{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,9,17]],"date-time":"2026-09-17T14:41:07Z","timestamp":1789656067921,"version":"4.0.1"},"reference-count":100,"publisher":"MDPI AG","issue":"9","license":[{"start":{"date-parts":[[2023,9,16]],"date-time":"2023-09-16T00:00:00Z","timestamp":1694822400000},"content-version":"vor","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":["JPM"],"abstract":"<jats:p>Liver disease is not uncommon during pregnancy and is associated with increased maternal and fetal\/neonatal morbidity and mortality. Physiological changes during pregnancy, including a hyperestrogenic state, increase in circulating plasma volume and\/or reduction in splanchnic vascular resistance, and hemostatic imbalance, may mimic or worsen liver disease. For the clinician, it is important to distinguish among the first presentation or exacerbation of chronic liver disease, acute liver disease non-specific to pregnancy, and pregnancy-specific liver disease. This last group classically includes conditions such as hyperemesis gravidarum, intrahepatic cholestasis of pregnancy, liver disorders associated with the pre-eclampsia spectrum, and an acute fatty liver of pregnancy. All of these disorders often share pathophysiological mechanisms, symptoms, and laboratory findings (such as elevated liver enzymes), but a prompt and correct diagnosis is fundamental to guide obstetric conduct, reduce morbidity and mortality, and inform upon the risk of recurrence or development of other chronic diseases later on in life. Finally, the cause of elevated liver enzymes during pregnancy is unclear in up to 30\u201340% of the cases, and yet, little is known on the causes and mechanisms underlying these alterations, or whether these findings are associated with worse maternal\/fetal outcomes. In this narrative review, we aimed to summarize pragmatically the diagnostic work-up and the management of subjects with elevated liver enzymes during pregnancy.<\/jats:p>","DOI":"10.3390\/jpm13091388","type":"journal-article","created":{"date-parts":[[2023,9,17]],"date-time":"2023-09-17T06:12:21Z","timestamp":1694931141000},"page":"1388","update-policy":"https:\/\/doi.org\/10.3390\/mdpi_crossmark_policy","source":"Crossref","is-referenced-by-count":12,"title":["Diagnostic Approach to Elevated Liver Function Tests during Pregnancy: A Pragmatic Narrative Review"],"prefix":"10.3390","volume":"13","author":[{"ORCID":"https:\/\/orcid.org\/0000-0003-2905-1146","authenticated-orcid":false,"given":"Elton","family":"Dajti","sequence":"first","affiliation":[{"name":"IRCCS Azienda Ospedaliero-Universitaria di Bologna, European Reference Network on Hepatological Diseases (ERN RARE-LIVER), 40138 Bologna, Italy"},{"name":"Department of Medical and Surgical Sciences (DIMEC), University of Bologna, 40138 Bologna, Italy"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Angelo","family":"Bruni","sequence":"additional","affiliation":[{"name":"IRCCS Azienda Ospedaliero-Universitaria di Bologna, European Reference Network on Hepatological Diseases (ERN RARE-LIVER), 40138 Bologna, Italy"},{"name":"Department of Medical and Surgical Sciences (DIMEC), University of Bologna, 40138 Bologna, Italy"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Giovanni","family":"Barbara","sequence":"additional","affiliation":[{"name":"IRCCS Azienda Ospedaliero-Universitaria di Bologna, European Reference Network on Hepatological Diseases (ERN RARE-LIVER), 40138 Bologna, Italy"},{"name":"Department of Medical and Surgical Sciences (DIMEC), University of Bologna, 40138 Bologna, Italy"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0003-3675-8545","authenticated-orcid":false,"given":"Francesco","family":"Azzaroli","sequence":"additional","affiliation":[{"name":"IRCCS Azienda Ospedaliero-Universitaria di Bologna, European Reference Network on Hepatological Diseases (ERN RARE-LIVER), 40138 Bologna, Italy"},{"name":"Department of Medical and Surgical Sciences (DIMEC), University of Bologna, 40138 Bologna, Italy"}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"1968","published-online":{"date-parts":[[2023,9,16]]},"reference":[{"key":"ref_1","doi-asserted-by":"crossref","first-page":"97","DOI":"10.1053\/j.gastro.2022.01.060","article-title":"Pregnancy-Associated Liver Diseases","volume":"163","author":"Terrault","year":"2022","journal-title":"Gastroenterology"},{"key":"ref_2","doi-asserted-by":"crossref","first-page":"594","DOI":"10.1016\/S0140-6736(09)61495-1","article-title":"Liver disease in pregnancy","volume":"375","author":"Joshi","year":"2010","journal-title":"Lancet"},{"key":"ref_3","doi-asserted-by":"crossref","first-page":"5761","DOI":"10.1080\/14767058.2021.1892633","article-title":"Liver transaminase levels during pregnancy: A Japanese multicenter study","volume":"35","author":"Ushida","year":"2022","journal-title":"J. Matern.