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Burns in pregnancy

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					               Burns in Pregnancy


                            Dr.Mridula A. Benjamin
                               Dept of Obs and Gyn
                                   RIPAS Hospital
16 June 2011                                 1
                   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




                                                             2
         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




                                                           3
                     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




                                                              4
    Causes



27.45%
                  Accidental
                  Intentional
         72.55%




                                5
     Causes

40
35
30            Scalding
25            Flame
              Flash
20
              Electrical
15            chemical
10            Friction
 5
 0

                           6
  Place of occurrence

  2%   8%
                        Home
25%          62%        Garden
                        Work
                        RTA
  3%                    Others




                                 7
                Brunei statistics 2006

Total Burn          123         163    Males
                                       Females
Patients: 286




                           42
                     244              Inpatient
                                      Outpatient



                                                   8
Brunei statistics
    15           27
                            Males
                            Females




             2            1st decade
         2
5                     3   2nd decade
                          3rd decade
             3            4th decade
                          5th decade



                                       9
                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




                                                            10
           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




                                                            11
Current opinion




                  12
                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




                                                              13
                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




                                                           14
                     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



                                                         15
                  Management
• All female burn patients of childbearing age should be
  tested for pregnancy unless the pregnancy is obvious




                                                           16
              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.


                                                           17
       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.




                                                                18
                 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.


                                                               19
Estimation of burns %




                        20
           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

                                                                  21
              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

                                                            22
                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


                                                           23
            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

                                                            24
          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




                                                            25
% of          Age of gestation       Management
burns
        First                        No obstetric interference
        trimester
        Second                       No obstetric interference
< 30%
        trimester
                      More than      Induce labour / caesarian section
        Third         36 wks
        trimester
                      Less than 36   Conservative approach and
                      wks            monitoring of heart rate
        First                        Foetal monitoring by ultrasound 3-4
        trimester                    wks
        Second                       Foetal monitoring every 3-4 wks.
30–50
        trimester                    Tocolytic therapy
%
                      Less than 36   Careful foetal monitoring
        Third         wks
        trimester
                      More than      Deliver foetus within 48 h            26
                      36 wks
% of          Age of             Management
burns   gestation
        First                    Terminate pregnancy
        trimester
        Second                   Terminate pregnancy
50-     trimester
70%                    If baby   Induce labour / caesarian section
        Third          viable
        trimester
                       IUD       No active intervention up to 4 wks / monitoring of
                                 foetus of haemocoagulation factors
        First                    No treatment
        trimester

>70 %
        Second                   No treatment
        trimester


                                 Caesarian section as an emergency procedure at the
        Third                    earliest
        trimester                                                                27
             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



                                                             28
                    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
                                                               29
                     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)


                                                                 30
Thank you




            31

				
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