions about the nature of COVID-19 infection in pregnancy. [8]

Effect on pregnant women

In May 2020, the Royal College of Obstetricians and Gynaecologists (RCOG) and the Royal College of Midwives (RCM) reported the results from a UK Obstetric Surveillance System (UKOSS) study of 427 pregnant women and their babies. [9] This study showed that 4.9 pregnant women per 1000 were admitted to hospital with COVID-19 and 1 in 10 of these required intensive care. [10]

The findings of this study support earlier suggestions that pregnant women are not at greater risk of severe illness than non-pregnant women. Similar risk factors also apply: women in the study were more likely to be admitted to hospital if they were older, overweight or obese, or had pre-existing conditions such as diabetes or high blood pressure. [9] Five women died but it is not yet clear whether the virus was the cause of death. [9] Since the majority of women who became severely ill were in their third trimester of pregnancy, the RCOG and RCM emphasised the importance of social distancing for this group. [9] The study also found that 55% of pregnant women admitted to hospital with COVID-19 were from a black or other minority ethnic (BAME) background, which is far higher than the percentage of BAME women in the UK population. Speaking for the RCOG, Dr Christine Ekechi stated that it is of "great concern" that over half of those admitted to hospital were from a BAME background, that there were already "persisting vulnerabilities" for this group, and that the RCOG was updating guidance to lower the threshold to review, admit and consider escalation of care for pregnant women of BAME background. [9] The UK Audit and Research Collaborative in Obstetrics and Gynaecology undertook a UK wide evaluation of women's health care services in response to the acute phase of the pandemic, finding more work was required in the long term for the provision of both maternity and gynaecology oncology services. [11] [12] [ failed verification ]

A case series of 43 women from New York who tested positive for COVID-19 showed similar patterns to non-pregnant adults: 86% had mild disease, 9.3% had severe disease and 4.7% developed critical disease. [13] Another study found the cases of COVID-19 pneumonia in pregnancy were milder and with good recovery. [14]

A study of 9 infected women at the third trimester of pregnancy from Wuhan, China showed that they showed fever (in six of nine patients), muscle pain (in three), sore throat (in two) and malaise (in two). Fetal distress was reported in two. None of the women developed severe COVID-19 pneumonia or died. All of them had live birth pregnancies and no severe neonatal asphyxia was observed. The samples of breast milk, amniotic fluid, cord blood and neonatal throat swab were tested for SARS-CoV-2, and all results were negative. [6]

In another study on 15 pregnant women, majority of the patients presented with fever and cough, while laboratory tests yielded lymphocytopenia in 12 patients. [14] Computed tomography findings of these patients were consistent with previous reports of non-pregnant patients, consisting of ground-glass opacities at early stage. [14] [15] Follow-up images after delivery showed no progression of pneumonia. [14]

Media reports indicate that over 100 women with COVID-19 might have delivered, and in March 2020, no maternal deaths were reported. [16] In April 2020, a 27-year old pregnant woman at 30 weeks of pregnancy died in Iran; her death may have been caused by COVID-19. [17]

The RCOG advised in early April 2020 that because pregnancy is a hypercoagulable state and that people admitted to hospital with COVID-19 are also hypercoagulable, infection with COVID-19 could increase the risk of venous thromboembolism and that this risk could be compounded by reduced mobility due to self-isolating. [18] Their guidelines thus advise that any pregnant woman admitted to hospital with a COVID-19 infection should receive at least 10 days of prophylactic low-molecular-weight heparin after being discharged from the hospital. [19]

Recently, the International Registry of Coronavirus Exposure in Pregnancy (IRCEP) was launched as a collaboration between Pregistry and the Harvard TH Chan School of Public Health. [20]

Effect on labour

There are limited data concerning the implications of COVID-19 infections for labour. [5] Al-kuraishy et al. reported that COVID-19 in pregnancy may increase the risk of preterm labour. Preterm delivery is regarded as a chief outcome of COVID-19 pneumonia during pregnancy. [18] The UKOSS study found that median gestational age at birth was 38 weeks and that 27% of women studied had preterm births. Of these, 47% were interventions given because of risk to the mother's health and 15% were because of risk to the foetus. [7]