-Fetal Neonatal Med."},{"key":"ref_4","doi-asserted-by":"crossref","first-page":"246","DOI":"10.1111\/j.1471-0528.1997.tb11054.x","article-title":"Liver function tests in pre-eclampsia: Importance of comparison with a reference range derived for normal pregnancy","volume":"104","author":"Girling","year":"1997","journal-title":"BJOG Int. J. Obstet. Gynaecol."},{"key":"ref_5","doi-asserted-by":"crossref","first-page":"e30408","DOI":"10.1097\/MD.0000000000030408","article-title":"Prevalence of elevated alanine aminotransferase (ALT) in pregnancy: A cross-sectional labor and delivery-based assessment","volume":"101","author":"Kushner","year":"2022","journal-title":"Medicine"},{"key":"ref_6","doi-asserted-by":"crossref","first-page":"117","DOI":"10.1038\/s41575-020-00361-w","article-title":"Viral hepatitis and pregnancy","volume":"18","author":"Terrault","year":"2021","journal-title":"Nat. Rev. Gastroenterol. Hepatol."},{"key":"ref_7","doi-asserted-by":"crossref","unstructured":"European Association for the Study of the Liver (2017). EASL 2017 Clinical Practice Guidelines on the management of hepatitis B virus infection. J. Hepatol., 67, 370\u2013398.","DOI":"10.1016\/j.jhep.2017.03.021"},{"key":"ref_8","doi-asserted-by":"crossref","first-page":"318","DOI":"10.1002\/hep.31559","article-title":"Reproductive Health and Liver Disease: Practice Guidance by the American Association for the Study of Liver Diseases","volume":"73","author":"Sarkar","year":"2021","journal-title":"Hepatology"},{"key":"ref_9","doi-asserted-by":"crossref","first-page":"1810","DOI":"10.1136\/gutjnl-2014-308211","article-title":"Clinical and virological predictors of hepatic flares in pregnant women with chronic hepatitis B","volume":"64","author":"Giles","year":"2015","journal-title":"Gut"},{"key":"ref_10","doi-asserted-by":"crossref","first-page":"1283","DOI":"10.14309\/ajg.0000000000000221","article-title":"Flares in Pregnant North American Women with Chronic Hepatitis B Infection: Results From a Prospective Observational Study","volume":"114","author":"Bzowej","year":"2019","journal-title":"Am. J. Gastroenterol."},{"key":"ref_11","doi-asserted-by":"crossref","first-page":"2324","DOI":"10.1056\/NEJMoa1508660","article-title":"Tenofovir to Prevent Hepatitis B Transmission in Mothers with High Viral Load","volume":"374","author":"Pan","year":"2016","journal-title":"N. Engl. J. Med."},{"key":"ref_12","doi-asserted-by":"crossref","first-page":"368","DOI":"10.1186\/1471-2334-14-368","article-title":"Clinical features and outcome of acute hepatitis B in pregnancy","volume":"14","author":"Han","year":"2014","journal-title":"BMC Infect. Dis."},{"key":"ref_13","doi-asserted-by":"crossref","first-page":"211","DOI":"10.1007\/s12072-021-10285-5","article-title":"Asian Pacific association for the study of liver (APASL) guidelines: Hepatitis B virus in pregnancy","volume":"16","author":"Kumar","year":"2022","journal-title":"Hepatol. Int."},{"key":"ref_14","doi-asserted-by":"crossref","first-page":"775","DOI":"10.7326\/M16-2350","article-title":"Hepatitis C Virus Infection Among Reproductive-Aged Women and Children in the United States, 2006 to 2014","volume":"166","author":"Ly","year":"2017","journal-title":"Ann. Intern. Med."},{"key":"ref_15","doi-asserted-by":"crossref","first-page":"751","DOI":"10.1002\/hep.510310328","article-title":"Prevalence and clinical course of chronic hepatitis C virus (HCV) infection and rate of HCV vertical transmission in a cohort of 15,250 pregnant women","volume":"31","author":"Conte","year":"2000","journal-title":"Hepatology"},{"key":"ref_16","doi-asserted-by":"crossref","first-page":"1033","DOI":"10.1111\/jvh.12430","article-title":"Chronic hepatitis C virus infection is associated with increased risk of preterm birth: A meta-analysis of observational studies","volume":"22","author":"Huang","year":"2015","journal-title":"J. Viral Hepat."