Archives of Academic Emergency Medicine. 2021; 9(1): e5 https://doi.org/10.22037/aaem.v9i1.923 CA S E RE P O RT Possible Vertical Transmission of COVID-19 to the New- born; a Case Report Yekta Parsa1,2, Nazila Shokri1,2, Tayebeh Jahedbozorgan1,3, Zahra Naeiji1,3, Shahrzad Zadehmodares1,3, Atefeh Moridi1,3∗ 1. Department of Obstetrics and Gynecology, Mahdiyeh Hospital, Shahid Beheshti University of Medical Sciences, Tehran, Iran. 2. Department of Obstetrics and Gynecology, School of Medicine, Shahid Beheshti University of Medical Sciences, Tehran, Iran. 3. Preventative Gynecology Research Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran. Received: September 2020; Accepted: October 2020; Published online: 14 November 2020 Abstract: Vertical transmission of the novel coronavirus 2019 (COVID-19), has been reported in case reports and series, while the data regarding its transmission is still not enough. Thus, presenting different experiences form various regions could help better understand the virus behavior in pregnancy. We herein report a possible vertical trans- mission of COVID-19 from a mother to the neonate. A 41-year-old mother with signs and symptoms of acute respiratory illness presented with labor pain and vaginal leak at 37 weeks of gestation. She tested positive for COVID-19 using RT-PCR and underwent emergency cesarean section delivery and gave birth to a girl neonate. The baby tested positive for the COVID-19. Although vertical transmission of COVID-19 has not been proved yet, but there are several lines of evidences suggesting it. Paying close attention to the mother and newborn with COVID-19 and long-term follow-up are needed for better understanding of the virus in pregnancy. Keywords: Severe acute respiratory syndrome coronavirus 2; COVID-19; Infant, Newborn; Infectious Disease Transmission, Vertical Cite this article as: Parsa Y, Shokri N, Jahedbozorgan T, Naeiji Z, Zadehmodares Sh, Moridi A. Possible Vertical Transmission of COVID-19 to the Newborn; a Case Report. Arch Acad Emerg Med. 2021; 9(1): e5. 1. Introduction The novel coronavirus 2019 (COVID-19) has infected more than 4 million people and caused more than 300,000 deaths worldwide by May 2020. It has been declared as pandemic by the World Health Organization (WHO) in March 2020 (1). COVID-19 pneumonia is highly infectious and can be trans- mitted through various routes including respiratory droplets and close contact (2). Infection during pregnancy has been the spotlight of many studies; yet, evidence on vertical trans- mission is scarce and mostly based on small series and case reports (3-5). COVID-19 infection during pregnancy raises 3 major concerns: first, the treatment and management of pregnant women infected with the virus is still a matter of debate and needs further investigation; second, prenatal and ∗Corresponding Author: Atefeh Moridi; Department of Obstetrics and Gy- necology, Mahdiyeh Hospital, Shishe Gar khaneh Alley, Fadaian Islam Av- enue, Shoosh Square, Tehran, Iran. P. O. BOX:11858- 17311, Tel: (+98)- 21- 5506-2628, Fax: (+98)- 21- 5506-2627, Emails: a.moridi@sbmu.ac.ir, moridi59@gmail.com, ORCID: 4439-7791-0002-0000. pregnancy complications are still unknown and it is not well- established whether prenatal COVID-19 infection increases the risk of adverse pregnancy outcomes or not; and third, ver- tical transmission of the virus from the mother to the child needs further investigation. Recently, a systematic review evaluated all the published articles on pregnant women in- fected with COVID-19 and reported that vertical transmis- sion of COVID-19 does not occur based on the evidence pro- vided so far (3). However, a growing body of evidence sug- gests the vertical transmission of COVID-19 from the mother to the child (4-9). Laboratory analysis revealed that amniotic fluid and cord blood from neonates delivered by COVID-19 positive mothers were negative for the virus (8, 10). Thus, the knowledge regarding vertical transmission of COVID-19 is in- sufficient and adding experience from different regions can help complete the whole picture and understand the behav- ior of the virus in pregnancy. We herein report a case of verti- cal transmission of COVID-19 to the newborn, confirmed by laboratory analysis and investigation in Iran. This open-access article distributed under the terms of the Creative Commons Attribution NonCommercial 3.0 License (CC BY-NC 3.0). Downloaded from: http://journals.sbmu.ac.ir/aaem Y. Parsa et al. 2 2. Case presentation In our center in Tehran, Iran (Mahdiyeh Hospital affiliated with Shahid Beheshti University of Medical Sciences), From March 1s t to April 20t h , we screened 25 pregnant women with suspected COVID-19 infection, 9 of whom tested pos- itive using real time polymerase chain reaction (RT-PCR), which found specimens in nasopharyngeal swab of the pa- tients. The neonates born to 8 of these mothers tested neg- ative for COVID-19; however, 1 newborn tested positive 24 hours after birth. The