Prenatal Nonvisualization of the Gallbladder: A Diagnostic and Prognostic Dilemma

Introduction: Nonvisualization of the fetal gallbladder has been associated with benign conditions such as isolated gallbladder agenesis or severe diseases such as biliary atresia (BA). Recently, gamma-glutamyl transpeptidase (GGTP) fetal blood levels were reported as useful after 22 weeks. Objective: To determine the contribution of fetal blood GGTP levels after 22 weeks, based on 2 cases. Case 1: 20 +4 -week secundipara, with subcutaneous edema and pleural effusion. At 24 +4 weeks, the gallbladder could not be visualized. Progressive hydrops deterioration was observed. 32 +2 -week magnetic resonance imaging (MRI) confirmed nonvisualization of the gallbladder. BA was suspected. The patient decided to terminate the pregnancy and fetal blood sample was obtained at feticide. GGTP was 573 IU/L. Fetal necropsy confirmed BA. Case 2: At the 22 +6 - and 24 +0 -week ultrasound scan, the gallbladder could not be visualized. Amniocentesis was offered, but declined by the patient. MRI at 35 +0 weeks failed also to visualize it. Fetal cord blood sample at delivery was obtained, and GGTP was 129 IU/L. Ultrasound confirmed gallbladder agenesis with normal extra- and intrahepatic bile ducts. Conclusion: Cases of nonvisualized gallbladder after 22 weeks have rarely been reported in the literature. Until now, no standard management has been proposed. Our cases support the potential usefulness of fetal blood digestive enzymes.