},{"key":"ref_17","doi-asserted-by":"crossref","first-page":"39","DOI":"10.1016\/j.clinre.2016.07.004","article-title":"Hepatitis C infection and intrahepatic cholestasis of pregnancy: A systematic review and meta-analysis","volume":"41","author":"Wijarnpreecha","year":"2017","journal-title":"Clin. Res. Hepatol. Gastroenterol."},{"key":"ref_18","doi-asserted-by":"crossref","first-page":"765","DOI":"10.1093\/cid\/ciu447","article-title":"Vertical Transmission of Hepatitis C Virus: Systematic Review and Meta-analysis","volume":"59","author":"Benova","year":"2014","journal-title":"Clin. Infect. Dis."},{"key":"ref_19","doi-asserted-by":"crossref","first-page":"F156","DOI":"10.1136\/adc.2004.059436","article-title":"When does mother to child transmission of hepatitis C virus occur?","volume":"90","author":"Mok","year":"2005","journal-title":"Arch. Dis. Child.-Fetal Neonatal Ed."},{"key":"ref_20","first-page":"543","article-title":"Obstetric risks and vertical transmission of hepatitis C virus infection in pregnancy","volume":"79","author":"Hillemanns","year":"2000","journal-title":"Acta Obstet. Gynecol. Scand."},{"key":"ref_21","doi-asserted-by":"crossref","first-page":"136","DOI":"10.5144\/0256-4947.2020.136","article-title":"Seroprevalence of hepatitis E virus infection in pregnant women: A systematic review and meta-analysis","volume":"40","author":"Ahmad","year":"2020","journal-title":"Ann. Saudi Med."},{"key":"ref_22","doi-asserted-by":"crossref","unstructured":"Bigna, J.J., Modiyinji, A.F., Nansseu, J.R., Amougou, M.A., Nola, M., Kenmoe, S., Temfack, E., and Njouom, R. (2020). Burden of hepatitis E virus infection in pregnancy and maternofoetal outcomes: A systematic review and meta-analysis. BMC Pregnancy Childbirth, 20.","DOI":"10.1186\/s12884-020-03116-2"},{"key":"ref_23","doi-asserted-by":"crossref","unstructured":"Dagnew, M., Belachew, A., Tiruneh, M., and Moges, F. (2019). Hepatitis E virus infection among pregnant women in Africa: Systematic review and meta-analysis. BMC Infect. Dis., 19.","DOI":"10.1186\/s12879-019-4125-x"},{"key":"ref_24","doi-asserted-by":"crossref","first-page":"1240","DOI":"10.1111\/jvh.13129","article-title":"Hepatitis E during pregnancy: Maternal and foetal case-fatality rates and adverse outcomes\u2014A systematic review","volume":"26","author":"Hallager","year":"2019","journal-title":"J. Viral Hepat."},{"key":"ref_25","first-page":"3467","article-title":"Hepatitis E virus infection and its associated adverse feto-maternal outcomes among pregnant women in Qinhuangdao, China","volume":"33","author":"Li","year":"2019","journal-title":"J. Matern.-Fetal Neonatal Med."},{"key":"ref_26","doi-asserted-by":"crossref","first-page":"61","DOI":"10.1046\/j.1365-2893.2003.00398.x","article-title":"Aetiology, clinical course and outcome of sporadic acute viral hepatitis in pregnancy*","volume":"10","author":"Khuroo","year":"2003","journal-title":"J. Viral Hepat."},{"key":"ref_27","doi-asserted-by":"crossref","first-page":"1428","DOI":"10.1002\/lt.21250","article-title":"Herpes simplex virus hepatitis: An analysis of the published literature and institutional cases","volume":"13","author":"Norvell","year":"2007","journal-title":"Liver Transplant."},{"key":"ref_28","doi-asserted-by":"crossref","first-page":"971","DOI":"10.1016\/j.jhep.2015.06.030","article-title":"EASL clinical practice guidelines: Autoimmune hepatitis","volume":"63","author":"Lohse","year":"2015","journal-title":"J. Hepatol."},{"key":"ref_29","doi-asserted-by":"crossref","first-page":"655","DOI":"10.1111\/apt.14925","article-title":"Pregnancy and birth outcomes in a Danish nationwide cohort of women with autoimmune hepatitis and matched population controls","volume":"48","author":"Vilstrup","year":"2018","journal-title":"Aliment. Pharmacol. Ther."},{"key":"ref_30","doi-asserted-by":"crossref","first-page":"556","DOI":"10.1111\/j.1572-0241.2006.00479.x","article-title":"Pregnancy in Autoimmune Hepatitis: Outcome and Risk Factors","volume":"101","author":"Schramm","year":"2006","journal-title":"Am. J. Gastroenterol."},{"key":"ref_31","doi-asserted-by":"crossref","first-page":"350","DOI":"10.1097\/MCG.0b013e318176b8c5","article-title":"Follow-up of pregnant women with autoimmune hepatitis: The disease behavior along with maternal and fetal outcomes","volume":"43","author":"Terrabuio","year":"2009","journal-title":"J. Clin. Gastroenterol."