Burns During Pregnancy: Is the Outcome Still Gloomy? A Follow-up Case Series

Abstract

INTRODUCTION

Burns are one of the most devastating injuries which not only cause death or disability but also a major economic burden and long-term mental and physical complications.^1,2 Despite the incidence of burns in pregnancy not being high, varying between 0.67% and 15% in multiple reports,^3–9 its occurrence leads to high morbidity and mortality for both mother and fetus.^1,10–12 It has been reported that maternal and fetal mortality rates approach 50% when 40%-60% of the mother’s total body surface area (TBSA) is burned.^13,14,15

The presence of a fetus creates maternal physiological changes and burns place additional stress on systems that are already highly modified.¹⁶ The patient’s ability to respond to the burn may be compromised, and due to limited reserves to ensure the safety of the fetus.

Burns during pregnancy are generally not often reported in developed countries.¹⁷ Most of the literature has come from third world countries where accidents while using kerosene stoves present the greatest risk.³ Because of the rarity of occurrence, management guidelines as well as maternal and fetal risk factors have not been well established.¹⁷ Hence, management of critical burn injuries during pregnancy remains a challenge, since cases are not common, the clinical presentations are variable; no 2 cases are similar as regards the burn or the stage of pregnancy.

In 1997, we published a series of 27 cases of pregnant women who were managed and followed up for fetal and maternal outcomes at Ain Shams University’s burn unit and Maternity Hospital during the period from October 1995 to September 1996.³ During the 12-month period, 27 pregnant burned patients were managed.

Fetal and maternal mortality correlated with the TBSA burned, with the mortality rate being 63% for both mothers and fetuses in the 25%-50% TBSA group. A fetal loss of 56% with no maternal loss was recorded in the 15%-25% TBSA group. The high fetal and maternal mortalities prompted us to name the manuscript “Burns during pregnancy; a gloomy outcome.”¹

Now, 2 decades later, we report on 7 cases of burns admitted to the burn unit and the Maternity Hospital at Ain Shams University, during the period from January 2019 through June 2022.

PATIENTS AND METHODS

From January 2019 through June 2022, pregnant patients admitted to the burn unit and the Maternity Hospital at Ain Shams University were included in this study.

Demographic data and obstetric history were documented for each patient as well as TBSA, degree, cause, and type of burn, maternal mortalities, fetal mortalities, obstetric interventions, and surgical interventions.

Obstetric interventions

Fetomaternal monitoring appropriate to the gestational age was undertaken in all cases; each case was seen by a specialist obstetrician immediately after admission to the burn unit; and an obstetric ultrasound examination was performed as soon as the case was stabilized. Decisions for continuation or termination of pregnancy were discussed with a team of obstetricians including the consultant obstetrician in charge of the casualty department. Termination of pregnancy was performed according to the approved guidelines at Ain Shams University Maternity Hospital (ASUMH), following the 2018 World Health Organization (WHO) recommendations for induction of labor at or beyond term.¹⁸

Surgical interventions

In all cases, surgical procedures were performed under general anesthesia. Escharotomies were performed immediately after presentation to the emergency room in case of circumferential full-thickness burns over limbs, neck, or chest. Burn wounds were treated with closed dressings for 48 h (until resuscitation fluid regimen was administered), then the dressing was reassessed to determine the need for surgery. Escharectomies and skin grafting were carried out for full-thickness and deep partial-thickness burns according to local assessment regarding vascularity of burned skin in all cases, regardless of the duration of pregnancy. Priority was given to abdominal, perineal, and breast wounds to allow subsequent delivery and lactation.

RESULTS

Seven pregnant burned cases were admitted to the burn unit and the Maternity Hospital at Ain Shams University, during the period from January 2019 through June 2022. The age ranged from 19 to 33 years, the duration of marriage ranged from 2 months to 9 years, 4 of the cases were in their first trimester, 2 cases in the second trimester, and 1 case in the third trimester.

The total burned surface area ranged from 12% to 40%; no maternal mortalities occurred in this series, 3 miscarriages, 1 preterm labor, and 3 term pregnancies with 4 surviving neonates.

