Burns in Pregnancy

1. 10 June 2012 1 Burns in Pregnancy Dr.Mridula A. Benjamin Dept of Obs and Gyn RIPAS Hospital

2. 2 Introduction Burns is an important subject in trauma management But burns in pregnancy is not a topic mentioned in obstetric texts or books on burn care The aim of this literature review was to understand the impact burns has on pregnancy and maternal and fetal survival and the subtle differences in the management of pregnant burn victims

3. 3 Materials and methods An Internet search was done using Pubmed search engine to collect case reports and articles on the topic Statistics of Burns unit, RIPAS Hospital

4. 4 Incidence 7% in USA (Amy et al. Fort Houston), The highest of all burn incidences in pregnancy was found in India, ranging from 7%, calculated by Akhtar (Nagpur), to 13.3%, reported by Jain (Bhilai) Of the 379 cases reported in the literature between 1958 and the present day that have come to our attention, 129 (34%) occurred in India

5. 5 Causes

6. 6 Causes

7. 7 Place of occurrence

8. 8 Brunei statistics 2006

9. 9 Brunei statistics

10. 10 Effect of Burns Slight burns had no effect on the course of pregnancy, while burns of at least 35% TBSA were capable of provoking early labour and the loss of the foetus following intrauterine death within a week of the burn

11. 11 Old school of thought Onset of labour in a premature delivery is due to secretion of adrenocortical hormones related to stress. Spontaneous miscarriage and premature delivery are due to the synthesis and release of prostaglandins (responsible for early uterine contractions) from the skin in the burn area

12. 12 Current opinion

13. 13 Current opinion After burns there is increased capillary permeability and third space loss leading to hypovolemia This leads to hypotension if the patient is inadequately resuscitated This leads to placental insufficiency, fetal ischemia, hypoxia and acidosis All these events lead to premature labor

14. 14 Current opinion Onset of spontaneous uterine contractions is also favoured by the release from bacteria and the placenta of an enzyme, phospholipase A, which is necessary for the conversion of arachidonic acid into prostaglandin Considerable reduction in plasma levels of 17B-oestradiol in pregnant burned women who had either an abortion or a still birth in the first week post-burn

15. 15 Prognosis Fatality rate among patients with TBSA of 50% or more was 3.33 times the fatality rate among women with smaller burns Fetal survival depends on the gestational age, extent of maternal injury and maternal survival Fetal survival during first trimester was 27.2 % in comparison with 28.5 % in second and 35.2 % in third trimester

16. 16 Management All female burn patients of childbearing age should be tested for pregnancy unless the pregnancy is obvious

17. 17 General treatment Prevention of hypovolaemic shock by adequate early fluid so that the uterine blood flow is maintained. Diuresis of 30-60 ml/h Maintenance of arterial pressure levels Episodes of hypotension should be avoided in the event of surgical operations. It is recommended that surgery should be performed with intraoperative maintenance of a minimum of 1 ml/kg/h of urine volume and 100% oxygen saturation.

18. 18 The Emergency Management The loss of fluid often is underestimated in pregnant patients. On arrival to the hospital and after the vital signs of the mother and fetus (monitor) are evaluated, a large-bore (ie, 18-gauge) intravenous line is started. If burns more than 20% of the surface area, a central venous or Swan-Ganz catheter provides a better guide to fluid replacement. Lactated Ringer solution is started at 200 mL/h until the fluid replacement volume is calculated.

19. 19 Degree Of Burns 1st degree: only epithelial layer. Very painful but resolves with no residual scarring. Skin is red and painful but no blisters 2nd degree: epithelium and part of dermis. Pain and scarring vary according to depth of burn. A) Superficial 2nd degree burns: epidermis and uppermost part of dermis B) Deep 2nd degree burns spares only the deepest portion of dermis 3rd degree: Full thickness. Usually painless due to destruction of cutaneous innervation. Leads to scarring.

20. 20 Estimation of burns %

21. 21 The Fluid Requirements During late pregnancy, 5% is added if anterior abdomen is involved Fluid requirements for the first 24 hours are calculated as follows: BSA (%) multiplied by 2-4 mL/kg body weight For example, a 20% burn is calculated as 20 X 3 mL X 70 kg = 4200 mL Fluid requirements are met with lactated Ringer solution 50% fluid is given in first 8 hrs and the rest in the next 16 hrs In the second 24 hours, colloids (albumin) are administered to maintain the serum albumin > 3 g/100 mL

22. 22 General treatment A pregnant patient's oxygenation can often be improved by nursing in semi-sitting position In pleuropulmonary complications secondary to inhalation ventilatory support should be initiated as soon as possible. Inhaled carbon monoxide can cross placental barrier to compete for binding sites on foetal haemoglobin, provoking foetal cardiac oedema, and affect cardiac development If bronchopneumonia use antibiotics that the foetus can tolerate

23. 23 Local treatment Drugs to avoid: Chloramphenicol, Gentamycin, Silver sulfa diazine, Povidone Iodine, Ketamine Salicylates to be avoided in term pregnancies Hypertonic glucose solutions can lead to secondary hyperinsulinaemia with foetal macrosomia Safe drugs: penicillins and cephalosporins Reports of using potato peals and banana leafs as dressing materials

24. 24 Surgical Treatment Early coverage of burns minimizes septic complications, need for antibiotics and analgesic drugs. SSG of wounds over the abdomen and breast have to be treated first 1. Pain-free stretching of the abdominal skin during the developing pregnancy to term 2. Abdominal obstetric supervision of the growing foetus 3. Performance of caesarian section if required

25. 25 Obstetric management Depends on the following Gestational period Severity of the burn Foetal viability: confirm biophysical measurements as foetal muscle tone, limb motion and breathing patterns, placental morphology, and amniotic fluid volume 

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28. 28 Manner of delivery Spontaneous vaginal delivery is generally preferred Obstetric considerations affect the choice of route and the timing of the delivery Serial foetal sonography and electronic heart rate monitoring, by means of cardiotocographic recording, identifies foetal stress at an early stage In a critically burned woman with a living and near-term pregnancy, foetal salvage by caesarian section is justifiable

29. 29 Conclusion Incidence of burns in pregnancy is high in developing countries Overcoming of maternal shock is of fundamental importance for foetal prognosis Hypovolaemia and hypoxia are the cause of spontaneous uterine contractions that lead to abortion or premature delivery after IUD General and topical treatment has to take into account the embryonal, foetal, and perinatal toxicity Early surgical intervention

30. 30 Conclusion Monitoring of the pregnancy by frequent ultrasound scanning, daily measuring of the blood clotting factor, cardiotocographic monitoring. Intrauterine death of the foetus may be preceded by a reduction of 178-oestradiol and E, levels Calculation of the stage of gestation and the gravity of the burn choice of method of delivery (vaginal route, caesarian section)

31. 31 Thank you