Gestational alloimmune liver disease treated with intravenous immunoglobulin resulting in maternal drug-induced liver injury

Gestational alloimmune liver disease (GALD) is a rare pregnancy complication involving maternal antibody-mediated fetal liver injury that recurs in 90% of affected pregnancies. The fetal and neonatal mortality rate is high, up to 82%, and affected fetuses can develop fetal hydrops, growth restriction, and oligohydramnios. Intravenous immunoglobulin (IVIG) administration can prevent GALD recurrence. We present a patient whose three live births were impacted by GALD. Her first pregnancy was an elective termination. Her second pregnancy resulted in neonatal demise due to autopsy-proven GALD. Her third pregnancy was complicated by liver injury secondary to biopsy-proven drug-induced liver injury (DILI) after IVIG administration and resulted in precipitous preterm twin delivery. In her fourth pregnancy, she received IVIG and high-dose steroids and did not develop DILI; the infant, delivered preterm due to GALD, died due to complications of prematurity. GALD is a highly recurrent condition that results in significant neonatal mortality. In this rare case of DILI due to IVIG administration, high-dose steroids treated DILI recurrence and prevented acute liver injury and may be beneficial to patients who are unable to tolerate IVIG due to liver injury.