Patients with severe valve disease may be asymp- tomatic, which can pose a diagnostic and thera- peutic dilemma in women with these disorders who are considering pregnancy. Exercise testing is reasonable to assist with risk assessment in patients in whom it is unclear whether pregnancy can be tolerated without an intervention to repair or replace the valve before pregnancy.3 5,11,13 15 Symptoms provoked by exercise testing are syn- onymous with spontaneous symptoms. Patients who develop symptoms on exercise testing should be treated as having symptomatic valve disease (Stage D), and should undergo pre-preg- nancy counseling by a cardiologist with expertise in managing women with VHD during pregnancy 13.1.1. Medical Therapy for Women With VHD Before and During Pregnancy Recommendations for Medical Therapy of Pregnant Women With VHD Referenced studies that support the recommendations are summarized in Online Data Supplement 43. COR LOE Recommendations In pregnant women with VHD, beta-blocker medications are reasonable as required for heart rate control or treatment of In pregnant women with VHD and HF symptoms (Stage D), diuretic medications are reasonable if needed for volume overload.7,8 3: Harm B-NR In pregnant women with VHD, ACE inhibitors and ARBs should not be given because of fetal Synopsis Women with severe VHD are at risk of HF, arrhythmia, and other cardiac disorders during pregnancy. Although medical therapy may be necessary to preserve the moth- er s health, there may be negative consequences for the fetus. Therefore, the fetal effects of cardiac medications must be understood so that the appropriate risks and benefits can be weighed.1 6 Data from ROPAC (Registry On Pregnancy And Cardiac Disease), a large multicenter registry supported by the European Society of Cardiol- ogy, showed an association between the use of cardiac medications during pregnancy and adverse fetal out- come. 