This article reviews the appropriate evaluation and management of cardiac arrhythmias in the pregnant patient. Any treatment strategy in this patient population has the inherent potential to adversely affect the health of the unborn child. As such, there is no room for empiric therapy in these patients. Adequate arrhythmia documentation is paramount, preferably by noninvasive means. The decision to treat should be based on symptom severity and the risk to both mother and fetus posed by potentially recurring arrhythmia episodes throughout the pregnancy. Minimal symptoms in the setting of a structurally normal heart call for a conservative approach. Less is better. If pharmacologic therapy is justified, drugs with historically demonstrated safety profiles in pregnancy should be tried first. The safety profiles of virtually all drugs used to treat cardiac arrhythmias during human pregnancy are based solely on an accumulation of past clinical experience. Newer antiarrhythmics therefore carry a largely unknown risk. Most inherent rhythm disorders manifest long before a woman reaches childbearing age. Women with previously diagnosed arrhythmias frequently experience a recurrence or worsening of their arrhythmia during the pregnancy. Counseling of these individuals and perhaps preemptive treatment by means such as arrhythmia ablation prior to a planned pregnancy would seem optimal.