the physiological changes associated with pregnancy may predispose pregnant women to pulmonary edema . other known causes of pulmonary edema during pregnancy include tocolytic drugs , preeclampsia , eclampsia , and peripartum cardiomyopathy . we describe a rare case of pulmonary edema caused by takotsubo cardiomyopathy in a pregnant woman at 14 weeks of gestation who was undergoing emergency transvaginal cervical cerclage . intraoperative chest radiography revealed severe pulmonary edema and echocardiography indicated moderate left ventricular dysfunction with akinesia of the mid to apical left ventricular wall segment , which is reflective of takotsubo cardiomyopathy . with early detection and appropriate management , the patient was stabilized in a relatively short period of time . based on her clinical signs and symptoms , we suspect that the pulmonary edema was caused by takotsubo cardiomyopathy . pulmonary edema is characterized by the accumulation of fluid in the pulmonary interstitial spaces and alveoli that prevents the adequate diffusion of both oxygen and carbon dioxide . pulmonary edema development is more likely in pregnant women due to the physiological changes associated with pregnancy . other known causes of pulmonary edema during pregnancy include simultaneous use of multiple tocolytics , infection , pre - existing cardiac disease , preeclampsia , and eclampsia . pulmonary edema development during pregnancy is associated with an increased risk of maternal and fetal morbidity and mortality . in the present report , we describe a rare case of acute pulmonary edema that was likely caused by takotsubo cardiomyopathy in a pregnant woman . we believe that favorable outcomes can be ensured in such cases by increased awareness of cardiogenic pulmonary edema , early identification of the condition , and administration of appropriate treatment . a 32-year - old woman ( gravida 2 , para 1 ) was diagnosed with an incompetent cervix at 14 weeks of gestation and was scheduled to undergo emergency transvaginal cervical cerclage . the patient 's height and weight were 154  cm and 81  kg , respectively . before admission after taking the medication , she gained 7  kg in the week prior to admission . the preoperative laboratory evaluation findings , including chest radiography ( 14 days prior to surgery ) , were not remarkable ( fig . regarding her preoperative vital signs , her blood pressure ( bp ) was 100/77 mm hg , heart rate was 100  beats / min ( regular sinus rhythm ) , and peripheral oxygen saturation ( spo2 ) was 95% . the surgery was performed with the patient in the trendelenburg position and under local anesthesia . however , at that point , she complained of dyspnea and pain at the operative site . the severity of the dyspnea made it impossible to maintain the trendelenburg position and , hence , she was placed in a head - up position . ten minutes after surgery , she developed shortness of breath and exhibited a poor pulse oximetry waveform . however , her heart rate measured by electrocardiogram ( ecg ) and spo2 could not be monitored due to her agitation . accordingly , the patient was monitored via noninvasive bp determination , ecg , and pulse oximetry . anesthesia was intravenously induced using thiopental sodium ( 250  mg ) and succinylcholine ( 75  mg ) . anesthesia was maintained using 2  l / min o2 , 2  l / min air , and 1 to 2 vol% sevoflurane ( inspired ) . volume - controlled mechanical ventilation was performed with a tidal volume of 500  ml , positive end - expiratory pressure of 5  cm h2o , and respiratory rate of 12 to 15  breaths / min to maintain an end - tidal carbon dioxide concentration of 32 to 35 mm hg . the surgery was quickly completed , but she exhibited new - onset audible crackles in both lung fields . she exhibited spasmodic coughing and a consistent discharge of pink frothy sputum , along with the extrusion of large amounts of foamy fluid . the spo2 further decreased to 80% after 1  min , and the systolic bp decreased to 80 mm hg . intraoperative chest radiography indicated increased opacification of the bilateral lung fields , which suggested severe pulmonary edema ( fig . in addition , an arterial line was placed into the right radial artery to continuously monitor bp and collect blood samples and a central venous catheter was placed into the right internal jugular vein to monitor central venous pressure and administer drugs . the total amount of infused intravenous fluids during the surgery was 500  ml of lactated ringer solution . arterial blood gas analysis exhibited a ph of 6.99 , paco2 of 101 mm hg , pao2 of 51 mm hg , and sao2 of 63% ( table 1 ) . in addition , dobutamine ( 5  g / kg per min ) and norepinephrine ( 0.05  g / kg per min ) were intravenously administered . at 30  min after tracheal intubation , intraoperative transthoracic echocardiography , performed by an anesthesiologist , exhibited an ejection fraction of 40% and akinesia of the mid to apical left ventricular ( lv ) wall segments ( fig . 