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\begin{document}

\title{Is termination of early pregnancy indicated in women with COVID-19?}



\author[1]{Yan-ting Wu}%
\author[1]{Cheng Li}%
\author[1]{Chenjie Zhang}%
\author[1]{Yan-fen Chen}%
\author[2]{He-Feng Huang}%
\affil[1]{Affiliation not available}%
\affil[2]{The International Peace Maternity and Child Health Hospital}%


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  \date{May 26, 2024}


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\textbf{Is termination of early pregnancy indicated in women with
COVID-19?}

Yan-Ting Wu, M.D.\textsuperscript{1,2}, Cheng Li,
M.D.\textsuperscript{1}, Chen-Jie Zhang, M.D.\textsuperscript{1},
Yan-fen Chen, M.D.\textsuperscript{3}, He-Feng Huang,
M.D.\textsuperscript{1,2}, FRCOG

\textsuperscript{1} International Peace Maternity and Child Health
Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai

\textsuperscript{2} Chinese Maternal and Child Health Association

\textsuperscript{3} The Central Hospital of WuHan, Tongji Medical
College, Hua Zhong University of Science and Technology

Corresponding to He-Feng Huang, International Peace Maternity and Child
Health Hospital, School of Medicine, Shanghai Jiao Tong University, 910,
Hengshan Rd., Shanghai 200030, China. E-mail: huanghefg@sjtu.edu.cn.

By Mar 2\textsuperscript{nd}, 2020, more than 80174 confirmed cases and
715 suspected cases infected with 2019 novel coronavirus disease
(COVID-19) have been reported in China.\textsuperscript{1} Besides the
human-to-human transmission via respiratory droplet, vertical
transmission has been concerned and not determined since one case of a
mother and neonate was laboratory-confirmed with COVID-19. Several days
ago, a news program of Hubei TV suggested that early pregnant women
infected with COVID-19 should terminate their pregnancies. This
viewpoint seems oversimplified but has triggered controversy widely. In
February, there were 3 pregnant women with mild COVID-19 infection in
the Wuhan Central Hospital (Houhu District) who terminated their
pregnancy in the first trimester.

Early pregnancy is a challenging and vulnerable period, and viral
infection at this stage could potentially affect embryogenesis and fetal
organ development, but there is still no evidence for the vertical
transmission of COVID-19 so far. In February 13rd, 2020, Chen \emph{et
al} . reviewed nine cases of COVID-19 infected pregnant women, and
reported none of their neonates had been infected through vertical
transmission.\textsuperscript{2} Prior to COVID-19, there were a total
of six coronavirus species that induced human infection including severe
acute respiratory syndrome coronavirus (SARS-CoV) and Middle East
respiratory syndrome coronavirus (MERS-CoV) which led to the outbreak of
pneumonia, but no vertical transmission of the coronavirus had been
confirmed.\textsuperscript{3,4} With reference to the experience to SARS
or MERS, they can cause preterm, miscarriage, stillbirth, and fetal
growth restriction in pregnant women, associated with placental
insufficiency, but not vertical transmission. There is no evidence that
SARS-CoV or MERS-CoV itself can cause fetal malformations, because
neither of them passes across the placental
barrier.\textsuperscript{3,4} Children born to pregnant women infected
with SARS showed similar physical and mental development when followed
up to 10 months in both full-term and preterm babies. Current research
on long-term health of pregnant women of SARS or MERS is not available,
but we anticipate that maternal SARS-CoV-2 infection would not result in
significant, long-term health risks to the offspring.

Pregnant women with SARS-CoV infection have a three times higher
mortality rate than non-pregnant populations. However, SARS-CoV-2
infection outcome seems to have a better prognosis than SARS-CoV
infection.\textsuperscript{5} Only 7.45\% of all confirmed cases are
defined as ``severe'' according to an announcement by National Health
Commission of China on Feb 15\textsuperscript{th}, 2020. Based on the
limited number of cases reported, there is no evidence indicating a
worse outcome of maternal patients than that of general population. On
the other hand, pregnancy terminations in early pregnancy may result in
post-abortion infection, which might aggravate the maternal COVID-19
illness. Therefore, consideration of termination of pregnancy has to be
individualized during this COVID-19 outbreak. For pregnant patients with
mild symptoms, treatment should be modified to avoid using teratogenic
drugs near the fetus. Patients are commonly at higher oxygen demand
during early pregnancy, so hypoxemia should be monitored, and
interventions should be provided without delay. For severe patients
during early pregnancy, the first priority is to ensure maternal safety.
Decisions of early pregnancy termination should be considered upon risk
factors including viral load, transmission generations, range of lung
lesions by CT (more than two lobes), maternal age, and coexisting
disorders (diabetes, cardiovascular diseases etc.).

Although we have made a judgment from a rational level, that is, early
pregnant women infected with COVID-19 need to make a careful decision to
terminate the pregnancy. However, the reality is that many mild COVID-19
pregnant women still choose to terminate the pregnancy without medical
indications (request initiatively or recommended). why? As a sudden
public disaster, doctors often overlook the social effects of the
epidemic. Even more terrifying than viruses is terror itself. When
pregnant women or doctors' fear of the virus is beyond the bounds of
reason, people inadvertently exaggerate the adverse consequences of the
virus infection. For example, worrying that the current mild illness
will worsen, fearing that the teratogenicity of the virus will appear to
herself in the form of an individual case, and eventually some COVID-19
pregnant women decide to terminate the pregnancy full of uncertainty
(request initiatively or recommended).

Is termination of early pregnancy indicated in women with COVID-19? It's
not just a medical issue.

Acknowledgements

Thanks to everyone involved in the fight against the epidemic.

Disclosure of interests

No conflict of interest.

Contribution to authorship

Yan-fen Cai shared case information from the front line of the outbreak.
He-feng Huang put forward the initial ideas and opinions, which were
drafted by Yan-ting Wu, Cheng Li, and Chen-jie Zhang.

Ethics approval

Not applicable.

Funding

Not applicable.

\textbf{Reference:}

\begin{enumerate}
\tightlist
\item
  Centers for Disease Control and
  Prevention.\emph{http://2019ncov.chinacdc.cn/2019-nCoV}. (Accessed on
  March 2, 2020).
\item
  Chen H, Guo J, Wang C, et al. Clinical characteristics and
  intrauterine vertical transmission potential of COVID-19 infection in
  nine pregnant women: a retrospective review of medical records.
  Lancet. 2020. doi:https://doi.org/10.1016/S0140-6736(20)30360-3.
\item
  Wong SF, Chow KM, Leung TN, et al.Pregnancy and perinatal outcomes of
  women with severe acute respiratory syndrome.Am J Obstet Gynecol.
  2004;191(1):292-7.
\item
  Alserehi H, Wali G, Alshukairi A, et al. Impact of Middle East
  respiratory syndromecoronavirus (MERS-CoV) on pregnancy and perinatal
  outcome. BMC Infect Dis. 2016;16:105.
\item
  Munster VJ, Koopmans M, van Doremalen N, et al. A Novel Coronavirus
  Emerging in China - Key Questions for Impact Assessment.N Engl J Med.
  2020. doi: 10.1056/NEJMp2000929.
\end{enumerate}

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