Infections During Pregnancy: Impact, Management, and Prevention

Abstract

Purpose

This article aims to comprehensively review the spectrum of infections that can occur during pregnancy, detailing their prevalence, potential impact on both maternal and fetal health, and the critical importance of early diagnosis, effective management, and proactive prevention strategies. It seeks to highlight how certain infections, while seemingly minor in a non-pregnant state, can pose significant risks to the developing fetus, leading to a range of adverse outcomes.

Findings

The investigation reveals that while many common infections, such as those affecting the urinary or respiratory tracts, typically present no serious complications during pregnancy, a distinct subset carries substantial risks. These particularly concerning infections, including various sexually transmitted infections (STIs), certain viral diseases, and specific bacterial or protozoal pathogens, possess the capacity for vertical transmission to the fetus or newborn, either antenatally (before birth) or perinatally (during birth). Such transmissions can result in severe fetal harm, including congenital anomalies (e.g., deafness, limb defects, microcephaly), or lead to devastating outcomes like miscarriage, stillbirth, and preterm birth. Effective management necessitates a careful risk-benefit analysis for medication use, with specific antibiotics and antivirals generally deemed safe, while others pose contraindications. Routine screening, vaccination, and adherence to safe practices are paramount for prevention.

Research Limitations/Implications

This review synthesizes current medical understanding and clinical guidelines regarding infections in pregnancy. While comprehensive, the rapidly evolving landscape of infectious diseases and ongoing research into novel treatments and diagnostic tools means that specific recommendations may be subject to updates. The implications are profound for clinicians involved in prenatal care, public health practitioners, and pregnant individuals themselves, underscoring the necessity of vigilant monitoring and tailored interventions to safeguard maternal and child health.

Practical Implications

For healthcare providers, the practical implications emphasize the critical role of thorough prenatal screening, patient education on infection prevention, and judicious selection of antimicrobial agents. For pregnant individuals, it highlights the importance of adhering to prenatal care schedules, reporting any symptoms promptly, and understanding the risks associated with various infections. Public health initiatives must prioritize vaccination programs and awareness campaigns regarding common and high-risk infections during gestation.

Social Implications

The effective prevention and management of infections during pregnancy have far-reaching social implications, contributing significantly to reduced infant mortality rates, improved long-term health outcomes for children, and a healthier start to life for future generations. It alleviates the emotional and economic burden on families and healthcare systems associated with adverse pregnancy outcomes and childhood disabilities, fostering more resilient communities.

Originality/Value

This article offers a concise yet comprehensive overview of a critical area in maternal-fetal medicine, integrating information on common and high-risk infections, their specific impacts, and contemporary management principles. Its value lies in consolidating essential knowledge for a broad audience, from healthcare students to expectant parents, promoting informed decision-making and better health outcomes.

Keywords: Pregnancy infections, Maternal health, Fetal health, Sexually transmitted infections, Viral infections, Bacterial infections, Prenatal care, Miscarriage, Stillbirth, Preterm birth, Congenital anomalies, Public health, Infectious disease management, Obstetrics.

Article Type: Original Research

Introduction

Pregnancy represents a unique physiological state where the health of the expectant mother is inextricably linked to the well-being and development of her fetus. This delicate physiological balance involves significant immunological and hormonal adaptations designed to support fetal growth while protecting the mother. However, these very adaptations can sometimes alter a pregnant woman’s susceptibility to certain infectious agents or modify the typical course of an infection. While the human body possesses remarkable adaptive capabilities during gestation, it also becomes particularly vulnerable to various infectious agents. The landscape of infections during pregnancy is broad, ranging from common, often benign, ailments that might cause little concern in a non-pregnant individual, to severe pathogens that can have devastating and irreversible consequences for both mother and child. Understanding these infections, their diverse modes of transmission, their potential impacts on different stages of fetal development, and the appropriate management strategies is paramount for ensuring healthier pregnancy outcomes and safeguarding the long-term health of future generations.

This paper provides a comprehensive overview of the most common and clinically significant infections encountered during pregnancy. It delves into how these infections can manifest in the pregnant woman, their specific risks to the developing fetus and newborn, and the critical importance of early diagnosis, judicious treatment, and proactive preventive measures. The discussion will categorize infections based on their primary mode of transmission or clinical relevance, offering a structured approach to this complex area of maternal-fetal medicine. The goal is to equip healthcare providers, public health officials, and expectant parents with vital knowledge to navigate the challenges posed by infectious diseases during this crucial period. By shedding light on the intricate interplay between maternal infection and fetal health, this article aims to foster more informed clinical practice and empower individuals to make proactive health choices throughout pregnancy.