2 ) . portable transthoracic echocardiograph ( parasternal long axis view ) showing typical ballooning of the apex in the heart during systole . continuous renal replacement therapy was therefore conducted along with intravenous infusion of dobutamine and norepinephrine to rapidly resolve the pulmonary congestion . the levels of cardiac troponin i ( 1.135  ng / ml ; normal range , < 1.5  ng / ml ) and creatine kinase mb ( 3.8  ng / ml ; normal range , < 5  ng / ml ) were somewhat elevated , although both remained within normal limits . on postoperative day ( pod ) 1 , her vital signs were stable and there were no signs of respiratory disturbance . therefore , extubation was performed and treatment with inotropic agents , vasopressors , and continuous renal replacement therapy was discontinued . she was transferred to the general ward in an overall stable condition while the fetal status was continuously observed via obstetric ultrasonography . on pod 3 , follow - up echocardiography revealed that the ejection fraction had improved to 52% , with normal lv wall motion . on pod 13 , she was discharged , with no complications noted in the patient or fetus . information on the natural history of pulmonary edema in pregnant women is scarce . due to the presence of a reduced plasma protein osmotic pressure , even small changes in hydrostatic pressure these physiological changes could explain the development of pulmonary edema in pregnant women with normal or minimally elevated pulmonary capillary wedge pressure . in fact , pulmonary edema is reported to develop in 0.05% of the general obstetric population . the potential cause of the pulmonary edema should be determined to identify the specific therapy required to reverse the primary pathological process . in the present case , the potential causes of pulmonary edema included peripartum cardiomyopathy , use of tocolytics , and stress - induced cardiomyopathy . the acute and rapidly reversible lv failure observed in the present case corresponds to peripartum cardiomyopathy with the following typical elements : pulmonary edema , echocardiographic lv dysfunction , and no other cause of cardiomyopathy or myocarditis . the diagnostic criteria for peripartum cardiomyopathy include cardiac failure development in the last month of pregnancy or within 5 months of delivery ; no identifiable cause of the cardiac failure ; no recognizable heart disease before the last month of pregnancy ; and an ejection fraction of < 45% or a combination of an m - mode fractional shortening of < 30% and an end - diastolic dimension of > 2.7  cm / m . the symptoms of heart failure , such as dyspnea , dizziness , pedal edema , and orthopnea , can also develop in patients with normal pregnancy . however , the sudden development of swelling and other heart failure symptoms in an otherwise normal case of pregnancy in any peripartum patient should prompt physicians to consider peripartum cardiomyopathy . in the present case , because the patient was only at 14 weeks of gestation , we believed that it was inappropriate to diagnose the patient with peripartum cardiomyopathy . tocolytic - induced pulmonary edema is a unique syndrome that develops as a complication of sympathomimetic therapy for premature labor . dyspnea , chest pain , and cough are the major symptoms of tocolytic - induced pulmonary edema , and physical examination in such cases typically indicates tachypnea and tachycardia while auscultation reveals bibasilar crackles without any clinical evidence of heart failure . in our present case , however , the echocardiographic findings in tocolytic - induced pulmonary edema are usually normal , inconsistent with the present case . takotsubo cardiomyopathy , apical ballooning syndrome , or stress cardiomyopathy have recently been reported as conditions that develop from a transient stunned myocardium as a result of psychological and/or physical stress . in 1991 , dote et al first described a syndrome characterized by transient wall motion abnormalities that extended beyond a single coronary distribution and involved the apical and mid - portions of the left ventricle in the absence of significant obstructive coronary disease . the syndrome was initially described in japan as  takotsubo  due to the similarity in its shape to