Rheumatic disease results in thickening, deformity, and shortening of the individual aortic valve cusps, changes that prevent their proper opening during systole and closure during diastole. Generally, it’s well-tolerated during pregnancy. If it is severe/symptomatic, or associated with LV dysfunction, valve surgery should be 10 considered before pregnancy. If congestive heart failure occurs with pregnancy, treatment should include afterload reduction. ACE inhibitors and ARBs should be avoided. If endocarditis occurs and the infection is not rapidly controlled, mortality with medical therapy is high, and surgical therapy is indicated. If this occurs late in pregnancy, consideration of associated cesarean section is appropriate.