Postpartum shortness of breath and cough

This woman in her 20s presented one week post partum with shortness of breath, orthopnoea, tachypnoea, and cough productive of pink frothy sputum. She had delivered via caesarean section because of pre-eclampsia and had a two year history of essential hypertension, treated with amlodipine. On admission, her blood pressure was 152/106 mm Hg, pulse 120 beats/min, and oxygen saturations were 85% on room air. NT-proBNP was 1008.7 pg/mL (normal range <400 pg/mL) Echocardiography showed reduced left ventricular systolic function with an ejection fraction of 25%. Chest computed tomography (fig 1) showed left ventricle enlargement and pulmonary oedema. A diagnosis of peripartum cardiomyopathy (PPCM) was made.