Annals of
Burns and Fire Disasters - vol. XIII - n° 1 - March 2000
BURNS IN PREGNANCY
Napoli B., ¹
D'Arpa N.,¹
Masellis M.,¹
Graziano R.²
¹ Divisione di Chirurgia Plastica e Terapia delle Ustioni, Ospedale Civico,
Palermo, Italy
² Divisione Ostetricia e Ginecologia, Ospedale Civico, Palermo
SUMMARY. Two
cases are reported of bums in pregnancy. After a survey of the literature and a discussion
of the incidence of bums in pregnancy, the physiopathology of spontaneous uterine activity
is considered together with aspects of the treatment of bums and obstetric management in
relation to maternal and foetal prognosis.
Introduction and survey
of the literature
Texts on obstetrics do
not deal with bums in pregnancy nor is the topic considered in books devoted to the
treatment of bums. Tables I and II present the authors and cases present
in the literature in papers, covering the problem.
Case
number |
Author |
Year |
Period of
study |
Number of
cases |
Maternal
death |
Foetal
death |
1 |
Mulla |
1958 |
- |
1 |
1 |
1 |
2 |
Ryan |
1962 |
- |
2 |
0 |
0 |
3 |
Merger |
1963 |
- |
2 |
0 |
0 |
4 |
Tica |
1969 |
- |
1 |
0 |
1 |
5 |
Schmitz |
1971 |
1961-69 |
6 |
0 |
2 |
6 |
Stage |
1973 |
1963-72 |
3 |
0 |
1 |
7 |
Bhatt* |
1974 |
1967-71 |
28 |
20 |
23 |
8 |
Taylor |
1976 |
1950-74 |
19 |
7 |
7 |
9 |
Champagnie |
1977 |
- |
1 |
0 |
0 |
10 |
Sismondi |
1979 |
- |
1 |
0 |
0 |
11 |
Yingbei Z. |
1981 |
1956-78 |
24 |
2 |
5 |
12 |
Stilwell |
1982 |
- |
1 |
0 |
1 |
13 |
Matthews |
1982 |
- |
16 |
6 |
8 |
*
Cases of Indian origin |
|
Table
I - Summary table of authors and cases until 1982 |
|
Besides the
description of individual cases or limited series of cases collected over protracted
periods, we find works based on case histories from various bums centres. Matthews
discusses 50 cases based partly on a questionnaire sent to all bums centres in the UK (16
cases) and partly on the previous literature (34 cases), and provides data regarding works
by Sismondi et al., Yingbei Z. et al., and Stilwell; his work thus presents an almost
complete survey of the literature up to 1982.
Case
number |
Author |
Year |
Period of
study |
Number of
cases |
Maternal
death |
Foetal
death |
14 |
Rayburn |
1984 |
1964-81 |
30 |
8 |
12 |
15 |
Deitch |
1985 |
1978-83 |
11 |
0 |
3 |
16 |
Amy |
1985 |
1950-84 |
11 |
3 |
6 |
17 |
Bartle |
1988 |
1955-75 |
42 |
3 |
20 |
18 |
Srivastava |
1988 |
1984-87 |
8 |
0 |
2 |
19 |
Benineir |
1988 |
1970-86 |
8 |
2 |
3 |
20 |
Cheah |
1989 |
1981-87 |
9 |
2 |
2 |
21 |
Rode |
1990 |
1986-87 |
33 |
8 |
13 |
22 |
Mabogunge |
1990 |
1972-81 |
7 |
1 |
2 |
23 |
Gang |
1992 |
1984-89 |
8 |
1 |
3 |
24 |
Jain* |
1993 |
1986-91 |
25 |
5 |
9 |
25 |
Akhtar* |
1994 |
1991-93 |
50 |
35 |
36 |
26 |
loannovich |
1994 |
1988-93 |
5 |
1 |
2 |
27 |
Caleffi |
1994 |
- |
1 |
0 |
0 |
28 |
Prasanna* |
1996 |
1992-94 |
6 |
1 |
1 |
29 |
Sarkar* |
1996 |
1993-95 |
20 |
0 |
12 |
* Cases of
Indian origin |
|
Table
II - Summary table of authors and cases after 1982 |
|
The characteristics of later papers untilthe present day are however no
different. Raybum et al. report 30 cases studied over an 18-yr period in three American
university bums centres; Arny et al. also describe 30 cases, 19 of which had however
already described by Taylor et al. some years previously; Gang et al. reported 16 cases,
half of which had already been presented by Srivastava et al. Cases previously described
and collections of cases from other centres have contributed to the overall number of
observations that have made it possible to establish the correct procedures to be observed
as regards bums, i.e. in the mother, and as regards pregnancy, i.e. in the foetus, in
relation to the stage of pregnancy. Before proceeding any further, however, a word of
warning is necessary - Champagnie` published his case twice, while and Yingbei et al.
