COVID-19 as a potential trigger for mirror syndrome: exploring an infectious etiology in a rare obstetric triad

Abstract

Mirror syndrome (Ballantyne's syndrome)—the triad of maternal edema, fetal hydrops, and placental hydrops—is a sporadic, life-threatening condition. Its etiology is diverse, including infections, isoimmunization, and fetal anomalies. This case report aims to explore and highlight a possible correlation between COVID-19 infection and the precipitation of mirror syndrome in a primigravida. In this case, a 25-year-old primigravida (PCOS history) presented to OPD at 28 weeks 4 days gestation with dyspnea and grade IV edema/anasarca. Ultrasound and MRI confirmed fetal hydrops (ascites, pleural effusion), polyhydramnios (Liquor 25-26 cm), and placentomegaly, fulfilling the diagnostic criteria for mirror syndrome. Further evaluation revealed maternal bilateral pleural effusion and consolidation, confirmed as a new-onset COVID-19 infection by CT and RT-PCR. Due to PPROM, the pregnancy was terminated, resulting in a stillbirth. Mirror syndrome's pathogenesis is thought to involve trophoblastic damage and endothelial dysfunction, similar to preeclampsia. Given that COVID-19 infection is known to induce systemic inflammation, coagulopathy, and endothelial injury, the timing of the maternal infection in this case suggests a potential infectious etiology. While a direct causal link requires further study, this case supports the hypothesis that COVID-19 may act as a trigger, contributing to the angiogenic-antiangiogenic imbalance implicated in the syndrome. This case highlights an unusual presentation of mirror syndrome coinciding with acute maternal COVID-19 infection. Due to the high morbidity/mortality of mirror syndrome, we advise wider screening for this condition in COVID-19 positive pregnant patients, and vice versa, to ensure early detection and prompt, etiology-based management.