Ultrasound findings associated with neonatal acute liver failure secondary to gestational alloimmune liver disease: A case series.

Objectives: Gestational alloimmune liver disease is the leading cause of neonatal acute liver failure, hypothesized to emerge from maternal exposure to an antigen that is expressed on fetal hepatocytes, resulting in maternal-fetal alloimmune attack and activation of the complement cascade. Despite maximal medical therapy, some require liver transplantation for survival. Prompt recognition is vital. Ultrasound is the first imaging modality utilized in acute liver failure. Results often include nonspecific findings. There is a need for more sonographic findings to facilitate timely diagnosis. We present a case series of neonates who presented with acute liver failure secondary to gestational alloimmune liver disease at Texas Children's Hospital from 2018 to 2025. Methods: This study was approved by the Baylor College of Medicine International Review Board H40231. Medical records, imaging studies, and biopsy results from 2018 to 2025 were analyzed retrospectively. A General Electric LOGIQ E10 ultrasound machine was used. Results: All four patients with gestational alloimmune liver disease shared four findings on ultrasound: a widely patent ductus venosus, small right portal veins, reversal of flow in the right portal vein, and innumerable liver lesions. Conclusion: Our sonographic findings can be used to prompt clinical suspicion for gestational alloimmune liver disease and expedite treatment.