},{"key":"ref_32","doi-asserted-by":"crossref","first-page":"1368","DOI":"10.1111\/apt.16924","article-title":"Systematic review with meta-analysis: Outcomes of pregnancy in patients with autoimmune hepatitis","volume":"55","author":"Si","year":"2022","journal-title":"Aliment. Pharmacol. Ther."},{"key":"ref_33","doi-asserted-by":"crossref","first-page":"3160","DOI":"10.1111\/j.1572-0241.2002.07124.x","article-title":"Improvement of autoimmune hepatitis during pregnancy followed by flare-up after delivery","volume":"97","author":"Buchel","year":"2002","journal-title":"Am. J. Gastroenterol."},{"key":"ref_34","doi-asserted-by":"crossref","first-page":"608","DOI":"10.1016\/S1590-8658(02)80098-6","article-title":"Spontaneous remission of autoimmune hepatitis during pregnancy","volume":"34","author":"Muratori","year":"2002","journal-title":"Dig. Liver Dis."},{"key":"ref_35","doi-asserted-by":"crossref","first-page":"855","DOI":"10.1111\/liv.15511","article-title":"Importance of complete response for outcomes of pregnancy in patients with autoimmune hepatitis","volume":"43","author":"Fischer","year":"2023","journal-title":"Liver Int."},{"key":"ref_36","doi-asserted-by":"crossref","first-page":"2819","DOI":"10.1016\/j.cgh.2018.12.030","article-title":"Presentation and Outcomes of Pregnancy in Patients With Autoimmune Hepatitis","volume":"17","author":"Llovet","year":"2019","journal-title":"Clin. Gastroenterol. Hepatol."},{"key":"ref_37","doi-asserted-by":"crossref","first-page":"622","DOI":"10.1016\/S1542-3565(04)00245-9","article-title":"Severe autoimmune hepatitis first presenting in the early post partum period","volume":"2","author":"Samuel","year":"2004","journal-title":"Clin. Gastroenterol. Hepatol."},{"key":"ref_38","doi-asserted-by":"crossref","first-page":"931","DOI":"10.1016\/j.autrev.2014.05.008","article-title":"Pregnancy in women with primary biliary cirrhosis","volume":"13","author":"Efe","year":"2014","journal-title":"Autoimmun. Rev."},{"key":"ref_39","doi-asserted-by":"crossref","first-page":"418","DOI":"10.1016\/j.jhep.2004.08.029","article-title":"Pregnancy in women with ursodeoxycholic acid-treated primary biliary cirrhosis","volume":"42","author":"Poupon","year":"2005","journal-title":"J. Hepatol."},{"key":"ref_40","doi-asserted-by":"crossref","first-page":"1179","DOI":"10.1016\/j.cgh.2013.11.030","article-title":"Good Maternal and Fetal Outcomes for Pregnant Women With Primary Biliary Cirrhosis","volume":"12","author":"Trivedi","year":"2014","journal-title":"Clin. Gastroenterol. Hepatol."},{"key":"ref_41","doi-asserted-by":"crossref","first-page":"1117","DOI":"10.1136\/gut.2010.228924","article-title":"Pregnancy in primary sclerosing cholangitis","volume":"60","author":"Wellge","year":"2011","journal-title":"Gut"},{"key":"ref_42","doi-asserted-by":"crossref","first-page":"509","DOI":"10.1016\/j.dld.2021.08.015","article-title":"Outcome of pregnancy in patients with primary sclerosing cholangitis","volume":"54","author":"Wronka","year":"2022","journal-title":"Dig. Liver Dis."},{"key":"ref_43","doi-asserted-by":"crossref","first-page":"876","DOI":"10.1111\/1471-0528.16119","article-title":"Pregnancy outcomes in women with primary biliary cholangitis and primary sclerosing cholangitis: A retrospective cohort study","volume":"127","author":"Cauldwell","year":"2020","journal-title":"BJOG Int. J. Obstet. Gynaecol."},{"key":"ref_44","doi-asserted-by":"crossref","first-page":"933","DOI":"10.1016\/j.jhep.2015.11.030","article-title":"Pregnancy and liver disease","volume":"64","author":"Westbrook","year":"2016","journal-title":"J. Hepatol."},{"key":"ref_45","doi-asserted-by":"crossref","first-page":"303","DOI":"10.1097\/00004836-199006000-00014","article-title":"Abnormal Liver Enzymes and Ketonuria in Hyperemesis Gravidarum A Retrospective Review of 80 Patients","volume":"12","author":"Morali","year":"1990","journal-title":"J. Clin. Gastroenterol."},{"key":"ref_46","first-page":"e8709","article-title":"Study of Liver Dysfunction in Hyperemesis Gravidarum","volume":"12","author":"Gaba","year":"2020","journal-title":"Cureus"},{"key":"ref_47","first-page":"e13","article-title":"Hyperemesis gravidarum: A ten-year French retrospective study of 109 patients","volume":"44","author":"Ouldamer","year":"2015","journal-title":"Presse Med."