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| ORIGINAL ARTICLE |
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| Year : 2012 | Volume
: 20
| Issue : 1 | Page : 36-41 |
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Pregnancy in burns: Maternal and fetal outcome
Zulqarnain Masoodi, Imran Ahmad, Fahad Khurram, Ansarul Haq
Department of Plastic, Burn and Reconstructive Surgery, JNMCH, AMU, Aligarh, Uttar Pradesh, India
| Date of Web Publication | 13-May-2013 |
Correspondence Address:
Zulqarnain Masoodi
Department of Plastic Burns and Reconstructive Surgery, JNMCH, AMU, Aligarh - 202 002, Uttar Pradesh
India
 Source of Support: None, Conflict of Interest: None  | Check |
DOI: 10.4103/0971-653X.111780
Background : Burns occurring in conjunction with pregnancy can be a potentially life-threatening scenario as it may lead to a rapid depletion of the already diminished maternal reserves. The management protocol in a pregnant burn female has to be tailored, taking into consideration the additional factor of fetal well-being and the fetal susceptibility to various agents. For such alterations to be incorporated, it is imperative on part of the treating doctor to correctly ascertain the pregnant/nonpregnant status of an adult burn female. Though most cases of pregnancy can be diagnosed on the basis of history/ examination but it is not a totally reliant method and hence liberal use of the urine pregnancy test should be done. Material and Methods : This is a retrospective study of a total of 2217 burn patients who were admitted to JNMCH, AMU between July 2007 and July 2011. All burned women have been included and no exclusion criteria were used. Incidence of pregnancy in burned females, etiology, gestational age, total burn surface area, fate of pregnancy, duration of hospitalization, and the relationship between mentioned items were studied. Results : Out of a total of 2217 patients studied 954 of them were female of whom 685 were in the reproductive age group and 87 of these females were pregnant. 76 burnt mothers had sustained burns less than 50% TBSA. 19 mothers died as a result of burns of whom 14 had burns more than 50% TBSA. All fetuses died of mothers burnt more than 50% TBSA, while fetal mortality was 62.5% in burns involving 31-50% of TBSA and fetal mortality was 2.5% in burns with TBSA less than 30%. Conclusion : Both maternal and fetal mortality are directly proportional to the TBSA and best care should be offered to such patients suffering burns during pregnancy by a special multidisciplinary team experienced in managing such critical patients. Keywords: Burns, fetus, pregnancy, survival, total burn surface area
How to cite this article:
Masoodi Z, Ahmad I, Khurram F, Haq A. Pregnancy in burns: Maternal and fetal outcome. Indian J Burns 2012;20:36-41 |
| Introduction | |  |
Burns in pregnancy is not a topic frequently mentioned in obstetric texts or books on burn care. [1],[2],[3] Despite the relatively high incidence of burns in the developing countries and its importance in pregnancy, there are only a few reports, which have studied different aspects of this problem.
Pregnancy and burns occurring together are not an uncommon phenomenon with rates highest in the developing world. [4],[5] The additional risk that burn injury poses on outcome of pregnancy and/or risks of pregnancy on outcome of burns has also been documented earlier in many studies. [6],[7]
Previous studies have been controversial regarding the outcome of burns between pregnant and nonpregnant patients; some have concluded that pregnancy does not increase the maternal mortality rate in burn patients while some others have drawn opposite results. [7],[8],[9] Existence of this controversy necessitates some more studies to be performed to clearly define the protocols that should be obeyed when a pregnant woman is admitted to a hospital because of burns.
The present study was designed to determine the incidence of pregnancy in female patients admitted in a multispecialty hospital with burns along with the etiology, gestational age, total burn surface area, fate of pregnancy, duration of hospitalization and their relationship with each other in JNMCH, AMU and also to investigate the mentioned controversy. It seems that the most important decision to be made is whether the pregnancy should be terminated or not.
| Materials and Methods | | |
This is a retrospective study. A total of 2217 burn patients were admitted to JNMCH, AMU between July 2007 and July 2011. Data used in this study have been gathered from the files of the patients. All burned women have been included and no exclusion criteria were used. Incidence of pregnancy during burns, etiology, gestational age, total burn surface area, fate of pregnancy, duration of hospitalization, and the relationship between mentioned items were studied. SPSS Software (version 16) was used for statistical assessment.
