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PubMed This is a summary of 18 peer-reviewed journal articles Updated
Cardiology

Is This Normal? Distinguishing PPCM from Pregnancy Changes

At a Glance

Shortness of breath while resting, needing multiple pillows to breathe at night, and severe swelling are not normal parts of pregnancy or postpartum recovery. These are red flag symptoms of peripartum cardiomyopathy (PPCM) that require immediate medical testing.

It is common for the early signs of Peripartum Cardiomyopathy (PPCM) to be mistaken for the standard “aches and pains” of the third trimester or the exhaustion of the “fourth trimester” (postpartum) [1][2]. Because pregnancy naturally causes weight gain, swelling, and some shortness of breath, even experienced medical professionals may mistakenly provide “false reassurance,” telling you that what you are feeling is normal [3][4].

However, there are specific “red flag” symptoms that distinguish a healthy pregnancy from a heart condition. Understanding these differences can help you advocate for the testing you need [5][1].

Distinguishing Normal Changes from Red Flags

Symptom Normal Pregnancy / Postpartum PPCM Red Flag
Shortness of Breath Feeling “winded” after climbing stairs or heavy activity [6]. Dyspnea: Feeling breathless while sitting still or performing very light tasks like getting dressed [5].
Sleep & Breathing General discomfort; finding it hard to get a good night’s rest. Orthopnea: Needing to prop yourself up on multiple pillows to breathe, or being unable to breathe while lying flat [1][7].
Waking Up Waking up to use the bathroom or care for the baby. Paroxysmal Nocturnal Dyspnea (PND): Waking up suddenly in the middle of the night gasping for air [5][1].
Swelling Mild swelling in ankles that improves after a night’s sleep. Severe Edema: Swelling that involves the legs, thighs, or even the face and hands, and does not go away with rest [5][7].
Cough Occasional congestion or a cold. A persistent, dry, hacking cough that worsens significantly when you lie down [8].

Why PPCM is Often Missed

The “masking” effect is the primary reason for late diagnosis [6]. During late pregnancy, your body naturally increases its blood volume and heart rate to support the baby [6][9]. Because these changes look similar to the early stages of heart failure, doctors may attribute your symptoms to the “normal physiological burden” of pregnancy [4][10].

Unfortunately, delays in diagnosis are linked to slower recovery for the heart muscle [6][11]. If your symptoms are worsening instead of improving after delivery, it is critical to look beyond “new mom fatigue” [12][13].

Seeking an Objective Evaluation

If you suspect your symptoms are not normal, you can ask for objective tests that look specifically at heart function:

  • NT-proBNP Test: A simple blood test that measures a protein produced when the heart is under stress or “stretched” [14][15].
  • Echocardiogram: An ultrasound of the heart that allows doctors to see how well the heart is pumping and measure your Ejection Fraction (EF) [16][12].
  • POCUS (Point-of-Care Ultrasound): A quick bedside scan that can check for fluid in the lungs or signs of heart strain [17][18].

Take Immediate Action: If you experience these red flag symptoms—especially shortness of breath while resting, inability to lie flat, or waking up gasping—go to the nearest emergency room immediately. Explicitly tell the triage nurse: “I am recently postpartum and I am concerned I have heart failure.” Trust your intuition [3][4].

Common questions in this guide

What is the difference between normal shortness of breath in pregnancy and a PPCM red flag?
Normal pregnancy may leave you feeling winded after physical activity like climbing stairs. A red flag for PPCM is feeling breathless while sitting completely still or doing very light tasks like getting dressed.
Why is peripartum cardiomyopathy often missed or diagnosed late?
During late pregnancy, your body naturally increases blood volume and heart rate, which mimics the early stages of heart failure. Because of this masking effect, doctors may mistakenly attribute PPCM symptoms to the normal physical burden of pregnancy.
What does it mean if I have to sleep propped up on pillows after giving birth?
Needing multiple pillows to breathe comfortably or being unable to breathe while lying flat is called orthopnea. This is not normal postpartum fatigue; it is a significant warning sign of heart strain that requires medical evaluation.
What tests can show if my postpartum symptoms are caused by a heart condition?
You can ask your doctor for an NT-proBNP blood test to measure heart strain, an echocardiogram to check how well your heart is pumping, or a quick bedside ultrasound called a POCUS to look for fluid in your lungs.

Questions for Your Doctor

5 questions

  • •I am experiencing shortness of breath that feels different from normal pregnancy fatigue; can we order an NT-proBNP blood test to check my heart strain?
  • •I have to sleep propped up on three pillows to breathe comfortably; is this a sign of orthopnea related to my heart?
  • •Can we perform an echocardiogram to rule out PPCM, given that my symptoms are progressing rather than improving?
  • •How do you distinguish my severe swelling (edema) from the normal swelling expected after childbirth?
  • •If my symptoms are not heart-related, what is the specific medical explanation for why I am waking up gasping for air at night?

Questions for You

4 questions

  • •When I lie flat on my back, do I feel a sudden need to sit up or gasp for air?
  • •How many pillows do I need to use at night to feel like I'm getting enough oxygen?
  • •Is my swelling 'pitting' (meaning if I press my finger into my shin, does a visible dimple remain for several seconds)?
  • •Do I have a persistent, dry cough that seems to get worse specifically when I lie down to sleep?