Common Infections and Their Potential Impacts

While many infections during pregnancy, such as those affecting the urinary tract or respiratory tract, often cause no serious problems for the mother or the developing fetus, a distinct subset carries significant risks. The benign nature of common colds or mild urinary tract infections (UTIs) might lead some to underestimate the broader threat of infections during gestation. However, the severity of the impact often depends crucially on several factors: the specific type of pathogen involved, the gestational age at which the infection occurs (as different organ systems are developing at various stages), and the mother’s immune status, which can be subtly altered during pregnancy. Some infections are particularly concerning because they possess the capacity for vertical transmission—meaning they can be passed from the mother to her offspring. This transmission can occur in several critical ways:

• Transplacental (Antenatal) Transmission: The pathogen crosses the placental barrier from the maternal bloodstream to the fetal circulation. This can happen at any point during pregnancy, with the timing often dictating the type and severity of fetal damage. Early gestational infections (first trimester) are often associated with major congenital malformations, while later infections may lead to growth restriction, neurological issues, or stillbirth. Examples include rubella, syphilis, toxoplasmosis, cytomegalovirus, and Zika virus.
• Ascending Transmission: Pathogens from the vagina or cervix ascend into the uterus, infecting the amniotic fluid, placenta, and potentially the fetus. This is a common route for bacterial infections, often associated with preterm labor and prelabor rupture of membranes (PROM).
• Intrapartum (Perinatal) Transmission: The pathogen is transmitted to the newborn as it passes through the birth canal during vaginal delivery, coming into contact with maternal blood, vaginal secretions, or lesions. Examples include herpes simplex virus, HIV, Chlamydia, and Gonorrhea.
• Postnatal Transmission: Though less common for the severe outcomes discussed here, some infections can be transmitted after birth through breastfeeding or close contact.

Regardless of the route, such transmissions can lead to a cascade of adverse outcomes, including severe fetal harm (e.g., congenital anomalies like deafness, limb defects, or microcephaly), or devastating outcomes such as miscarriage (loss of pregnancy before 20 weeks), stillbirth (fetal death after 20 weeks), or preterm birth (delivery before 37 weeks of gestation), which itself carries significant risks for neonatal morbidity and mortality.

Sexually Transmitted Infections (STIs)

Sexually transmitted infections (STIs) represent a particularly concerning group of pathogens during pregnancy due to their high potential for vertical transmission and the severe fetal or neonatal consequences that can ensue. Given their often asymptomatic nature in women, proactive screening and early intervention are absolutely critical components of comprehensive prenatal care.

