Background: In women with pre-existing cardiovascular disease (CVD), the haemodynamic changes of pregnancy may increase the risk of maternal and fetal complications. Preconception care should use patient-centred counselling to help modifying additional risk factors as part of a comprehensive risk assessment. This will ensure the woman enters pregnancy in an optimised condition. Specialist obstetric cardiology multidisciplinary teams can improve preconception care and decision-making, but access to these services may be inconsistent. The aim of this manuscript was to develop a comprehensive obstetric cardiology pathway for women with intermediate to high-risk CVD. Methods: A comprehensive review was conducted of scientific literature, registries, international guidelines, consensus statements and recommendations, combined with our research/clinical team’s expertise. Findings: Our proposed care pathway starts with referral of women with modified World Health Organisation (m-WHO) 2.0 class II–III to IV and who intent to conceive to specialised, interdisciplinary obstetric cardiac team. Subsequently, three components form the basis of preconception care: 1) comprehensive assessment and risk stratification, 2) person-centred, interdisciplinary counselling and 3) health optimisation. A comprehensive assessment includes evaluation of cardiac condition, an obstetric history, as well as lifestyle, psychosocial and genetic assessments to inform risk stratification. Person-centred, interdisciplinary counselling involves shared decision-making with the patient and should include discussions about risk estimates, follow-up planning and targeted interventions, including cardiac optimisation. Then, health optimisation interventions may be performed based on results of the person-centred interdisciplinary counselling. Interpretation: Preconception care should be a cornerstone of obstetric cardiac care. Our proposed pathway provides structured guidance for cardio-obstetric health professionals to better support women with intermediate to high-risk CVD plan for pregnancy. Further research is needed to co-develop and evaluate strategies that enable routine implementation.