},{"key":"ref_48","doi-asserted-by":"crossref","first-page":"120","DOI":"10.1016\/j.mce.2012.10.027","article-title":"Nuclear receptors, bile acids and cholesterol homeostasis series-bile acids and pregnancy","volume":"368","author":"Papacleovoulou","year":"2013","journal-title":"Mol. Cell. Endocrinol."},{"key":"ref_49","doi-asserted-by":"crossref","first-page":"96","DOI":"10.1038\/s41586-020-2434-2","article-title":"Whole-genome sequencing of patients with rare diseases in a national health system","volume":"583","author":"Turro","year":"2020","journal-title":"Nature"},{"key":"ref_50","doi-asserted-by":"crossref","first-page":"11823","DOI":"10.1038\/s41598-017-11626-x","article-title":"An expanded role for heterozygous mutations of ABCB4, ABCB11, ATP8B1, ABCC2 and TJP2 in intrahepatic cholestasis of pregnancy","volume":"7","author":"Dixon","year":"2017","journal-title":"Sci. Rep."},{"key":"ref_51","doi-asserted-by":"crossref","first-page":"e95","DOI":"10.1111\/1471-0528.17206","article-title":"Intrahepatic cholestasis of pregnancy: Green-top Guideline No. 43 June 2022","volume":"129","author":"Girling","year":"2022","journal-title":"BJOG Int. J. Obstet. Gynaecol."},{"key":"ref_52","doi-asserted-by":"crossref","unstructured":"European Association for the Study of the Liver (2009). EASL Clinical Practice Guidelines: Management of cholestatic liver diseases. J. Hepatol., 51, 237\u2013267.","DOI":"10.1016\/j.jhep.2009.04.009"},{"key":"ref_53","doi-asserted-by":"crossref","first-page":"899","DOI":"10.1016\/S0140-6736(18)31877-4","article-title":"Association of adverse perinatal outcomes of intrahepatic cholestasis of pregnancy with biochemical markers: Results of aggregate and individual patient data meta-analyses","volume":"393","author":"Ovadia","year":"2019","journal-title":"Lancet"},{"key":"ref_54","doi-asserted-by":"crossref","first-page":"1482","DOI":"10.1002\/hep.26617","article-title":"Association of severe intrahepatic cholestasis of pregnancy with adverse pregnancy outcomes: A prospective population-based case-control study","volume":"59","author":"Geenes","year":"2014","journal-title":"Hepatology"},{"key":"ref_55","doi-asserted-by":"crossref","first-page":"570.e1","DOI":"10.1016\/j.ajog.2015.06.021","article-title":"Predictors of adverse neonatal outcomes in intrahepatic cholestasis of pregnancy","volume":"213","author":"Kawakita","year":"2015","journal-title":"Am. J. Obstet. Gynecol."},{"key":"ref_56","doi-asserted-by":"crossref","first-page":"3456","DOI":"10.1111\/jog.14925","article-title":"Maternal serum calprotectin level in intrahepatic cholestasis of pregnancy","volume":"47","author":"Agaoglu","year":"2021","journal-title":"J. Obstet. Gynaecol. Res."},{"key":"ref_57","doi-asserted-by":"crossref","first-page":"1492","DOI":"10.1053\/j.gastro.2012.08.004","article-title":"Efficacy of Ursodeoxycholic Acid in Treating Intrahepatic Cholestasis of Pregnancy: A Meta-analysis","volume":"143","author":"Bacq","year":"2012","journal-title":"Gastroenterology"},{"key":"ref_58","doi-asserted-by":"crossref","first-page":"63","DOI":"10.1016\/j.dld.2016.10.006","article-title":"Ursodeoxycholic acid therapy in intrahepatic cholestasis of pregnancy: Results in real-world conditions and factors predictive of response to treatment","volume":"49","author":"Bacq","year":"2017","journal-title":"Dig. Liver Dis."},{"key":"ref_59","doi-asserted-by":"crossref","first-page":"148","DOI":"10.1016\/j.preghy.2021.09.008","article-title":"The 2021 International Society for the Study of Hypertension in Pregnancy classification, diagnosis & management recommendations for international practice","volume":"27","author":"Magee","year":"2022","journal-title":"Pregnancy Hypertens."},{"key":"ref_60","doi-asserted-by":"crossref","first-page":"1","DOI":"10.1002\/ijgo.12802","article-title":"The International Federation of Gynecology and Obstetrics (FIGO) initiative on pre-eclampsia: A pragmatic guide for first-trimester screening and prevention","volume":"145","author":"Poon","year":"2019","journal-title":"Int. J. Gynaecol. Obstet. Off. Organ Int. Fed. Gynaecol. Obstet."