The maternal cardiovascular adaptations during pregnancy can place significant strain on the heart affected by pre-existing cardiac disease and can even expose unknown underlying cardiac disease. Thus, pregnancy is often referred to as a natural cardiovascular stress test. People with cardiac disease are at increased risk for cardiac complications and adverse outcomes during the pregnancy and post-partum, as well as adverse neonatal outcomes. Scoring systems are available to risk stratify these patients, primarily in terms of cardiac complications. These are helpful to guide management for these patients, including optimal location of delivery. For the patients at highest of risk of cardiac complications, the importance of having a cohesive and experienced multidisciplinary team composed of cardiologists and maternal fetal medicine specialists, cannot be understated.