Severe burn injury in late pregnancy: a case report and literature review
Shi et al. Burns & Trauma
Severe burn injury in late pregnancy: a case report and literature review
Yan Shi 0
Xiong Zhang 0
Bo-Gao Huang 0
Wen-Kui Wang 0
Yan Liu 0
0 Department of Burn and Plastic Surgery, Shanghai Jiaotong University, School of Medicine Affiliated Ruijin Hospital , Shanghai 200025 , China
The management of serious burn injuries during pregnancy is an unsolved clinical problem because of the low incidence of this disease. Although it has been documented that the effect of burns on fetal and maternal survival is detrimental, there have been conflicting reports among the different burn centers regarding the mortality of burned pregnant women and the management of burn patients during pregnancy. We report a case of severe burn in late pregnancy treated at our burn center. Additionally, we searched and summarized the literature concerning the management of pregnant patients to provide useful information for their treatment.
Burn; Pregnancy; Fluid resuscitation
The management of serious burn injuries during
pregnancy needs to be better studied and standardized due
to the low incidence of this disastrous condition. In
general, severe burn injury in pregnant patients is more
common in developing countries because most of the case
reports have come from low-income countries [1-4]. The
maternal mortality and morbidity in the literature
concerning severe burn injury in pregnant patients are usually
significantly higher than those in the general population
with the same degree of injury, although there are
tremendous differences among different reports [3,5]. As early as
the 1990s, Rode et al., reported that when over 50% of the
total body area was burned, the mother’s survival was
unlikely . Since then, the mortality and morbidity rates
have not changed. In a 9-year prospective study conducted
on 51 pregnant women with a severe burn injury, the
authors reported that both the maternal and fetal mortality
rates reached 100% in the pregnant women with the total
burned body surface area exceeding 40% total body
surface area (TBSA) . Recently, however, in a 6-year
cross-sectional study, 39 (1.88%) women were found to be
pregnant among 2,067 women with a severe burn injury,
and the mortality rate of all the pregnant women reached
66.7% with more than 50% death rate when the burn area
exceeded 60% . It is widely recognized that the effect of
burns on fetal and maternal survival is detrimental, and
there is a positive relationship between the percentage
of maternal total body burn area and maternal and fetal
mortality, as well as premature delivery . However,
Amy et al.  reported that pregnancy does not alter the
maternal outcome after thermal injury. Because there
were conflicting reports among different burn centers and
an enormously high mortality in pregnant women with
severe burn injury, collecting more information and
reaching a consensus on the management of burns in
pregnancy are necessary.
The patient was a 28-year-old woman who was referred
to our Burn Institute 1.5 h after a flame burned her
head, trunk, and limbs. The patient had a distressed
facial expression and was cooperative in the physical
examination. She had no breathing difficulty, although
obvious swelling, particularly on the head, was observed.
No ashes or blisters were found on the oropharyngeal
mucosa by laryngoscopy examination. Physical
examination data on admission were as follows: body weight, 56
kg; blood pressure, 132/67 mmHg; pulse rate, 88 bpm;
body temperature, 36.8°C; and respiratory rate, 15 bpm.
The burn wounds were distributed on the face, neck,
trunk, and limbs, and the total burn area was 50%
TBSA. Wounds were presented as red, or red and white
in appearance, and parts of them were dry with
diminished sensation. The laboratory results were as follows:
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The solution delivered during surgery (which was excluded from the total fluid resuscitation): 1,000 mL of lactate Ringer’s solution, 500 mL of normal saline, and
600 mL of plasma.
blood routine examination: WBC, 18.64 × 109/L;
neutrophil granulocyte, 90.3%; Hgb, 105 g/L; RBC, 4.03 × 1012/L;
Hct, 0.329; platelet, 296 × 109/L. The liver and kidney
function indexes were all in the normal range except that
the total protein level was 50 g/L and the albumin level
was 24 g/L. The obstetric examination results were as
follows: The patient was 35 weeks and 5 days pregnant, the
uterine fundus was halfway between the umbilicus and
xiphoid process, and the fetal outline was palpable. No
vaginal bleeding or discharge was observed, and uterine
contraction was not palpable. Fetal movements were
occasionally felt. The cervix was not open, and the fetal
membranes had not broken. The fetal heart rate (FHR) was 150
bpm. There was no gestational hypertension, gestational
diabetes, or other combined diseases reported. The
admission diagnosis was that the flame burned 50% TBSA
(superficial second-degree 20% TBSA, deep partial
thickness burn 30% TBSA) with a third-trimester pregnancy.