References

References (18)
  1. 1

    All that wheezes is not asthma: A cautionary case study of shortness of breath in pregnancy.

    Varnier NA, Chwah S, Miller T, et al.

    Obstetric medicine 2015; (8(3)):149-51 doi:10.1177/1753495X15590020.

    PMID: 27512471
  2. 2

    Peripartum cardiomyopathy: a review.

    Iorgoveanu C, Zaghloul A, Ashwath M

    Heart failure reviews 2021; (26(6)):1287-1296 doi:10.1007/s10741-020-10061-x.

    PMID: 34138401
  3. 3

    Experiences of health care in women with Peripartum Cardiomyopathy in Sweden: a qualitative interview study.

    Patel H, Schaufelberger M, Begley C, Berg M

    BMC pregnancy and childbirth 2016; (16(1)):386 doi:10.1186/s12884-016-1178-3.

    PMID: 27931191
  4. 4

    Life-threatening peripartum cardiomyopathy-Not expected when expecting.

    Magnusson P, Kihlström G, Wallhagen M, Rambaree K

    Clinical case reports 2019; (7(6)):1127-1132 doi:10.1002/ccr3.2158.

    PMID: 31183081
  5. 5

    Improving Outcomes in Peripartum Cardiomyopathy with Vericiguat: A Clinical Case.

    Cacciapuoti F, Mauro C, Capone V, et al.

    Journal of cardiovascular echography 2024; (34(4)):214-218 doi:10.4103/jcecho.jcecho_48_24.

    PMID: 39895888
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    Heart rate as an early predictor of severe cardiomyopathy and increased mortality in peripartum cardiomyopathy.

    Cooney R, Scott JR, Mahowald M, et al.

    Clinical cardiology 2022; (45(2)):205-213 doi:10.1002/clc.23782.

    PMID: 35129215
  7. 7

    [Case of peripartum cardiomyopathy misdiagnosed as pulmonary changes due to COVID-19].

    Gavrilov DV, Bagirova ZR, Pleskatsevich DI, et al.

    Kardiologiia 2022; (62(12)):80-84 doi:10.18087/cardio.2022.12.n1668.

    PMID: 36636979
  8. 8

    Symptoms in women with Peripartum Cardiomyopathy: A mixed method study.

    Patel H, Berg M, Barasa A, et al.

    Midwifery 2016; (32()):14-20.

    PMID: 26515744
  9. 9

    Pathophysiology and risk factors of peripartum cardiomyopathy.

    Hoes MF, Arany Z, Bauersachs J, et al.

    Nature reviews. Cardiology 2022; (19(8)):555-565 doi:10.1038/s41569-021-00664-8.

    PMID: 35017720
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    Peripartum cardiomyopathy: a review of current literature.

    Simpson C, Mittal R, Jain R, Jain R

    Future cardiology 2022; (18(4)):337-343 doi:10.2217/fca-2021-0045.

    PMID: 35196861
  11. 11

    Clinical Characteristics and Prognosis of Peripartum Cardiomyopathy in 28 Patients.

    Liu Y, Zeng Y

    Zhongguo yi xue ke xue yuan xue bao. Acta Academiae Medicinae Sinicae 2016; (38(1)):78-82 doi:10.3881/j.issn.1000-503X.2016.01.014.

    PMID: 26956861
  12. 12

    The outcome of peripartum cardiomyopathy patients-single center experience.

    Demir E, Ceylan N, Bayraktaroğlu S, et al.

    Echocardiography (Mount Kisco, N.Y.) 2022; (39(12)):1608-1615 doi:10.1111/echo.15498.

    PMID: 36447302
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    Unveiling the Mystery of Peripartum Cardiomyopathy: A Traditional Review.

    Chinweuba GC, Rutkofsky IH

    Cureus 2020; (12(10)):e10790 doi:10.7759/cureus.10790.

    PMID: 33042652
  14. 14

    Age-adjusted natriuretic peptide thresholds for a diagnosis of heart failure in the community: Diagnostic accuracy study.

    Taylor CJ, Taylor KS, Jones NR, et al.

    ESC heart failure 2025; (12(5)):3552-3568 doi:10.1002/ehf2.15383.

    PMID: 40717271
  15. 15

    NT-ProBNP and high-sensitivity troponin T as screening tests for subclinical chronic heart failure in a general population.

    Averina M, Stylidis M, Brox J, Schirmer H

    ESC heart failure 2022; (9(3)):1954-1962 doi:10.1002/ehf2.13906.

    PMID: 35322586
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    A contemporary review of peripartum cardiomyopathy.

    Patel PA, Roy A, Javid R, Dalton JA

    Clinical medicine (London, England) 2017; (17(4)):316-321 doi:10.7861/clinmedicine.17-4-316.

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  17. 17

    SONO case series: a 63-year-old male with shortness of breath.

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    Emergency medicine journal : EMJ 2021; (38(2)):155-157 doi:10.1136/emermed-2019-209095.

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  18. 18

    Can Bedside Ultrasound Inferior Vena Cava Measurements Accurately Diagnose Congestive Heart Failure in the Emergency Department? A Clin-IQ.

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This page is for informational purposes only to help distinguish normal pregnancy changes from heart issues. If you experience severe shortness of breath or cannot lie flat, go to the nearest emergency room immediately.

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