Effect on the fetus

There are currently no data to suggest increased risk of miscarriage or early pregnancy loss in relation to COVID-19. [18]


Early studies indicated no evidence for vertical transmission of COVID-19 from mother to child in late pregnancy [6] but more recent reports indicate that vertical transmission may occur in some cases. [21] [22] [23]

Early research found two neonates to be infected with COVID-19 but it was considered that transmission likely occurred in the postnatal period. [24]

It is also to be noted that the human placenta expresses factors that are important in the pathogenesis of COVID-19. [25]

More recent small-scale findings indicate that vertical transmission may be possible. One infant girl born to a mother with COVID-19 had elevated IgM levels two hours after birth, suggesting that she had been infected in utero and supporting the possibility of vertical transmission in some cases. [21] A small study involving 6 confirmed COVID-19 mothers showed no indication of SARS-CoV-2 in their newborns' throats or serum but antibodies were present in neonatal blood sera samples, including IgM in two of the infants. [22] This is not usually passed from mother to fetus so further research is required to know whether the virus crossed the placenta or whether placentas of women in the study were damaged or abnormal. [22]

A set of triplets were born prematurely with COVID-19 at the Ignacio Morones Prieto Central Hospital in San Luis Potosí, Mexico, on June 17, 2020. Both parents tested negative and the children were reported stable. [26]


Since COVID-19 shows similarities to SARS-CoV and MERS-CoV, it is likely that their effect on pregnancy are similar. During the 2002–03 pandemic, 12 women who were infected with SARS-CoV were studied. [27] Four of seven had first trimester miscarriage, two of five had fetal growth restriction in the second trimester, and four of five had preterm birth. Three women died during pregnancy. None of the newborns were infected with SARS-CoV. [27] A report of ten cases of MERS- CoV infection in pregnancy in Saudi Arabia showed that the clinical presentation is variable, from mild to severe infection. The outcome was favorable in a majority of the cases, but the infant death rate was 27%. [28]

A review suggested that COVID-19 appeared to be less lethal to mothers and infants than SARS and MERS but that there may be an increased risk of preterm birth after 28 weeks' gestation. [29]

47 million women in 114 low and middle-income countries are projected by UNFPA to be unable to use modern contraceptives if the average lockdown, or COVID-19-related disruption, continues for 6 months with major disruptions to services: For every 3 months the lockdown continues, assuming high levels of disruption, up to 2 million additional women may be unable to use modern contraceptives. If the lockdown continues for 6 months and there are major service disruptions due to COVID-19, an additional 7 million unintended pregnancies are expected to occur by UNFPA. The number of unintended pregnancies will increase as the lockdown continues and services disruptions are extended. [30]


The World Health Organization and Centers for Disease Control and Prevention of the United States advises pregnant women to do the same things as the general public to avoid infection, such as covering cough, avoid interacting with sick people, cleaning hands with soap and water or sanitizer. [2] [4]

COVID-19 vaccines

The CDC now encourages pregnant women to get COVID-19 vaccines.

General recommendations

The United Nations Population Fund (UNFPA) recommends seven general measures for all episodes of contact with maternity patients undergoing care: [31]