mother of this neonate was a 41-year- old woman, living in Tehran, Iran, with low socioeconomic background and opium addiction. The pregnancy history included gravid 6, parity 4, live 4, and abortion 1. She had the signs and symptoms of acute respiratory illness including shortness of breath and cough. She underwent spiral chest CT-scan which revealed ground-glass opacities in bilateral upper and lower lobes. The laboratory results revealed lym- phopenia (9.2×103 /µL) and elevated C-reactive protein lev- els (18.8 mg/L). Thus, RT-PCR was done for the mother and the result was positive and she was diagnosed with COVID- 19 pneumonia. She presented with labor pain and amniotic fluid leakage and due to previous history of cesarean delivery (4 previous sections), an emergency cesarean delivery was scheduled. The cesarean section was performed with com- plete protection of the mother, newborn, and the medical team. The result of the delivery was a girl neonate, with 1-min Apgar score of 9 and 5-min Apgar score of 10, and weigh of 3500 gr. The RT-PCR results of the amniotic fluid and neonate (less than 24 hours after birth) were positive for COVID-19 and she was diagnosed with the viral infection. Her chest ra- diography was normal, and the laboratory results were un- remarkable. She was vomiting during the first 24 hours after birth, which was due to opium withdrawal syndrome. She was admitted to the neonatal intensive care unit (NICU) and received supportive care without need for respiratory sup- port. The baby was fed formula as the mother was admit- ted to the ICU and isolation for supportive care. After 11 days, she tested negative for COVID-19 and the test results at day 14 were also negative. The neonate did not have any symptoms including vomiting, dyspnea, or cough but devel- oped fever (38.6◦C) from the 10t h day of birth. Conserva- tive therapy was not successful and thus, a lumbar puncture was performed on day 10, which was clear. The fever resolved with appropriate anti-pyretic therapy and antibiotic therapy. The chest radiography was also unremarkable. She was dis- charged from the hospital with good condition on day 28. The mother also received supportive care in an isolated unit. She was completely symptom free and afebrile. She was dis- charged in good condition. 3. Discussion The vertical transmission of COVID-19 is a matter of debate and the clinical evidence is extremely scanty. In the cur- rent study, we reported the possible vertical transmission of COVID-19 from a mother to a newborn less than 24 hours af- ter birth. In our report, the newborn girl tested positive in the first 24 hours of her life after a cesarean delivery. Although we do not have the RT-PCR results of the placenta, but we be- lieve that the transmission has been vertical as the neonate and amniotic fluid tested positive for the virus less than 24 hours after birth. The current case can contribute to the lit- erature regarding the knowledge of COVID-19 in pregnancy. Recently, Wang et al. (5) reported a neonate with positive RT- PCR after 36 hours of birth from a 34-year-old woman who was diagnosed with COVID-19. The presented case provides the possibility of vertical transmission of COVID-19, while the probability could not been confirmed with laboratory analysis (5). In another recent study of a neonate delivered by cesarean section from an infected mother, there were ele- vated IgM antibody levels and abnormal test results for IL-6 and IL-10 cytokines 2 hours after birth. The increase in IgM antibody level implies that the neonate was infected in utero, as IgM antibody usually does not appear until 3 to 7 days af- ter infection and cannot be transmitted through the placenta (6). Alzamora et al. (11) also reported a 41-year-old woman undergoing cesarean delivery and the neonate tested posi- tive for COVID-19, 16 hours after delivery. IgM and IgG were positive for the mother on the fourth day after giving birth (9 days after the onset of symptoms). The positive RT-PCR test result on the first day of life indicated the possibility of vertical transmission, which is similar to our study (11). In a recent review, Lamouroux et al. (12) reviewed the literature and included the data on 68 deliveries and 71 neonates with maternal infection in the third trimester of pregnancy. Only 4 cases were tested positive within 48 hours of birth and they provided several evidence for and against vertical transmis- sion (12). In a systematic review by Della Gatta et al. (3), which in- cluded 51 pregnant women with positive test results for COVID-19, they concluded that the high rate of preterm de- livery by cesarean delivery was a reason for concern. How- ever vertical transmission was completely rejected by the re- sults of this review (3). Karimi-Zarchi et al. (7) reviewed data of published articles or official websites up to March 4, 2020, to investigate the the risk of vertical transmission of COVID- 19 to the fetus of infected mothers. They finally included 31 pregnant women with positive COVID-19 test results. They reported 2 maternal mortalities, however, there was no ev- idence for intrauterine transmission of COVID-19 from in- fected pregnant women to their fetuses. Chen et al. (8) de- scribed the clinical characteristics of 9 pregnant patients with This open-access article distributed under the terms of the Creative Commons Attribution NonCommercial 3.0 License (CC BY-NC 3.0). Downloaded from: http://journals.sbmu.ac.ir/aaem 3 Archives of Academic Emergency Medicine. 