Diagnosis of pregnancy was made by history and examination and confirmed by urine for hCG and abdominal ultrasound. Because in our modest setup routine urine pregnancy tests were not carried out in all females of child-bearing age group, some of the positive cases may have been missed. As a routine protocol, obstetric consultation was sought promptly on admission for each pregnant patient. All pregnant patients were managed in the high dependency unit of the obstetric ward by the medical and surgical services including surgical dressings in consultation with the obstetrical service. Pregnant burnt females after confirmation of diagnosis were admitted in the high-dependency unit of the obstetrics ward, as facilities for continuous fetal monitoring were not possible in the general burn ward. Maternal assessment included cause of burn, site, depth, and extent of burn, burn-related complications, and maternal outcome. Fetal outcome was assessed in relation to gestational age, maternal TBSA involvement, and complications.
| Results | | |
Out of 2217 cases of burns, 777 (35.04%) were in children, 486 (21.9%) were adult males and 954 (43.01%) were adult females [Figure 1].
As far as the age distribution among burnt females was concerned, the adult females involved were 954 with an age range of 14-90 years (total = 954).
In terms of the marital status, out of the total 954 patients, 682 were married, and 272 were unmarried.
Out of the total 954 female patients 685 were in the child bearing age, between 15 and 45 years [Figure 2].
A total of 87 (12.70%) of burned women of child-bearing age (between 15 years and 45 years) were pregnant (9.11% of all women).
As far as the etiology of the burns was concerned, flame burns were the most common mode, followed by scald burns and electrical burns. There was a solitary case of chemical burns as well.
The most common place of occurrence where the patient sustained burn injury remained her home.
According to the history provided by the patient/attendants majority of the burns were of accidental nature.
The distribution of burns according to the TBSA in males, females, and children is elucidated in [Table 1].
The distribution of TBSA in the burnt pregnant female group is shown in [Table 2]. It can be seen that more than 80% of patients in this study had a TBSA of less than 50%.
The gestational ages of the burnt pregnant females are shown in [Figure 3]. The second trimester was the most common trimester followed by the first trimester.
| Fetal Assessment | | |
A total of 47 (54.02%) women had dead fetus during hospitalization and 40 (45.97%) discharged with alive fetus (total = 87).
Gestational ages of those who had fetal death and those whose fetuses survived are abstracted in [Table 3] and [Table 4].
A total of 43 (91.4%) of fetal deaths happened when the mother was still alive and in 4 cases (8.51%), fetal death happened with or soon after maternal death. Most of fetal deaths happened in the first days after the burn.
The most common cause of fetal death was decreased uterine and placental circulation as demonstrated by Doppler ultrasound.
In the other group (discharged with alive fetus), 8 aborted the fetus within 1 month of burn, 30 had normal vaginal deliveries (one still birth without definite cause), and 2 had caesarian section due to obstetric indications.
All the fetuses died where more than 50% TBSA was burnt while fetal mortality was 62.5% in burns involving 31--50% of TBSA and fetal mortality was 2.5% in burns with TBSA < 30% as given in [Table 5].
| Maternal Assessment | | |
A total of 19 mothers died as a result of burns. All of them had majority third-degree burns. Distribution of the TBSA of dead mothers is summarized in [Table 6]. Duration of hospitalization was between 1 and 120 days (mean 21.12 days). Twelve (59.9%) were from low, 5 (33.3%) from mid, and 2 (6.8%) from high socioeconomic classes.
| Mortality in Pregnant Females | | |
The distribution of mortality in pregnant females according to the TBSA is given in [Table 7] and compared with that of nonpregnant females of child-bearing age group and older nonpregnant females.
In this study the overall mortality in females was 273 (28.67%). The incidence of death in the pregnant females was 21.84%, while it was 26.98% in nonpregnant females of child-bearing age group and 33.67% in older nonpregnant females.
