Maternal mortality (MM) has increased in the last twenty years (1). A substantial role of cardiovascular diseases (CVD) in this rising trend has been well-established (2), and more than 33% of pregnancy-related deaths have been attributed to CVD (3–6). Corrected congenital heart disease (cCHD), valvular heart diseases (VHD), and cardiomyopathies are the most frequent CVD in pregnancy (7). Moreover, because of the improvements in cCHD surgery, it has become more and more frequent that females survivors with cCHD embark on pregnancy (2, 8); in addition, a more advanced maternal age (9) and, consequently, a greater prevalence of cardiovascular (CV) risk factors have been shown to contribute to CV deaths and morbidity (2). Indeed it has been recognized that women over 30 years have a higher MM rate (9). Conversely, the development of complications such as intrauterine growth restriction (IUGR), preterm birth, preeclampsia, and other hypertensive disorder of pregnancy are more likely to be related to future CVD after delivery (10).

Remarkably, it has been estimated that more than 68% of CV-related MM could have been avoided (5). Therefore, in order to minimize MM, a multidisciplinary approach to pregnancy-associated conditions has been advocated (11, 12). In the latest decades, it has been proposed to create a cardio-obstetric or pregnancy heart team (PHT) involving cardiologists, gynecologists, obstetrics, anesthesiologists, nurses, and other specialists according to the specific clinical competencies required. Women with CVD or CV risk factors should be referred to this multidisciplinary team to improve care and outcomes for those at higher risk. The role of PHT is not only limited to the pregnancy period, but it is also crucial before pregnancy and in the post-delivery period (11–13). Indeed, women referred to PHT should receive appropriate counseling on maternal and fetal risk and the potential teratogenic effects of several drugs. Contraception should also be provided if required. An accurate clinical examination and close follow-up during pregnancy and, importantly, planning delivery should be provided. Finally, in the post-partum period, women should be carefully monitored for managing CV complications.

However, although the positive impact of team-based multidisciplinary strategies on pregnancy outcomes has been assessed, the role of the PHT has not been definitively recognized in clinical practice, and significant gaps exist in implementing a multiplanar approach for reducing pregnancy-associated comorbidity CVD burden. This paper aims to comprehensively discuss the efficacy and appropriateness of multidisciplinary evaluation, which enables an improvement in quality care.

Maternal death is defined as a non-accidental, pregnancy-related fatal event occurring during pregnancy or within 42 days of its termination, irrespective of its duration and location (14). Moreover, all life-threatening events occurring during pregnancy and delivery are defined as severe maternal morbidities.

It has been estimated that the global maternal mortality ratio (MMR) is 216/100,000 live births (1), with a wide variability between developing and more developed countries (1). Indeed, social and geographic differences have also been considered to influence the pregnancy outcome, and a significant geographical heterogeneity has been shown. Black and Hispanic ethnicities belonging have been considered pregnancy-related mortality risk factors (15). Notably, a particularly high MMR (12/100.000) has been reported in the United States (1). Conversely, a lower mortality rate was recorded in European countries (1, 16), ranging from 2.7/100.000 to 10.9/100.000 live births in Norway and Slovakia, respectively (16). It has been reported that MM occurs mostly in preterm women or at delivery. However, a prevalence of MM of 20% until six weeks postpartum and later has been reported. CVD has been shown to cause more than ¼ of MM so that they are considered one of the major causes of MM (17).

Blood volume expansion, higher cardiac output, lower systemic vascular resistance, obstruction of the vena cava, anemia, and systemic blood pressure (BP) fluctuations are hemodynamic changes that physiologically characterize each pregnancy and can result in the worsening of preexisting CVD (18). Therefore, underlying CV conditions (19) can be exacerbated by pregnancy.

Conversely, acquired CVD, can develop during pregnancy (19).

Although the awareness of MMR has increased in the last decades, the management of these patients still needs to be better organized.

In order to improve the quality of care for complex pregnant women avoiding discrepancies among different hospitals, the development of a PHT including cardiologists, gynecologists, anesthesiologists, and other specialized figures such as geneticists, neonatologists, cardiac surgeons, endocrinologists, and oncologists has been proposed (13, 17, 20, 21). Teams has been proposed. PHT should be finalized not only to guarantee accurate monitoring during the pregnancy and delivery but also should be organized to last from pre-conception counseling (22) to the postpartum follow-up, including labor and delivery time (14, 17–19).

Pre-conceptional counseling before pregnancy is crucial for identifying high-risk patients for maternal and fetal complications (22, 23). Contraception in young patients with CVD should also be encouraged by the PHT in order to avoid unplanned pregnancies (22). Moreover, women should be supported by the PHT and provided with the opportunity to choose the best timing for the pregnancy and undergo planned treatment. Remarkably, the inheritance of several conditions should also be faced. Heredity is expected to manifest in 50% of patients with genetic disorders associated with cCHD, such as DiGeorge (22q11 deletion) (24, 25), Marfan (26), Heart-hand syndromes (26, 27) Holt-Oram (28), Nooman (29), Alagille (30), CHARGE (31), Williams-Beuren (32), Cutis laxa (33), Vascular Ehlers–Danlos (vED) (34), and Silver-Russel syndromes (35). Several scores have been proposed to assess risk in pregnant women or those planning pregnancy. CARPREG II (Cardiac Disease in PregnancyStudy) (36), ZAHARA (Zwangerschap Bij Aangeboren Hartafwijking) (37), and modified WHO (World Health Organization) (38–40) have been validated to clinically evaluate the CVD burden, in order to favor not only preconception counseling, but also pregnancy and delivery management, and eventually termination of pregnancy in particularly high-risk conditions.