  1. Ensure staff and patient access to clean hand washing facilities prior to facility entry.
  2. Have basic soap at each health facility wash station along with a clean cloth or disposable hand towels for hand drying.
  3. If midwives provide direct patient care, they must frequently wash their hands with soap and water for at least 20 seconds each time. This must happen before every new woman is seen and again before their physical exam. Midwives should wash again immediately after the exam and again once the patient leaves. Washing should also occur after cleaning surfaces and coughing or sneezing. Hand sanitizer can also be applied especially if clean water is unavailable. [31]
  4. Avoid touching the mouth, nose or eyes.
  5. Staff and patients should be advised to cough into a tissue or their elbow and wash hands afterwards.
  6. Midwives should keep a social distance of at least 2 arms lengths during any clinical visit. As long as hand washing is performed before and after the physical exam women without suspected or confirmed COVID-19, the physical exam and patient contact should continue as usual, if hand washing is performed before and after. [31]
  7. Spray surfaces used by patients and staff with bleach or another. Be sure to wipe down the surface with a paper towel or clean cloth in between patients and wash hands. [31]
  8. Childbirth, antenatal care and postnatal care are carried out by midwives and represent some of the most important health care services in the women's health sector and are directly linked to mortality and morbidity rates. [31]
  9. It is essential that the SRMNAH workforce, including midwives, is included in the emergency response and distribution plans to receive sufficient PPE and orientation how to use PPE correctly. [31]
  10. Since midwifery care is continuing to be an essential service that women must be able to access it is very important that midwives receive support, mentoring and orientation how to re-organise services to keep providing quality care (i.e. respecting the public health advice of at least 2m between women, as few as possible midwives looking after one woman (few staff in the room), hand washing hygiene). [31]
  11. Midwives must receive evidence-based information that they can protect themselves from contracting COVID-19 when caring for a symptomatic woman, or from a woman who was exposed to a COVID-19 positive person. [31]
  12. Midwives play an essential role in reducing stigma and battling the spreading belief that health facilities are to be avoided to stay healthy/ not contract COVID-19. [31]
  13. It can be expected that the reorganisation/ removal of funds from sectors that midwives work in, will directly be linked to an upward trend of maternal and newborn morbidity and mortality pushing countries further away from their SDG targets]. [31]

Antenatal care

The RCOG and RCM strongly advise that antenatal and postnatal care should be regarded as essential, and that "pregnant women will continue to need at least as much support, advice, care and guidance in relation to pregnancy, childbirth and early parenthood as before". [18]

In May 2020, a spokesperson for the RCOG suggested that black and other minority ethnic women should be warned that they may have greater risk of complications from the virus and should be advised to seek help early if concerned. [9] Moreover, healthcare professionals should be aware of the increased risk and have a lower threshold to review, admit and escalate care provided to women of BAME background. [7]

To minimise the risk of infection, the RCOG and RCM advise that some appointments may be conducted remotely via teleconferencing or videoconferencing. [18] A survey conducted in Shanghai among pregnant women in different trimesters of pregnancy identified a strong demand for online access to health information and services. [32] Women expecting their first baby were more willing to have online consultation and guidance than who had previously given birth. [32]

The RCOG and RCM recommend that in-person appointments be deferred by 7 days after the start of symptoms of COVID-19 or 14 days if another person in the household has symptoms. [18] Where in-person appointments are required, pregnant patients with symptoms or confirmed COVID-19 who require obstetric care are advised to notify the hospital or clinic before they arrive in order for infection control to be put in place. [5] [18]

Universal screening at the New York–Presbyterian Allen Hospital and Columbia University Irving Medical Center found that out of 215 pregnant patients, four (1.9%) had symptoms and were positive for COVID-19 and 29 (13.7%) were asymptomatic but tested positive for the virus. [33] Fever subsequently developed in three asymptomatic patients. One patient who had tested negative subsequently became symptomatic postpartum and tested positive three days after the initial negative test. [33] The doctors conducting the screening recommended that in order to reduce infection and allocate PPE, due to high numbers of patients presenting as asymptomatic, universal screening of pregnant patients should be conducted. [33]

During labour

In the UK, official guidelines state that women should be permitted and encouraged to have one asymptomatic birth partner present with them during their labour and birth. [18]

There is no evidence regarding if there is vaginal shedding of the virus, so the mode of birth (vaginal or caesarean) should be discussed with the woman in labour and take into consideration her preferences if there are no other contraindications. [16] [18] If a patient has a scheduled elective caesarean birth or a planned induction of labour, an individual assessment should consider whether it is safe to delay the procedure to minimise the risk of infecting others. [18] Products of conception, such as the placenta, amnion etc. have not been shown to have congenital coronavirus exposure or infection, and do not pose risk of coronavirus infection. [34]

