Two case reports of neonatal pulmonary embolism with respiratory and cardiac arrest as the first symptom

Background Pulmonary embolism (PE) is traditionally regarded as extremely rare in neonates, but there is now strong evidence that its true incidence is seriously underestimated because of nonspecific clinical manifestations and the limited utility of standard diagnostic pathways in this population. In hemodynamically unstable infants, computed tomography pulmonary angiography (CTPA), the diagnostic gold standard in adults, is often impractical, hence the urgent need for alternative bedside-focused diagnostic strategies. Case presentation We describe two 28-week premature neonates who had episodes of cardiopulmonary arrest and who underwent thorough investigation, yielding no evidence of structural cardiac abnormalities, pneumothorax, electrolyte disturbance, or infectious complications. Bedside studies disclosed markedly elevated D-dimer levels and transthoracic echocardiographic findings of right ventricular dilation, impaired systolic function, and indirect signs of pulmonary hypertension. Because neonatal pulmonary embolism is rapid and dangerous and the infeasibility of CTPA in the unstable clinical context, empiric anticoagulation with heparin was initiated, followed by thrombolytic therapy due to persistent clinical deterioration. The patient had rapid hemodynamic recovery and normalization of D-dimer levels. Conclusions The cases make it very clear that a high index of suspicion for PE should be maintained in neonates with unexplained hemodynamic collapse, recurrent apnea, or cardiorespiratory arrest, especially when risk factors are present. Therefore, a multi-modal diagnostic approach combining clinical evaluation, D-dimer testing, and focused echocardiography is optimal when CTPA is not feasible. Prompt, guideline-directed anticoagulant and thrombolytic strategies can markedly improve outcomes in this rare but devastating condition.