burns in pregnancy

8/12/2019 Burns in Pregnancy

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BURNS IN PREGNANCY

Napoli B., D'Arpa N., Masellis M., Graziano R.

Divisione i C!ir"r#ia Plas$i%a e &erapia elle Us$ioni, speale Civi%o, Paler(o, I$al) Divisione s$e$ri%ia e Gine%olo#ia, speale Civi%o, Paler(o

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 booksdevoted to the treatment of bums. Tables I andIIpresent the authors and cases present in the

literature in papers, covering the problem.

Casen"(*er

A"$!or Year Perio o+

s$")N"(*er o+

%asesMa$ernal

ea$!oe$alea$!

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 Taylr 1976 1950-74 19 7 7

9 !ham"agnie 1977 - 1 0 0

10 Si#mn$i 1979 - 1 0 0

11 %ing&ei () 1981 1956-78 24 2 5

12 Stilell 1982 - 1 0 1

13 Matthe# 1982 - 16 6 8

* !a#e# + ,n$ian rigin

Table I- Summary table of authors and cases until 1!"


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#esides 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. $atthews discusses

%& cases based partly on a 'uestionnaire sent to all bums centres in the () *1+ cases and partlyon the previous literature * cases, and provides data regarding works by Sismondi et al.,

/ingbei 0. et al., and Stilwell his work thus presents an almost complete survey of the literature

up to 1!".

Casen"(*er

A"$!or Year Perio o+

s$")N"(*er o+

%asesMa$ernal

ea$!oe$alea$!

14 Ray&urn 1984 1964-81 30 8 12

15 eitch 1985 1978-83 11 0 3

16 .my 1985 1950-84 11 3 6

17 Bartle 1988 1955-75 42 3 20

18 Sri/a#ta/a 1988 1984-87 8 0 2

19 Benineir 1988 1970-86 8 2 3

20 !heah 1989 1981-87 9 2 2

21 R$e 1990 1986-87 33 8 13

22 Ma&gunge 1990 1972-81 7 1 2

23 ang 1992 1984-89 8 1 3

24 ain* 1993 1986-91 25 5 9

25 .htar* 1994 1991-93 50 35 36

26 lann/ich 1994 1988-93 5 1 2

27 !ale++i 1994 - 1 0 0

28 ra#anna* 1996 1992-94 6 1 1

29 Sarar* 1996 1993-95 20 0 12

* !a#e# + ,n$ian rigin

Table II - Summary table of authors and cases after 1!"

The characteristics of later papers untilthe present day are however no different. 2aybum et al.

report & cases studied over an 1!-yr period in three American university bums centres Arny et

al. also describe & cases, 1 of which had however already described by Taylor et al. someyears previously 3ang et al. reported 1+ cases, half of which had already been presented by

Srivastava et al. 4ases 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


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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. #efore proceeding any further, however, a

word of warning is necessary - 4hampagnie5 published his case twice, while and /ingbei et al.published their " 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 ofreproductive 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 &.+6 reported from

7srael by #enmeir et al., Taylor et al. calculated an incidence of 86, a rate also found by Amy etal.in later years *+.86, 9ort :ouston, while the rate of 8.6 reported by Srivastava et al. was

confirmed by 3ang et al. *8.!6, )uwait. The highest of all burn incidences in pregnancy was

found in 7ndia, ranging from 86, calculated by Akhtar *;agpur, to 1.6, reported by


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Fig. 1- Cxtraction of foetus. Fig. - =atient after caesarian section.

Fig. !- The living and viable foetus.

"iscussion

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 tobe triggered by the endocrine function, and in particular by that of the secretion of adrenocortical

hormones related to stress.

Dater observations confirmed that slight bums had no effect on the course of pregnancy, while

bums of at least %6 T#SA were capable of provoking early labour and the loss of the foetusfollowing intrauterine death within a week of the bum.

#oth spontaneous miscarriage and premature delivery were subse'uently thought to be related to

the synthesis and release of prostaglandins *responsible for early uterine contractions from theskin in the burn area. Dater, 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 =&" and conse'uently, as in this case, foetal hypoxia. Table IIIpresents 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 accompaniedby 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.


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Table III- Cvents determining spontaneous uterine activity

As the maternal intravascular space is in a state of e'uilibrium with the amniotic li'uid, the

reduction of this li'uid during serious hypovolaemia can cause the intrauterine death of thefoetus. The onset of spontaneous uterine contractions is also favoured by the release from

bacteria and the placenta of an enEyme, phospholipase A, which is necessary for the conversion

of arachidonic acid into prostaglandin. 7t has recently been shown that there is a considerable

reduction in plasma levels of 18#-oestradiol in pregnant burned women who had either anabortion or a still birth in the first week post-bum.

#.Burns treatment - its influence on the course of pregnancy and the foetus

#l. 3eneral treatment.