The RCOG and the RCM recommend that epidurals should be recommended to patients with confirmed or suspected COVID-19 in labour so that the need for general anaesthesia is minimised if urgent intervention for birth is required. [18] They also suggest that women with suspected or confirmed COVID-19 should have continuous electronic fetal monitoring. [18] The use of birthing pools is not recommended for suspected or confirmed cases of COVID-19 due to the risk of infection via faeces. [18]

Postnatal care

An infographic from the World Health Organization on COVID-19 preventive measures to be taken while breastfeeding WHO EN women with COVID-19 can breastfeed COVID-19.png
An infographic from the World Health Organization on COVID-19 preventive measures to be taken while breastfeeding

In the UK, official recommendations state that precautionary separation of a mother and a healthy baby should not be undertaken lightly and that they should be kept together in the postpartum period where neonatal care is not required. [18] According to UN Population Fund, women are encouraged to breastfeed as normal to the extent possible in consultation with the healthcare provider. [34]

Literature from China recommended separation of infected mothers from babies for 14 days. [18] In the US there is also the recommendation that newborns and mothers should be temporarily separated until transmission-based precautions are discontinued, and that where this is not possible the newborn should be kept 2 metres away from the mother. [5]

Besides, some current guidelines include that mothers with COVID-19 should be encouraged to breastfeed if they are able, but should wear personal protective equipment to do so. This suggestion has been made, given that neonatal infection is generally mild and often asymptomatic, and the benefits of breastfeeding may outweigh the potential transmission risk. [35]

UNFPA recommends it is critical that all women have access to safe birth, the continuum of antenatal and postnatal care, including screening tests according to national guidelines and standards, especially in epicenters of the pandemic, where access to services for pregnant women, women in labour and delivery, and lactating women is negatively impacted. [36]

Impact of the COVID-19 pandemic on pregnant women

According to UN Women, the diversion of attention and critical resources away from women's reproductive health could exacerbate maternal mortality and morbidity and increase the rate of adolescent pregnancies. [37] The United Nations Population Fund recommends that having access to safe birth, antenatal care, postnatal care and screening tests according to national guidelines is critical, particularly in areas where the pandemic has overwhelmed hospitals, so that reproductive health is negatively impacted. [34]

See also

Related Research Articles


Midwifery is the health science and health profession that deals with pregnancy, childbirth, and the postpartum period, in addition to the sexual and reproductive health of women throughout their lives. In many countries, midwifery is a medical profession. A professional in midwifery is known as a midwife.

Obstetrics is the field of study concentrated on pregnancy, childbirth and the postpartum period. As a medical specialty, obstetrics is combined with gynecology under the discipline known as obstetrics and gynecology (OB/GYN), which is a surgical field.

Maternal death Aspect of human reproduction and medicine

Maternal death or maternal mortality is defined by the World Health Organization (WHO) as "the death of a woman while pregnant or within 42 days of termination of pregnancy, irrespective of the duration and site of the pregnancy, from any cause related to or aggravated by the pregnancy or its management but not from accidental or incidental causes." These maternal deaths are divided into two categories: direct obstetric deaths and indirect obstetric deaths. The latter are deaths for which there was a preexisting disease that was aggravated by the pregnancy. Another WHO classification is pregnancy related deaths which include both direct and indirect deaths that occur after 42 days but less than one year after the pregnancy outcome.

Postpartum period Period beginning immediately after the birth of a child and extending for about six weeks

The postpartum period begins immediately after childbirth as the mother's body, including hormone levels and uterus size, returns to a non-pregnant state. The terms puerperium, puerperal period, or immediate postpartum period are commonly used to refer to the first six weeks following childbirth. The World Health Organization (WHO) describes the postnatal period as the most critical and yet the most neglected phase in the lives of mothers and babies; most maternal and newborn deaths occur during this period. In scientific literature, the term is commonly abbreviated to Px, where x is a number; for example, "day P5" should be read as "the fifth day after birth". This is not to be confused with the medical nomenclature that uses G P to stand for number and outcomes of pregnancy.

