Initial Management of Women With VHD Before and During Pregnancy Recommendations for Initial Management of Women With VHD Before and During Pregnancy Referenced studies that support the recommendations are summarized in Online Data Supplement 43. COR LOE Recommendations Women with suspected valve disease who are considering pregnancy should undergo a clinical evaluation and TTE before pregnancy.1 5 Women with severe valve disease (Stages C and D) who are considering pregnancy should undergo pre-pregnancy counseling by a cardiologist with expertise in managing women with VHD during pregnancy.1 5 Pregnant women with severe valve disease (Stages C and D) should be monitored in a tertiary-care center with a dedicated Heart Valve Team of cardiologists, surgeons, anesthesiologists, and maternal-fetal medicine obstetricians with expertise in the management of high-risk cardiac conditions during pregnancy.1 12 In asymptomatic women with severe valve disease (Stage C1) who are considering pregnancy, exercise testing is reasonable before pregnancy for risk assessment.3 5,11,13 15 Synopsis To assure the best possible outcome for a woman with VHD and her baby, a comprehensive evaluation is best performed before the time of conception. During preg- nancy, the frequency and intensity of follow-up and treatment are heavily dependent on the type and sever- ity of valve lesion, as well as patient symptoms. Recommendation-Specific Supportive Text 1. The risks to the mother and fetus during preg- nancy are highly dependent on the type and sever- ity of valve disease. Clinical evaluation of women with VHD who are contemplating pregnancy includes a complete TTE with full anatomic and hemodynamic assessment of the valves.1 5 A con- genital bicuspid or unicuspid aortic valve is often associated with dilation of the aortic sinuses, the ascending aorta, or both. 