The management of prosthetic heart valves during pregnancy is substantially different from the man- agement of prosthetic heart valves in a nonpregnant patient. There is a much higher risk of mechanical valve thrombosis during pregnancy because of the hypercoagulable state. Choosing the appro- priate anticoagulation strategy to balance risks to the mother and fetus requires a team familiar with management of prosthetic heart valves in preg- nancy to provide comprehensive counseling. The management of anticoagulation also requires spe- cialized expertise, and frequent titration of VKA or heparin doses is needed.2,10 Transvalvular gradients increase during pregnancy because of increased heart rate, plasma volume, and stroke volume.1 In the event that valve intervention is required during pregnancy, the comprehensive Heart Valve Team and maternal-fetal medicine team is required to optimize maternal and fetal outcomes. 3. Each anticoagulation strategy has relative advan- tages and disadvantages in terms of maternal and fetal safety, but there is no anticoagulation strat- egy that is consistently safe for the mother and fetus. The maternal mortality rate is >1%, and seri- ous maternal and fetal complications are common, even with modern mechanical heart valves and After counseling, some women with mechanical heart valves may choose not to become pregnant, whereas others may wish to proceed with pregnancy, so comprehensive and candid counseling about the risks of pregnancy with a mechanical heart valve is important. 4. Pregnancy is a time of increased risk of mechani- cal valve thrombosis, so there should be high suspicion of valve thrombosis in women with an embolic event, clinical deterioration, symptoms of HF, or a pronounced increase in valve gradients or valve regurgitation during pregnancy. TEE is use- ful to visualize leaflet motion and thrombus bur- den. Fluoroscopy and gated cardiac CT are also useful in evaluating patients with suspected valve 13.2.2. 