Gestational age is a measure of the age of a pregnancy which is taken from the beginning of the woman's last menstrual period (LMP), or the corresponding age of the gestation as estimated by a more accurate method if available. Such methods include adding 14 days to a known duration since fertilization, or by obstetric ultrasonography. The popularity of using such a definition of gestational age is that menstrual periods are essentially always noticed, while there is usually a lack of a convenient way to discern when fertilization occurred.

Pregnancy Time when children develop inside the mothers body before birth

Pregnancy, also known as gestation, is the time during which one or more offspring develops inside a woman. A multiple pregnancy involves more than one offspring, such as with twins. Pregnancy usually occurs by sexual intercourse, but can also occur through assisted reproductive technology procedures. A pregnancy may end in a live birth, a spontaneous miscarriage, an induced abortion, or a stillbirth. Childbirth typically occurs around 40 weeks from the start of the last menstrual period (LMP). This is just over nine months —where each month averages 31 days. When using fertilization age it is about 38 weeks. An embryo is the developing offspring during the first eight weeks following fertilization, after which, the term fetus is used until birth. Signs and symptoms of early pregnancy may include missed periods, tender breasts, morning sickness, hunger, and frequent urination. Pregnancy may be confirmed with a pregnancy test.

Group B streptococcal infection Medical condition

Group B streptococcal infection, also known as Group B streptococcal disease or just Group B strep, is the infection caused by the bacterium Streptococcus agalactiae. GBS infection can cause serious illness and sometimes death, especially in newborns, the elderly, and people with compromised immune systems.

Maternal health is the health of women during pregnancy, childbirth, and the postpartum period. It encompasses the health care dimensions of family planning, preconception, prenatal, and postnatal care in order to ensure a positive and fulfilling experience, in most cases, and reduce maternal morbidity and mortality, in other cases. Maternal health revolves around the health and wellness of women, particularly when they are pregnant, at the time they give birth, and during child-raising. WHO has indicated that even though motherhood has been considered as a fulfilling natural experience that is emotional to the mother, a high percentage of women go through a lot of challenges where they suffer health-wise and sometimes even die. Because of this, there is a need to invest in the health of women. The investment can be achieved in different ways, among the main ones being subsidizing the healthcare cost, education on maternal health, encouraging effective family planning, and ensuring progressive check up on the health of women with children.

Antenatal depression, also known as prenatal or perinatal depression, is a form of clinical depression that can affect a woman during pregnancy, and can be a precursor to postpartum depression if not properly treated. It is estimated that 7% to 20% of pregnant women are affected by this condition. Any form of prenatal stress felt by the mother can have negative effects on various aspects of fetal development, which can cause harm to the mother and child. Even after birth, a child born from a depressed or stressed mother feels the affects. The child is less active and can also suffer from emotional distress. Antenatal depression can be caused by the stress and worry that pregnancy can bring, but at a more severe level. Other triggers include unplanned pregnancy, difficulty becoming pregnant, history of abuse, and economic or family situations.

Obstetric medicine, similar to maternal medicine, is a sub-specialty of general internal medicine and obstetrics that specializes in process of prevention, diagnosing, and treating medical disorders in with pregnant women. It is closely related to the specialty of maternal-fetal medicine, although obstetric medicine does not directly care for the fetus. The practice of obstetric medicine, or previously known as "obstetric intervention," primarily consisted of the extraction of the baby during instances of duress, such as obstructed labor or if the baby was positioned in breech.

HIV in pregnancy is the presence of an HIV/AIDS infection in a woman while she is pregnant. There is a risk of HIV transmission from mother to child in three primary situations: pregnancy, childbirth, and while breastfeeding. This topic is important because the risk of viral transmission can be significantly reduced with appropriate medical intervention, and without treatment HIV/AIDS can cause significant illness and death in both the mother and child. This is exemplified by data from The Centers for Disease Control (CDC): In the United States and Puerto Rico between the years of 2014-2017, where prenatal care is generally accessible, there were 10,257 infants in the United States and Puerto Rico who were exposed to a maternal HIV infection in utero who did not become infected and 244 exposed infants who did become infected.

