Gestational alloimmune liver disease: a cause of fetal death in utero

Recent evidence suggests that neonatal haemochromatosis is caused by gestational alloimmune liver disease (GALD), and is an underdiagnosed entity, especially in cases of unexplained stillbirth or premature birth. 1 We present an autopsy case of a 35-year-old mother, G4P3, who was diagnosed with fetal death in utero (FDIU) at 32 weeks gestation. She had a previous child born with severe liver damage of unknown cause but suspected to be alloimmune. Her subsequent pregnancy was treated with immu-noglobulin and she delivered a normal child. This pregnancy immunoglobulin was not administered due to side-effects. At 32 weeks she noticed reduced fetal movements and FDIU was diagnosed. A full autopsy was performed which found features of terminal hypoxia, advanced liver autolysis, but no morphological abnormalities and negative Perls stain. Due to high clinical suspicion of neonatal haemochromatosis, liver autopsy samples and liver biopsy of child with severe hepatitis were sent to Children’s Memorial Research Centre, Chicago, for further analysis. Slides were stained with C5b-9 complex and were unequivocally positive in both liver biopsies. This is strong evidence that FDIU and severe hepatitis was due to GALD. Pathologists and clinicians need to be aware of GALD as a cause of FDIU.