},{"key":"ref_61","doi-asserted-by":"crossref","first-page":"291","DOI":"10.1016\/j.preghy.2018.05.004","article-title":"The hypertensive disorders of pregnancy: ISSHP classification, diagnosis & management recommendations for international practice","volume":"13","author":"Brown","year":"2018","journal-title":"Pregnancy Hypertens."},{"key":"ref_62","doi-asserted-by":"crossref","first-page":"8","DOI":"10.1038\/s41572-023-00417-6","article-title":"Pre-eclampsia","volume":"9","author":"Dimitriadis","year":"2023","journal-title":"Nat. Rev. Dis. Primers"},{"key":"ref_63","doi-asserted-by":"crossref","first-page":"1046","DOI":"10.1161\/HYPERTENSIONAHA.113.01892","article-title":"Spiral artery remodeling and trophoblast invasion in preeclampsia and fetal growth restriction: Relationship to clinical outcome","volume":"62","author":"Lyall","year":"2013","journal-title":"Hypertens"},{"key":"ref_64","doi-asserted-by":"crossref","first-page":"876","DOI":"10.1111\/j.1471-0528.1981.tb02222.x","article-title":"Morphological changes of the spiral arteries in the placental bed in relation to pre-eclampsia and fetal growth retardation","volume":"88","author":"Gerretsen","year":"1981","journal-title":"Br. J. Obstet. Gynaecol."},{"key":"ref_65","doi-asserted-by":"crossref","first-page":"336","DOI":"10.1111\/febs.15745","article-title":"Revisiting preeclampsia: A metabolic disorder of the placenta","volume":"289","author":"Hu","year":"2022","journal-title":"FEBS J."},{"key":"ref_66","doi-asserted-by":"crossref","first-page":"658","DOI":"10.1080\/14767058.2016.1185411","article-title":"Metabolomic determination of pathogenesis of late-onset preeclampsia","volume":"30","author":"Syngelaki","year":"2017","journal-title":"J. Matern.-Fetal Neonatal Med."},{"key":"ref_67","doi-asserted-by":"crossref","first-page":"3583","DOI":"10.1038\/s41598-022-07509-5","article-title":"Hematobiochemical variability and predictors of new-onset and persistent postpartum preeclampsia","volume":"12","author":"Fondjo","year":"2022","journal-title":"Sci. Rep."},{"key":"ref_68","doi-asserted-by":"crossref","unstructured":"Gelaw, Y., Asrie, F., Walle, M., and Getaneh, Z. (2022). The value of eosinophil count in the diagnosis of preeclampsia among pregnant women attending the University of Gondar Comprehensive Specialized Hospital, Northwest Ethiopia, 2021. BMC Pregnancy Childbirth, 22.","DOI":"10.1186\/s12884-022-04892-9"},{"key":"ref_69","doi-asserted-by":"crossref","first-page":"21","DOI":"10.1080\/10641955.2016.1218505","article-title":"Hemolysis, elevated liver enzymes, and low platelet syndrome: Outcomes for patients admitted to intensive care at a tertiary referral hospital","volume":"36","author":"Gedik","year":"2017","journal-title":"Hypertens. Pregnancy"},{"key":"ref_70","doi-asserted-by":"crossref","first-page":"147","DOI":"10.1080\/jmf.13.3.147.151","article-title":"The evaluation of maternal parameters at diagnosis may predict HELLP syndrome severity","volume":"13","author":"Carpani","year":"2003","journal-title":"J. Matern.-Fetal Neonatal Med."},{"key":"ref_71","doi-asserted-by":"crossref","unstructured":"Ang, S.X., Chen, C.P., Sun, F.J., and Chen, C.Y. (2021). Comparison of maternal and neonatal outcomes between acute fatty liver of pregnancy and hemolysis, elevated liver enzymes and low platelets syndrome: A retrospective cohort study. BMC Pregnancy Childbirth, 21.","DOI":"10.1186\/s12884-021-03761-1"},{"key":"ref_72","doi-asserted-by":"crossref","first-page":"279","DOI":"10.1080\/10641955.2021.1981373","article-title":"Predictability of adverse outcomes in hypertensive disorders of pregnancy: A multicenter prospective cohort study","volume":"40","author":"Vasquez","year":"2021","journal-title":"Hypertens. Pregnancy"},{"key":"ref_73","doi-asserted-by":"crossref","first-page":"910701","DOI":"10.3389\/fcvm.2022.910701","article-title":"Prediction of Delivery Within 7 Days After Diagnosis of Early Onset Preeclampsia Using Machine-Learning Models","volume":"9","author":"Herraiz","year":"2022","journal-title":"Front. Cardiovasc. Med."