**6. Clinical presentations**

PPCM is common in first postpartum month; it is also rare before 36 weeks of gestation (**Figure 2**). The common presentations of PPCM are dyspnea, cough, orthopnea, and paroxysmal nocturnal dyspnea, which may be confused with the physiological changes of pregnancy. Initial diagnosis may be delayed since symptoms such as nonspecific fatigue, shortness of breath, and pedal edema are similar to those observed in normal pregnancy The patient may have arrhythmia and even cardiac arrest rarely [4]; PPCM can present with thromboembolic manifestations; patients with left ventricular ejection fraction (LVEF) < 35% are at risk for developing left ventricular thrombus. PPCM is manifested after 38 weeks of pregnancy, whereas pregnant patients with chronic heart disease develop sign and symptoms of heart failure in the second trimester of pregnancy due to stress of hemodynamic overload.

**Figure 2.** *Pregnancy and occurrence of PPCM [19].*
