A 450-G, WHITE male neonate was delivered at 24 weeks' gestation due to complications of severe pregnancy-induced hypertension. He was not fed and required mechanical ventilation and placement of umbilical artery and venous catheters. An initial chest radiograph showed changes of respiratory distress syndrome despite surfactant therapy and, in the abdomen, a lack of gas beyond the stomach. On the sixth day, a patent ductus arteriosus (PDA) was diagnosed and treated with intravenous indomethacin, and antibiotic treatment was begun. The PDA closed, noted on clinical and echocardiographic evaluation 5 days later. Combined treatment with dexamethasone and ranitidine were begun on day 9 for continued respiratory distress. A radiograph taken after endotracheal tube replacement showed a pneumoperitoneum (Figure 1). One day later, a radiograph was obtained for abdominal distention and again demonstrated free intraperitoneal air (Figure 2). The infant had previously been clinically and hemodynamically stable and had been weaned from mechanical ventilation and supplementary oxygen.