published their 24 cases no fewer than three times.
Incidence
The literature on bums
in pregnancy is indeed limited, but the incidence of the phenomenon, as calculated by the
various authors in relation to the total number of female burn patients of reproductive
age, does not appear to be low, while the incidence in early pregnancy is unknown in the
absence of routine pregnancy testing on admission. Apart from the 0.6% reported from
Israel by Benmeir et al., Taylor et al. calculated an incidence of 7%, a rate also found
by Amy et al.in later years (6.7%, Fort Houston), while the rate of 7.9% reported by
Srivastava et al. was confirmed by Gang et al. (7.8%, Kuwait). 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), and 15% reported by Prasanna (Karnataka).
This high incidence reflects the fact that 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 (Tables I, II). In Italy only two cases have ever been reported in
the literature (Sismondietal. and Caleffi et al.). We supplement these two cases and the
international literature with two other cases that have come to our attention in recent
years.
Clinical cases
Case 1
De P.A., age 39 yr, first quarter pregnancy (4th week of amenorrhoea), suffered
full-thickness skin burns in BSA 30% on 6 June 1994. On 25 August 1994 the patient was
subjected in general anaesthesia to free skin graft and discharged on 13 September 1994.
The patient originally opted for a voluntary abortion, which gave us a certain degree of
freedom of action in the management of the pregnancy, but she later decided for religious
reasons to carry the child to term. On 29 March 1995 she was delivered of a foetus
presenting a serious cardiac malformation. The child died a few days after birth.
Case 2
R.I., age 20 yr,, third quarter pregnancy (33rd week of amenorrhoea), suffered
full-thickness skin bums in 20% BSA on 28 December 1995. The treatment of the bums and the
management of the pregnancy culminated in a surgical operation two weeks after the
patient's admission. On 12 January 1996, after prophylaxis for hyaline membrane disease,
the patient was subjected to a caesarian section. The foetus presented in podalic position
(buttocks variety). The foetus, of female sex, weighed 2.4 kg and was alive and well, with
Apgar 8 at minute 1 and 10 at minute 5. Immediately after closure of the abdominal wall,
the patient was subjected to free skin graft in the burned areas (Figs. 1-3). On objective
examination the baby showed nothing pathological in the various organs and systems but was
kept in hospital in view of her prematurity. After a normal obstetric and surgical course
the patient was dismissed on 23 January 1996.
 |
 |
Fig. 1
- Extraction of foetus. |
Fig. 2
- Patient after caesarian section. |
 |
Fig. 3
- The living and viable foetus. |
|
Discussion
A. Thermal trauma
and spontaneous uterine activity
The onset of labour in a premature delivery shortly after a serious burn was in the past
thought to be triggered by the endocrine function, and in particular by that of the
secretion of adrenocortical hormones related to stress.
Later observations confirmed that slight bums had no effect on the course of pregnancy,
while bums 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 bum.
