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 Table of Contents  
ORIGINAL ARTICLE
Year : 2016  |  Volume : 6  |  Issue : 1  |  Page : 28-31

Burns during pregnancy: A retrospective analysis of 19 cases


1 Department of General Surgery, Rajendra Institute of Medical Sciences, Ranchi, Jharkhand, India
2 Department of General Surgery, Sikkim Manipal College, Sikkim, India
3 Department of Surgical Oncology, Dr. Ram Manohar Lohia Institute of Medical Sciences (RMLIMS), Lucknow, India
4 Department of Biology, Yogada Satsang Mahavidyalaya, Ranchi, Jharkhand, India
5 Department of Obstetrics and Gynaecology, KEMM Hospital, Kerala, India
6 Department of Primary Health Services, PHC, Basti, India
7 Department of Nursing, Institute of Medical Sciences, Banaras Hindu University, Varanasi, India

Date of Web Publication28-Jul-2016

Correspondence Address:
Dr. Sanjay Kumar Yadav
3/50, RIMS Boys Hostel, Rajendra Institute of Medical Sciences, Ranchi - 834 009, Jharkhand
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/2278-9596.187198

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  Abstract 

Background: Due to the limited availability of literature on management of burns during pregnancy, many surgical units face the difficult task of handling such cases. Keeping this in mind, a retrospective analysis of all the burnt females with pregnancy was done.
Patients and Methods: A total of 19 cases of burns in pregnancy were analyzed in this study. The demographic characteristic and stage of pregnancy of the patients were evaluated. In addition, the causes, severity of the treatment, and outcome were noted.
Results: The highest number of cases was in the 2nd trimester. The third trimester was associated with the highest incidence of abortion. Abortion was spontaneous in 70% of the cases. Maternal deaths were least in the 1st trimester. The rate of spontaneous abortion was highest in the 1st trimester.
Conclusion: Burns in pregnancy are associated with high fetal loss. Prevention of burns in the pregnant woman is essential in reducing the morbidity and mortality associated with these injuries.

Keywords: Abortion, burn injury, gestational age, maternal deaths, pregnancy, pregnant females, rule of nine, total body surface area (TBSA)


How to cite this article:
Chandra G, Gaurav K, Kumar S, Yadav SK, Ranjan R, Nambiar M, Agrahari AC, Yadav S. Burns during pregnancy: A retrospective analysis of 19 cases. Arch Int Surg 2016;6:28-31

How to cite this URL:
Chandra G, Gaurav K, Kumar S, Yadav SK, Ranjan R, Nambiar M, Agrahari AC, Yadav S. Burns during pregnancy: A retrospective analysis of 19 cases. Arch Int Surg [serial online] 2016 [cited 2021 Sep 16];6:28-31. Available from: https://www.archintsurg.org/text.asp?2016/6/1/28/187198


  Introduction Top


In developing countries such as India, burn injuries constitute a major cause of morbidity and mortality among the general population.[1] This scenario gets worse when it involves a pregnant woman, as it endangers the life of both the mother and the fetus. Close cooperation between the surgical and the obstetric teams and individualization of management are always necessary. The paucity of published data on the specific problems of burnt pregnant women has made it difficult to determine the incidence, morbidity, mortality rate, or the most effective management program for them.[2]

This retrospective study was conducted at the Rajendra Institute of Medical Sciences (RIMS), Ranchi, Jharkhand (India), which is a tertiary care center in the eastern part of central India to evaluate the etiology, gestational age, total burn surface area (TBSA), and fate of pregnancy among burnt pregnant females.


  Patients and Methods Top


It is a retrospective study design. All the pregnant burned females admitted from January 2013 to January 2014 from RIMS emergency were included in this study. All pregnant women who presented with burns were consecutively included in the study. The incidence of pregnancy during burns, gestational age, total burn surface area, fate of pregnancy, and the relationship between mentioned items were studied.

The percentage of burn was calculated by the Wallace rule of nine formula. Pregnancy was confirmed by history, clinical examination, and ultrasonography (USG) of the abdomen. All cases were managed by a combined team of obstetricians and surgeons. Data analysis was carried out with the statistical package for social sciences version 16.0 (SPSS Inc., Chicago, Illinois, USA).


  Results Top


A total of 667 cases of burn were admitted during period of study, out of which 395 were female patients. One hundred and five females were in the reproductive age group and out of them, 19 cases were pregnant. Due to our modest setup, we presume that some cases of higher degree of burn with early pregnancy who died immediately after hospitalization could have been missed.

