Heart disease complicates more than 1% of pregnancies and is now the leading cause of indirect maternal deaths. The spectrum and severity of heart disease observed in reproductive-aged women is changing. Today, congenital heart disease accounts for more than half of cardiac disease in pregnancy, and ischemic heart disease is on the rise as a result of obesity, hypertension, diabetes, and delayed childbearing. Pregnancy is still contraindicated in women with pulmonary hypertension, severe systemic ventricular dysfunction, dilated aortopathy, and severe left-sided obstructive lesions, but advances in medical and surgical management have resulted in an increasing number of patients with congenital heart defects reaching childbearing age who are interested in pregnancy. A multidisciplinary approach can best determine whether acceptable outcomes can be expected and what management strategies may improve the prognosis for pregnant women with heart disease.