• Chlamydia: This common bacterial infection, caused by Chlamydia trachomatis, frequently goes unnoticed in pregnant women because it is often asymptomatic. However, its presence can lead to serious pregnancy complications, including prelabor rupture of the membranes (PROM), where the amniotic sac breaks prematurely, significantly increasing the risk of both ascending infection to the fetus and the onset of preterm labor. If transmitted to the newborn during vaginal delivery, Chlamydia trachomatis can cause ophthalmia neonatorum (a severe eye infection known as conjunctivitis), which, if left untreated, can lead to permanent vision damage or even blindness. Beyond ocular infections, it can also cause chlamydial pneumonia in infants, a serious respiratory infection that typically manifests between 4 and 12 weeks of age (CDC, 2024a). Routine screening in early pregnancy and treatment with appropriate antibiotics (e.g., azithromycin) are highly effective in preventing these outcomes.
• Gonorrhea: Similar to chlamydia, Neisseria gonorrhoeae infection in pregnant women can cause serious complications like preterm labor and PROM, contributing to adverse birth outcomes. More critically, it can be transmitted to the newborn during passage through the birth canal, leading to gonococcal ophthalmia neonatorum. This is a rapidly progressing eye infection characterized by purulent discharge and swelling, which, if not promptly treated with topical and systemic antibiotics, can result in irreversible blindness. While less common, systemic gonococcal infection in the newborn, affecting joints or blood, can also occur (CDC, 2024b). Universal screening and treatment are vital.
• Syphilis: This bacterial infection, caused by Treponema pallidum, poses an exceptionally grave threat to the fetus, making it a major public health concern globally. It can be transmitted from an infected mother to the fetus through the placenta at any stage of pregnancy, including early gestation, even if the mother is asymptomatic. Congenital syphilis can manifest in a wide range of severe birth defects affecting multiple organ systems, leading to a constellation of symptoms including bone deformities (e.g., saber shins, saddle nose), hepatosplenomegaly (enlarged liver and spleen), skin rashes, anemia, and profound neurological impairments (e.g., developmental delays, seizures, hydrocephalus). Tragically, it is also a leading preventable cause of stillbirth and neonatal death. Recognizing this severe risk and its preventability, pregnant women are universally and routinely tested for syphilis early in pregnancy, often during the first prenatal visit, and again in the third trimester in high-risk areas or for women with new risk factors. Crucially, treatment of syphilis with penicillin during pregnancy is highly effective, usually curing both the mother and preventing or treating congenital syphilis in the fetus, underscoring the paramount importance of early detection and immediate intervention (CDC, 2024c).
• Human Immunodeficiency Virus (HIV) Infection: HIV infection poses a significant risk of vertical transmission from mother to child. Without any intervention, approximately one-fourth of pregnancies in women with HIV infection can result in the virus being transmitted to the fetus or newborn, either transplacentally, during labor and delivery, or through breastfeeding. However, significant advancements in antiretroviral therapy (ART) have revolutionized prevention of mother-to-child transmission (PMTCT). Women with HIV infection are strongly advised to take a combination of antiretroviral medications throughout pregnancy, during labor, and to their newborns (infant prophylaxis), as this dramatically reduces the risk of transmission to less than 1% in many high-income settings. The choice of ART regimen is carefully tailored to the mother’s health and viral load. For some women with high viral loads near term (typically >1,000 copies/mL), a planned cesarean delivery may be recommended to further minimize the risk of transmitting HIV to the baby during vaginal birth. Furthermore, avoidance of breastfeeding is often recommended in settings where safe and affordable alternatives are available, though WHO guidelines in resource-limited settings may recommend exclusive breastfeeding with maternal ART (WHO, 2023).
• Genital Herpes: Caused by the herpes simplex virus (HSV), genital herpes can be transmitted to the baby, particularly during a vaginal delivery if the mother has active lesions or viral shedding in the genital area. Neonatal herpes infection, though rare, is a severe and often life-threatening condition with high morbidity and mortality if untreated. Babies infected with herpes can develop different forms of the disease: localized (skin, eye, mouth), central nervous system (CNS) disease (herpes encephalitis, leading to seizures, permanent brain damage), or disseminated disease (affecting multiple internal organs like the liver, lungs, and adrenal glands, often leading to multi-organ failure and death). To prevent this devastating outcome, if women have a history of recurrent genital herpes, they are typically prescribed suppressive antiviral medications (e.g., acyclovir, valacyclovir, famciclovir) in late pregnancy (usually from 36 weeks gestation until delivery) to suppress viral shedding and prevent active outbreaks at the time of delivery. If symptoms of herpes are present (e.g., tingling, itching, pain) or new herpes sores develop in the genital area at the onset of labor, the vulvovaginal area should be thoroughly inspected and, if an active infection is confirmed or even suspected, women are almost always advised to give birth by cesarean delivery to avoid exposing the baby to the virus in the birth canal (ACOG, 2020).
• Zika Virus Infection: Zika virus infection in a pregnant woman can lead to severe congenital abnormalities, most notably microcephaly, where the baby has an abnormally small head due to incomplete brain development, often accompanied by underlying brain damage. Other severe outcomes associated with Congenital Zika Syndrome include severe eye abnormalities (e.g., macular scarring, optic nerve hypoplasia), hearing defects, joint contractures, and impaired growth. The Zika virus is primarily spread by mosquitoes (Aedes species), but it can also be transmitted through sexual intercourse, blood transfusions, and critically, from a pregnant woman to her baby before or during birth. Given the devastating consequences and the lack of specific treatment or vaccine, travel advisories to affected areas and strict prevention measures, including sexual abstinence or consistent and correct condom use with partners from affected areas, are crucial for pregnant women and those planning pregnancy. Diagnosis often relies on serological testing and nucleic acid amplification tests, which can be challenging due to cross-reactivity with other flaviviruses and the transient nature of viremia (CDC, 2024d).

