Strengths and limitations
To the best of our knowledge, this is the first systematic review and
meta-analysis on this topic. Previous reviews of the literature studied
considerably fewer pregnancies, were not available in English or were no
systematic reviews 28-32. To ensure high quality of
evidence and representativeness of the pregnant population with liver
cirrhosis, we excluded case reports and case series.
Although in individual studies the quality of selection of cohorts and
controls was generally high, selection bias in our study could exist,
since included studies used different inclusion criteria. For example,
some studies18, 24 excluded decompensated cirrhosis,
leading to an underestimation of reported outcomes.
Before sensitivity analysis the meta-analysis showed significant
heterogeneity between studies (reasons are mentioned below). The high
heterogeneity of the analysis of cesarean section (I268%) cannot be only attributed to differences in known patient
characteristics, as is demonstrated by the inability of our sensitivity
analyses to lower heterogeneity to an acceptable level. Overall
differences in clinical management differences in cesarean section rates
between countries are more likely to underlie the heterogeneity.
Specifically there may be distinct regional differences in the
management of delivery in liver cirrhosis, where some local policies may
favour cesarean section to prevent variceal hemorrhage during delivery,
while other policies may favor vaginal delivery in order to avoid
perioperative risks involved in abdominal surgery. 3,
33
In our meta-analysis it was not possible to perform subgroup-analyses
based on diagnosis underlying cirrhosis or severity of cirrhosis, due to
the small number of events and missing information in included studies,
which could in future studies further allow individualized counseling
and management.