A Case of Takotsubo Cardiomyopathy Following Postpartum Hemorrhage in a Patient with Concurrent Influenza A

Background Takotsubo cardiomyopathy, also known as stress cardiomyopathy and broken heart syndrome, is a transient, non-ischemic cardiomyopathy marked by reversible left ventricular dysfunction with a unique apical ballooning appearance(Amin, Amin et al. 2020). It can occur any time, is typically triggered by physical or emotional stress and mimics myocardial infarction (MI) in nonexistence of coronary artery disease (CAD)(Amin, Amin et al. 2020). The prevalence is 1-2.5% and most commonly affects postmenopausal women(Gianni, Dentali et al. 2006, Sharkey, Lesser et al. 2011). In contrast, peripartum cardiomyopathy is a disease of ventricular dysfunction (left ventricular ejection fraction <45% or fractional shortening <30%, or both) that lacks the characteristic echocardiographic findings of Takotsubo and develops in the last month of pregnancy or up to 5 months postpartum(Honigberg and Givertz 2019, Arany 2024). Although both conditions present with acute systolic dysfunction, they differ in etiology and affected populations. Takotsubo cardiomyopathy is rarely seen in postpartum women, making such cases diagnostically challenging and clinically important when they arise. Objective This report presents a rare case of Takotsubo cardiomyopathy in a 24-year-old postpartum patient following significant hemorrhage due to uterine atony. Concurrent influenza A infection may have further contributed to development of Takotsubo cardiomyopathy in this patient. As cardiovascular disease remains a leading cause of maternal mortality, increasing recognition of stress-induced cardiomyopathy in obstetric patients is essential for prompt clinical diagnosis and management. Study Design This case report details the clinical presentation and multidisciplinary management of a patient with Takotsubo cardiomyopathy in the setting of postpartum hemorrhage and influenza A infection. Results A 24-year-old gravida 1 para 1 presented via transfer from a rural community hospital following a primary low transverse cesarean section performed at 39 weeks and 4 days. The operation was performed after attempted vaginal delivery due to arrest of descent in the setting of fetal macrosomia and was complicated by blood loss of greater than 3 liters in the setting of uterine atony. Additionally, influenza A infection was confirmed by positive upper respiratory panel results at both the referring hospital and our facility. On presentation to our hospital, the patient was clinically stable. However, a post-hemorrhage echocardiogram was significant for apical ballooning and akinesis with preserved basal wall motion, and LVEF of 10-15%. These findings are characteristic for a diagnosis of Takotsubo cardiomyopathy. At the time of cardiac consultation, the patient’s only symptoms were tachycardia, fatigue, nausea, and mild abdominal discomfort. She was started on metoprolol 12.5 mg twice daily, which resolved the tachycardia. A couple of days prior to discharge, the patient’s LVEF had improved to approximately 34% and her metoprolol was discontinued. Outpatient follow-up echo and consultation one month after discharge found an ejection fraction of 57% and complete resolution of the apical ballooning and left ventricular wall motion abnormalities. Discussion This case underscores the unusual presentation of Takotsubo cardiomyopathy in a previously healthy 24-year-old woman with a recent influenza A infection who developed symptoms following postpartum hemorrhage. Most literature describes Takotsubo cardiomyopathy in older, often postmenopausal women, and its pathophysiology remains poorly understood. Notably, some studies have suggested a possible link between Takotsubo cardiomyopathy and recent influenza A infection, though such cases are rare and typically reported in older women. In this patient, the presence of multiple concurrent stressors – including viral illness, significant postpartum hemorrhage, and a possible familial predisposition (evidenced by a recent diagnosis of Takotsubo cardiomyopathy in her grandmother) – created several potential contributing factors for the development of Takotsubo cardiomyopathy, making it difficult to identify a single, definitive cause. This case challenges current assumptions about the demographics and triggers of Takotsubo cardiomyopathy and highlights the need for more inclusive research to better understand its mechanisms and long-term outcomes. Conclusion This case highlights the importance of including Takotsubo cardiomyopathy as part of the differential diagnosis in young, postpartum patients following acute physiological and emotional stress. It is essential to recognize that Takotsubo cardiomyopathy is a distinct condition from peripartum cardiomyopathy; although the two share overlapping features, they differ in etiology, prognosis, and management.