Ann. Medit. Burns Club - voL VII - n. 3 - September 1994

PREGNANCY AND BURNS: EXPERIENCE FROM FIVE CASES*

loannovich J, Kastana D., Alexakis D., Tsoutsos D., Panayotou P.

Department of Plastic Surgery and Microsurgery, General State Hospital of Athens, Greece

SUMMARY. The bums disease influences the course of pregnancy and has specific effects on both mother and fetus. The already hypermetabolic pregnant woman has to overcome the metabolic and septic complications of the bums disease. The alterations in the metabolic, hydrostatic, electrolytic and hormonal environment of the mother have direct consequences on the fetus's growth, metabolism, nutrition and the general status. Spontaneous abortion is often due to heat-induced degradation of albumins and to the circulation of various tissue hormones. The septic complications of the burns disease may also induce premature labour. This study presents five cases of pregnant women with burns and discusses the consequences of the burns disease in pregnancy.

The burns disease influences the course of pregnancy and has specific effects on both mother and fetus. The already hypermetabolic pregnant woman also has to overcome the metabolic and septic complications of the burns disease.
It is widely believed that the prognosis of the burn disease in the pregnant woman is good, owing to enhanced wound healing. This concept has not been found to'be true in large series and should not be taken for granted. On the contrary, careful monitoring of the metabolic, hydrostatic, electrolytic and hormonal alterations must be followed throughout treatment, with close collaboration from the gynaecologists.

Five pregnant women with burns disease were treated in our unit in the period 1988-1993 (burn range: 9-60% T13SA, partial- and full-thickness). Four patients survived and one died of acute respiratory failure. Of the survivors, one patient had a miscarriage and the other three continued their gestation.
The first patient, a 23-year~old woman at week 28 of gestation, sustained a 9% T13SA partial-thickness burn. The burn wound involved the upper extremities, the face and the neck. She was admitted immediately after injury and hospitalized for seven days. Resuscitation was commenced with Ringer's lactate to maintain adequate urine output. Analgesia was maintained with paracetamol per os. Local treatment consisted of paraffin dressings and Betadine solution, since the extent of her injury was limited. The wounds healed without complications and the patient was discharged on day 7 post-burn. The remainder of the pregnancy was uneventful.

• Paper presented at the 7th MBC meeting at Perpignan, December 1993.

The second patient was 16 years old and in her 28th week of pregnancy. She was admitted on day 2 post-bum with 30% T13SA burns in the chest, abdomen and lower extremities. The leg burns were full-thickness. The patient was operated on with epidural anaesthesia on day 10 postburn. All full-thickness areas were covered with splitthickness meshed skin grafts. The post-operative recovery was uneventful and the grafts took well. The patient was then transferred to a maternity hospital, where she had a normal delivery.
The third case was a 26-year-old woman in her 20th week of pregnancy, brought to our department on day 40 post-burn. She presented deep partial-thickness burns in the abdominal wall. On day 10 post-burn she had suffered a pulmonary embolism. Conservative treatment was applied with paraffin gauze and povidone iodine solution. The patient developed uterus bleeding on day 47 post-burn and was transferred to a maternity hospital, where she had a miscarriage two days later.
The fourth patient was a 37-year-old woman in the 28th week of pregnancy. She was admitted on day 2 postburn with 40% T13SA deep partial- and full-thickness burns in the upper and lower extremities, abdominal wall and buttocks. On admission the patient was dehydrated and the amniotic fluid was found to be limited. Resuscitation was commenced with Ringer's lactate and plasma to maintain adequate urine output. Immediately after resuscitation the amniotic fluid was adequate. The fetal pulse was normal. Conservative treatment was initiated in order to reach the 30th week of pregnancy. Five days later the patient developed dyspnoea and blood gas abnormalities. A diagnosis was made of multiple small pulmonary infarcts. It was decided to perform a premature delivery by Caesarian section. The child was delivered healthy and transferred to a maternity hospital. The mother was put on mechanical ventilation for 72 hours because of her respiratory distress. She was also received anticoagulant therapy. Ten days later she was subjected to surgery. Split-thickness skin grafts were used to cover the burned surfaces of the lower extremities. This protedure was repeated seven days later in general anaesthesia. The child remained healthy and the mother was discharged on day 60 post-burn.
The fifth and last patient was a, 30-year-old woman in her 24th week of gestation. She was admitted on day 2 post-burn with 60% TI3SA full-thickness burns in the face, arms and torso. She also had inhalation injury. On resuscitation the patient developed acute respiratory distress and despite immediate intubation she died. Postmortem examination revealed pulmonary oedema and aspiration of gastric fluid.

All five pregnant women with burns were resuscitated using the Parkland formula with alterations adjusted to individual needs and changes in the intravascular volume. Gynaecological advice and treatment were immediate and continued throughout the patients' treatment. All the patients received tocolytic drugs.

All metabolic changes of the burn disease are enhanced by the hypennetabolic state of gestation. There is also an increase of the intravascular space in pregnant women of up to 40% in volume. Extreme care should therefore be taken to initiate resuscitation therapy as soon as possible, since the mother's intravascular space is in equilibrium with the amniotic fluid. Resuscitation should be vigorous to prevent intrauterine death of the child due to loss of amniotic fluid.

Special care should also be taken regarding the position of the patient in order to prevent:

1. restriction of the respiratory moments and pulmonary atelectasis;
2. pressure on the large veins which combined with clotting will lead to venous thrombosis.

Absorbable local antiseptic or antibacterial agents should be avoided, specially when the TBSA burned is extensive.

The burn disease has serious consequences for the pregnant woman. There is an increase in morbidity and mortality in the mother and fetus, and the normal termination of gestation is endangered.

RESUMIE. La maladie des brûlés modifie le cours de la grossesse et produit des effets spécifiques sur la mère et sur l'enfant. La femme enceinte, hypermétabolique à cause de sa condition, doit surmonter les complications métaboliques et septiques provoquées par les brûlures. Les altérations des conditions métaboliques, hydrostatiques, électrolytiques et hormonales de la mère ont des conséquences directes sur la croissance, le métabolisme, la nutrition et les conditions générales du foetus. L'avortement spontané est souvent causé par la dégradation des albumines provoquée par la chaleur ou par la circulation des divers hormones des tissus. Les complications septiques de la maladie des brûlés peut aussi provoquer le travail prématuré. Les auteurs présentent cinq cas de femmes enceintes atteintes de brûlures et ils considérent les conséquences des brûlures pendant la grossesse.

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