Other Significant Infections

Beyond STIs, several other infections, acquired through various routes, can pose substantial risks during pregnancy, necessitating awareness and preventive measures.

• Rubella (German Measles): While largely preventable through routine childhood vaccination (MMR vaccine), rubella infection during early pregnancy can cause Congenital Rubella Syndrome (CRS), a constellation of severe and often irreversible birth defects. The risk of CRS is highest if the mother contracts rubella in the first trimester (up to 90% risk if infected in the first 11 weeks). CRS can include inadequate growth before birth (small for gestational age), cataracts and other ocular defects (e.g., glaucoma, retinopathy), birth defects of the heart (e.g., patent ductus arteriosus, pulmonary artery stenosis), sensorineural hearing loss (the most common manifestation), and delayed development or intellectual disability. Pre-conception vaccination is the most effective preventive strategy, as the vaccine itself is a live attenuated virus and is contraindicated during pregnancy (CDC, 2024e).
• Cytomegalovirus (CMV) Infection: CMV is a common herpesvirus that, if transmitted congenitally (from mother to fetus), can cross the placenta and cause significant harm to the fetus. Congenital CMV infection is the most common viral cause of congenital abnormalities and long-term neurodevelopmental disabilities globally. While most infected newborns are asymptomatic at birth, some can develop severe symptoms, including damage to the fetus’s liver (hepatosplenomegaly, jaundice) and brain (microcephaly, intracranial calcifications, developmental delays), hearing loss (which can be progressive and late-onset), vision problems, and the fetus may not grow as much as expected (intrauterine growth restriction). Prevention primarily involves hygiene measures for pregnant women, especially avoiding contact with saliva and urine of young children, who are often asymptomatic carriers (CDC, 2024f). There is currently no widely available vaccine or effective treatment for congenital CMV.
• Chickenpox (Varicella): Primary chickenpox infection (caused by varicella-zoster virus, VZV) during pregnancy, particularly in the first or early second trimester (up to 20 weeks), increases the risk of miscarriage. It can also lead to Congenital Varicella Syndrome (CVS) in the fetus, which may cause severe birth defects, including characteristic skin scarring (zigzag pattern), limb defects (hypoplasia of limbs), ocular abnormalities (blindness, cataracts, chorioretinitis), and intellectual disability. The fetus’s head may also be smaller than normal (microcephaly). If maternal infection occurs late in pregnancy (5 days before to 2 days after delivery), the newborn is at high risk for severe neonatal varicella, which can be life-threatening. Post-exposure prophylaxis with varicella-zoster immune globulin (VZIG) can be given to susceptible pregnant women exposed to VZV (CDC, 2024g).
• Toxoplasmosis: This protozoal infection, caused by Toxoplasma gondii, is typically acquired through contact with cat feces (e.g., from litter boxes or contaminated soil) or consumption of undercooked meat (especially pork, lamb, venison) or unwashed fruits and vegetables. If acquired during pregnancy, it can lead to congenital toxoplasmosis, which may cause miscarriage, fetal death, or serious birth defects. The classic triad of congenital toxoplasmosis includes hydrocephalus (fluid on the brain), intracranial calcifications, and chorioretinitis (eye inflammation leading to vision loss). Other manifestations include hepatosplenomegaly, jaundice, and developmental delays. Prevention focuses on food safety (cooking meat thoroughly, washing produce), avoiding contact with cat litter, and wearing gloves while gardening (CDC, 2024h).
