Background: The management of heart disease in pregnancy is highly specialized. Guidelines are based on observational studies. This paper describes our experience of these patients, including adverse cardiac events, adherence to guidelines, and areas of suboptimal management. Methods: Patients referred to the service between 01/05/1999 and 30/06/2005 were identified using clinic lists and keyword searches in databases. A list of 40 management standards was created from European Society of Cardiology and the Confidential Enquiry into Maternal and Child Health guidelines. Adherence to these was recorded and adverse cardiac events noted. Results: There were 177 pregnancies in 155 women with a mean age of 28 ยฑ 6 years. Service referrals increased linearly throughout the study period. Of 131 cardiac pregnancies 101 had congenital heart disease (77.1%). Pulmonary oedema, deteriorating functional class, sustained arrhythmia or cardiac intervention occurred in 13 pregnancies (10.2%), though not always in high risk cases. Management guidelines were largely followed, though areas of suboptimal management included lack of pre-conception advice and inadequate post-partum follow-up. Controversial areas include the use of ฮฒ-blockade in coarctation of the aorta and the use of elective Caesarean section in high risk patients. Conclusions: Cardiac pregnancies are increasing, mainly due to the rise in patients with congenital heart disease. Some patients will experience adverse cardiac events, including low risk patients. Pre-conception advice and post-partum follow-up should be improved. In the absence of prospective studies, management is likely to be driven by observational studies.