Case 3: Three Occurrences of a Rare Phenomenon in the Premature Population with Varying Outcomes.

### Patient 1: Clinical Course Patient 1 was delivered via cesarean delivery at 25 5/7 weeks’ gestation in the setting of fetal bradycardia. The prenatal course was complicated by preterm premature rupture of membranes 16 days before delivery. The neonate’s mother had received 2 doses of betamethasone and adequate antibiotic treatment for positive group B Streptococcus status. The neonate had poor respiratory effort after birth and required intubation; his Apgar scores were 4 and 8 at 1 and 5 minutes of age, respectively. Soon after birth, he was critically ill with severe hypotension, which was attributed to possible sepsis requiring multiple inotropes; hydrocortisone was not needed. Ampicillin and gentamicin were initiated. He was initially given volume-control conventional ventilation at a rate of 30 breaths/min, positive end-expiratory pressure (PEEP) of 5 cm H20, tidal volume of 6 mL/kg, pressure support of 8 cm H2O, and fraction of inspired oxygen (Fio2) of 0.5. Because of worsening respiratory acidosis, he was transitioned to high-frequency oscillatory ventilation (requiring Fio2 1.0) and was started on inhaled nitric oxide within the first day after birth. In the setting of persistent hypotension, ceftazidime and azithromycin were also added to the antibiotic regimen. After the hypotension resolved, feedings were initiated 5 days after birth. The inhaled nitric oxide was weaned off on the sixth day after birth. Gentamicin was discontinued at 5 days of age, azithromycin was discontinued at 7 days of age, and ampicillin and ceftazidime were discontinued at 8 days of age. On the eighth day after birth when the neonate was taking 20 mL/kg of gastric feedings per day, his abdominal girth increased and he had an episode of nonbilious emesis. His abdomen was soft but tender to palpation. Abdominal radiography showed isolated gastric pneumatosis along the superior portion of the stomach …