Abstract 4145480: Acute Pulmonary Edema in Peripartum Period: An Unusual Presentation of Takotsubo Cardiomyopathy

Introduction: Acute respiratory distress in the peripartum period can occur from a variety of reasons including pulmonary or cardiac causes. Careful integration of the history, physical examination and imaging studies is crucial to make a definitive diagnosis. Case presentation: The patient is a 22-yr-old G1P0 African American woman with no significant medical history who had two unsuccessful external cephalic versions and required Cesarean section. Intraoperatively, she became dyspneic and hypoxic. She had labored breathing, tachycardia, scattered wheezes and hypotension. She had acute pulmonary edema, requiring endotracheal intubation. PA catheter placement revealed cardiac output of 3.7 L/min, Pulmonary artey pressure was 37/27 mmHg and SPO2 of 80% on 100% FiO2. Transthoracic echocardiogram (TTE) revealed moderately reduced left ventricular ejection fraction, (LVEF) 30-35% and moderate mitral regurgitation. She had preserved apical LV function with reduced contractility in the basal segments suggestive of reverse Takotsubo syndrome. RV size and function were normal, making significant pulmonary embolism less likely. CXR revealed interstitial edema. EKG had sinus tachycardia. Peak troponin I was 3.3ng/mL and Lactic acid 4.2 mmol/L. Patient received IV diuretic and inotropic support with Norepinephrine, Epinephrine and Milrinone. She was extubated after 2 days. TTE four days later revealed recovery of LVEF to 53%. Three weeks later, she was asymptomatic. Cardiac MRI showed normal LVEF 58% and no wall motion abnormalities. Discussion: The patient had acute pulmonary edema and systolic dysfunction . In the absence of chest pain or ST elevation on EKG, spontaneous coronary dissection was unlikely. Takotsubo cardiomyopathy (TMC) is an acute but transient cardiac dysfunction following significant physical or emotional stress. Attempted external cephalic version may have triggered TMC. It is important to distinguish between TCM and Peripartum cardiomyopathy (PPCM) in these patients as it may prevent the continuation of long term medical therapy for heart failure. PPCM has a more gradual onset. Quick normalization of her LV function strongly favors that she experienced Takotsubo, not Peripartum cardiomyopathy. Conclusion: Making an accurate diagnosis of Takotsubo cardiomyopathy by serial echocardiography to demonstrate quick improvement in LV function has long-term implications regarding future pregnancies and prognosis.