The percentage of death in pregnant females was higher than those of nonpregnant females in every subgroup of TBSA as shown in [Table 8].
| Discussion | | |
Burn injury during pregnancy creates a severe threat to baby, as well as to the mother. [10],[11] Most of the causes of burn injuries in a developing country like India are indirectly related to social problems, economical problems, illiteracy and poverty which many times complicate its prevention. In a developing country like India, burns in women of reproductive age occur more frequently than they do among similarly aged women residing in more developed countries. Thermal injury sustained during pregnancy presents a special problem for the gravid woman and her fetus.
In the majority of cases the history provided by the patient/attendants relates these burns to being accidental in nature. Owing to the socio-cultural makeup of our country and the rampant sabotage against women, whether this figure is a true reflection of the actual scenario or not still remains doubtful. [12],[13]
This study was carried out with an aim to determine the incidence of pregnancy in burnt females admitted in a multispecialty hospital in JNMCH, Aligarh and also the maternal and fetal outcome in relation to burn, the extent and gestational age of fetus, and the dynamics surrounding burns during pregnancy.
In this study, 12.70% of women of child-bearing age (9.11% of all admitted females) 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 reproductive age. [14]
The total maternal mortality rate in our study was 21.84%, while other studies reported a maternal mortality rate between 28.3% and 63%. [7],[14],[15] The overall incidence of death was lower in pregnant females (21.84%) than that in nonpregnant females (26.98%) owing to the lesser number of subjects with TBSA >50% in the pregnant group. According to the distribution by TBSA the mortality% was higher in the pregnant group in each class compared with the nonpregnant females. In our study, we concluded that pregnancy increases the mortality of burned women.
Some earlier studies had suggested that the TBSA is the only statistically important factor that affects the prognosis of the mother and fetus. [8] However, in our study, it has been shown that pregnant females presenting with burns are also an indicator of poor outcome of both mother and fetus.
On the other hand, there is a direct relationship between the total burn surface area (TBSA) and fetal viability: Fetal mortality is about 2.5% when the TBSA is 30% and 62.5% when the TBSA is 50%. [16] So early delivery could be performed in this burn group if the fetus is viable to save the fetus. The other concept that is confirmed is the grave effects of burn on the fetus that may lead to abortion or preterm delivery. Factors that are involved in this process include TBSA, hypovolemia, septicemia, pulmonary injuries, severe catabolism, hyponatremia, side effects of drugs 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. [17]
| 'A Team Approach…' | | |
After the initial management of a severely burned patient, her care requires a team approach with the obstetrician acting as a team leader.
In our study we found this formation as most suited to patient needs. The patient is best managed in a place where there is a facility for continuous fetal monitoring which in our setup was a high-dependency unit in the obstetrics ward. While the patient is managed by a multidisciplinary team the obstetrician remains the overall team head [Figure 4].
| Factors Determining Obstetric Procedures | | |
Obstetrical management should be individualized. It is advocated that in viable pregnancies (>32 weeks) early delivery should be performed as soon as the mother is resuscitated following severe burn injury (>40% TBSA) as this may increase the rate of fetal survival. [18]
In a more advanced state of pregnancy (second to third trimester) in women with over 50% TBSA, burns had an unfavorable effect on mother and would also further cause an unfavorable environment for the fetus and so termination of the fetus would be better for both mother and fetus. Even if the fetus is not viable, termination would lessen the burden on the mother. In burns involving less than 30% TBSA pregnancy and its continuation had no effect on prognosis in the mother and every attempt should be made to interrupt inception of labor if the fetus is too immature to survive.
If TBSA <30% - - - -
- 1 st trimester - Continue pregnancy under strenuous ANC care
- 2 nd trimester - Individualize approach
- 3 rd trimester - *Fetus immature/NICU unavailable Do not induce labor
*Early induction if fetus viable (>32 weeks in our setup)
| Conclusions | | |
- Most burns in pregnancy are accidental-in the15-35 years age group and are flame burns at home
- Fetal mortality is proportional to the TBSA burned and maternal survival
- Maternal mortality is proportional to the TBSA burned and pregnancy related complication
- Best care possible should be offered using a team approach supervised by the obstetrician
- Early delivery of a viable pregnancy (>32 weeks) should be attempted after resuscitation if the TBSA burnt is 30-50% and termination of pregnancy should be done irrespective of gestational age if the TBSA burnt is >50%
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[Figure 1], [Figure 2], [Figure 3], [Figure 4]
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6], [Table 7], [Table 8]
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