},{"key":"ref_74","doi-asserted-by":"crossref","unstructured":"Thangaratinam, S., Allotey, J., Marlin, N., Dodds, J., Cheong-See, F., von Dadelszen, P., Ganzevoort, W., Akkermans, J., Kerry, S., and Mol, B.W. (2017). Prediction of complications in early-onset pre-eclampsia (PREP): Development and external multinational validation of prognostic models. BMC Med., 15.","DOI":"10.1186\/s12916-017-0827-3"},{"key":"ref_75","doi-asserted-by":"crossref","first-page":"219","DOI":"10.1016\/S0140-6736(10)61351-7","article-title":"Prediction of adverse maternal outcomes in pre-eclampsia: Development and validation of the fullPIERS model","volume":"377","author":"Payne","year":"2011","journal-title":"Lancet"},{"key":"ref_76","doi-asserted-by":"crossref","first-page":"2160627","DOI":"10.1080\/14767058.2022.2160627","article-title":"Elevated liver enzymes and adverse outcomes among patients with preeclampsia with severe features","volume":"36","author":"Greiner","year":"2023","journal-title":"J. Matern.-Fetal Neonatal Med."},{"key":"ref_77","doi-asserted-by":"crossref","first-page":"e198","DOI":"10.3346\/jkms.2020.35.e198","article-title":"Elevated Alanine Aminotransferase in Early Pregnancy and Subsequent Development of Gestational Diabetes and Preeclampsia","volume":"35","author":"Lee","year":"2020","journal-title":"J. Korean Med. Sci."},{"key":"ref_78","doi-asserted-by":"crossref","first-page":"949","DOI":"10.1111\/liv.13617","article-title":"Prepregnancy liver enzyme levels and risk of preeclampsia in a subsequent pregnancy: A population-based cohort study","volume":"38","author":"Cho","year":"2018","journal-title":"Liver Int."},{"key":"ref_79","doi-asserted-by":"crossref","first-page":"963957","DOI":"10.3389\/fcvm.2022.963957","article-title":"High-normal liver enzyme levels in early pregnancy predispose the risk of gestational hypertension and preeclampsia: A prospective cohort study","volume":"9","author":"Zhang","year":"2022","journal-title":"Front. Cardiovasc. Med."},{"key":"ref_80","doi-asserted-by":"crossref","first-page":"951","DOI":"10.1136\/gut.2008.148676","article-title":"A prospective national study of acute fatty liver of pregnancy in the UK","volume":"57","author":"Knight","year":"2008","journal-title":"Gut"},{"key":"ref_81","doi-asserted-by":"crossref","first-page":"1723","DOI":"10.1056\/NEJM199906033402204","article-title":"A Fetal Fatty-Acid Oxidation Disorder as a Cause of Liver Disease in Pregnant Women","volume":"340","author":"Ibdah","year":"1999","journal-title":"N. Engl. J. Med."},{"key":"ref_82","doi-asserted-by":"crossref","first-page":"1366","DOI":"10.1002\/hep.31144","article-title":"Acute Liver Failure (ALF) in Pregnancy: How Much Is Pregnancy Related?","volume":"72","author":"Casey","year":"2020","journal-title":"Hepatology"},{"key":"ref_83","doi-asserted-by":"crossref","first-page":"127","DOI":"10.1080\/17474124.2020.1715210","article-title":"Fatty liver in pregnancy: A narrative review of two distinct conditions","volume":"14","author":"Azzaroli","year":"2020","journal-title":"Expert Rev. Gastroenterol. Hepatol."},{"key":"ref_84","doi-asserted-by":"crossref","first-page":"838","DOI":"10.1038\/ajg.2017.54","article-title":"Acute Fatty Liver Disease of Pregnancy: Updates in Pathogenesis, Diagnosis, and Management","volume":"112","author":"Liu","year":"2017","journal-title":"Am. J. Gastroenterol."},{"key":"ref_85","doi-asserted-by":"crossref","first-page":"474.e1","DOI":"10.1016\/j.ajog.2016.04.051","article-title":"The association of early unexplained elevated alanine aminotransferase with large-for-gestational-age birthweight","volume":"215","author":"Yarrington","year":"2016","journal-title":"Am. J. Obstet. Gynecol."},{"key":"ref_86","doi-asserted-by":"crossref","first-page":"876","DOI":"10.1136\/gut.51.6.876","article-title":"Prospective study of liver dysfunction in pregnancy in Southwest Wales","volume":"51","author":"Morgan","year":"2002","journal-title":"Gut"},{"key":"ref_87","doi-asserted-by":"crossref","first-page":"254","DOI":"10.1089\/met.2015.0106","article-title":"The Association of Alanine Aminotransferase in Early Pregnancy with Gestational Diabetes","volume":"14","author":"Yarrington","year":"2016","journal-title":"Metab. Syndr. Relat. Disord."},{"key":"ref_88","doi-asserted-by":"crossref","first-page":"27291","DOI":"10.1038\/srep27291","article-title":"Plasma Levels of Alanine Aminotransferase in the First Trimester Identify High Risk Chinese Women for Gestational Diabetes","volume":"6","author":"Leng","year":"2016","journal-title":"Sci. Rep."