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. This association was attributable, in part, to the associated maternal cardiac diseases that required the Anticoagulation for pregnant women with AF should conform to the guidelines in nonpregnant Recommendations for anticoagulation regi- mens during pregnancy are discussed in section 13.2.2. Recommendation-Specific Supportive Text 1. Beta-blocker medications are used to control heart rate or to treat arrhythmias. However, maternal use of beta blockers has been associated with a newborn birth weight approximately 100 g lower than that of newborns whose mothers did not take beta blockers.6 The use of beta blockers with beta-1 selectivity avoids the beta-2 effects on uterine relaxation. The incidence of fetal growth retardation is lower with metoprolol treatment than with atenolol treatment in pregnancy.1 6 2. Diuretic medications can alleviate the effects of vol- ume overload in pregnant women with VHD and HF symptoms (Stage D). However, reduction of volume overload must be balanced against the reduction in placental blood flow associated with diuretic medi- Additionally, data from ROPAC suggested that maternal diuretic use was associated with rates of low birth weight and fetal mortality that were higher than for women not taking any medications. In part, this association was attributable to the severity of the underlying HF requiring treatment.7,8 3. ACE inhibitors and ARBs are strongly associated with fetal malformations when used by women 13.1.2. Intervention for Women With Native VHD Before and During Pregnancy 13.1.2.1. 