El-Gallal A.R.S., Yousef S.M.

Plastic Surgery and Burns Unit, University of Garyounis, Faculty of Medicine, Benghazi, Libya

SUMMARY. Thirty-one pregnant women admitted to the Burns Unit based at Aljala Hospital in Benghazi (Libya) with thermal injuries (mostly domestic accidents) over a ten-year period (1992-2001) were studied retrospectively. There were eight patients had minor injuries, fifteen with moderate injuries, and the remaining eight patients presented serious major burns. Eight patients had other associated co-morbid problems. Six patients were in the first trimester of pregnancy, eight in the second, and 17 in the third. Seven patients with major burns died, while 20 patients with moderate and minor burns required skin grafting procedures in the course of their burn management. Fourteen patients with minor and moderate injuries gave birth to normal healthy babies; only five were by caesarean section. In this study, we present the Benghazi Burn Unit’s last ten years’ experience in the management of burned pregnant patients. We conclude that dealing with such cases is still difficult, and consideration must be given to prevention.

Introduction

Burned pregnant patients requiring admission are not frequently seen in our Accident and Emergency Department, yet this remains one of the most difficult cases to deal with. It is often associated with a high rate of both foetal and maternal mortality and morbidity. We aim in this paper to highlight the importance of this clinical status, to determine its prevalence in our region, and to evaluate our results, which have not been previously reported.

Patients and methods

Aljala Hospital in Benghazi is a 450-bed Accident and Emergency teaching hospital with an annual admission rate of about 15,000 cases that include 850 to 950 burns and scalds; it serves about 30% of Libya’s 4.5 million population.

The hospital’s records, operation register, and obstetric notes for all admitted burned pregnant women for the ten-year period January 1992-December 2001 were thoroughly reviewed and analysed with reference to the following variables: age, nationality, illegitimacy, associated pre-existing medical and/or social problems, type and cause of injury, percentage total body surface area (TBSA) burned, period of gestation, and foetal and maternal outcome. Using criteria established by the American Burn Association (1976), the burns in our patients were categorized into minor, moderate, or major.

Pregnancy tests and ultrasonography were the main diagnostic examinations used for confirming pregnancy and its progress in all patients. The patients were nearly all evaluated and followed up by the same team of plastic surgeons.

Results

Thirty-one burned pregnant patients - 29 Libyan and 2 non-Libyan (Egyptian and Sudanese) - were encountered during the ten-year period; on admission the patients ranged in age from 21 to 48 yr, with a mean age of 31.9 yr.

On admission, three women were known diabetic patients, two were hypertensive, and two were epileptic patients whose medical conditions were found to be uncontrolled at the time of their burn. Three patients gave a history of attempting suicide and these were considered to have psychosocial problems.

Of the 31 patients reviewed, eight were admitted with minor burn injuries and fifteen with moderate burns; eight patients had sustained serious major injuries.

The nature of the injury was accidental in 28 patients: 20 cases were due to gas explosions in the home and eight patients were seriously scalded by hot water, oil, or food. There were three attempted suicide cases; all had suffered clothing burns (using kerosene oil to burn themselves). The TBSA range was 6-85%, with a mean value of 27.7 %. Smoke inhalation and respiratory complications were the major problem in four patients with moderate and major injuries in the first few post-admission days.

The patients’ gestational age ranged from 9 to 39 weeks. Six patients were in the first trimester, eight in the second, and 17 in the third trimester. The pregnancy of three patients (two single and one divorced) proved to be illegitimate.

With regard to foetal and maternal outcomes, Table I shows that out of the eight patients with minor burns only one had a miscarriage in the first trimester; six patients underwent skin grafting procedures in the course of their burn management; one patient required a caesarean section. Among the 15 patients with moderate burns (Table II), six perinatal deaths and two miscarriages were encountered; 13 patients underwent skin grafting procedures; four patients required a caesarean section. Regarding the patients with major burns (Table III), seven died within two weeks: three deaths were due to gram-negative septicaemia,

two to inhalation injury and respiratory complications, and two to renal failure. Three miscarriages and five perinatal deaths were encountered among these severely injured patients.

Discussion

Burn injury during pregnancy is comparatively rare in our society, allowing little opportunity for the problem to be viewed in a true prospective. This point is emphasized by the record made in this study, in which only thirty-one burned pregnant patients were encountered during the ten-year period. This low prevalence is not peculiar to our community, since - excluding some non-comparable figures from India1-4 - such a low incidence has also been reported elsewhere.5-8

The importance of associated co-morbid factors, which not only further complicate management but may also themselves be responsible for the burn injuries, is clearly shown in our study, in which, out of the eight patients with scald injuries, four (i.e. 50%) were epileptic and diabetic. The cultural concept of illegitimacy in our conservative society is intimately and deeply linked to the honour and dignity of the whole family, and this puts intense psycho-social pressure on the family as well as on the patient; this may have been the motive for the attempted suicides of three of our patients in their first trimester (major cases with >60% TBSA).

Burn injury during pregnancy remains a serious clinical problem that needs close co-operation between the surgical and the obstetric teams, and individualization of its management is always necessary. There have been quite a number of papers describing the effects of burn injury and the influence of its standard treatment on the foetus and the course of pregnancy;1,9-14 nearly all of these agreed that burns in pregnancy should be considered a clinical state that demands special management. This necessarily requires early and adequate resuscitation13 and the use of a limited choice of antibiotics and local antibacterial agents;1,15 it often necessitates early surgical intervention4,16 and calls for a special obstetric protocol.1,5,8,16

Among the patients with minor and moderate injuries, fourteen pregnancies had a favourable outcome and, of these, nine patients had normal vaginal deliveries almost at term. We attribute the relative success in the management of these cases to early adequate resuscitation and early obstetric involvement.

Our experience with these cases has shown that, overall, maternal and foetal outcomes appear to be largely determined by the severity of the burn injury as well as by the period of gestation, and this does not differ much from what has been observed in other centres serving similar societies.6,8 Foetal demise can also be attributed to the existence of serious complications,1,8,16 and in our series this is evident in four cases where the burns were complicated by inhalation injury.

Conclusion

It is therefore clear that our maternal and foetal outcomes, together with the difficulties involved in the management of such cases, highlight the importance of incorporating burn prevention in routine prenatal care; surgeons and obstetricians should also be urged to work on an acceptable management protocol for burned pregnant patients.

RESUME. Une étude rétrospective a été effectuée dans 31 patientes enceintes hospitalisées pendant une période de dix ans (1992-2001) dans l’Unité des Brûlures basée à l’Hôpital d’Aljala à Benghazi (Libye) atteintes de brûlures thermiques (principalement dues à des accidents domestiques). Huit des patientes présentaient des lésions mineures, quinze des lésions modérées et huit des lésions graves. Huit patientes présentaient en outre des problèmes de co-morbidité associée. Six patientes étaient au premier trimestre de la gestation, huit dans le second et 17 dans le troisième. Sept patientes atteintes de brûlures graves sont mortes, et 20 patientes atteintes de brûlures modérées et mineures ont eu besoin des procédures de greffe cutanée dans le cours de la gestion des brûlures. Quatorze patientes avec des lésions mineures et modérées ont donné naissance à des enfants sains normaux; en seulement cinq cas une section césarienne a été nécessaire. Dans cette étude les Auteurs présentent l’expérience de l’Unité de Brûlures de Benghazi pendant les dix derniers ans dans la gestion des patientes enceintes brûlées. Ils concluent que le traitement de cette catégorie de patients continue à présenter des difficultés et qu’il faut toujours apporter toute notre attention à la prévention.

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