A Case of Postpartum Pulmonary Edema Associated With Prolonged Trendelenburg Positioning

Acute pulmonary edema is an uncommon but potentially life-threatening complication of the postpartum period.The contribution of prolonged Trendelenburg positioning to this condition remains poorly understood.We report the case of a 37-year-old woman who developed acute dyspnea, orthopnea, and pleuritic chest pain approximately 18 hours after initiation of Trendelenburg positioning.This intervention had been prescribed for a planned duration of 24 hours as part of conservative management for a suspected cerebrospinal fluid leak identified 48 hours after an uncomplicated vaginal delivery with epidural analgesia.Initial management consisted of bed rest, a compressive dressing, and Trendelenburg positioning; additional hydration and an epidural blood patch were not pursued initially.The patient presented with severe hypoxemia, with an oxygen saturation of 75% on room air.Chest radiography and computed tomography pulmonary angiography demonstrated pulmonary edema and bilateral pleural effusions, without evidence of pulmonary embolism.N-terminal pro-B-type natriuretic peptide was elevated at 1,457 pg/mL, whereas transthoracic echocardiography showed preserved ventricular systolic function and no significant structural abnormalities.The recorded cumulative fluid balance was approximately +800 mL, without evidence of substantial exogenous fluid overload.Management included discontinuation of Trendelenburg positioning, head elevation, supplemental oxygen, and intravenous furosemide, followed by progressive clinical and radiological improvement.The patient was discharged on postpartum day eight.At the three-month follow-up, electrocardiography and transthoracic echocardiography remained normal, and no recurrence of symptoms had occurred.Prolonged Trendelenburg positioning may have contributed to pulmonary edema through central blood volume redistribution and increased pulmonary hydrostatic pressure, superimposed on the physiological hemodynamic changes of the early postpartum period.Although causality cannot be established, this case highlights the need to carefully assess the risks and benefits of prolonged head-down positioning postpartum and to promptly investigate new respiratory symptoms.