2esuscitation treatment in the burned pregnant woman is no different from that in thenonpregnant burned woman. The prevention of hypovolaemic shock by ade'uate early fluid

therefore re'uires that the uterine blood flow should be able maintain foetus tissue =@"levels

within the normal range. 7t has been recommended that a 'uantity of fluid should be

administered that is sufficient to maintain the motherBs blood pressure within the normal rangeand a diuresis of &-+& mlFh. The maintenance of arterial pressure levels at normal values is

essential at all stages of the burn disease. ?iuretics and anti-hypertension drugs should thereforebe avoided whenever possible. Cpisodes of hypotension should be avoided also in the event of

surgical operations. 7t is recommended that surgery should be performed with intraoperative

maintenance of a minimum of 1 mlFkgFh of urine volume and 1&&6 oxygen saturation.

Since extensive surface bums are fre'uently associated with an increased rate of arterial shuntingand hypoxia, it becomes necessary to administer oxygen. A pregnant patientBs oxygenation can


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often be improved by nursing her in a semi-sitting position. $aternal =@"values of less than +&

ram :g during the pleuropulmonary complications that are often secondary to inhalation have

been considered critical, and it has therefore been recommended that ventilatory support shouldbe 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 .7f the respiratorycomplication 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.

#". Docal treatment.The local treatment of burns in pregnant women is not simple, because of the limitations

imposed by the state of pregnancy. 4hloramphenicol, either in powder form *4hemicetine or as

an ointment in association with collagenase *lruxol, is among the drugs to be avoidedthroughout 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.

3entamicin *3entalyn cream, gentalyn ointment is an aminoglycoside capable of passingthrough the placenta after absorption through bums. 7f used after the 1th week of pregnancy it

can cause lesions in the !th 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.

7n addition to ototoxicity aminoglycosides are responsible for nephrotoxicity.2ifamycin SG *2ifocyn 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 sulphadiaEine-Sofargen are suspected of potential teratogenous activity if

administered before the 1th week of pregnancy and of retarding growth, determining low birth

weight if subse'uently 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. 9or the same reason they should not be used in the final period of

pregnancy because they prolong gestation and delay spontaneous delivery. There is littleevidence regarding the possibility that salicylates have a teratogenous effect, although the birth

weight of babies born to women subected to chronic administration of salicylates has been

reported to be below average. An increase in perinatal mortality has also been reported. Theseresults have not however been confirmed in other studies.

=ovidone-iodine *lodoten is widely used for bums cleansing. 7t must however be avoided in

pregnant women since large amounts of iodine can be absorbed through the burn wound. (se ofpovidone-iodine is inadvisable in bums exceeding "&6 T#SA because the iodine passing

through the placenta can be absorbed in sufficient 'uantities to affect thyroid functions and cause

metabolic acidosis.7t is thus clear that the state of pregnancy considerably reduces use of the commonest protocols

for the topical treatment of burns. Cven 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 fre'uentlyused and most active antistaphylococcal drugs, is considered to be potentially teratogenous and

ciprophloxacin may possibly damage articular cartilages in undeveloped organisms.


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@ther commonly used antibiotics *7mipenem, teicoplanin should be avoided in the absence of

ade'uate 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 pregnancybecause of their varying effects on foetal growth, bones, teeth, and the immune system.

>ith 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 iscapable of triggering effective contractions also, when the pregnancy is near term and delivery

is imminent, ketamine may cause respiratory depression in the neonate.

#. Surgical treatment.

7n view of the difficulties related to local medical treatment, early surgical therapy assumes vitalimportance. This is because early surgical facilitates healing of the wounds and thus improves

prognosis in both mother and neonate. Carly coverage of the bums also minimiEes septic

complications and the need to administer antibiotics in addition, it reduces painful medicationsand the necessity of analgesic drugs.

The treatment comprises early tangential excision and split-thickness skin-grafting -8 days post-

buni in the deeper burned areas *but not more than 1%-"&6 T#SA at one operation. >ounds

over the abdomen and breast have to be treated first. 3ood early healing of the abdominal woundfavoursH

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 re'uired

Carly surgery of the breast wound prevents infection and sloughing of nipples and permits

subse'uent breast feeding.

C. bstetric management of the pregnant !oman !ith burns7f 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 tocolithictreatment, induction andFor acceleration of labour. @ther 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 visualiEed in order to assess foetal health.>ith regard to the stage of gestation, foetuses delivered before " weeks generally will not

survive, while those delivered after " weeks will do well with modem neonatal intensive care ifborn without hypoxia or birth trauma. The most difficult to manage are foetuses of between "

and " weeksB gestational age, where e" utero survival is difficult to predict. 7n such cases,

therefore, when pre-term labour occurs, tocolysis procedures are initiated.

