Delivery plan in cardio-obstetric management of pregnant patients with heart disease: an Italian Delphi study

Background: Cardiovascular disease (CVD) is the leading indirect cause of maternal morbidity and mortality in high-income countries. Managing pregnant women with cardiac conditions requires multidisciplinary coordination and individualized planning. Early risk stratification, commonly performed using the modified World Health Organization (mWHO) classification, is essential to guide the management of pregnant women with heart disease. The Delivery Plan (DP) is proposed as a standardized tool to guide peripartum care in this population. Objective: To evaluate expert consensus on the structure and implementation of a standardized DP for pregnant women with heart disease, using a modified Delphi methodology. Methods: A two-round Delphi survey was conducted among 30 cardio-obstetric experts from five tertiary Italian centers. The first phase assessed current practices regarding cardiac follow-up and investigations in pregnancy. The second phase evaluated agreement on 21 proposed DP items across different mWHO risk classes and explored the role of non-cardiac risk factors. Results: In phase one, consensus (≥70% agreement) was achieved for 78.4% of cardiac follow-up practices and 87.9% of diagnostic investigations. In phase two, all 21 DP items were endorsed for general inclusion. Stratification by mWHO risk class showed no consensus for mWHO I, partial agreement for mWHO II, and full consensus for mWHO II/III to IV. Strong agreement (median ≥ 9, IQR ≤ 2) was observed for most items in higher-risk classes. Additionally, obesity, hypertension, and preeclampsia were identified as relevant non-cardiac risk factors warranting structured planning. Conclusions: The study supports the use of a structured, risk-adapted DP for pregnant women with cardiac disease. High consensus in moderate-to-severe risk groups confirms the DP's utility in enhancing multidisciplinary coordination and may contribute to improved maternal-fetal outcomes, pending prospective validation.