Case Analysis of Neonatal Acute Liver Failure Presumably Caused by Gestational Alloimmune Liver Disease.

Neonatal acute liver failure is a rare, life-threatening condition. We present a 33 6/7 -week-old neonate with severe coagulopathy and hyperbilirubinemia refractory to vitamin K 1 , plasma, and platelet transfusions. The mother had a history of two previous neonatal deaths, one of whom had similar coagulopathy. Gestational alloimmune liver disease (GALD) was strongly suspected following multidisciplinary review, although a definitive diagnosis could not be confirmed because of negative labial salivary gland iron staining and the decision to decline liver biopsy. Double-volume exchange transfusion on day 15 rapidly improved bilirubin and coagulation parameters, allowing discharge in stable condition. Mild recurrent cholestasis occurred after discharge. This case underscores that refractory coagulopathy and cholestasis unresponsive to conventional therapy, especially in the presence of a relevant family history, should raise suspicion for immune-mediated causes such as GALD. Exchange transfusion may be critical for improving outcomes.