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Abstract：
BACKGROUND: Coronavirus disease 2019 (COVID-19), the global pandemic that has spread throughout the world, is caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). Given the limited scientific evidence on the manifestations and potential impact of this virus on pregnancy, we decided to report this case.
METHODS: The patient was a 38 year-old Iranian woman with a triplet pregnancy and a history of primary infertility, as well as hypothyroidism and gestational diabetes. She was hospitalized at 29 weeks and 2 days gestational age due to elevated liver enzymes, and finally, based on a probable diagnosis of gestational cholestasis, she was treated with ursodeoxycholic acid. On the first day of hospitalization, sonography was performed, which showed that biophysical scores and amniotic fluid were normal in all three fetuses, with normal Doppler findings in two fetuses and increased umbilical artery resistance (pulsatility index [PI] > 95%) in one fetus. On day 4 of hospitalization, she developed fever, cough and myalgia, and her COVID-19 test was positive. Despite mild maternal symptoms, exacerbated placental insufficiency occurred in two of the fetuses leading to the rapid development of absent umbilical artery end-diastolic flow. Finally, 6 days later, the patient underwent cesarean section due to rapid exacerbation of placental insufficiency and declining biophysical score in two of the fetuses. Nasopharyngeal swab COVID-19 tests were negative for the first and third babies and positive for the second baby. The first and third babies died 3 and 13 days after birth, respectively, due to collapsed white lung and sepsis. The second baby was discharged in good general condition. The mother was discharged 3 days after cesarean section. She had no fever at the time of discharge and was also in good general condition.
CONCLUSIONS: This was a complicated triplet pregnancy, in which, after maternal infection with COVID-19, despite mild maternal symptoms, exacerbated placental insufficiency occurred in two of the fetuses, and the third fetus had a positive COVID-19 test after birth. Therefore, in cases of pregnancy with COVID-19 infection, in addition to managing the mother, it seems that physicians would be wise to also give special attention to the possibility of acute placental insufficiency and subsequent fetal hypoxia, and also the probability of vertical transmission.
METHODS: The patient was a 38 year-old Iranian woman with a triplet pregnancy and a history of primary infertility, as well as hypothyroidism and gestational diabetes. She was hospitalized at 29 weeks and 2 days gestational age due to elevated liver enzymes, and finally, based on a probable diagnosis of gestational cholestasis, she was treated with ursodeoxycholic acid. On the first day of hospitalization, sonography was performed, which showed that biophysical scores and amniotic fluid were normal in all three fetuses, with normal Doppler findings in two fetuses and increased umbilical artery resistance (pulsatility index [PI] > 95%) in one fetus. On day 4 of hospitalization, she developed fever, cough and myalgia, and her COVID-19 test was positive. Despite mild maternal symptoms, exacerbated placental insufficiency occurred in two of the fetuses leading to the rapid development of absent umbilical artery end-diastolic flow. Finally, 6 days later, the patient underwent cesarean section due to rapid exacerbation of placental insufficiency and declining biophysical score in two of the fetuses. Nasopharyngeal swab COVID-19 tests were negative for the first and third babies and positive for the second baby. The first and third babies died 3 and 13 days after birth, respectively, due to collapsed white lung and sepsis. The second baby was discharged in good general condition. The mother was discharged 3 days after cesarean section. She had no fever at the time of discharge and was also in good general condition.
CONCLUSIONS: This was a complicated triplet pregnancy, in which, after maternal infection with COVID-19, despite mild maternal symptoms, exacerbated placental insufficiency occurred in two of the fetuses, and the third fetus had a positive COVID-19 test after birth. Therefore, in cases of pregnancy with COVID-19 infection, in addition to managing the mother, it seems that physicians would be wise to also give special attention to the possibility of acute placental insufficiency and subsequent fetal hypoxia, and also the probability of vertical transmission.
摘要：
背景：2019年冠状病毒病（COVID-19），在世界各地蔓延的全球流行病，是由严重急性呼吸道综合症冠状病毒2（SARS-CoV-2）引起的。鉴于关于这种病毒对怀孕的表现和潜在影响的科学证据有限，我们决定报告这个案子。
方法：患者是一名38岁的伊朗妇女，有三胎妊娠和原发性不孕症病史，以及甲状腺功能减退和妊娠期糖尿病。由于肝酶升高，她在胎龄29周零2天时住院，最后，根据妊娠胆汁淤积的可能诊断，她接受了熊去氧胆酸治疗。住院的第一天,进行了超声检查，这表明所有三个胎儿的生物物理评分和羊水都是正常的，两个胎儿的多普勒表现正常，一个胎儿的脐动脉阻力增加（搏动指数[PI]>95％）。住院第4天,她发烧了,咳嗽和肌痛，她的COVID-19检测呈阳性。尽管产妇症状轻微,其中两个胎儿发生胎盘功能不全，导致脐动脉舒张末期血流缺失的快速发展。最后,6天后,患者因胎盘功能不全迅速恶化和其中2例胎儿的生物物理评分下降而接受了剖宫产.鼻咽拭子COVID-19测试对第一个和第三个婴儿呈阴性，对第二个婴儿呈阳性。第一个和第三个婴儿在出生后3天和13天死亡，分别,由于白肺塌陷和败血症。第二个婴儿在良好的情况下出院。产妇在剖宫产术后3天出院。她出院时没有发烧，一般情况也很好。
结论：这是一个复杂的三胎妊娠，其中，在母亲感染COVID-19后，尽管母亲症状轻微，加剧的胎盘功能不全发生在两个胎儿，第三个胎儿出生后COVID-19检测呈阳性。因此,在妊娠感染COVID-19的情况下，除了管理母亲，医生似乎也应该特别注意急性胎盘功能不全和随后的胎儿缺氧的可能性，以及垂直传播的可能性。
方法：患者是一名38岁的伊朗妇女，有三胎妊娠和原发性不孕症病史，以及甲状腺功能减退和妊娠期糖尿病。由于肝酶升高，她在胎龄29周零2天时住院，最后，根据妊娠胆汁淤积的可能诊断，她接受了熊去氧胆酸治疗。住院的第一天,进行了超声检查，这表明所有三个胎儿的生物物理评分和羊水都是正常的，两个胎儿的多普勒表现正常，一个胎儿的脐动脉阻力增加（搏动指数[PI]>95％）。住院第4天,她发烧了,咳嗽和肌痛，她的COVID-19检测呈阳性。尽管产妇症状轻微,其中两个胎儿发生胎盘功能不全，导致脐动脉舒张末期血流缺失的快速发展。最后,6天后,患者因胎盘功能不全迅速恶化和其中2例胎儿的生物物理评分下降而接受了剖宫产.鼻咽拭子COVID-19测试对第一个和第三个婴儿呈阴性，对第二个婴儿呈阳性。第一个和第三个婴儿在出生后3天和13天死亡，分别,由于白肺塌陷和败血症。第二个婴儿在良好的情况下出院。产妇在剖宫产术后3天出院。她出院时没有发烧，一般情况也很好。
结论：这是一个复杂的三胎妊娠，其中，在母亲感染COVID-19后，尽管母亲症状轻微，加剧的胎盘功能不全发生在两个胎儿，第三个胎儿出生后COVID-19检测呈阳性。因此,在妊娠感染COVID-19的情况下，除了管理母亲，医生似乎也应该特别注意急性胎盘功能不全和随后的胎儿缺氧的可能性，以及垂直传播的可能性。