• Listeriosis: A bacterial infection caused by Listeria monocytogenes, often acquired from contaminated food sources such as unpasteurized dairy products, soft cheeses, deli meats, smoked seafood, and raw sprouts. Pregnant women are particularly susceptible to listeriosis, and it significantly increases the risk of severe pregnancy complications such as preterm labor, miscarriage, and stillbirth. If the newborn acquires the infection during birth or transplacentally, they may develop neonatal listeriosis, which can present as sepsis or meningitis. While some newborns may show immediate symptoms, others may have delayed onset of symptoms until several weeks after birth, making diagnosis challenging. Strict adherence to food safety guidelines is crucial for prevention (CDC, 2024i).
• Bacterial Vaginosis (BV): This common bacterial imbalance in the vagina, characterized by an overgrowth of certain anaerobic bacteria, is not strictly an STI but is associated with sexual activity. While often asymptomatic or causing mild symptoms like unusual discharge, BV has been consistently linked to adverse pregnancy outcomes. It may lead to preterm labor, where uterine contractions begin too early, or prelabor rupture of the membranes (PROM), increasing the risk of ascending infection (chorioamnionitis) and subsequent premature delivery. Screening for BV in asymptomatic high-risk women (e.g., those with a history of preterm birth) and treatment with antibiotics may be considered, though the benefit in preventing preterm birth in asymptomatic women remains debated (ACOG, 2020).
• Urinary Tract Infections (UTIs): UTIs are common in pregnancy due to hormonal changes that relax the urinary tract and the mechanical compression of the uterus on the bladder, leading to urinary stasis. If left untreated, even asymptomatic bacteriuria (bacteria in the urine without symptoms) or lower UTIs (cystitis) can rapidly progress to more severe kidney infections (pyelonephritis). Pyelonephritis significantly increases the risk of serious maternal complications (e.g., sepsis, acute respiratory distress syndrome) and adverse pregnancy outcomes, including preterm labor and prelabor rupture of the membranes, posing a direct threat to the pregnancy. Routine screening for asymptomatic bacteriuria early in pregnancy and prompt treatment of any UTI are essential to prevent these complications (ACOG, 2020).
• Hepatitis (Viral Hepatitis B and C): While hepatitis viruses can be transmitted sexually, they are also frequently transmitted through blood (e.g., shared needles, transfusions) or other bodily fluids, and thus are not exclusively considered STIs. Hepatitis infection in a pregnant woman, particularly Hepatitis B, can increase the risk of preterm birth. More importantly, both Hepatitis B and C can be transmitted from the mother to the baby during delivery (perinatal transmission), leading to chronic infection in the newborn. This chronic infection can cause long-term liver problems, including cirrhosis, liver failure, and liver cancer, later in life. Routine screening for Hepatitis B surface antigen (HBsAg) is standard in pregnancy. For HBsAg-positive mothers, interventions like antiviral therapy in late pregnancy (to reduce viral load) and immunoprophylaxis (Hepatitis B immune globulin and Hepatitis B vaccine) for the newborn immediately after birth can significantly reduce transmission risk. Prevention of Hepatitis C transmission is more challenging as there is no vaccine or effective post-exposure prophylaxis for infants (CDC, 2024j).

