Twin pregnancies have an increased incidence in recent years, especially due to the development of assisted human reproduction techniques. Although most of the in vitro fertilization pregnancies are dichorionic tasks, exceptions may also occur following the placental fusion process. Twin pregnancies in which the fusion process occurs associate the complications of monochorial pregnancies such as prematurity, growth discordance between the twins, twin-to-twin transfusion syndrome, twin reversed arterial perfusion, with higher perinatal mortality and morbidity. In recent years, most studies have focused on correlations between the macro and microscopic aspects of the placenta and the associated complications.

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We describe the case of a newborn with the antenatal onset of hepatic failure, which has been investigated for all etiologies that can cause liver damage: infectious, metabolic, genetic, and immune. The lack of a clear answer regarding the etiology and the response to immunoglobulin therapy led us to the diagnosis of gestational alloimmune liver disease. Gestational alloimunne liver disease is an uncommon and very severe cause of neonatal acute liver failure (NALF). Initially, the therapeutic approach aimed at correcting the effects produced by iron loading, respectively, iron chelators and antioxidants. Since all aspects of this case indicated characteristic features typical for GALD, therapy with intravenous immunoglobulins (IVIG) was introduced. If such therapy alters the prognosis of newborns with GALD, the etiology and pathophysiology remain uncertain. However, in cases regarding severe hepatic failure with the perinatal onset and apparently unknown etiology, immunoglobulin or exchange transfusion therapy should be taken into account even before finalizing all the etiological investigations. The prognosis is uncertain and varies between clinical resolution, chronic hepatitis/cirrhosis, and the need for a hepatic transplant, and overall survival depends on prompt therapeutic intervention.

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