Pulmonary edema during cesarean delivery secondary to Takotsubo syndrome revealing pheochromocytoma: a case report

Acute pulmonary edema during delivery is a serious condition with a wide range of etiologies, including Takotsubo syndrome (TTS), a form of transient left ventricular dysfunction most often presenting as apical ballooning. We report the case of a 35-year-old woman who developed severe hypertension (205/130 mmHg), polypnea, and a drop in oxygen saturation to 80% during cesarean delivery under spinal anesthesia. She received non-invasive ventilation while the cesarean section continued and was transferred to the intensive care unit. Point-of-care ultrasound showed a left ventricular ejection fraction (LVEF) of 35% with apical ballooning and diffuse B-lines on lung ultrasound. Computed tomography identified a right adrenal mass. A diagnosis of pulmonary edema complicating TTS was made, and the patient received furosemide and oxygen therapy. Further investigations, including urinary catecholamine metabolites, confirmed the diagnosis of pheochromocytoma. One week later, LVEF had recovered to 57% with mild residual apical hypokinesia and complete clinical recovery. The patient was then transferred to the surgical unit for management of the pheochromocytoma. This case demonstrates that TTS can cause pulmonary edema in the peripartum period, and that timely diagnosis is essential for a favorable outcome. Point-of-care ultrasound can be instrumental in guiding the assessment of such critical situations, and non-invasive ventilation may be of particular value in selected pregnant patients. This case also underscores the importance of an etiological workup and prompt treatment of hypertensive disorders in pregnancy, especially when pheochromocytoma is suspected, since anesthesia and surgery can precipitate decompensation.