Clear documenta- tion is important so that all providers are well aware of the risks and expected outcomes, in- cluding risk of maternal volume shifts, arrhyth- mias, labor and delivery plan, and need for maternal cardiac monitoring when indicated. Contingency plans for anticipated complica- tions related to the presence of CHD should also be developed. 3. Chronic anticoagulation during pregnancy is as- sociated with increased risk of maternal bleed- ing and thrombotic events as well as a higher risk of fetal loss, and in the case of warfarin, the risk of teratogenicity.S3.13.1-5,S3.13.1-14 The choice of specific anticoagulant must balance maternal well-being and risks for mother and fetus, and should be individualized. Patients with me- chanical valves should be treated according to 4. The hemodynamic changes of pregnancy, labor, and delivery can result in hemodynamic decom- pensation for some women with CHD.S3.13.1-1, Management involving the expertise of ACHD, maternal-fetal medicine, and anesthesiology should help anticipate and miti- gate some of the potentially detrimental maternal or fetal outcomes. 5. Women at high risk include, but are not limited to, those diagnosed with cardiac conditions that meet World Health Organization maternal cardiac risk classification IV.S3.13.1-26 a. PAH of any cause b. Severe systemic ventricular dysfunction: LV ejection fraction <30% and/or NYHA III IV symptoms c. Severe left heart obstruction d. Severe native coarctationS3.13.1-16,S3.13.1-27,S3.13.1-28 These patients have an extremely high risk of maternal mortality or severe morbidity, and if pregnant, the option of pregnancy termina- tion should be discussed 6. Prepregnancy counseling regarding the risk of CHD recurrence in offspring provides helpful in- formation to parents to inform decision-making regarding family planning and delivery options, and should allow adequate time dedicated to answering important questions from the parents. 7. CPET performed before conception can predict maternal and neonatal outcomes in pregnant women with CHD. 