↓ Figure 1. ECG revealing sinus rhythm and premature atrial complexes (arrow). ECG: electrocardiogram.
| Journal of Medical Cases, ISSN 1923-4155 print, 1923-4163 online, Open Access |
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Case Report
Volume 000, Number 000, May 2026, pages 000-000
A Case of Peripartum Cardiogenic Shock Resulting From Reverse Takotsubo Cardiomyopathy
Figure
Tables
| Timepoint | Phase | Events and interventions | Key findings |
|---|---|---|---|
| BP: blood pressure; BNP: brain natriuretic peptide; CCU: cardiac care unit; CXR: chest X-ray; EBL: estimated blood loss; ECG: electrocardiogram; GDMT: guideline-directed medical therapy; LR: lactated Ringer’s; LV: left ventricle; LVEF: left ventricular ejection fraction; MR: mitral regurgitation; O2: oxygen; PACs: premature atrial complexes; PACU: post-anesthesia care unit; TCM: takotsubo cardiomyopathy; TTE: transthoracic echocardiography. | |||
| Initial presentation | Perioperative | Planned repeat cesarean section under combined spinal and epidural anesthesia | No complaints; vitals unremarkable |
| Combined spinal-epidural anesthesia administration | Perioperative | Hypertensive emergency + severe headache → IV labetalol 10 mg → hypotension → fetal bradycardia → emergency cesarean (EBL 830 mL) | Maternal BP 222/152 mm Hg→ hypotension nadir 67/36 mm Hg |
| PACU | Acute decompensation | Persistent hypotension refractory to 6.1 L LR + 250 mL albumin → phenylephrine initiated Acute hypoxic respiratory failure requiring 10 L O2; maternal fetal medicine consulted; diuresis started | Lactate 1.5 mmol/L; BNP 23 pg/mL; troponin I 0.29 → 0.35 → 0.51 ng/mL; ECG: sinus rhythm with PACs, no ischemic changes; CXR: enlarged cardiac silhouette and signs of pulmonary vascular congestion |
| PACU | Acute decompensation | Emergent cardiology consult → bedside TTE performed | LVEF 30%; diffuse hypokinesis with apical sparing; moderate MR |
| CCU admission | Acute decompensation | Transferred to CCU; dobutamine 2.5 µg/kg/min initiated → hemodynamic improvement; phenylephrine transitioned to norepinephrine | Improved hemodynamics on inotropic support |
| CCU day 1–2 | Stabilization and GDMT | Spironolactone 25 mg daily initiated; dobutamine weaned and discontinued within 48 h | Troponin I 0.33 ng/mL; continued hemodynamic improvement |
| CCU day 3 | Stabilization and GDMT | Metoprolol succinate 25 mg daily started (day after dobutamine discontinued); repeat TTE performed → spironolactone discontinued | Troponin I 0.09 ng/mL; normal LV size; LVEF 51%; trace MR |
| CCU day 6 | Stabilization and GDMT | Enalapril 5 mg daily initiated | Continued clinical improvement; breastfeeding maintained on GDMT |
| Day 7–discharge | Recovery | Discharged home on enalapril + metoprolol succinate; patient continued breastfeeding | LVEF 51% at discharge |
| 4-month follow-up | Recovery | Continued on metoprolol succinate monotherapy (enalapril discontinued given normalized EF) | LVEF 55–60% |
| Takotsubo CM | Peripartum CM | |
|---|---|---|
| Adapted from Tzerefos et al [9] and Garg et al [10]. CM: cardiomyopathy; LVEF: left ventricular ejection fraction; GDMT: guideline-directed medical therapy. | ||
| Echocardiographic findings | Transient regional wall motion abnormalities, most often apical ballooning | Global left ventricular hypokinesis |
| Timeline | Occurs within the days surrounding delivery | Can occur within the months surrounding delivery |
| Left ventricular function prognosis | More favorable prognosis of LVEF recovery | Less favorable prognosis of LVEF recovery |
| Recovery | Quicker recovery of LVEF, within 1 month (75% of patients recover within 10 days) [8] | Delayed recovery of LVEF |
| Incidence | Higher incidence (1 in 5,000 admissions) | Lower incidence (1 in 1,000–4,000 live births) |
| Management | Supportive management with GDMT | Heart failure management with GDMT |