Prenatal dental care is the care of the oral cavity during fetal development. The woman’s body is subject to hormonal changes leading to several physical changes in the oral cavity during pregnancy. Some of these changes may cause tooth decay, erosion and periodontal health changes.

Dental aerosol Hazardous biological compound

A dental aerosol is an aerosol that is produced from dental instrument, dental handpieces, three-way syringes, and other high-speed instruments. These aerosols may remain suspended in the clinical environment. Dental aerosols can pose risks to the clinician, staff, and other patients. The heavier particles contained within the aerosols are likely to remain suspended in the air for relatively short period and settle quickly onto surfaces, however, the lighter particles may remain suspended for longer periods and may travel some distance from the source. These smaller particles are capable of becoming deposited in the lungs when inhaled and provide a route of diseases transmission.

COVID-19 Contagious disease caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2)

Coronavirus disease 2019 (COVID-19) is a contagious disease caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). The first known case was identified in Wuhan, China, in December 2019. The disease has since spread worldwide, leading to an ongoing pandemic.

Gendered impact of the COVID-19 pandemic Aspect of viral outbreak

COVID-19 affects men and women differently both in terms of the outcome of infection and the effect of the disease upon society. The mortality due to COVID-19 is significantly higher in men. Slightly more men than women contract COVID with a ratio of 1:0.9.

Impact of the COVID-19 pandemic on hospitals Consequences of COVID-19 pandemic for hospitals

The COVID-19 pandemic has impacted hospitals around the world. Many hospitals have scaled back or postponed non-emergency care. This has medical consequences for the people served by the hospitals, and it has financial consequences for the hospitals. Health and social systems across the globe are struggling to cope. The situation is especially challenging in humanitarian, fragile and low-income country contexts, where health and social systems are already weak. Health facilities in many places are closing or limiting services. Services to provide sexual and reproductive health care risk being sidelined, which will lead to higher maternal mortality and morbidity. The pandemic also resulted in the imposition of COVID-19 vaccine mandates in places such as California and New York for all public workers, including hospital staff.

Impact of the COVID-19 pandemic on healthcare workers

The COVID-19 pandemic has impacted healthcare workers physically and psychologically. Healthcare workers are more vulnerable to COVID-19 infection than the general population due to frequent contact with infected individuals. Healthcare workers have been required to work under stressful conditions without proper protective equipment, and make difficult decisions involving ethical implications. Health and social systems across the globe are struggling to cope. The situation is especially challenging in humanitarian, fragile and low-income country contexts, where health and social systems are already weak. Services to provide sexual and reproductive health care risk being sidelined, which will lead to higher maternal mortality and morbidity.

There is no specific, effective treatment or cure for coronavirus disease 2019 (COVID-19), the disease caused by the SARS-CoV-2 virus. One year into the pandemic, highly effective vaccines have now been introduced and are beginning to slow the spread of SARS-CoV-2; however, for those awaiting vaccination, as well as for the estimated millions of immunocompromised persons who are unlikely to respond robustly to vaccination, treatment remain important. Thus, the lack of progress developing effective treatments means that the cornerstone of management of COVID-19 has been supportive care, which includes treatment to relieve symptoms, fluid therapy, oxygen support and prone positioning as needed, and medications or devices to support other affected vital organs.

Marian Knight is a British physician who is a Professor of Maternal and Child Population Health at the University of Oxford. She is an Honorary Consultant of Public Health for Public Health England. During the COVID-19 pandemic Knight studied the characteristics and outcomes of pregnant women who tested positive for coronavirus disease.

Transmission of COVID-19 Mechanisms that spread coronavirus disease 2019

The transmission of COVID-19 is the passing of coronavirus disease 2019 from person to person. The disease is mainly transmitted via the airborne route when people inhale droplets and small airborne particles that infected people breath out as they breathe, talk, cough, sneeze, or sing. Infected people are more likely to transmit COVID-19 when they are physically close. However, infection can occur over longer distances, particularly indoors.


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