Immunosuppression advances have enabled organ transplant recipients to consider parenthood, but pregnancy poses risks to maternal and fetal health. This systematic review examines pregnancy outcomes and immunosuppression management in cardiothoracic transplant recipients. We conducted a literature search of PubMed/Medline, Embase, and Maternity & Infant Care Database in December 2022. We identified 54 relevant studies and data from the Transplant Pregnancy Registry International (TPRI), covering 404 pregnancies from 272 heart recipients (HTR) and 148 pregnancies from 121 lung recipients (LTR). Live births occurred in 74.3% of HTR and 65.5% of LTR pregnancies (22% preterm). Graft dysfunction developed in 11.5% (during) and 12.4% (after) of HTR pregnancies, and 17.6% (during) and 18% (after) of LTR pregnancies. Other complications included hypertension (HTR: 36.9%, LTR: 58.8%), preeclampsia (HTR: 19.7%, LTR: 12.2%), and diabetes (HTR: 11%, LTR: 27%). Mortality was 17.4% for HTR and 26.5% for LTR. Half of HTR and two-thirds of LTR were on Tacrolimus. Common immunosuppression changes included discontinuation of Mycophenolate Mofetil (MMF), Azathioprine, or Sirolimus with corticosteroid dose adjustment. Despite high successful pregnancy rates, HLTR may face substantial risks of graft dysfunction and maternal death post-pregnancy. (182 words)