2021; 9(1): e5 COVID-19 infection during the third trimester and demon- strated that there is no evidence for intrauterine transmission of COVID-19; the results were further confirmed by another systematic review (13). In conclusion, vertical transmission of COVID-19 through placenta is still unclear and the existing data in this regard is very limited. However, the current case and similar previous reports support the probability of the virus causing COVID- 19 being transmitted vertically through the placenta. This is supported by the fact that test results of the neonates become positive within the first day of life. The long- and short-term effects of COVID-19 infection on the neonates are still un- clear and should be investigated in follow-ups. The knowl- edge on vertical transmission of COVID-19 is insufficient and adding experience from different regions can help complete the whole picture and understand the nature of the virus in pregnancy. 4. Conclusion The fact that the neonate in our case report tested positive for COVID-19 within the first day of her life adds to the body of evidence suggesting the possibility of vertical transmission of this disease. 5. Declarations 5.1. Acknowledgements We would like to thank the patient and her family who par- ticipated in this study. We would also like to acknowledge the editorial assistance of Diba Negar Research Institute. 5.2. Authors’ contributions All authors met the criteria for gaining authorship based on the recommendations of the International Committee of Medical Journal Editors. 5.3. Conflict of interest There isn’t any conflict of interest to be declared regarding the manuscript. 5.4. Ethical issues This study was carried out according to the Declaration of Helsinki. Also, written informed consent for publication of the manuscript and the related individual data were obtained from the patient (ethics code: IR.SBMU.MSP.REC.1399.460 ). References 1. Sun J, He WT, Wang L, Lai A, Ji X, Zhai X, et al. COVID- 19: Epidemiology, Evolution, and Cross-Disciplinary Per- spectives. Trends Mol Med. 2020;26(5):483-95. 2. Kucharski AJ, Russell TW, Diamond C, Liu Y, Edmunds J, Funk S, et al. Early dynamics of transmission and control of COVID-19: a mathematical modelling study. Lancet Infect Dis. 2020;20(5):553-8. 3. Della Gatta AN, Rizzo R, Pilu G, Simonazzi G. Coron- avirus disease 2019 during pregnancy: a systematic re- view of reported cases. Am J Obstet Gynecol. 2020. 4. Fan C, Lei D, Fang C, Li C, Wang M, Liu Y, et al. Peri- natal Transmission of COVID-19 Associated SARS-CoV-2: Should We Worry? Clin Infect Dis. 2020. 5. Wang S, Guo L, Chen L, Liu W, Cao Y, Zhang J, et al. A case report of neonatal COVID-19 infection in China. Clin In- fect Dis. 2020. 6. Dong L, Tian J, He S, Zhu C, Wang J, Liu C, et al. Possible Vertical Transmission of SARS-CoV-2 From an Infected Mother to Her Newborn. Jama. 2020;323(18):1846-8. 7. Karimi-Zarchi M, Neamatzadeh H, Dastgheib SA, Ab- basi H, Mirjalili SR, Behforouz A, et al. Vertical Transmis- sion of Coronavirus Disease 19 (COVID-19) from Infected Pregnant Mothers to Neonates: A Review. Fetal Pediatr Pathol. 2020:1-5. 8. Chen H, Guo J, Wang C, Luo F, Yu X, Zhang W, et al. Clinical characteristics and intrauterine vertical trans- mission potential of COVID-19 infection in nine preg- nant women: a retrospective review of medical records. Lancet. 2020;395(10226):809-15. 9. Chen Y, Peng H, Wang L, Zhao Y, Zeng L, Gao H, et al. In- fants Born to Mothers With a New Coronavirus (COVID- 19). Front Pediatr. 2020;8:104. 10. Lu Q, Shi Y. Coronavirus disease (COVID-19) and neonate: What neonatologist need to know. J Med Virol. 2020. 11. Alzamora MC, Paredes T, Caceres D, Webb CM, Valdez LM, La Rosa M. Severe COVID-19 during Pregnancy and Possible Vertical Transmission. Am J Perinatol. 2020. 12. Lamouroux A, Attie-Bitach T, Martinovic J, Leruez-Ville M, Ville Y. Evidence for and against vertical transmission for SARS-CoV-2 (COVID-19). Am J Obstet Gynecol. 2020. 13. Cheruiyot I, Henry BM, Lippi G. Is there evidence of intra-uterine vertical transmission potential of COVID- 19 infection in samples tested by quantitative RT-PCR? Eur J Obstet Gynecol Reprod Biol. 2020. This open-access article distributed under the terms of the Creative Commons Attribution NonCommercial 3.0 License (CC BY-NC 3.0). Downloaded from: http://journals.sbmu.ac.ir/aaem Introduction Case presentation Discussion Conclusion Declarations References