A 37-year-old woman with a past medical history of migraine headache and reflux esophagitis was seen in our autonomic clinic for evaluation of recurrent syncope. In the last nine years, she had experienced episodes of debilitating recurrent syncope. Her first episode occurred six months after she gave birth to her daughter. At that time, she described an episode that occurred while standing at work during which she became “fuzzy”, lightheaded, and subsequently suffered from an episode of syncope with a brief loss of consciousness. She had no convulsive activity during this episode. She continued to experience episodes of lightheadedness without frank syncope. Six years after her first episode the symptoms and the frequency of episodes progressed to the point where she experienced approximately eight episodes of lightheadedness and palpitations over a period of six months, occasionally resulting in syncope. In the interim, multiple neurologists evaluated her. Ultimately, a cardiologist sent her for head up tilt test (HUTT). Upon the assumption of upright posture during the tilt test, her heart rate increased from 86 beats per minute (bpm) (baseline) to 126 bpm within 5 minutes, and her blood pressure dropped from 126 mm Hg (baseline) to 90 mm Hg, associated with symptoms of lightheadedness, palpitations and loss of consciousness. She was initially treated with fludrocortisone, which failed to relieve her symptoms. Midodrine (an alpha agonist) and methylphenidate (noncatecholamine sympathomimetic) were also tried but ineffective. She suffered multiple injuries (including head injuries) during these episodes of syncope, and her quality of life had markedly decreased. During one traumatic syncopal episode, she fell while attending physical therapy. In addition, she also suffered from loss of memory and balance problems.

Multiple cardiovascular adaptations occur during pregnancy, which are essential for successful completion of pregnancy. These include an increase in cardiac output, sodium, and water retention with increase in expansion of blood volume and a reduction in peripheral vascular resistance and diastolic blood pressure [3]. These cardiovascular adaptations continue in the postpartum period and allow for return to a nonpregnant state. These changes in the postpartum period have not been well reported or studied [4]. Our patient developed recurrent episodes of syncope in the postpartum period. Postpartum syncope with significant maternal morbidity and one infant mortality has been reported previously [1]. There have been reports that patients with POTS can have a favorable outcome during pregnancy and in postpartum period [5, 6]. The joint hypermobility syndrome might have predisposed our patient to symptoms of orthostatic intolerance and made her vulnerable especially as she returned to the prepregnant state with gradual loss of estrogen/progesterone, induced fluid retention in the postpartum period.