that of a japanese octopus pot . the pathophysiological mechanism underlying the syndrome remains unclear , although exaggerated sympathetic stimulation is believed to be critically involved . however , a case of takotsubo cardiomyopathy in an eclamptic pregnant patient was reported recently by kunal et al . the most commonly reported cardinal presenting symptoms include chest pain and dyspnea , although initial presentations with syncope and palpitations , nausea and vomiting , hypotension and shock , ventricular fibrillation , or cardiac arrest have also been reported . takotsubo cardiomyopathy is diagnosed based on the presence of mayo clinic criteria at presentation ; that is , transient hypokinesis , akinesis , or dyskinesis of the lv mid - segments , with or without apical involvement ; regional wall motion abnormalities extending beyond a single epicardial vascular distribution ; and , often ( but not always ) , presence of a stressful trigger ; absence of obstructive coronary disease or angiographic evidence of acute plaque rupture ; new ecg abnormalities ( either st - segment elevation and/or t wave inversion ) or modest elevation of cardiac troponin levels ; and absence of pheochromocytoma and myocarditis . for the diagnosis of takotsubo cardiomyopathy , all of these 4 criteria must be present . in the present case , a young woman in her first trimester of pregnancy presented with dyspnea at onset , prior to the induction of general anesthesia for emergency surgery . however , there were some limitations for the diagnosis of takotsubo cardiomyopathy , including the lack of changes in the ecg and st - t wave and normal cardiac enzyme test results ( despite some elevation ) . nevertheless , she exhibited some other characteristics commonly observed in takotsubo cardiomyopathy , including pulmonary edema , moderate lv dysfunction , and the echocardiographic features of this condition . the patient quickly recovered normal lv function , which is typical in this syndrome and indicates its reversibility . according to grayburn and hill , significant operative pain , withdrawal of anesthesia , or shifts in intravascular volume in the present case , the perioperative stress , such as pain , anxiety , and respiratory discomfort , caused by the trendelenburg position could have contributed to the development of takotsubo cardiomyopathy , and the intraoperative administration of catecholamines and vasoconstrictive substances may have enhanced the cardiopulmonary compromise . most cases of pulmonary edema exhibit some response to diuresis , regardless of the etiology . nevertheless , the diagnostic measures are very important . after the initial stabilization of the condition , steps should be taken to accurately determine the specific pathology involved . historical factors may help to elucidate the cause . in most cases of pulmonary edema in pregnant women , the symptoms resolve with the judicious use of diuretics , supplemental oxygen , and restriction of fluid administration . despite such measures , the symptoms progress in approximately 15% to 20% of patients , who then require intubation and mechanical ventilation . both the diagnosis of pulmonary edema and the understanding of the underlying pathophysiology have important implications for treatment . moreover , a registry of acute pulmonary edema should be established to investigate its natural history . we believe that the development of this syndrome should be anticipated in pregnant woman , and the condition should be urgently treated to prevent further respiratory and cardiovascular compromise . the patient signed informed consent for the publication of this case report and any associated images .
abstractbackground : the physiological changes associated with pregnancy may predispose pregnant women to pulmonary edema . other known causes of pulmonary edema during pregnancy include tocolytic drugs , preeclampsia , eclampsia , and peripartum cardiomyopathy.methods:we describe a rare case of pulmonary edema caused by takotsubo cardiomyopathy in a pregnant woman at 14 weeks of gestation who was undergoing emergency transvaginal cervical cerclage.results:intraoperative chest radiography revealed severe pulmonary edema and echocardiography indicated moderate left ventricular dysfunction with akinesia of the mid to apical left ventricular wall segment , which is reflective of takotsubo cardiomyopathy.conclusion:with early detection and appropriate management , the patient was stabilized in a relatively short period of time . 
 based on her clinical signs and symptoms , we suspect that the pulmonary edema was caused by takotsubo cardiomyopathy .