Cardio-Obstetrics Care: Challenging Scenarios in Heart Failure and Future Directions

Cardiovascular disease (CVD) is a leading and increasingly prevalent cause of maternal morbidity and mortality worldwide, with heart failure (HF) representing a major contributor before, during, and after pregnancy. The age at first pregnancy is rising, with a growing proportion of women aged over 40 years, and hypertension, obesity, and established coronary artery disease at the onset of pregnancy are no longer uncommon. In parallel, advances in the management of congenital, inherited heart disease and childhood cancer have resulted in more women surviving to adulthood and entering pregnancy with impaired cardiac function or residual disease, contributing to late maternal morbidity and mortality from HF and thromboembolic events. This review highlights the critical role of dedicated cardio-obstetric care in the prevention, risk stratification, and management of women with CVD, with particular emphasis on HF and those at high risk of developing HF across the reproductive life course. It focuses on key challenging scenarios, including inherited cardiomyopathies, peripartum cardiomyopathy, hypertensive disorders of pregnancy, and pregnancies classified as very high risk. It emphasises the growing importance of genetic counselling and testing in cardio-obstetric decision-making, from pre-conception risk assessment and reproductive planning to pregnancy management and neonatal care. We discuss termination of pregnancy (TOP) and the associated ethical, clinical, and practical considerations in selected high-risk cases. Finally, integrated cardio-obstetric service models extending from pre-conception counselling through pregnancy and into the postpartum period are described, highlighting their potential to reduce preventable maternal morbidity and mortality. The need for formal recognition of cardio-obstetrics as a dedicated subspecialty, supported by structured training and multidisciplinary collaboration, is highlighted in response to the increasing complexity of cardiovascular disease in pregnancy. In this context, the review addresses: (1) integration of genetic counselling and testing at different stages of pregnancy; (2) identification and management of hypertensive disorders of pregnancy; (3) clinical management of very high-risk pregnancies, including TOP; (4) practical approaches to establishing cardio-obstetric care in centres managing women with HF or at risk of HF; and (5) cardio-obstetrics as an evolving clinical care model and subspecialty.