Postpartum cardiomyopathy complicated with upper-extremity deep vein thrombosis and pulmonary embolism

A 33-year-old white primigravida presented to the emergency department, 11 days after an uneventful cesarean section, with a right arm swelling evolving acutely within the previous 10 h. She complained of a 10-day history of worsening dyspnea, fatigue, orthopnea, and persistent cough. Her medical history was remarkable for a surgical closure of a patent ductus arteriosus at 5 years of age and Hodgkin's disease for which she had received radiation therapy and an unknown course of chemotherapy 12 years before presentation. She was thought to be in complete remission. She was on no current medications. She had been receiving oral ritodrine hydrochloride from the 29th to the 34th week of pregnancy because of premature uterine contractions. On presentation, she was afebrile, with a heart rate of 98 bpm and blood pressure of 105/55 mm Hg. Examination showed bilateral basilar rales, elevated jugular venous pulse, hepatomegaly, and peripheral edema. Duplex ultrasonography revealed an acute thrombosis of the right axillary, subclavian, and internal jugular veins (Fig. 1, panels A and B). Contrast-enhanced CT showed a filling defect in the right lower lobe pulmonary artery consistent with a pulmonary embolus and bilateral pleural effusion (Fig. 1, panel C). Echocardiography revealed a diffusely hypokinetic left ventricle with an ejection