Delivery Choice in Pregnancies Complicated by Cardiac Disease: A Systematic Review and Meta-Analysis Based on Modified World Health Organization Staging.

INTRODUCTION

Cardiovascular conditions represent a leading cause of indirect maternal morbidity, making delivery planning a critical component of care in affected pregnancies. To evaluate the delivery mode selection in pregnancies complicated by cardiac disease, stratified by disease severity according to the modified World Health Organization (mWHO) staging system.

METHODS

We conducted comprehensive searches in four major electronic databases (PubMed, Web of Science, Scopus, and Embase) for literature published through July 11, 2025. The electronic search was supplemented by manual screening of reference lists from included studies. We included peer-reviewed English full-text studies with ≥ 15 participants that reported delivery modes in pregnant women with cardiac disease, categorized by mWHO stages (I-IV). Both observational and interventional study designs were eligible. Our primary outcome was the rate of cesarean delivery (CS), with assisted vaginal delivery (AVD) rates analyzed as a secondary outcome. Study quality was assessed using the Joanna Briggs Institute Critical Appraisal Checklists. We performed random-effects meta-analyses to pool delivery method prevalence estimates. Subgroup analyses stratified studies by country income level (World Bank gross national income per capita categories) to examine socioeconomic influences on delivery choice.

RESULTS

From 26 eligible cohort studies (n = 89,333 pregnancies with cardiac disease), 24 met quality criteria for meta-analysis. Pooled CS rates increased progressively with mWHO severity: Stage I (40.6% [95% CI: 28.8%-52.4%]), Stage II (43.4% [95% CI: 31.5%-55.4%]), Stage II/III (50.0% [95% CI: 36.5%-63.5%]), Stage III (56.0% [95% CI: 42.0%-70.0%]), and Stage IV (67.8% [95% CI: 50.4%-85.2%]). For combined risk categories, low-risk (mWHO I-II) pregnancies showed lower intervention rates (CS: 39.2% [95% CI: 32.8%-45.7%]; AVD: 13.9% [95% CI: 7.0%-20.8%]) compared to high-risk (mWHO III-IV) pregnancies (CS: 57.7% [95% CI: 49.1%-66.2%]; AVD: 16.6% [95% CI: 8.6%-24.7%]). Notably, higher-income countries demonstrated significantly lower CS rates in both low- and high-risk groups (p < 0.05), suggesting socioeconomic influences on delivery decisions.

CONCLUSION

This study documents concerning CS overuse in cardiac pregnancies with disease severities. Current guidelines recommend vaginal delivery as standard practice, reserving surgical intervention for specific obstetric or critical cardiac conditions. However, our findings suggest a substantial gap between clinical practice and current guideline recommendations in this regard, requiring extensive attention.

PROSPERO REGISTRATION: The review protocol was registered on 11/10/2024 under reference number CRD42024608358.