Both spontaneous miscarriage and premature delivery were subsequently thought to be
related to the synthesis and release of prostaglandins (responsible for early uterine
contractions) from the skin in the burn area. Later, however, the correct importance was
attributed both to maternal shock, which determines a considerable reduction in the
uterine blood flow and causes foetal hypoxia, and to pleuropulmonary complications,
especially in cases of inhalation lesions with grave reduction of maternal P02 and
consequently, as in this case, foetal hypoxia. Table III presents the events that
as a result of foetal hypoxia and acidosis determine spontaneous uterine activity. The
condition of hypotension and acute respiratory insufficiency is thus accompanied by
septicaemia. This can lead to complications in the foetus, even some time after the bum,
owing to the fact that the foetus may be able to tolerate the early phases of maternal
sepsis but is notably affected in the advanced phases, when the mother is decompensated
and her cardiovascular system collapses.
 |
Table III -
Events determining spontaneous uterine activity |
|
As the
maternal intravascular space is in a state of equilibrium with the amniotic liquid, the
reduction of this liquid during serious hypovolaemia can cause the intrauterine death of
the foetus. The 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. It has recently been shown that there
is a 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-bum.
B. Burns treatment -
its influence on the course of pregnancy and the foetus
Bl. General treatment.
Resuscitation treatment in the burned pregnant woman is no different from that in the
nonpregnant burned woman. The prevention of hypovolaemic shock by adequate early fluid
therefore requires that the uterine blood flow should be able maintain foetus tissue PO2
levels within the normal range. It has been recommended that a quantity of fluid should be
administered that is sufficient to maintain the mother's blood pressure within the normal
range and a diuresis of 30-60 ml/h. The maintenance of arterial pressure levels at normal
values is essential at all stages of the burn disease. Diuretics and anti-hypertension
drugs should therefore be avoided whenever possible. Episodes of hypotension should be
avoided also 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.
Since extensive surface bums are frequently associated with an increased rate of arterial
shunting and hypoxia, it becomes necessary to administer oxygen. A pregnant patient's
oxygenation can often be improved by nursing her in a semi-sitting position. Maternal PO2
values of less than 60 ram Hg during the pleuropulmonary complications that are often
secondary to inhalation have been considered critical, and it has therefore been
recommended that ventilatory support should be initiated as soon as possible. This is all
the more necessary because inhaled carbon monoxide can also cross the placental barrier to
compete for binding sites on foetal haemoglobin, provoking foetal cardiac oedema, and also
affect cardiac development .If the respiratory complication is bronchopneumonia, it is
necessary to use antibiotic treatment, if possible selecting drugs that the foetus can
tolerate. The same applies to cases of suspected and manifest sepsis.
B2. Local treatment.
The local treatment of burns in pregnant women is not simple, because of the limitations
imposed by the state of pregnancy. Chloramphenicol, either in powder form (Chemicetine) or
as an ointment in association with collagenase (lruxol), is among the drugs to be avoided
throughout pregnancy since it is teratogenous if administered during the first period of
pregnancy and responsible for neonatal pathology if used during the final period (grey
syndrome).
Gentamicin (Gentalyn cream, gentalyn ointment) is an aminoglycoside capable of passing
through the placenta after absorption through bums. If used after the 14th week of
pregnancy it can cause lesions in the 8th pair of cranial nerves, with vestibular and
acoustic damage. The full-temi foetus has been found to present antibiotic concentrations
analogous to those of the mother. In addition to ototoxicity aminoglycosides are
responsible for nephrotoxicity.
Rifamycin SV (Rifocyn for local use) is absolutely to be avoided in the last period of
pregnancy because its interference with bilimbin metabolism can cause indirect
hyperbilirubinaemia, with the risk of kemicterus.
Sulpha drugs (silver sulphadiazine-Sofargen) are suspected of potential teratogenous
activity if administered before the 14th week of pregnancy and of retarding growth,
determining low birth weight if subsequently administered. Sulpha drugs administered at
the term of pregnancy are responsible for kernicterus.
Salicylates (salicylate vaseline) exert an anti-prostaglandin action and may therefore
have a protective effect on pregnancy. For the same reason they should not be used in the
final period of pregnancy because they prolong gestation and delay spontaneous delivery.
There is little evidence regarding the possibility that salicylates have a teratogenous
effect, although the birth weight of babies born to women subjected to chronic
administration of salicylates has been reported to be below average. An increase in
perinatal mortality has also been reported. These results have not however been confirmed
in other studies.
