This systematic review and meta-analysis of 30 observational studies investigated the association between elevated maternal serum uric acid (SUA) levels and adverse pregnancy outcomes. Elevated SUA levels were significantly associated with higher odds of preterm birth (OR = 2.05, 95% CI: 1.55–2.72, I² = 90.22%, n = 20), preeclampsia (OR = 3.84, 95% CI: 2.5–5.89, n = 8), admission to the neonatal intensive care unit (OR = 2.20, 95% CI: 1.63–2.97, I² = 0%, n = 5), cesarean delivery (OR = 1.44, 95% CI: 1.16–1.79, I² = 52%, n = 9), and intrauterine growth restriction (IUGR; OR = 3.03, 95% CI: 1.16–7.91, I² = 52%, n = 9). 84.23%, n = 8). They were also associated with low Apgar scores at 1 minute (OR = 3.63, 95% CI: 1.47–8.95, I² = 62.75%, n = 4) and at 5 minutes (OR = 4.66, 95% CI: 1.84–11.78, n = 4). Conversely, high SUA levels were associated with a reduced likelihood of spontaneous vaginal delivery (OR = 0.68, 95% CI: 0.51–0.91, I² = 93.29%, n = 8) and a non-significant reduction in the number of live births (OR = 0.65, 95% CI: 0.02–24.11, I² = 55.98%, n = 4). Studies showed high heterogeneity and do not support causality or routine screening based on SUA.