A cardiac clinical nurse specialist and link midwife can together act as intermediaries between cardiology and obstetrics. Together, they can develop care pathways and provide clear guidance to nursing and midwifery staff in each of their areas. In the event that a mother has to deliver in the cardiac unit, this co-worker relationship across the two specialties is invaluable. Despite preconception counseling and a prepregnancy investigation, early delivery might be needed for maternal health reasons. Obstetric complications, such as twin pregnancy, preeclampsia, or the development of unheralded arrhythmias may exacerbate minor hemodynamic problems, leading to clinical deterioration even in the setting of noncomplex heart disease. Good neonatal intensive care unit services permit timely delivery, thus ensuring maternal health is prioritized while fetal welfare is not significantly compromised.
Other services that should be in close proximity and readily accessible, with defined referral protocols, include cardiac surgery, a coronary interventionist, an experienced structural interventionist, and a transplant center that offers mechanical circulatory support. These specialist services provide a “comfort zone” when in the face of unexpected and or serious complications. Not all women will have remained under specialist follow-up for their cardiac disease, and therefore some re-present in pregnancy with significant disease that needs urgent treatment, for example aortic valvuloplasty for aortic stenosis. Cardiac surgery, although rarely needed, can be life-saving if there has been an acute catastrophic event such as mechanical valve thrombosis or aortic dissection, while ventricular assist devices are life-saving for those with severe impairment of ventricular function and hemodynamic collapse.
All pregnant women with heart disease should be referred to a specialist high-risk obstetric service with a MDT as defined above. They should have at least one specialist cardiology and obstetric review, with clinical assessment and transthoracic echocardiogram. Thereafter, based on the risk assessment (WHO I–IV), they can be stratified to the following antenatal care pathways:
Level I care—exclusive care by a specialist high-risk antenatal service
Level II care—shared care; regular specialist cardiology review and local obstetric care, with clear lines of communication between specialists
Level III care—local care; local cardiology review and local obstetric care, with clearly defined lines of communication between specialists.
Following each review, a report should be generated that includes diagnosis, a heart diagram, a clinical summary, recent investigations, and the anticipated hemodynamic impact of pregnancy. In the later stages of pregnancy, the report should also provide guidance on delivery planning (monitoring requirements, drugs to be available on labor ward, requirements for endocarditis prophylaxis, and peri-/postpartum care requirements). A copy should be given to the patient and all medical personnel involved both within the specialist center and in the local unit. A template for such a report is shown in Figure 5.3. This care model needs to be flexible to the needs of the patient, and easily transferable between centers so that if there are unexpected complications or if any of the care providers do not feel comfortable, then the patient can be moved to a higher level of care provision. An overall schema for this pattern of care is shown in Figure 5.4.