What is the most likely diagnosis for a young postpartum woman, two months after delivery with a history of postpartum hemorrhage, presenting with shortness of breath, diaphoresis, mildly elevated troponins, and mild tachycardia?

Peripartum Cardiomyopathy is the Most Likely Diagnosis

In a young postpartum woman presenting two months after delivery with shortness of breath, diaphoresis, mildly elevated troponins, and tachycardia—especially following postpartum hemorrhage—peripartum cardiomyopathy (PPCM) is the most likely diagnosis. 1

Why Peripartum Cardiomyopathy is Most Likely

• PPCM most commonly presents in the postpartum period, with peak presentation occurring 2-62 days after delivery, which aligns perfectly with this patient's two-month timeline 1
• Elevated troponin I should lead to consideration of underlying ischemic heart disease or cardiomyopathy, even in young patients 1
• Severe postpartum hemorrhage with hemorrhagic shock can lead to elevated troponin levels with ischemic ECG changes and LV wall motion abnormalities, creating a dual mechanism for cardiac injury in this patient 1
• The combination of dyspnea, diaphoresis, tachycardia, and elevated troponins represents classic heart failure presentation, which is the hallmark of PPCM 1

Why Other Diagnoses are Less Likely

Pulmonary Embolism (PE)

• PE typically presents within the first week postpartum (87% of postnatal VTE occurs within 1 week of delivery), not at two months 2
• While PE remains possible, the elevated troponins with dyspnea and diaphoresis point more toward primary cardiac pathology 1
• The main differential diagnoses of acute ischemic chest pain include pre-eclampsia, acute pulmonary embolism, and aortic dissection, but the timing and troponin elevation favor cardiomyopathy 1

Anemia-Related Symptoms

• While postpartum hemorrhage causes anemia, anemia alone does not typically cause troponin elevation unless there is underlying cardiac ischemia 3
• Myocardial ischemia during postpartum hemorrhage occurs in 51% of cases with severe hemorrhagic shock, but this is an acute phenomenon, not a delayed presentation at two months 3
• The two-month delay makes acute hemorrhage-related ischemia unlikely as the primary cause 3

Aortic Dissection

• Spontaneous coronary artery dissections are more prevalent in pregnant women and mostly reported around delivery or in the early postpartum period, not at two months 1
• Dissection typically presents with severe, tearing chest pain and hemodynamic instability, which is not described here 1

Diagnostic Approach

Immediate echocardiography is essential to evaluate for:

• Left ventricular systolic dysfunction (LVEF typically reduced in PPCM) 1
• Wall motion abnormalities that would suggest ischemia or infarction 1
• Chamber dimensions (PPCM usually presents with less dilation than idiopathic dilated cardiomyopathy) 1

Additional workup should include:

• ECG to assess for ischemic changes (though negative T waves can appear in pregnancy without ischemia) 1
• BNP or NT-proBNP levels to confirm heart failure 1
• Consider D-dimer and CT pulmonary angiogram if PE remains in differential, though timing makes this less likely 1

Critical Management Considerations

• Rapid treatment is essential, especially with pulmonary edema or hypoxemia 1
• Oxygen should be administered to achieve arterial oxygen saturation ≥95%, using non-invasive ventilation with PEEP 5-7.5 cm H₂O if needed 1
• Intravenous diuretics (furosemide 20-40 mg IV bolus) should be given when there is congestion and volume overload 1
• Intravenous nitrates (nitroglycerin 10-20 up to 200 mcg/min) are recommended if systolic blood pressure >110 mmHg 1

Common Pitfall to Avoid

Do not dismiss cardiac symptoms in young postpartum women as simply anxiety or anemia. The history of postpartum hemorrhage increases risk for both acute myocardial ischemia during the hemorrhagic event and subsequent development of PPCM. A significant proportion of PPCM patients (up to 50%) normalize their LV function within the first 6 months postpartum, making early diagnosis and treatment crucial for optimal outcomes 1