Takotsubo Syndrome After Emergency Cesarean Delivery in Twin Pregnancy: A Rare Cause of Acute Postpartum Heart Failure.

Background: Takotsubo syndrome (TTS) is considered rare in premenopausal women and presents as a transient, nonischemic acute heart failure with relatively fast, spontaneous recovery of myocardial function. It is typically characterized by apical ballooning, or less commonly, akinesia of the midsegments of the left ventricle, commonly triggered by acute emotional stress and therefore also known as "broken-heart syndrome" and "stress-induced cardiomyopathy." Case: In this article, we present a case of a 26-year-old female patient pregnant with dichorionic-diamniotic twins, who developed TTS peripartum following emergency cesarean section due to premature membrane rupture at 33 weeks of gestation. On the first postoperative day, she suddenly developed dyspnea with desaturation to 80% oxygen on pulse oximetry. She became hypotensive and tachycardic. An electrocardiogram revealed T-wave inversion in aVL and ST-segment changes in leads V4-V6. An assay of cardiac enzymes was elevated. In order to exclude acute myocardial infarction and pulmonary thromboembolism, CT angiography of the lungs and coronary arteries was performed. Transthoracic echocardiography revealed akinesia of the midsegments of the left ventricle and a moderately reduced ejection fraction. After the introduction of cardioprotective therapy with bisoprolol 1.25 mg, her ECG normalized. She was normotensive, normocardic, and oxygen saturation on pulse oximetry was within the normal range.The echocardiogram on the 11th postpartum/postoperative day revealed partial spontaneous regression of segmental motion disorders and improvement of left ventricular ejection fraction. On the day of discharge, the patient was eupnoic with normal oxygen saturation without supplemental oxygen. She was normotensive and normocardic. The uterus was appropriately contracted, lochia normal, and the wound was healing normally. She was breastfeeding. She was prescribed with bisoprolol 1.25 mg once daily until follow-up heart ultrasound 6 months after the discharge. Conclusions: In a state that suggests cardiac emergency, TTS should be considered among other differential diagnoses, such as myocardial infarction, acute myocarditis, pulmonary embolism, and peripartal cardiomyopathy. It is very important to differentiate TTS from peripartal cardiomyopathy because of the differences in management and prognosis. The clinical awareness and holistic approach to differential diagnosis are crucial for management of acute heart failure after cesarean section.