The connection between cardiology and obstetrics has never been closer than in the current era. Increasing rates of cardiovascular disease such as hypertension, metabolic syndrome, diastolic dysfunction, cardiomyopathy, valvular or congenital heart disease are affecting women of childbearing age. When women with any of these conditions become pregnant, several physiological challenges arise, putting them at risk for adverse outcomes including heart failure, arrhythmias, stroke or even death. The overall incidence of these complications has exponentially grown, and since 2018, cardiovascular disease has been the leading cause of maternal mortality in the U.S.

The collaboration between the fields of maternal-fetal medicine and cardiovascular disease is key to decreasing maternal morbidity and mortality, and education of trainees is of extreme importance to ensure adequate pre-conceptional counseling, cardiovascular risk assessment during pregnancy, management of adverse pregnancy outcomes, recommendations regarding mode of delivery and postpartum care. Training cardiologists in cardio-obstetrics will depend on the specific curriculum and logistics of each fellowship program; however, below are some practical guidelines for motivated Fellows in Training (FITs) to embark on this fulfilling experience.

1. Identify clinical mentors within the pregnancy heart team. This is essential for a successful experience. You may find them at:
   • The combined maternal-fetal and cardiovascular medicine clinic where patients are seen by both specialists during the same visit.
   • The adult congenital heart disease clinic.
   • The clinic of the cardiologist with the greatest expertise in pregnancy management at your institution. If you cannot identify this person, do not hesitate to ask the high-risk obstetrics team which cardiologist they refer their patients for assessment.
2. Seek longitudinal clinic exposure that will give you access to:
   • Pre-pregnancy counseling: Discuss potential risks with your patients but devote extra attention to those with mechanical heart valves, aortopathies, symptomatic heart failure and pulmonary hypertension. Obtaining a genetics consult may be necessary to guide parents with heritable diseases. Discussing surrogacy with very high risk patients may be considered. For pediatric cardiology FITs having the discussion of "planning for the future" with adolescent patients with congenital heart disease may help reduce unplanned pregnancies.
   • Pregnancy management: identify who is at risk for complications (review ESC guidelines, CARPREG II risk score), review safety of medications according to the U.S. Food and Drug Administration pregnancy risk classification, identify pathological changes early and actively manage them.
   • Labor and delivery planning: When the third trimester starts, engage in a multidisciplinary discussion with anesthesia, obstetrics and other specialty services (based on your patients' needs) to elaborate recommendations regarding mode of delivery, need for facilitated second stage of labor, anesthesia type and anticipatory guidance.
   • Postpartum care: Review safety of medications during lactation and ensure follow-up while your patient cares for her baby.
3. Care for pregnant patients in other settings:
   • Emergency situations: Patients could present with pulmonary embolism, coronary or aortic dissection. Remember that the use of imaging modalities that carry radiation exposure is justified when the mother's life is at risk.
   • Cardiac care unit: Some pregnant patients are admitted after having symptomatic heart failure, arrhythmia or symptomatic severe valvular heart disease.
4. Be mindful and sensitive about psychosocial situations that could affect maternal outcomes such as insurance status changes after delivery, lack of family support, abuse, postpartum depression or psychosis, diseases affecting the baby. If you identify any of these involve the maternal-fetal team, social worker and the appropriate specialist to develop a support/management strategy.
5. Think about the future: Adverse pregnancy outcomes have been associated with future development of cardiovascular disease in women. Despite 40 weeks seeming a long time, our mission is not finished without ensuring that these mothers achieve long-term well-being by:
   • Promoting return to pre-pregnancy weight and functional status.
   • Encouraging our patients with preeclampsia to achieve blood pressure goals.
   • Ensuring adequate diabetes prevention strategies in those who had gestational diabetes.
   • Actively engaging patients with chronic cardiovascular diseases in regular follow-up.
6. Nurture your mind in as many ways as possible: Independent reading, topic discussion with experts, participation in conferences and scholarly activities are strongly recommended to have a complete exposure. Be on the lookout for the Heart Outcomes in Pregnancy (HOPE) registry results, the first cardio-obstetrics registry in the U.S.

Cardio-obstetrics is a team sport, and your participation as an FIT will be invaluable not only for your future career but also for those around you who may consider initiating this specific combined program at your institution. Currently, only a few combined programs exist in the U.S. and many large tertiary centers lack one despite the great need. You could make a difference by collaborating with successful programs; analyzing strengths, weaknesses, opportunities and threats; and spearheading the creation of a cardio-obstetrics program at your own institution. Take the challenge!

This article was authored by Katia Bravo-Jaimes, MD, Fellow in Training (FIT) at the University of California, Los Angeles in Los Angeles, CA. Twitter: @Bravo__MD