On February 23th 2020, a 38 year-old triplet pregnant woman was hospitalized at 29 weeks and 2 days gestational age due to once a time high blood pressure at level 140/90 and elevated liver enzymes. A week before admission, she had been hospitalized in another hospital for 5 days.
She had a history of a two-year primary infertility and had become pregnant by induction ovulation and also, a history of hypothyroidism treated with levothyroxine. Also, she had previously been diagnosed with gestational diabetes from a month before admission treated with 16 units of insulin daily (6 unit levemir and 10 unit nevorapid). Other administered medications were aspirin and enoxaparin and also she had received a course of betamethasone for fetal lung maturation about 10 days before hospitalization.
Two weeks before hospitalization, liver enzymes increased fourfold than normal alanine aminotransferase (ALT) 218 u/l and aspartateaminotransferase (AST) 283 u/l) and due to a probable diagnosis of gestational cholestasis, she was treated with ursodeoxycholic acid (300 mg twice a day) from one week before hospitalization. Lab tests at admission time included: ALT=94 U/L, AST= 57u/l, total bilirubin= 0.7 and direct bilirubin= 0.1, LDH=276 U/L. Other tests including white blood cell count, hemoglobin, platelet,serum creatinine, and urine analysis were in normal range. She underwent a 24-hour blood pressure monitor and for all measurements, 18.8% of systolic blood pressure and 15.6% of diastolic blood pressure, readings exceeded the set limit of 140 and 90 mmHg respectively. Echocardiographic findings were quite normal and also 24-hour urine protein was reported in normal range.On February 24th, a sonography was performed in which biophysical scores and amniotic fluid were found normal in all three fetuses but one of the fetuses had increased umbilical artery resistance (PI>95%) and estimated weight below 5%, but umbilical cord and middle cerebral arteries findings were normal in the other two fetuses. On February 27th,she developed fever and cough. On the same day, urine culture, blood culture and complete blood count test were sent. Next day, due to the persistent fever and cough and also an onset of myalgia, a real-time reverse transcriptase–polymerase chain reaction (RT-PCR) for Covid-19 nucleic acid of nasopharyngeal swabs was conducted. All steps including sample collection, processing and laboratory testing were based on World Health Organization (WHO) guidelines.
Unfortunately the result was positive, so oseltamivir and hydroxychloroquine were administered. She had a mild fever and her maximum temperature was 38.3 ° C. There was no complaint of shortness of breath and also her respiratory rates werebetween 18 to 20 per minute all over the time. Urine culture and blood culture were negative and serum procalcitonin was in normal range. Chest X ray and Computed Tomography Scan were not performed due to patient’s lack of consent.On February 27th، a sonography was performed again: The fetus who already had an increased umbilical artery resistance showed an exacerbated condition involving absent umbilical artery end diastolic flow and one of the other fetuses featured umbilical artery resistance (PI>95%), but umbilical cord and middle cerebral arteries findings were normal in the third fetus. On March 1st, umbilical artery end diastolic flow of the second fetus also turned to absent. Therefore due to the progressive and severe increased cord resistance in the two fetuses, ultrasound was performed daily and finally, on March 3rd, the biophysical score in two of fetuses declined. Duo to rapid deterioration of fetal conditions and exacerbated placental insufficiency,the woman underwent cesarean sectionon the same day.The first baby was born with a weight of 1320 grams and umbilical cord PH= 7.25 and her five minute Apgar score was 4, the second baby was born with a weight of 1600 grams and umbilical cord PH= 7.23 and his five minute Apgar score was 7, the third baby was born with a weight of 1250 grams and umbilical cord PH= 7.21 and her five minute Apgar score was 6. All three were intubated after birth and were admitted to neonatal intensive care unit (NICU). RT-PCR for Covid-19 nucleic acid of nasopharyngeal swabs was carried out for all three newborns immediately after birth.The mother was discharged three days after cesarean section. She had no fever at discharge time and also she was in good general condition, but the cough was persistent.
The first and third newborns each received three doses and the second newborn received two doses of surfactant respectively. All three newborns developed clinical symptoms of sepsis and also pulmonary hemorrhage.Although pulmonary hemorrhage can occur secondary to prematurity as well as surfactant infusion, the remarkable point in these newborns was that they did not respond to surfactant, and also they had completely white lung x-rays.The primary results of Covid-19 RT-PCRwere negative for all three newborns.According to bad general conditions of newborns and considering the false negative probability of the initial test, Covid-19 RT-PCR was repeated and the result was positive for the second baby whose weight was 1600 gram. It should be noted that during the period between two tests, the babies were completely isolated and had no suspected exposure, so, the possibility of vertical transmission should be considered.
The first baby died three days after birth with collapsed white lung and sepsis.The third neonate also has symptoms of sepsis and died 13 days after birth.The second neonate whose covid-19 PCR testwas positive, is ameliorating and his endotracheal tube had been removed and was discharged with a good general condition.