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STUDY QUESTION Does maternal infection with severe acute respiratory syndrome coronavirus (SARS-CoV-2) in the first trimester affect the risk of miscarriage before 13 week’s gestation? SUMMARY ANSWER Pregnant women with self-reported diagnosis of SARS-CoV-2 in the first trimester had a higher risk of early miscarriage. WHAT IS KNOWN ALREADY Viral infections during pregnancy have a broad spectrum of placental and neonatal pathology. Data on the effects of the SARS-CoV-2 infection in pregnancy are still emerging. Two systematic reviews and meta-analyses reported an increased risk of preterm birth, caesarean delivery, maternal morbidity and stillbirth. Data on the impact of first trimester infection on early pregnancy outcomes are scarce. This is the first study, to our knowledge, to investigate the rates of early pregnancy loss during the SARS-CoV-2 outbreak among women with self-reported infection. STUDY DESIGN, SIZE, DURATION This was a nationwide prospective cohort study of pregnant women in the community recruited using social media between 21st May and 31st December, 2020. We recruited 3545 women who conceived during the SARS-CoV-2 pandemic who were less than 13 week’s gestation at the time of recruitment. PARTICIPANTS/MATERIALS, SETTING, METHODS The COVID-19 Contraception and Pregnancy Study (CAP-COVID) was an on-line survey study collecting longitudinal data from pregnant women in the UK aged 18 years or older. Women who were pregnant during the pandemic were asked to complete on-line surveys at the end of each trimester. We collected data on current and past pregnancy complications, their medical history and whether they or anyone in their household had symptoms or been diagnosed with SARS-CoV-2 infection during each trimester of their pregnancy. RT-PCR–based SARS-CoV-2 RNA detection from respiratory samples (e.g., nasopharynx) is the standard practice for diagnosis of SARS-CoV-2 in the UK. We compared rate of self-reported miscarriage in three groups: ‘presumed infected’ i.e those who reported a diagnosis with SARS-CoV-2 infection in the first trimester; ‘uncertain’ i.e those who did not report a diagnosis but had symptoms/household contacts with symptoms/diagnosis; and ‘presumed uninfected’ i.e., those who did not report any symptoms/diagnosis and had no household contacts with symptoms/diagnosis of SARS-CoV-2. MAIN RESULTS AND THE ROLE OF CHANCE A total of 3545 women registered for the CAP-COVID study at less than 13 weeks gestation and were eligible for this analysis. Data for the primary outcome were available from 3041 women (86%). In the overall sample, the rate of self-reported miscarriage was 7.8% (238/3041 [95% CI, 7-9]). The median gestational age at miscarriage was 9 weeks (interquartile range 8-11). Seventy-seven women were in the 'presumed infected’ group (77/3041, 2.5% [95% CI 2 – 3]), 295/3041 were in the uncertain group (9.7%, [95% CI 9-11]) and the rest in the ‘presumed uninfected’ (87.8%, 2669/3041, [95% CI 87-89]). The rate of early miscarriage was 14% in the ‘presumed infected’ group, 5% in the ‘uncertain’ and 8% in the ‘presumed uninfected’ (11/77 [95% CI 6-22] versus15/295, [95% CI 3-8] versus 212/2669 [95% CI 7-9], p = 0.02). After adjusting for age, BMI, ethnicity, smoking status, gestational age at registration and the number of previous miscarriages, the risk of early miscarriage appears to be higher in the ‘presumed infected’ group (relative rate 1.7, 95% CI 1.0-3.0, p = 0.06). LIMITATIONS, REASONS FOR CAUTION We relied on self-reported data on early pregnancy loss and SARS-CoV-2 infection without any means of checking validity. Some women in the ‘presumed uninfected’ and ‘uncertain’ groups may have had asymptomatic infections. The number of ‘presumed infected’ in our study was low and therefore the study was relatively underpowered. WIDER IMPLICATIONS OF THE FINDINGS This was a national study from the UK, where infection rates were one of the highest in the world. Based on the evidence presented here, women who are infected with SARS-CoV-2 in their first trimester may be at an increased risk of a miscarriage. However, the overall rate of miscarriage in our study population was 8%. This is reassuring and suggests that if there is an effect of SARS-CoV-2 on the risk of miscarriage, this may be limited to those with symptoms substantial enough to lead to a diagnostic test. Further studies are warranted to evaluate a causal association between SARS-CoV-2 infection in early pregnancy and miscarriage risk. Although we did not see an overall increase in the risk of miscarriage, the observed comparative increase in the presumed infected group reinforces the message that pregnant women should continue to exercise social distancing measures and good hygiene throughout their pregnancy to limit their risk of infection STUDY FUNDING/COMPETING INTEREST(S) This study was supported by a grant from the Elizabeth Garrett Anderson Hospital Charity, (G13-559194). The funders of the study had no role in study design, data collection, data analysis, data interpretation, or writing of the report. JAH is supported by an NIHR Advanced Fellowship. ALD is supported by the National Institute for Health Research University College London Hospitals Biomedical Research Centre. All authors have completed the ICMJE uniform disclosure form at www.icmje.org/coi_disclosure.pdf and declare: support to JAH and ALD as above; no financial relationships with any organisations that might have an interest in the submitted work in the previous 3 years; no other relationships or activities that could appear to have influenced the submitted work. TRIAL REGISTRATION NUMBER

human reproduction

SARS-CoV-2 infection in the first trimester and the risk of early miscarriage: a UK population-based prospective cohort study of 3041 pregnancies conceived during the pandemic