SUMMARY. This is a prospective study of ten female patients with burns in the first trimester of pregnancy out of a total of 940 admissions treated in the burns unit of the Royal Jordanian Rehabilitation Centre, King Hussein Medical Centre, Jordan over the 5-yr period from 1/1/1996 to 31/12/2000. The commonest cause was an accidental direct flame burn due to gas, occurring in the home. The average total burn surface area was 36.6%. The maternal and foetal death rates were respectively 30 and 50%.
Burn injury has long been described as amongst the severest that afflict human beings. During pregnancy it is known to have an adverse effect on foetal and maternal survival.1-3 It presents special management problems for both the gravid woman and her foetus. A review of the literature shows that prognosis is poor, especially in the first trimester.4 With improvement in the overall survival of burn patients, the pregnant woman with burns also stands a better chance of survival. Our study investigates the outcome for both mother and foetus in the first trimester of pregnancy.
This is a prospective study of burns in the first trimester of pregnancy treated in the Burn Unit of the Royal Jordanian Rehabilitation Centre-King Hussein Medical Centre, Jordan, over the 5-yr period from 1/1/1996 to 31/12/2000. This forms part of a continuing audit of all burn admissions to our unit. Ten patients (1.06%) out of a total of 940 and 6.9% out of 143 female admissions within the reproductive age group over this 5-yr period were positively identified as being pregnant in the first trimester. These patients were analysed with respect to age, cause of burn, place of burn, hospital stay, total burn surface area, and outcome for mother and foetus.
The commonest cause of the burns was a direct flame burn (eight patients, 80%) due to gas, while two patients (20%) sustained a scald burn respectively from tea
and cooking broth. All the burn injuries occurred in the home.
The age of the patients ranged between 17 and 35 yr, with an average of 24.8 yr. All were married at the time of the burn.
Nine patients (90%) were burned accidentally burnt, while one patient (10%) had attempted suicide after a marital quarrel.
The total body surface area burned varied between 4 and 81%, with an average of 36.6%. Most patients suffered deep second- and third-degree burns.
Two patients died of septicaemia, while one with inhalation injury was put on a ventilator but died within 48 h of admission. All three deceased patients miscarried prior to their demise. The remaining seven patients (70%) were discharged from hospital after treatment of their burns in good general health; only one patient had a miscarriage during hospitalisation, while one abortion occurred three months after discharge (24 weeks gestation) for unknown reasons.
The overall foetal death rate for this cohort of patients was 50%; the remaining five pregnancies delivered normally at full term with no congenital anomalies (Table I).
<% createTable "Table I ","TBSA percentage burns and maternal and foetal survival","@; §1,3§Maternal deaths§1,2§Foetal deaths@;TBSA %;No.;No.;%;No.;% @;1-9;1;-;-;-;- @;10-29;3;-;-;1;33.03.00@;30-49;4;1;25;2;50@;50-69;-;-;-;-;- @;70-89;2;2;100;2;100","",4,300,true %>Five patients (50%) had surgery in the form of split-thickness skin grafts at least two weeks after admission, while the others were treated conservatively with early and adequate resuscitation, topical antimicrobial agents, nutritional supplements, infection control, and delayed grafts, as well as regular foetal monitoring with the help of the obstetrician.
Three patients in this series (30%) died after an average hospital stay of 3.6 days, while the remaining seven who survived (70%) had an average stay of 30.2 days.
Like anyone else, a pregnant woman is liable to burn injury. But treatment is difficult since the clinician has to treat both the mother and the foetus. As regards the mother, the aim is to treat her so that she has full range of function and the foetus is able to reach full term without any congenital defects.
Burn injury during pregnancy poses two important problems. First, there may be spontaneous uterine activity and, second, intrauterine foetal death may occur owing to compromised circulation in the less preferred gravid uterus and foetoplacental unit. Respiratory injuries aggravate the situation owing to respiratory exchange disturbances, which lead to further hypoxia.
Burns during pregnancy appear to be a problem in developing countries. Seven per cent of all adult female patients admitted to burns units are pregnant,1,6,7 compared to 6.9% in our series.
In the first trimester of pregnancy, treatment is more difficult because of the high risk of abortion. The use of anaesthesia for early escharectomy and grafting is hazardous for the foetus and may cause a congenital anomaly if the foetus survives. Our treatment was therefore conservative, with early and adequate resuscitation, topical antimicrobial agents, nutritional supplements, infection control, and surgical coverage with split-thickness skin graft when granulation tissue forms,5 plus close monitoring of the foetus.
There was no specific reason why some foetuses survived and others did not, in spite of the same treatment regimen. Foetal death was not preceded by maternal death.
The pregnancy did not affect the course and outcome of the mother compared with non-pregnant burned females.8 The three maternal mortalities were due to high TBSA percentage and septicaemia.
As most of the pregnant females were burned accidentally, there is scope for prevention planning through the education of such pregnant females in an antenatal care clinic. Preventive measures to reduce the severity of injury by instituting proper first-aid measures (prompt cooling of the burn with cold water) to reduce the depth of the injury are another possible strategy to counter poor survival.
We recommend conservative treatment in first-trimester burns and surgical intervention only when needed. In our series 50% of mothers required split-thickness skin grafting under general anaesthesia. No cases of abortion or maternal death were observed following the operation. Seventy per cent of the mothers had full-term normal vaginal deliveries without the occurrence of congenital anomalies. We observed that pregnant patients were more prone to develop hypertrophic scars and hyperpigmentation, which subsided to some extent after delivery although 30% of the patients needed minor procedures to release post-burn contractures later after delivery.
A routine pregnancy test is recommended for all admissions of women of childbearing age in order to identify pregnant women and treat them accordingly.
A pregnant woman is as susceptible to burn injury as any other person but treatment is difficult compared with that of a non-pregnant woman, especially in the first trimester.
Conservative treatment is satisfactory and there is 50% chance of survival of the foetus, as shown in our study.
A routine pregnancy test is recommended for all burned women of childbearing age.
RESUME. Les Auteurs présentent une étude prospective de dix patientes atteintes de brûlures dans le premier trimestre de la grossesse sur un numéro total de 940 hospitalisations auprès de l’unité des brûlures du Centre Royal Jordanien de Rééducation, Centre Médical Roi Hussein, Jordanie pendant une période de 5 ans (1/1/1996 - 31/12/2000. La cause la plus commune des brûlures était la flamme directe accidentelle causée par le gaz dans l’environnement domestique. La surface corporelle moyenne brûlée était 36,6%, et les taux de mortalité de la mère et du fœtus était respectivement 30 et 50%.