Burns in Pregnancy

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Burns in Pregnancy

• Dr.Mridula A. Benjamin
• Dept of Obs and Gyn
• RIPAS Hospital

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Introduction

• Burns is an important subject in trauma
  management
• But burns in pregnancy is not a topic mentioned
  in obstetric texts or books on burn care
• The aim of this literature review was to
  understand the impact burns has on pregnancy and
  maternal and fetal survival and the subtle
  differences in the management of pregnant burn
  victims

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Materials and methods

• An Internet search was done using Pubmed search
  engine to collect case reports and articles on
  the topic
• Statistics of Burns unit, RIPAS Hospital

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Incidence

• 7 in USA (Amy et al. Fort Houston),
• The highest of all burn incidences in pregnancy
  was found in India, ranging from 7, calculated
  by Akhtar (Nagpur), to 13.3, reported by Jain
  (Bhilai)
• Of the 379 cases reported in the literature
  between 1958 and the present day that have come
  to our attention, 129 (34) occurred in India

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Causes
27.45
72.55
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Causes
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Place of occurrence
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2
25
62
3
8
Brunei statistics 2006
163
123
Total Burn Patients 286
42
244
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Brunei statistics
27
15
2
2
3
5
3
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Effect of Burns

• Slight burns had no effect on the course of
  pregnancy, while burns of at least 35 TBSA were
  capable of provoking early labour and the loss of
  the foetus following intrauterine death within a
  week of the burn

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Old school of thought

• Onset of labour in a premature delivery is due to
  secretion of adrenocortical hormones related to
  stress.
• Spontaneous miscarriage and premature delivery
  are due to the synthesis and release of
  prostaglandins (responsible for early uterine
  contractions) from the skin in the burn area

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Current opinion
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Current opinion

• After burns there is increased capillary
  permeability and third space loss leading to
  hypovolemia
• This leads to hypotension if the patient is
  inadequately resuscitated
• This leads to placental insufficiency, fetal
  ischemia, hypoxia and acidosis
• All these events lead to premature labor

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Current opinion

• Onset of spontaneous uterine contractions is also
  favoured by the release from bacteria and the
  placenta of an enzyme, phospholipase A, which is
  necessary for the conversion of arachidonic acid
  into prostaglandin
• Considerable reduction in plasma levels of
  17B-oestradiol in pregnant burned women who had
  either an abortion or a still birth in the first
  week post-burn

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Prognosis

• Fatality rate among patients with TBSA of 50 or
  more was 3.33 times the fatality rate among women
  with smaller burns
• Fetal survival depends on the gestational age,
  extent of maternal injury and maternal survival
• Fetal survival during first trimester was 27.2
  in comparison with 28.5 in second and 35.2 in
  third trimester

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Management

• All female burn patients of childbearing age
  should be tested for pregnancy unless the
  pregnancy is obvious

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General treatment

• Prevention of hypovolaemic shock by adequate
  early fluid so that the uterine blood flow is
  maintained. Diuresis of 30-60 ml/h
• Maintenance of arterial pressure levels
• Episodes of hypotension should be avoided in the
  event of surgical operations. It is recommended
  that surgery should be performed with
  intraoperative maintenance of a minimum of 1
  ml/kg/h of urine volume and 100 oxygen
  saturation.

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The Emergency Management

• The loss of fluid often is underestimated in
  pregnant patients.
• On arrival to the hospital and after the vital
  signs of the mother and fetus (monitor) are
  evaluated, a large-bore (ie, 18-gauge)
  intravenous line is started.
• If burns more than 20 of the surface area, a
  central venous or Swan-Ganz catheter provides a
  better guide to fluid replacement.
• Lactated Ringer solution is started at 200 mL/h
  until the fluid replacement volume is calculated.
  

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Degree Of Burns

• 1st degree only epithelial layer. Very painful
  but resolves with no residual scarring. Skin is
  red and painful but no blisters
• 2nd degree epithelium and part of dermis. Pain
  and scarring vary according to depth of burn.
• A) Superficial 2nd degree burns
  epidermis and uppermost part of dermis
• B) Deep 2nd degree burns spares only the
  deepest portion of dermis
• 3rd degree Full thickness. Usually painless
  due to destruction of cutaneous innervation.
  Leads to scarring.

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Estimation of burns
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The Fluid Requirements

• During late pregnancy, 5 is added if anterior
  abdomen is involved
• Fluid requirements for the first 24 hours are
  calculated as follows BSA () multiplied by 2-4
  mL/kg body weight
• For example, a 20 burn is calculated as 20 X 3
  mL X 70 kg 4200 mL
• Fluid requirements are met with lactated Ringer
  solution
• 50 fluid is given in first 8 hrs and the rest in
  the next 16 hrs
• In the second 24 hours, colloids (albumin) are
  administered to maintain the serum albumin gt 3
  g/100 mL

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General treatment

• A pregnant patient's oxygenation can often be
  improved by nursing in semi-sitting position
• In pleuropulmonary complications secondary to
  inhalation ventilatory support should be
  initiated as soon as possible. Inhaled carbon
  monoxide can cross placental barrier to compete
  for binding sites on foetal haemoglobin,
  provoking foetal cardiac oedema, and affect
  cardiac development
• If bronchopneumonia use antibiotics that the
  foetus can tolerate

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Local treatment

• Drugs to avoid Chloramphenicol, Gentamycin,
  Silver sulfa diazine, Povidone Iodine, Ketamine
• Salicylates to be avoided in term pregnancies
• Hypertonic glucose solutions can lead to
  secondary hyperinsulinaemia with foetal
  macrosomia
• Safe drugs penicillins and cephalosporins
• Reports of using potato peals and banana leafs as
  dressing materials

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Surgical Treatment

• Early coverage of burns minimizes septic
  complications, need for antibiotics and analgesic
  drugs.
• SSG of wounds over the abdomen and breast have to
  be treated first
• 1. Pain-free stretching of the abdominal
  skin
• during the developing pregnancy to term
  
• 2. Abdominal obstetric supervision of
  the
• growing foetus
• 3. Performance of caesarian section if
  required

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Obstetric management

• Depends on the following
• Gestational period
• Severity of the burn
• Foetal viability confirm biophysical
  measurements as foetal muscle tone, limb motion
  and breathing patterns, placental morphology, and
  amniotic fluid volume

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Manner of delivery

• Spontaneous vaginal delivery is generally
  preferred
• Obstetric considerations affect the choice of
  route and the timing of the delivery
• Serial foetal sonography and electronic heart
  rate monitoring, by means of cardiotocographic
  recording, identifies foetal stress at an early
  stage
• In a critically burned woman with a living and
  near-term pregnancy, foetal salvage by caesarian
  section is justifiable

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Conclusion

• Incidence of burns in pregnancy is high in
  developing countries
• Overcoming of maternal shock is of fundamental
  importance for foetal prognosis
• Hypovolaemia and hypoxia are the cause of
  spontaneous uterine contractions that lead to
  abortion or premature delivery after IUD
• General and topical treatment has to take into
  account the embryonal, foetal, and perinatal
  toxicity
• Early surgical intervention

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Conclusion

• Monitoring of the pregnancy by frequent
  ultrasound scanning, daily measuring of the blood
  clotting factor, cardiotocographic monitoring.
  Intrauterine death of the foetus may be preceded
  by a reduction of 178-oestradiol and E, levels
• Calculation of the stage of gestation and the
  gravity of the burn
• choice of method of delivery (vaginal route,
  caesarian section)

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Thank you