A 36- year- old white woman at 40 week of gestation was admitted to a local obstetric clinic for elective repeated cesarean delivery due to slanting position of the fetus.
Both her previous and current pregnancy were uncomplicated.
Her past medical history was unremarkable and no family history of cardiac disease was reported.
The caesarean delivery was performed following the administration of standard spinal anesthesia.
During surgery the patient became hypotensive and ephedrine was injected to maintain her blood pressure in the normal range.
Three hours after delivery of healthy male infant, the patient complained of nausea, increasing dyspnoea and palpitations.
On physical examination tachycardia with ventricular extra systoles and pulmonary rales were detected.
Her blood pressure was 80/40 mmHg and demanded the administration of inotropic agents (initially continuous infusion of norepinephrine 0.5 mg/h followed by dobutamine 7 μg/kg/min).
Owing to worsening of oxygen saturation up to 70 % and gradual deterioration of consciousness, mechanical ventilation was applied and the patient was transferred to intensive care unit.
Chest X ray indicated pulmonary congestion.
Emergency computer tomography excluded pulmonary thromboembolism (PE) and confirmed severe pulmonary oedema (Fig.1).
The patient received loop diuretic, furosemide, at initial daily dose 80 mg, which was progressively reduced.
The diuretic was discontinued after 12 days of treatment.
The electrocardiogram disclosed sinus tachycardia with ST- segment elevation of 1,5 mm with negative T waves in aVL and ST- segment depression of 1 mm in II, III, aVF, V5-V6 (Fig.2).
Laboratory tests showed elevated troponin up to 908 pg/ml (normal value <14 pg/ml), NT- pro BNP 6236 pg/ml (normal value <125 pg/ml).
The bedside transthoracic echocardiography (TTE) revealed severe left ventricular (LV) systolic dysfunction.
Therefore the patient was transferred to Intensive Cardiac Therapy Clinic.
Repeated TTE showed LV ejection fraction 30 % with hypokinesis of the mid and basal segments of posterior, anterior and lateral wall with preserved contractility of the apical segments.
Urgent coronary angiography presented normal coronary arteries.
The diagnosis of inverted stress- induced cardiomyopathy was set upon the overall clinical data.
After 3 days the patient was weaned from respirator and extubated.
Following hemodynamic improvement, inotropic agents were tapered gradually.
Both TTE and magnetic resonance imaging (Figs.3 and ​4) performed on the fifth day showed complete recovery of myocardial function.
The patient was discharged after 15 days in good overall condition.
At 12- month follow- up she remained asymptomatic with no echocardiographic abnormalities.