In early observa- tional data, there was a significantly decreased risk of in-hospital death when surgery was per- formed >4 weeks after the stroke.73 These data were not risk adjusted. In an observational study that did adjust for factors such as age, para- valvular abscess, and HF, the risk of in-hospital death was not significantly higher in the group who underwent surgery within a median time from admission to operation of 5 days, with only a 1% risk of perioperative hemorrhagic Patients with hemorrhagic stroke and IE have a prohibitively high surgical risk for at least 4 weeks after the hemorrhagic event. One multicenter showed wide variation in patient deaths when those who underwent sur- gery within 4 weeks of a hemorrhagic stroke were compared with those whose surgery was delayed until after 4 weeks (75% versus 40%, respectively). The percentage of new postop- erative bleeds was 50% in patients whose sur- gery was performed in the first 2 weeks, 33% in patients whose surgery was performed in the third week, and 20% in patients whose surgery was performed at least 21 days after the neuro- 13. PREGNANCY AND VHD The physiological hemodynamic changes associated with pregnancy are usually well tolerated in women with structurally normal hearts. However, for women with VHD, the hemodynamic burden may pose signifi- cant challenges during pregnancy and delivery. 13.1. 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. 