Reply

We appreciate that Dr Carosso brought up several important points about our paper, which are worth discussing and clarifying. We stated that we did not find severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) in the lower female genital tract, and our results may provide evidence to guide the choice of delivery method for pregnant women with coronavirus disease 2019 (COVID-19). Although we did not mean that vaginal delivery should be overencouraged, we agree with the opinion that obstetricians should maintain their obstetrical indications. However, a high incidence of cesarean deliveries was mentioned by Dr Carosso. It might result from concerns that SARS-CoV-2 exists in the vagina. It was a reasonable suspicion because SARS-CoV-2 had been identified in anal swabs, urine, and tears in an earlier study.1Wang L. Wang Y. Ye D. Liu Q. Review of the 2019 novel coronavirus (SARS-CoV-2) based on current evidence.Int J Antimicrob Agents. 2020; 55: 105948Crossref PubMed Scopus (767) Google Scholar We did test samples from the vagina; however, no samples were positive. Therefore, SARS-CoV-2 infection should not be considered as a direct indication for cesarean delivery at present. Our results may provide evidence for obstetricians to choose the delivery method on the basis of obstetrical indications for pregnant women with COVID-19. In addition to choosing the appropriate delivery method, it is equally important to find out possible transmission routes and take targeted measures, as potential vertical transmission was reported after both vaginal delivery and cesarean delivery.2Alzamora M.C. Paredes T. Caceres D. Webb C.M. Valdez L.M. La Rosa M. Severe COVID-19 during pregnancy and possible vertical transmission.Am J Perinatol. 2020; ([Epub ahead of print])PubMed Google Scholar,3Hu X. Gao J. Luo X. et al.Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) vertical transmission in neonates born to mothers with coronavirus disease 2019 (COVID-19) pneumonia.Obstet Gynecol. 2020; ([Epub ahead of print])Crossref PubMed Scopus (94) Google Scholar We agree with Dr Carosso’s concerns about the anorectum as a potential transmission route during vaginal delivery. Based on the positive anal swab cases in our study, we think that we should pay full attention to the preventive measures during vaginal delivery. Because of the low positive rate of anal swabs in detecting SARS-CoV-2, results have been confusing. We are responsible for this result as all the samples were double tested and checked in 2 different labs with full qualification certification. As patients with COVID-19 were all in a separate special ward, the sample size of our research was a large one under the situation of the COVID-19 pandemic. The time between onset of symptoms and sample collection varied for the same reason. A small portion of patients did not have positive oropharyngeal swabs. The reasons had been listed in our original published article. In addition, all patients’ symptoms, including intestinal, were collected but not mentioned because of the length of limitation of the research letter. Vaginal delivery is a very complex physiological process, and vertical transmission of SARS-CoV-2 from the mother to the offspring via the placenta, birth canal, or intestinal tract is poorly understood at this moment. To obtain more evidence of transmission route of SARS-CoV-2, we need to involve as many pregnant women with COVID-19 as we can and test all samples including anal swabs. Vaginal delivery in COVID-19 pregnant women: anorectum as a potential alternative route of SARS-CoV-2 transmissionAmerican Journal of Obstetrics & GynecologyVol. 223Issue 4PreviewIn a recently published article in the Journal, Cui et al1 reported that they did not find severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) in the genital tract of 35 patients of reproductive and postmenopausal age who received a diagnosis of coronavirus disease 2019 (COVID-19). All vaginal and cervical swabs were reportedly negative for SARS-CoV-2, whereas 1 anal swab sample tested positive. The authors concluded from these findings that the lower female genital tract may not be a transmission route for SARS-CoV-2 and that such evidence may guide the choice of delivery method in women with COVID-19. Full-Text PDF