The modified World Health Organization (mWHO) risk score identifies five risk classes (WHO I, II, II-III, III, and IV) (38–40), investigating not only the risk assessment of CV events but also obstetric complications, such as miscarriage, postpartum hemorrhage, hypertensive disorders, prematurity, intrauterine growth restriction (IUGR), low birth weight (ELBW), and perinatal mortality (38).

Preconception counseling, frequency of controls during pregnancy, delivery time and modality, and postpartum care should be based on the risk assessment (8, 41–47).

Postpartum follow-up should be adequately monitored in women with known CVD, considering the fact that women with CVD remain at high risk for late CV complications (48). Females with an increased risk for adverse long-term CV outcomes can be identified using pregnancy risk prediction tools (48). The intrauterine device or progesterone-only subdermal implants can be used in the immediate postpartum period, taking into account the risk of thrombosis or bleeding.

Patients at great risk for developing CV complications should be monitored for the following 72 h (49). Several CV events, such as peripartum cardiomyopathy (PPCM), pulmonary embolism (PE), spontaneous coronary artery dissection (SCAD), and aortic dissection (AD), can occur postpartum. The so-called “red flag” symptoms are thought to be relevant in the early detection of CV complications. A self-monitoring of the patients is also beneficial. After discharge, the first visit should be performed for high-risk patients within three days (50). A postpartum evaluation within the first three weeks after delivery with interim follow-up has been recommended, including a comprehensive medical examination within 12 weeks (50). Nevertheless, heart failure (HF), arrhythmias, hypertensive disorders, and hemorrhagic and infective pregnancy-related events complications have been considered the most frequent causes of rehospitalizations in the first 42 days postpartum (51).

An increment in MM has been reported in the last two decades. CVD is considered the leading cause of MM and morbidity (3–6). Nowadays, advanced maternal age is commonly observed, being related to a more prevalence of comorbidities and CV risk factors such as hypertension, diabetes, and obesity (15).

In addition, the widespread use of assisted reproductive technology has been correlated with greater CV risk. On the other hand, the improved management of cCHD resulted in a more prevalence of adult females with cCHD. Due to the difficult management of CVD in pregnant women, referring these patients to highly specialized centers would be advisable to ensure a high quality of care and a multidisciplinary approach during pregnancy and in the first few months of postpartum (Table 1).

Progress in cardiovascular care and cardiac surgery has determined significant improvement in the conditions of women who choose to become pregnant. A close assessment before the pregnancy and monitoring during and after by a multidisciplinary group is able to reduce adverse events and improve maternal-fetal outcomes.

PHT management of comorbidities should be incorporated into pregnancy care in order to optimize appropriate and effective therapies (Figure 1).

Implementing PHT care will require a multidisciplinary team to address therapeutic optimization, active comorbid disease management, and evidence-based interventions. Therefore, optimizing care pathways in cardio-obstetric patients is a promising area of care innovation that should substitute the traditional care approaches.

All authors have seen and approved the manuscript being submitted, have contributed significantly, attest to the validity and legitimacy of the data and its interpretation, and agree to its submission. All authors agree with the content, and all give explicit consent to submit. All authors whose names appear on the submission: 1. Made substantial contributions to the conception, and design of the work and to acquisition, analysis, or interpretation of data. 2. Drafted the work or revised it critically for important intellectual content; 3. approved the version to be published; 4. agree to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.

Fabiana Lucà (MD, PhD, FESC) (Chairperson), Giorgio Caretta Ospedale S. Andrea - La Spezia, Stefano Cornara P.O. Levante Ospedale San Paolo - Savona, Irene Di Matteo ASST Ospedale Metropolitano Niguarda - Milano, Concetta Di Nora AOU Santa Maria della Misericordia - Udine, Silvia Favilli Azienda Ospedaliero Universitaria Meyer - Firenze, Simona Giubilato Azienda Ospedaliera Cannizzaro - Catania, Anna Pilleri ARNAS G. Brotzu - Cagliari, Andrea Pozzi ASST Papa Giovanni XXIII - Bergamo and Roberta Rossini Azienda Ospedaliera Santa Croce e Carle - Cuneo.

Maria Giovanna Russo (MD) (Chairperson), Gabriele Egidy Assenza Ospedale Sant'Orsola Malpighi - Bologna, Annalisa Alaimo P.O. Giovanni di Cristina – Palermo, Roberta Ancona AORN Ospedale dei Colli P.O. Monaldi – Napoli, Domenico Sirico Università di Padova, Gaia Spaziani A.O.U. Meyer – Firenze, Stefano Domenicucci Agenzia Ligure Sanità Regione Liguria – Genova, Giovanni Di Salvo Azienda Ospedale-Università di Padova and Maria Giulia Gagliardi Ospedale Pediatrico Bambino Gesù – Roma.

The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.