INTRODUCTION Pulmonary hypertension (PH) in neonates is a challenge in neonatal care which causes attenuation in lung perfusion as a result of increased pulmonary vascular resistance that brings hypoxia. Treatment of PH aims selective pulmonary vasodilatation, and inhaled nitric oxide (iNO) is the most effective drug among them. However, the issue that iNO was found to be successful approximately in 70% of infants creates the need of other therapies. 1 Inhaled iloprost, a stable prostacyclin analogue, was stated to be successful in neonatal case reports with some handicaps due to inhalation process as; hypoxia due to connection of inhalation unit among the ventilatory circuit during conventional ventilation and need to pause ventilatory treatment if high frequency oscillatory ventilation (HFOV) are being used. 2 Endotracheal instillation may overcome those problems while resulting beneficial short-term results. 3,4 In this report, we present two neonates with PH who were administered iloprost by endotracheal instillation in whom different systemic effects were observed. CASE REPORT The presented patients were followed in level-III neo- natal intensive care unit (NICU), Gazi University, Turkey. Case 1: A 3195 grams male neonate with left congenital diaphragmatic hernia (CDH) was delivered at term. Chest X-ray showed reticulogranular appearance besides the features of CDH. Ultrasound detected the herniated left lobe of liver, spleen, and stomach. Surfactant was administered, sedation and HFOV were started (Draeger-Babylog8000+, Leubeck, Germany). Echocardiography revealed PH (right-to-left shunt from ductus arteriosus, tricuspid insufficiency, dilated right atrium and ventricle with an estimated pulmonary artery pressure (PAP) of 80 mmHg). Our approaches for treatment of hypotension, PH, mechanical ventilation and oxygenation indices of every morning's blood gas analyses are shown in Figure 1. As iNO was unavailable, inhaled iloprost was initiated due to unresponsiveness to other PH treatments. As severe hypoxia after connection of inhaler system occurred, iloprost was instilled via the side tube of double lumen endotracheal tube. Solution containing 20 microgr iloprost in 1 ml (Ilomedin®) was diluted to 10 ml with saline and 1.5 μg iloprost was instilled every 2 hours. Pulse oxygen saturation (SpO 2 ) were increased above Journal of the College of Physicians and Surgeons Pakistan 2017, Vol. 27 (4): 257-259 257 CASE REPORT Iloprost Instillation in Two Neonates with Pulmonary Hypertension Sezin Unal 1,2 , Selma Aktas 1 , Meltem Aksu 1 , Ibrahim M. Hirfanoglu 1 , Yildiz Atalay 1 and Canan Turkyilmaz 1 ABSTRACT Pulmonary hypertension may coexist with certain diseases in neonates. Iloprost inhalation is one of the treatments which cause selective pulmonary vasodilatation. Inhalation is not an easy way of drug administration in mechanically ventilated infants; as some exhibit desaturations during inhalation. Moreover, inhalation of drug requires cessation of mechanical ventilation, if patient is on high frequency oscillatory ventilation. We presented two patients with pulmonary hypertension; term baby with congenital diaphragmatic hernia and preterm baby with respiratory distress syndrome; who had iloprost instillation during mechanical ventilation treatment. Iloprost instillation was well tolerated with no side effects in the term patient with diaphragmatic hernia; whereas severe blood pressure fluctuations were observed in the preterm infant. This report may courage administration of iloprost in term neonates with resistant pulmonary hypertension. Key Words: Iloprost instillation. Pulmonary hypertension. Preterm. Neonate. Endotracheal instillation. 1 Department of Pediatrics, Division of Neonatology, Gazi University Hospital, Ankara, Turkey. 2 Department of Neonatology, Etlik Zubeyde Hanim Women's Health Teaching and Research Hospital, Ankara, Turkey. Correspondence: Dr. Sezin Unal, Department of Neonatology, Etlik Zubeyade Hanim Women's Health Teaching and Research Hospital, Yeni-Etlik No.55, 06010, Etlik, Ankara, Turkey. E-mail: sezinunal@gmail.com Received: March 07, 2016; Accepted: January 16, 2017. Figure 1: Case 1: Oxygenation indices of each morning's blood gas analyses, mechanical ventilation, and approaches for treatment of hypotension and pulmonary hypertension are shown. Vertical bold line indicates the operation time. HFOV = High frequency oscillatory ventilation; NIV = Noninvasive ventilation; OI = Oxygenation index; PH = Pulmonary hypertension; SIMV+VG = Synchronized intermittent mandatory ventilation with volume guarantee.