},{"key":"ref_89","doi-asserted-by":"crossref","first-page":"4791","DOI":"10.2147\/DMSO.S335364","article-title":"The Predictive Ability of Hepatic Steatosis Index for Gestational Diabetes Mellitus and Large for Gestational Age Infant Compared with Other Noninvasive Indices Among Chinese Pregnancies: A Preliminary Double-center Cohort Study","volume":"14","author":"Song","year":"2021","journal-title":"Diabetes Metab. Syndr. Obes."},{"key":"ref_90","doi-asserted-by":"crossref","first-page":"1799","DOI":"10.1080\/01443615.2022.2039905","article-title":"Can alanine aminotransferase measured in early pregnancy predict macrosomia?","volume":"42","author":"Bulut","year":"2022","journal-title":"J. Obstet. Gynaecol."},{"key":"ref_91","doi-asserted-by":"crossref","unstructured":"Serra, C., Dajti, E., De Molo, C., Montaguti, E., Porro, A., Seidenari, A., Angilletta, E., Bernardi, V., Salsi, G., and Bakken, S.M. (2023). Utility of Doppler-Ultrasound and Liver Elastography in the Evaluation of Patients with Suspected Pregnancy-Related Liver Disease. J. Clin. Med., 12.","DOI":"10.3390\/jcm12041653"},{"key":"ref_92","doi-asserted-by":"crossref","first-page":"516","DOI":"10.1016\/j.jhep.2020.03.049","article-title":"Non-alcoholic fatty liver disease in pregnancy is associated with adverse maternal and perinatal outcomes","volume":"73","author":"Sarkar","year":"2020","journal-title":"J. Hepatol."},{"key":"ref_93","doi-asserted-by":"crossref","first-page":"743","DOI":"10.1111\/liv.14759","article-title":"Influences of pregravid liver enzyme levels on the development of gestational diabetes mellitus","volume":"41","author":"Kim","year":"2021","journal-title":"Liver Int."},{"key":"ref_94","doi-asserted-by":"crossref","first-page":"2","DOI":"10.1016\/j.bpobgyn.2020.02.011","article-title":"Implications of abnormal liver function in pregnancy and non-alcoholic fatty liver disease","volume":"68","author":"Lao","year":"2020","journal-title":"Best Pract. Res. Clin. Obstet. Gynaecol."},{"key":"ref_95","doi-asserted-by":"crossref","first-page":"1102","DOI":"10.2215\/CJN.12081115","article-title":"Preeclampsia: Updates in Pathogenesis, Definitions, and Guidelines","volume":"11","author":"Phipps","year":"2016","journal-title":"Clin. J. Am. Soc. Nephrol."},{"key":"ref_96","doi-asserted-by":"crossref","first-page":"S988","DOI":"10.1016\/j.ajog.2021.11.022","article-title":"Hemodynamic pathways of gestational hypertension and preeclampsia","volume":"226","author":"Gyselaers","year":"2022","journal-title":"Am. J. Obstet. Gynecol."},{"key":"ref_97","doi-asserted-by":"crossref","first-page":"93","DOI":"10.1016\/j.ejogrb.2019.10.021","article-title":"Angiogenic profiling in HELLP syndrome cases with or without hypertension and proteinuria","volume":"243","author":"Trottmann","year":"2019","journal-title":"Eur. J. Obstet. Gynecol. Reprod. Biol."},{"key":"ref_98","doi-asserted-by":"crossref","first-page":"123","DOI":"10.1002\/uog.9061","article-title":"Role of dysfunctional maternal venous hemodynamics in the pathophysiology of pre-eclampsia: A review","volume":"38","author":"Gyselaers","year":"2011","journal-title":"Ultrasound Obstet. Gynecol."},{"key":"ref_99","doi-asserted-by":"crossref","first-page":"4393","DOI":"10.3748\/wjg.v24.i38.4393","article-title":"Liver stiffness reversibly increases during pregnancy and independently predicts preeclampsia","volume":"24","author":"Ammon","year":"2018","journal-title":"World J. Gastroenterol."},{"key":"ref_100","doi-asserted-by":"crossref","first-page":"515.e1","DOI":"10.1016\/j.ajog.2022.04.048","article-title":"Liver stiffness and steatosis in preeclampsia as shown by transient elastography-a prospective cohort study","volume":"227","author":"Sgayer","year":"2022","journal-title":"Am. J. Obstet. Gynecol."}],"container-title":["Journal of Personalized Medicine"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/www.mdpi.com\/2075-4426\/13\/9\/1388\/pdf","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2025,10,10]],"date-time":"2025-10-10T20:52:17Z","timestamp":1760129537000},"score":1,"resource":{"primary":{"URL":"https:\/\/www.mdpi.com\/2075-4426\/13\/9\/1388"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2023,9,16]]},"references-count":100,"journal-issue":{"issue":"9","published-online":{"date-parts":[[2023,9]]}},"alternative-id":["jpm13091388"],"URL":"https:\/\/doi.org\/10.3390\/jpm13091388","relation":{},"ISSN":["2075-4426"],"issn-type":[{"value":"2075-4426","type":"electronic"}],"subject":[],"published":{"date-parts":[[2023,9,16]]}}}