Povidone-iodine (lodoten) is widely used for bums cleansing. It must however be avoided in
pregnant women since large amounts of iodine can be absorbed through the burn wound. Use
of povidone-iodine is inadvisable in bums exceeding 20% TBSA because the iodine passing
through the placenta can be absorbed in sufficient quantities to affect thyroid functions
and cause metabolic acidosis.
It is thus clear that the state of pregnancy considerably reduces use of the commonest
protocols for the topical treatment of burns. Even the local use of antibiotics that are
normally administered systemically presents considerable difficulties. The only
antibiotics that can be considered safe in pregnancy are the penicillins and
cephalosporins, while vancomycin, one of the most frequently used and most active
antistaphylococcal drugs, is considered to be potentially teratogenous and ciprophloxacin
may possibly damage articular cartilages in undeveloped organisms.
Other commonly used antibiotics (Imipenem, teicoplanin) should be avoided in the absence
of adequate information about their safety during pregnancy unless they are absolutely
necessary and their advantages outweigh any possible risk.
These considerations are also valid with reference to the parenteral use of the
above-mentioned drugs in the event of infective respiratory complications or sepsis.
Tetracyclines are not widely used in bums but it should not be forgotten that they are
contra-indicated during pregnancy because of their varying effects on foetal growth,
bones, teeth, and the immune system.
With regard to local treatment, if the medication is performed under anaesthesia it is
important to avoid the use of ketamine, which increases the excitability of the myometrium
because it is capable of triggering effective contractions; also, when the pregnancy is
near term and delivery is imminent, ketamine may cause respiratory depression in the
neonate.
B3. Surgical treatment.
In view of the difficulties related to local medical treatment, early surgical therapy
assumes vital importance. This is because early surgical facilitates healing of the wounds
and thus improves prognosis in both mother and neonate. Early coverage of the bums also
minimizes septic complications and the need to administer antibiotics; in addition, it
reduces painful medications and the necessity of analgesic drugs.
The treatment comprises early tangential excision and split-thickness skin-grafting 3-7
days post-buni in the deeper burned areas (but not more than 15-20% TBSA at one
operation). Wounds over the abdomen and breast have to be treated first. Good early
healing of the abdominal wound favours:
- pain-free stretching of the abdominal skin
during the developing pregnancy to term
- abdominal obstetric supervision of the
growing foetus
- performance of caesarian section if
required
Early surgery of the
breast wound prevents infection and sloughing of nipples and permits subsequent breast
feeding.
C. Obstetric management
of the pregnant woman with burns
If it is known that a burned female is pregnant, it is important to establish as precisely
as possible the exact stage of pregnancy at the time of the burn accident. This must be
based upon the menstrual history and foetal ultrasound examination. The gestational period
is in fact one of the factors determining obstetric procedures (no intervention,
protection of pregnancy by tocolithic treatment, induction and/or acceleration of labour).
Other factors are the severity of the burn and foetal viability, which must be confirmed
immediately. Such biophysical measurements as foetal muscle tone, limb motion and
breathing patterns, placental morphology, and amniotic fluid volume may be visualized in
order to assess foetal health.
With regard to the stage of gestation, foetuses delivered before 24 weeks generally will
not survive, while those delivered after 32 weeks will do well with modem neonatal
intensive care if born without hypoxia or birth trauma. The most difficult to manage are
foetuses of between 24 and 32 weeks' gestational age, where ex utero survival is
difficult to predict. In such cases, therefore, when pre-term labour occurs, tocolysis
procedures are initiated.
In the light of the findings of Ryan et al. (relative to two patients with respectively
65% and 70% TBSA bums presenting first-quarter pregnancy who survived and had full-term
deliveries), it was long believed that pregnancy improved prognosis in the mother.
However, the findings of Matthews indicated that a more advanced state of pregnancy
(2nd-3rd quarter) in women with over 50% TBSA bums had an unfavourable effect unless
delivery was immediate, as the burn created an unfavourable environment for the foetus; in
bums in less than 40% TBSA pregnancy and its continuation had no effect on prognosis in
the mother and every attempt had to be made to interrupt inception of labour if the foetus
was too immature to survive.
