A 1-day-old late preterm male newborn with antenatally diagnosed complex congenital heart disease has increased work of breathing and an abnormal chest radiograph obtained 1 hour after birth (Fig 1). Despite intubation and increased ventilatory support, his respiratory status worsens, with progressive respiratory acidosis and hypoxemia.

  • Born to a 30-year-old gravida 3, para 2 woman

  • Prenatal course significant for gestational diabetes treated with insulin. Prenatal ultrasonography performed at 24 weeks’ gestation identified heterotaxy, atrioventricular canal defect, pulmonary atresia, and duodenal atresia. Pregnancy complicated by the development of preterm, premature rupture of membranes (PPROM) at 32 weeks’ gestation

  • Estimated gestational age: 34 0/7 weeks

  • Induced vaginal delivery secondary to PPROM

  • Apgar scores: 7, 8, and 8 at 1, 5, and 10 minutes, respectively

The neonate required continuous positive airway pressure (CPAP) in the delivery room secondary to respiratory distress and was subsequently admitted to the NICU. Given his known...

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