Treatment of Infections During Pregnancy

The approach to treating infections during pregnancy is always a delicate balance, requiring careful and individualized consideration of the potential benefits of eradicating the infection against the known or theoretical risks of the medication to the developing fetus. This necessitates a thorough understanding of pharmacokinetics in pregnancy (how drugs are absorbed, distributed, metabolized, and excreted in the pregnant body) and fetal toxicology (the potential for drugs to cause harm to the fetus).

• Risk-Benefit Analysis: Doctors meticulously weigh the risks posed by the untreated infection (e.g., severe fetal damage, congenital anomalies, preterm birth, miscarriage, stillbirth, or significant maternal morbidity like sepsis) against the known or theoretical risks of using specific medications. This decision-making process is highly individualized, taking into account the gestational age (as teratogenic effects often vary by trimester), the severity and progression of the maternal infection, the specific medication’s safety profile (categorized by agencies like the FDA, though these categories are being phased out in favor of more detailed risk summaries), and the availability of safer alternative treatments. The goal is always to minimize harm to both mother and fetus.
• Antibiotics: The selection of antibiotics during pregnancy is guided by extensive research on fetal safety profiles. Some antibiotics are generally considered safe for use during pregnancy, having demonstrated a low risk of fetal harm across numerous studies and clinical experience. These include:
  • Penicillins: Such as amoxicillin, ampicillin, and penicillin G. These are widely used for various bacterial infections, including streptococcal infections, and are considered safe throughout all trimesters.
  • Cephalosporins: Like cephalexin, cefazolin, and ceftriaxone. These are also commonly prescribed for a range of bacterial infections and are generally well-tolerated in pregnancy.
  • Macrolides: Medications related to erythromycin, such as azithromycin and erythromycin itself, are often considered safe alternatives for certain infections, particularly in penicillin-allergic patients. However, other antibiotics are known to cause problems in the fetus and are generally avoided unless the benefit clearly outweighs the risk and no safer alternative exists. Examples include:
  • Tetracyclines: Such as doxycycline and tetracycline, which can cause permanent tooth discoloration (yellow-brown staining) and inhibit bone growth in the fetus if used during the second and third trimesters.
  • Fluoroquinolones: Like ciprofloxacin and levofloxacin, which have theoretical concerns regarding cartilage development in the fetus based on animal studies, although human data is less conclusive, they are generally avoided.
  • Sulfonamides (especially near term): While some sulfonamides may be used earlier in pregnancy, their use near term (third trimester) can increase the risk of kernicterus (a type of brain damage) in the newborn due to displacement of bilirubin. (ACOG, 2020; see also detailed drug information resources and tables like Some Medications and Risk of Problems During Pregnancy in clinical guidelines for specific recommendations).
• Antiviral Medications: Most antiviral medications used for conditions like herpes (e.g., acyclovir, valacyclovir) or HIV (e.g., various ART regimens) are considered safe and often essential in pregnancy. This is primarily due to the high risk of vertical transmission and severe fetal/neonatal outcomes if the maternal infection is left untreated. For instance, the benefits of preventing severe congenital herpes or life-threatening neonatal HIV infection typically far outweigh the risks of the medication. Pregnant women should always discuss their medication regimen with their doctor before starting, stopping, or altering any antiviral therapy, as adherence is crucial for efficacy and prevention of resistance.
• When Treatment May Not Be Indicated: It is also important to recognize situations where treatment may not offer significant benefits, or where the risks of intervention might outweigh the potential gains. For example, if a pregnant woman has bacterial vaginosis (BV) but is entirely asymptomatic and her pregnancy is not considered high-risk (e.g., no history of preterm birth or spontaneous abortion), treating the BV may not be known to improve pregnancy outcomes. In such cases, the the potential for medication side effects, patient inconvenience, or the development of antibiotic resistance might outweigh the unproven benefit of treatment. Similarly, for common viral infections like the common cold or influenza (if not severe enough to warrant antivirals), symptomatic relief rather than specific antimicrobial treatment is usually the approach.

Conclusion

Infections during pregnancy represent a significant and multifaceted area of concern in maternal-fetal health, demanding vigilant attention from healthcare providers and expectant parents alike. While many common infections are benign and self-limiting, a critical subset carries the potential for severe and sometimes irreversible adverse outcomes for the developing fetus and newborn, including congenital anomalies, miscarriage, stillbirth, and preterm birth. The diverse spectrum of risks posed by sexually transmitted infections, various viral pathogens (such as rubella, CMV, Zika), and specific bacterial or protozoal agents (like listeria, toxoplasmosis) necessitates a nuanced understanding and a proactive, integrated approach to care.

Effective management hinges on timely and accurate diagnosis, which often relies on routine prenatal screening and a high index of suspicion for symptoms. This must be followed by a careful, individualized risk-benefit assessment for any medication prescribed, taking into account gestational age, infection severity, and drug safety profiles. The availability of generally safe antibiotics and antivirals allows for crucial interventions that can dramatically improve outcomes, transforming the prognosis for conditions that were once devastating. Beyond treatment, however, the cornerstone of safeguarding maternal and fetal health lies in robust prevention strategies. This includes comprehensive prenatal screening for high-risk infections, promoting vaccination against preventable diseases like rubella, measles, mumps, and hepatitis B (pre-conception or during pregnancy as indicated), educating pregnant individuals on essential hygiene and food safety practices (e.g., avoiding unpasteurized products for listeriosis, thorough handwashing), and advocating for safe sexual practices. Furthermore, ensuring universal access to quality prenatal care, where these screenings and educational components are consistently delivered, is fundamental. By prioritizing these comprehensive measures, healthcare systems can significantly mitigate the impact of infections during pregnancy, contributing to healthier starts for countless lives, reducing infant morbidity and mortality, and fostering more resilient and thriving communities. The continued integration of public health initiatives with individualized clinical care, supported by ongoing research into emerging pathogens and novel interventions, remains essential in this vital endeavor to protect the most vulnerable members of our society.

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