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In contrast to most industrialized countries, maternal mortality in the USA is rising. Cardiovascular disease, both acquired heart disease (e.g. coronary disease, arrhythmias, and heart failure), as well as congenital heart disease survivors, are all potentially important factors in explaining this worrisome trend. Increase in acquired cardiac disease is likely attributable to greater rates of obesity, diabetes, hypertension, and an increase in the incidence of advanced maternal age, while congenital heart disease in pregnancy is increasing due to advances in pediatric cardiovascular surgery. Despite the growing cardiovascular risk of pregnant women, most obstetricians and cardiologists have limited experience in caring for women with heart disease. Accordingly, management is largely guided by expert opinion likely to vary greatly across centers. To address these challenges, a multidisciplinary approach to care that includes both cardiologists and obstetricians could leverage the knowledge of both specialties and support streamlined communication between the patient and her providers. Our experience highlights the necessary components and essential infrastructure for building a center of excellence in treating pregnant women with heart disease.Condensation: A guide for creating a center of excellence for prenatal care for women with cardiovascular disease.The problem: Cardiac disease is the leading cause of maternal mortality, and pregnancies affected by cardiac disease continue to rise, both congenital and acquired.The solution: Maternal fetal medicine, obstetricians, and cardiologists can join together in tertiary facilities to create Maternal Cardiac Centers of Excellence to provide multidisciplinary, structured care for these high-risk patients.

In the USA, maternal mortality has been rising since the 1980s. Cardiovascular disease is recognized as the leading cause of this worrisome trend, and a multidisciplinary approach to the care of patients with cardiovascular conditions during pregnancy is becoming increasingly important. We outline the literature supporting this multidisciplinary approach, highlight our center’s experience in building and expanding an integrated cardio-obstetrics practice, and provide guidance regarding patient selection and management within a combined practice. Antenatal management patterns and delivery planning for patients with cardiovascular disease during pregnancy vary substantially among cardiovascular and obstetric and maternal fetal medicine practices in the USA. The need for multidisciplinary care between cardiologists and obstetricians is evident and has been supported by best practice statements from the American Heart Association, the American College of Obstetrics and Gynecology, and the Cardiac Disease in Pregnancy Study (CARPREG) investigators, whose CARPREG II risk score included “late first antenatal visit” as a predictor of adverse outcomes of pregnancy. We have solid evidence supporting a multidisciplinary approach to the care of patients with cardiac conditions in pregnancy. This approach is optimal because it facilitates a consistent and clear message to the patient (and those caring for each patient) regarding management and risks associated with pregnancy, as well as subsequent risk and postpartum follow-up. We support the extension of clinical collaboration between obstetricians and cardiologists to the research realm and know that working together to investigate the outcomes of moms with heart conditions and their babies will provide clinically meaningful information to support the care of these unique patients.

Maternal mortality in the United States is highest among all developed nations and continues to rise. The leading cause of morbidity and mortality during pregnancy and the postpartum period is cardiovascular disease. While there are large European and Canadian studies exploring the care and outcomes of moms with heart disease in pregnancy, there are no large prospective studies to guide the care of this growing group of patients in the US. We review the current approach to the management of patients with heart disease in pregnancy and the gaps in knowledge thereof. Currently, antenatal management and delivery planning are highly variable for patients with heart disease in pregnancy and maternal risk models’ application to the US patient population is limited by their derivation from an international cohort of patients and their focus on patients with congenital heart disease. As the need for interdisciplinary care between cardiologists and obstetricians becomes evident, and as broad research efforts within this space are very much needed, we propose a research collaborative called the Heart Outcomes in Pregnancy: Expectations (HOPE) for Mom and Baby Registry. The HOPE Registry aims to address key clinical questions surrounding the preconception period, antenatal care, delivery planning and outcomes, and long-term postpartum care and outcomes of these unique patients. We have made progress in recent years by recognizing the clinical need to address and standardize the management of patients with heart disease in pregnancy. We now must initiate and propel US-based cardio-obstetrics research to address key gaps in knowledge and variability in the care of patients with heart disease in pregnancy.

One of the most significant accomplishments of modern medicine worldwide is the dramatic 28% decrease in neonatal mortality during the past 20 years. However, although neonatal survival is improving and, for most of the world, maternal mortality is decreasing, this trend has not been seen in the United States. Neonatal survival has improved in the United States, whereas maternal mortality has increased from 7.2 deaths per 100 000 in 1989 to 17 deaths per 100 000 in 2013. In fact, the United States is the only developed nation with a rising maternal mortality rate. Maternal mortality is even higher for black women, approaching 4-fold that of their white, Asian, or Hispanic counterparts. Although cardiac disease complicates a small number of all pregnancies, it has become a leading cause of maternal morbidity and mortality, surpassing both hemorrhage and embolic events. Understanding the causes of this worrisome trend must become a research priority with plans to develop novel interventions to improve maternal outcomes, particularly as the birthrate in women >35 years of age and the associated comorbidities that go along with advanced maternal age continue to increase. Before the widespread institution of penicillin, rheumatic heart disease was the most common form of heart disease encountered in pregnancy. Marked improvements in treating congenital heart disease have led to more women with congenital cardiac malformations reaching reproductive age and …