7n the light of the findings of 2yan et al. *relative to two patients with respectively +%6 and 8&6T#SA bums presenting first-'uarter pregnancy who survived and had full-term deliveries, it


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was long believed that pregnancy improved prognosis in the mother. :owever, the findings of

$atthews indicated that a more advanced state of pregnancy *"nd-rd 'uarter in women with

over %&6 T#SA bums had an unfavourable effect unless delivery was immediate, as the burncreated an unfavourable environment for the foetus in bums in less than &6 T#SA 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 I#presents a protocol that has recently been proposed. 7ts 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.

&o$al -*"rn

A#e o+ #es$a$ion Mana#e(en$

30

ir#t trime#ter tetric inter+erence

Secn$ trime#ter tetric inter+erence

Thir$ trime#terMre than 36 # ,n$uce la&ur cae#arian #ectin

e## than 36 # !n#er/ati/e a""rach an$ mnitring + heart rate

30-50

ir#t trime#ter etal mnitring &y ultra#un$ 3-4 #

Secn$ trime#ter etal mnitring e/ery 3-4 #) Tclytic thera"y

Thir$ trime#terMre than 32 # eli/er +etu# ithin 48 h

e## than 36 # !are+ul +etal mnitring

50-70

ir#t trime#ter Terminate "regnancy

Secn$ trime#ter Terminate "regnancy

Thir$ trime#ter

,+ &a&y i# /ia&le ,n$uce la&ur cae#arian #ectin ithin 24h

,ntrauterine $eath acti/e inter/entin u" t 4 # mnitring ++etu# + haemcagulatin +actr#

70

ir#t trime#ter treatment

Secn$ trime#ter treatment

Thir$ trime#ter !ae#arian #ectin a# an emergency "rce$ure at theearlie#t

rm ang et a 1992)

Table I# $ @bstetric management of the pregnant burned woman


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2egarding 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, bymeans of cardiotocographic recording, identifies foetal stress at an early stage and may permit

timely intervention, preventing intrauterine death. 7n a critically burned woman with a living and

near-term pregnancy, foetal salvage by caesarian section appears ustifiable.>hen 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 tobe low, especially in developing countries such as 7ndia 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 =@ "secondary to

pulmonary complications. :ypovolaemia and hypoxia are in fact the cause of the spontaneousuterine 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 theburned 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 isbeneficial for the mother may be harmful for the child. =articularly 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.

7n order to reduce pharmacological therapy to the minimum possible and to accelerate the burnhealing process *and thus improve prognosis, the maority of authors are favourable to early

surgical intervention. @bstetric management of pregnancy in the burned woman re'uiresH

monitoring of the pregnancy by fre'uent ultrasound scanning, daily measuring of the

blood clotting factor, and, where possible, cardiotocographic monitoring. 7ntrauterine

death of the foetus may be preceded by a reduction of 18!-oestradiol and C, levels

calculation of the stage of gestation and the gravity of the burn obstetric treatment must

be =-Aated to these two parameters

choice of method of delivery *vaginal route, caesarian section.

R%SUM%. Des Auteurs dIcrivent deux cas de brJlures pendant la grossesse. AprKs avoir examinI la littIrature

relative et discutI lBincidence du phInomKne, ils approfondissent la physiopathologie de lBactivitI utIrine spontanIe

et les aspects 'ui concernent soit le traitement des brJlures soit la gestion obstItricale en fonction du pronostic

maternofItale.


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&I&'I()RA*+Y

1. $atthews 2LH @bstetric implications of bums in pregnancy. #r. ., /ingie 0., /onghua S.H #ums during pregnancyH Analysis of " cases. 4hin.

$ed. ., Smith #., 9eller 7., Garner $., 4ruikshank ?.H $aor bums during pregnancyH Cffect on fetal

well-being. @bstet. 3ynecol., +H "-%, 1!.

+. Amy #.>., $c$anus >.9., 3oodwin 4.>., $ason A., =ruitt #.A., rH Thermal inury in the pregnant

patient. Surg. 3ynec. @bst., 1+1H "&-1", 1!%.

8. Taylor ., =lunkett 3.?., $c$anus >.9., =ruitt #.A., rH Thermal inury during pregnancy. @bstet.

3ynec., 8H -!, 18+.

!. 3ang 2.)., #aee


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"1. ?eitch C.A., 2ightmire ?.A., 4lothuer ., Siskind G., :emonen @.=., Slone ?.H =erinatal mortality and

birthweight in relation to aspirin taken during pregnancy. Dancet, 1H 18%-+, 18+.

"!. Agolini 3., $icali 3., 2aitano A.H Antisettici e chemioterapici nella terapia topica delle ustioni. 2iv. 7tal.

4hir., &H "-+8, 1!.

". 2yan 2.9., Dongenecker 4.3., Gincent 2.>.H Cffects on pregnancy on healing bums. S. 9orum Am. 4oll.

Surgeons, 1H !-%, 1+".

&. 2yan 2.9., Dongenecker 4.3., Gincent 2.>., #ergeron

burns in pregnancy

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