The percentage of TBSA varied 20-90% (mean: 42.63%). Two patients died within 24 h of admission who had 90% and 70% burns, respectively. All others were resuscitated successfully. In this study, wood and coal were the major causes of burn. Gestational age at the time of injury varied from 7 weeks to 34 weeks with seven cases in the 1st trimester, seven in the 2nd trimester, and five patients in the last trimester. Ten mothers died after sustaining severe burns and fetal deaths occurred in 14 of the 19 cases. Maternal mortality and fetal mortality increased with increasing TBSA [Figure 1]. Maternal outcome in relation to TBSA and maternal complications are shown in [Table 1]. Maternal death was directly attributable to irreversible burn shock in two cases, septicemia in seven cases, and respiratory complications and embolism in one case. Death due to septicemia was more common in burns >50%. Fetal death occurred in 14 of the 19 (73.68%) cases and was related to the extent of maternal burn. Only one mother delivered a premature baby during initial hospital admission but the baby did not survive. The remaining four pregnancies were continued normally but no information was available on the ultimate outcome of pregnancies when patients were discharged.
Figure 1: Maternal outcome versus TBSA

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Table 1: TBSA and maternal and fetal deaths

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Maternal outcome in relation to gestational age and TBSA are shown in [Table 2] and [Table 3] while fetal outcome in relation to gestational age in [Table 4].
Table 2: Maternal complications in relation to TBSA

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Table 3: Maternal outcome in relation to gestational age

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Table 4: Foetal outcome in relation to gestational age

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Burns between 25% and 50% survival rate among pregnant women was 50% as compared to 72.5% survival rate in nonpregnant women of the same age group [Table 5]. In burns, <25% of both the groups had almost similar survival rates. We had only two cases with TBSA >50% and both died within 24 h of admission.
Table 5: Survival rate in nonpregnant women of same age group

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  Discussion Top


In developing countries, burn remains a medical issue as well as a social issue. We call it a social issue because it is closely associated with the use of earthen lamps during night and the use of charcoal for cooking in developing nations. Because of such reasons, the incidence of burn is high in such countries. The incidence is varyingly reported to be 6% from Israel by Benmier et al.,[3] 7% by Taylor et al.[4] and Amy et al.,[5] and 7.9% by Srivastav et al.[6] and Gang et al. from Kuwait,[7] 7% by Akhtar et al.,[8] 13.3% by Jain et al.,[9] and 15% by Prasanna from India.[10]

In our study, 18% of the women of the reproductive age group who were admitted with burn injury were pregnant. This incidence rate may be underestimated because a pregnancy test is not routinely administered to burned women of a reproductive age.[11] The total maternal mortality rate in our study was 53% while other studies reported a maternal mortality rate between 28.3% and 63%.[11],[12] Most fetuses survive when the mother survives and remain free of severe complications such as sepsis, hypotension, and hypoxia. In the 1st trimester, all seven pregnant women had spontaneous abortion. But out of these seven mothers, five had burn >40% TBSA. Therefore, it is directly related with the extent of maternal thermal injury. In the second trimester, fetal loss largely depended on maternal survival. Out of seven burns, only two women survived and one fetus survived. In the 3rd trimester, fetal survival is dependent more on gestational age as four out of five fetuses survived.

The study highlights that as far as pregnancy is concerned, burns precipitate abortions and premature labor on a very significant scale. Effects on the fetus are deleterious and proceed to abortion. There is a direct relationship between the TBSA and fetal viability. Fetal mortality is about 2.5% when the TBSA is 30% and 62.5% when the TBSA is 50%.[13] Yingbei et al.[14] in their study reported that all abortions, dead fetuses, and still births occurred within the first postburn week. McCauley et al.[15] reported that a 2nd and 3rdtrimester burns may be lethal to the fetus with maternal burns more than 50% of the TBSA. In our study, TBSA was the most significant indicator of maternal mortality. There were no maternal deaths with TBSA less than 25% and TBSA more than 50% was associated with 100% maternal deaths. Rate of fetal mortality (74%) remained high in our study in accordance with Akhtar et al.,[8] which showed a fetal mortality of 72%, as was also reported from Tehran, Tehran Province, Iran by Mehdizadeth et al.,[12] who found 72.8% fetal mortality.

Management of burn during pregnancy should always be a team approach to maximize the chances of fetal survival and maternal survival. Factors that are involved in the process of preterm delivery or abortion include TBSA, hypovolemia, septicemia, pulmonary injuries, severe catabolism, hyponatremia, and side effects of drugs. 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.[16]

In termination of pregnancy before 24 weeks, fetuses generally will not survive while those delivered after 32 weeks will do well with modern neonatal intensive care, which are required to salvage a near-term fetus.[17] It also underscores that emergent resuscitation and timely operative procedures might be able to salvage a living fetus, particularly in patients with burns covering more than 60% of TBSA.[18] If patient is stable, normal vaginal delivery should be tried.[19]Ex utero survival of fetuses between 24 weeks and 32 weeks is difficult to predict; therefore, when preterm labor occurs, pharmacological inhibition of labor should be considered. Tocolytic therapy may be of value in preventing premature delivery or as a temporary method of arresting labor while maternal homeostasis is restored.[20] The period of maternal hypoxia can lead to precipitation of labor or fetal death. An additional factor is invasive burn wound sepsis, which may result in premature labor and adverse vasoactive effects. Thermally injured tissue produces prostaglandins and increases the synthesis of free arachidonic acid. Obstetric considerations affect the choice of route and the timing of the delivery; spontaneous vaginal delivery is generally preferred even in the presence of perineal burns. If burn wound exceeds 50% TBSA and the fetus is at risk, obstetric intervention is indicated within the first 24 h for high risk third trimester pregnancies.[21],[22] Other indications for obstetric intervention include progressive fetal distress or significant maternal complications.