Of the 4 cases presenting in their first trimester (cases 1, 2, 5, and 7), only 1 case, had a spontaneous complete abortion at 10 weeks after 72 h of admission, the other 3 cases continued to give birth at term, after recovery from their burns and discharge from the burn unit. Both cases presenting in their second trimester (cases 4 and 6) had a miscarriage shortly after admission to the burn unit (after 14 and 4 days of admission to the burn unit); one was a complete miscarriage not requiring medical or surgical intervention, the second required a suction evacuation procedure which was performed under sedation with ultrasound guidance. The case presenting in the third trimester (case 3) was subjected to induction of labor for termination of pregnancy at 34 weeks, 9 days after her admission, as it was agreed by the obstetrical team to be safer for the mother and the fetus, and to allow for surgical management of her burns.

Induction of labor according to guidelines at ASUMH was taken, and vaginal birth of a living neonate that was incubated and discharged after 5 days in good condition. Results are summarized in Table 1.

DISCUSSION

Burns during pregnancy remain a challenge to healthcare practice, the absence of clear guidelines for the management of burns during pregnancy originates from the diversity and scarcity of the cases, and the absence of specialized teams with experience in dealing with such cases.

Most literature consists of case reports and small case series^5,19–24 and management guidelines are lacking. Pregnancy is associated with a hyperdynamic cardiovascular state and an expanded total body plasma volume to supply the placental vascular bed.^5,20 When a burn occurs, capillary permeability increases and there is accelerated fluid loss which causes the patient to become hypovolemic.²² The mother may develop systemic hypotension if inadequately resuscitated, which can lead to placental insufficiency, fetal ischemia, hypoxia, and acidosis. The burn surgeon and the obstetrician must work together and implement the best treatment plan for each individual patient. Fetal outcome depends on fetal age and the extent of maternal injury.¹⁷

In this case series, the TBSA ranged from 12% to 40%, with no maternal mortalities but 3 miscarriages, 1 preterm labor, and 3 term pregnancies with 4 surviving neonates. At Ain Shams University Hospitals, the pre-existence of a team with accumulated experience that was developed over the last 2 decades, may have helped in altering the gloomy outcome of pregnancy.

In our previous study, patients with burns of TBSA more than 15%, were admitted to the burn unit, whereas those with TBSA less than 15% were admitted to the obstetric ward, in a special care room.³ Early fluid resuscitation was started on admission according to the Parkland formula (4 ml/kg/%TBSA) was begun on admission. Colloid was initiated from the second day onward. The amount of fluid was adjusted according to CVP measurement and urine output monitoring. Intravenous heparin therapy was initiated at a dose of 2 U/kg and was monitored by partial thromboplastin time. Crystalline penicillin 150-250 000 IU/kg intravenous drip was maintained for 48 h, after which it was stopped and culture and sensitivity samples were taken 24 h later. Antibiotic therapy was then resumed according to the results.³ In total, 10% TBSA wound excision and skin grafting was done on the first setting.³ In this study, all patients were admitted to the burn ICU regardless of the TBSA burned. However, the same regimens were followed regarding fluid resuscitation, colloids, and anticoagulation percent TBSA wound excision. Amoxicillin/clavulanate was used empirically in this study preceding culture and sensitivity testing, as opposed to penicillin in our previous study.³

We acknowledge that the change in the outcome is not merely due to the improvement of medical care; social, environmental, and economic factors have played an important role in warning against the risky behaviors that once resulted in the accidents leading to the occurrence of burns during pregnancy. The existence of guidelines for obstetric interventions combined with better fetomaternal monitoring capabilities and better-equipped neonatal care facilities also contribute to better outcomes. Further research is needed to reach specific guidelines for the management of pregnant burn patients, according to TBSA.

CONCLUSION

We reviewed 7 pregnant patients admitted with burns to the burn unit and the Maternity Hospital at Ain Shams University from January 2019 to June 2022 and described the extent of their injuries, cause, and type of burn, obstetric interventions, and surgical interventions, as well as maternal and fetal outcomes.

Author Contributions

Adel Mabrouk (Writing—original draft [equal], Writing—review & editing [supporting]), Alaa Elfeky (Conceptualization, Investigation, Methodology [lead]), Mohamed Samir Badawy (Data curation [equal], Validation [lead]), Mai Raafat Abdelazim Hammad (Data curation [supporting], Writing—original draft [equal], Writing—review & editing [lead]), and Amr Mabrouk (Conceptualization, Data curation [lead], Formal analysis [equal])

Funding

The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this article.

Conflict Of Interest Statement

None declared.

Ethics Statement

The research was conducted after the approval of the Ethical Review Committee of Ain Shams University, Faculty of Medicine.

REFERENCES