Table IV presents a protocol that has recently been proposed. Its presenters do not
suggest that the protocol should be applied rigidly in all cases but rather that it should
be regarded as a useful general guideline.
Total %
burn |
Age of gestation |
Management |
<
30 |
First trimester |
|
No obstetric interference |
Second trimester |
|
No obstetric interference |
Third
trimester |
More than 36 wks |
Induce labour / caesarian
section |
Less than 36 wks |
Conservative approach and
monitoring of heart rate |
30-50 |
First trimester |
|
Foetal monitoring by ultrasound
3-4 wks |
Second trimester |
|
Foetal monitoring every 3-4
wks. Tocolytic therapy |
Third trimester |
More than 32 wks |
Deliver foetus within 48 h |
Less than 36 wks |
Careful foetal monitoring |
50-70 |
First trimester |
|
Terminate pregnancy |
Second trimester |
|
Terminate pregnancy |
Third trimester |
If baby is viable |
Induce labour / caesarian
section within 24h |
Intrauterine death |
No active intervention up to 4
wks / monitoring of foetus of haemocoagulation factors |
> 70 |
First trimester |
|
No treatment |
Second trimester |
|
No treatment |
Third trimester |
|
Caesarian section as an
emergency procedure at the earliest |
From Gang et
aL 1992. |
|
Table
IV - Obstetric management of the pregnant burned woman |
|
Regarding
the manner of delivery (vaginal route, caesarian section), spontaneous vaginal delivery is
generally preferred, although 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 and may
permit timely intervention, preventing intrauterine death. In a critically burned woman
with a living and near-term pregnancy, foetal salvage by caesarian section appears
justifiable.
When there are obstetric indications for a caesarian section, this can be performed even
when the lower abdominal wall is part of the burned area.
Conclusion
Although the relevant
literature is limited, the incidence of bums in pregnancy does not appear to be low,
especially in developing countries such as India where bums constitute a social disease.
As hypovolaemia causes a reduction in uterine blood flow and in the amniotic fluid, the
overcoming of maternal shock is of fundamental importance for foetal prognosis. At a later
stage the drop in pressure related to septic episodes and the reduction of maternal PO2
secondary to pulmonary complications. Hypovolaemia and hypoxia are in fact the cause of
the spontaneous uterine contractions that lead to abortion or premature delivery after
intrauterine death of the foetus. An important role is played by the synthesis and
release of prostaglandin both by the burned skin and as a result of dehydration, if not
appropriately corrected.
The general and topical treatment of bums in
the pregnant woman has to take into account the embryonal, foetal, and perinatal toxicity
of the pharmacological therapy employed, since what is beneficial for the mother may be
harmful for the child. Particularly difficult therapeutic courses have been found to cause
serious malformations; and even the infusion of hypertonic glucose solutions can lead to
secondary hyperinsulaemia with foetal macrosornia.
In order to reduce pharmacological therapy to the minimum possible and to accelerate the
burn healing process (and thus improve prognosis), the majority of authors are favourable
to early surgical intervention. Obstetric management of pregnancy in the burned woman
requires:
- monitoring of the pregnancy by frequent
ultrasound scanning, daily measuring of the blood clotting factor, and, where possible,
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; obstetric treatment must be P-Aated to these two parameters
- choice of method of delivery (vaginal
route, caesarian section).
RESUME.
Les Auteurs décrivent deux cas de brûlures pendant la grossesse. Après avoir examiné
la littérature relative et discuté l'incidence du phénomène, ils approfondissent la
physiopathologie de l'activité utérine spontanée et les aspects qui concernent soit le
traitement des brûlures soit la gestion obstétricale en fonction du pronostic
maternofétale.
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This paper was received on 24
June 1999. Address correspondence to:
Dr B. Napoli
Divisione di Chirurgia Plastica e Terapia delle Ustioni
Ospedale Civico, Palermo, Italy
E-mail: rnbcpa@cres.it |
|