  Conclusion Top


The incidence of burns in pregnancy appears to be high, especially in developing countries such as India where burns constitute a social disease. Maternal mortality and fetal mortality remains high even in advance centers. The best way to ensure fetal survival is to ensure maternal survival. Maternal survival depends on TBSA and is less likely if the burn wound exceeds 50% TBSA. The rate of spontaneous abortion and premature labor is increased in burns and fetal gestational age is the best predictor of fetal survival. There should be an evidence-based management guideline on the lines of National Comprehensive Cancer Network (NCCN).

Acknowledgement

We acknowledge the help and guidance from Professor N.K. Jha, Head of Department (HOD) (Department of Surgery, RIMS) and Dr. DK Sinha (Associate Professor, Department of Surgery, RIMS) in preparation of this article.

Financial support and sponsorship

Nil.

Conflicts of interest

This is to declare that all authors have contributed to the study.

 
  References Top

1.
Schmitz JT. Pregnant patients with burns. Am J Obstet Gynecol 1971;110:57.  Back to cited text no. 1
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2.
Guo SS, Greenspoon JS, Kahn AM. Management of burn injuries during pregnancy. Burns 2001;27:394-7.  Back to cited text no. 2
    
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Taylor JW, Plunkett GD, McManus WF, Pruitt BA Jr. Thermal injury during pregnancy. Obstet Gynecol 1976;47:434-8.   Back to cited text no. 4
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Amy BW, McManus WF, Goodwin CW, Mason A Jr, Pruitt BA Jr. Thermal injury in the pregnant patient. Surg Gynecol Obstet 1985;161:206-12.   Back to cited text no. 5
    
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Srivastav S, Bang RL. Burns during pregnancy. Burns 1988;14:225-32.  Back to cited text no. 6
    
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Gang RK, Baje J, Tahboub M. Management of thermal injury in pregnancy — An analysis of 16 patients. Burns 1982;18:317-20.   Back to cited text no. 7
    
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Akhtar MA, Mulawkar PM, Kulkarni HR. Burns in pregnancy: Effect on maternal and foetal outcomes. Burns 1994;20:351-5.   Back to cited text no. 8
    
9.
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Prasann M, Sing K. Early burn wound excision in “major' burns with “pregnancy': A preliminary report. Burns 1996;22:234-7.   Back to cited text no. 10
    
11.
Mehdizadeh A, Akbarian A, Samareh Pahlavan P, Tavajjohi S, Mackay Rossignol A, Alaghehbandan R, et al. Epidemiology of burn injuries during pregnancy in Tehran, Iran. Ann Burns Fire Disasters 2002;15:163-70.   Back to cited text no. 11
    
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Khadzhiĭski S. Burns during pregnancy. Khirurgiia (Sofia) 1991;44:26-9.  Back to cited text no. 12
    
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Gronert GA, Theye RA. Pathophysiology of hyperkalemia induced by succinylcholine. Anesthesiology 1975;43: 89-99.  Back to cited text no. 13
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Ying-bei Z, Ying-jie Z, Xuewei W. Burns during pregnancy: An analysis of 24 cases. Burns Incl Therm Inj 1981;8:286-9.  Back to cited text no. 14
    
15.
McCauley RL, Stenberg BA, Phillips LG, Blackwell SJ, Robson MC. Long-term assessment of the effects of circumferential truncal burns in pediatric patients on subsequent pregnancies. J Burn Care Rehabil 1991; 12:51-3.   Back to cited text no. 15
    
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Rode H, Millar AJ, Cywes S, Bloch CE, Boes EG, Theron EJ, et al. Thermal injury in pregnancy-the neglected tragedy. S Afr Med J 1990;77:346-8.  Back to cited text no. 16
    
17.
Banerjee T, Karmakar A, Adhikari S. Foetal salvage by Caesarean section in a case of maternal burn injury. Singapore Med J 2012;53:e247-8.  Back to cited text no. 17
    
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Rölfing JH, Jensen PE, Lindblad BE. Second-degree burn in a pregnant woman. Ugeskr Laeger 2010;172:2770-1.  Back to cited text no. 18
    
19.
El-Gallal AR, Yousef SM. Burns in pregnancy: A ten-year review of admitted patients. Ann Burns Fire Disasters 2002;15:3.   Back to cited text no. 19
    
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Deitch EA, Rightmire DA, Clothier J, Blass N. Management of burns in pregnant women. Surg Gynecol Obstet 1985;161: 1-4.   Back to cited text no. 20
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Ullmann Y, Blumenfeld Z, Hakim M, Mahoul I, Sujov P, Peled IJ. Urgent delivery, the treatment of choice in term pregnant women with extended burn injury. Burns 1997;23:157-9.   Back to cited text no. 21
    
22.
Masoodi Z, Ahmad I, Khurram F, Haq A. Pregnancy in burns: Maternal and fetal outcome. Indian J Burns 2012;20:36-41.  Back to cited text no. 22
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    Figures

  [Figure 1]
 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5]


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