During emergency treatment, lactate Ringer’s solution
was infused for fluid resuscitation, and 1,500 mL of
lactate Ringer’s solution was infused during the first 9 h
after injury. The burns were covered with Vaseline gauze
after simple wound cleaning. Nine hours after the injury,
after consulting and discussing with the obstetrician, a
cesarean section was performed under spinal epidural
anesthesia, and a live baby girl was delivered. The surgery
lasted approximately 1 h, and the blood pressure was
stable during the surgery. The Hgb level after the surgery
was 97 g/L. The baby had a body weight of 2,220 g and a
body length of 46 cm with APGAR scores of 10’, 10’, and
10’. The vital signs of the patient were stable during
surgery. After delivery of the baby, intravenous fluid
resuscitation was continued for the patient using the Ruijin
(Resuscitation) formula. Ruijin’s formula involves the
infusion of a crystalloid solution, which comprised primarily
lactated Ringer’s solution and/or colloids, usually plasma,
at a rate of 1.5 mL/kg/percentage of the burned body
surface area for the first 24 h and half of the amount of the
actually infused crystalloid and colloid solution for the
second 24 h. In addition, 2,000~3,000 mL of
physicaldemanding water was applied every 24 h after injury. The
type and volume of the solution delivered for liquid
resuscitation are summarized in Table 1. The hourly urine output
was 50~350 mL during the first 48 h after the burn injury.
The treatment for the patient included the application of
Table 1 Volume of fluid resuscitation (mL)
silver sulfadiazine cream on the wounds when the dressing
was changed every 2 days, infusion of imipenem for the
antimicrobial prophylaxis of infection, and administration
of oxytocin and Chinese herbal medication to promote
uterine involution. No systemic infection or dysfunction of
internal organs was found during the patient’s stay in the
hospital. The patient discharged herself without postpartum
complications at 15 days after injury due to financial
reasons. At discharge, the superficial second-degree and part
of the deep partial thickness burn wounds that were
relatively superficial were healed, and less than 10% TBSA deep
partial thickness burn wounds remained on the neck, right
upper limb, and both legs. No signs of difficulty of healing
that could imply the connection of impaired healing and
pregnancy were observed. Physical examination results
were as follows: blood pressure, 119/76 mmHg; pulse rate,
90 bpm; body temperature, 36.4°C; and respiratory rate,
17 bpm. Laboratory results were as follows: blood routine
examination: WBC, 8.76 × 109/L; neutrophil granulocyte,
71.3%; Hgb, 111 g/L; RBC, 4.12 × 1012/L; Hct, 0.337;
platelet, 359 × 109/L; glutamic pyruvic transaminase, 19 IU/L;
glutamic-oxalacetic transaminase, 23 IU/L; alkaline
phosphatase, 81 IU/L; TP, 71 g/L; albumin, 36 g/L; urea
nitrogen, 3.6 mmol/L; creatinine, 37 μmol/L.
The hemodynamic changes for the severe burn patient in
late pregnancy showed specific characteristics. The cardiac
output and volume of circulating blood of the pregnant
woman started increasing from approximately 6 to 8
weeks and gradually reached a peak at 32~34 weeks of
pregnancy, an increase of 30%~45% in total volume (1,500
mL on average). After delivery, the increased cardiac
output and volume of circulating blood were gradually
restored to the basal level at approximately 2–3 weeks .
Although it is well known that intense resuscitation is
needed for pregnant women, there are no detailed
instructions regarding what is the proper amount of fluid
for those patients. There are many resuscitation formulas
adopted by different burn units , and Ruijin’s formula
was used for guiding the burn patients’ resuscitation at
our department. Ruijin’s formula is a modification of
Evans formula and is more suitable for patients of Asian
descent and has been applied in several burn centers of
China for more than 50 years. Ruijin’s formula and the
and colloid solution
Actual infused crystalloid
and colloid solution
Third Military Medical University (TMMU) formula are
the most influential formulas in China. Different from the
TMMU formula, Ruijin’s formula sets the ratio of
crystalloid solution versus colloid solution at 1:1. In this
case, the estimated volume of the crystalloid and colloid
solution for the first 24 h was 4,200 mL; the actual
infusion amount was 4,400 mL (including an intra-operative
amount of 2,100 mL). The actual infusion amount of the
second 24 h was 1,100 mL, which was 52.38% of the
estimated amount (half of 4,200 mL). Considering the extra
requirement for the surgery, the actual infusion amount
for the first 24 h was much lower than the estimated
amount. The urine amount at the first 48 h had reached
50~350 mL/h, which was significantly higher than 0.5~1
mL/kg/h of urine output, which is the general
requirement for an effective resuscitation. We believed that the
increased cardiac output and body circulating volume,
particularly when the baby was delivered, would make the
patient more tolerant to fluid loss. Therefore, the infusion
volume during shock resuscitation for these maternity
patients could be reduced appropriately depending on the
urine volume and general condition. Based on our
literature search, ours is the first case report to suggest
decreasing the infusion volume of fluid resuscitation, particularly
after the fetus is delivered. Unfortunately, we only
monitored the heart rate, blood pressure, and urine output for
the guidance of resuscitation. Indeed, it will be greatly
helpful to utilize more hemodynamic parameters to judge
the patients’ circulation status and heart function and
Pregnancy with burns not only makes treatment for the
mother difficult but also threatens the fetus. Within the
context of ensuring the survival of the neonate, late
pregnancy patients should terminate their pregnancy as early
as possible to prevent fetal distress, improve the survival
possibility of the fetus, and simplify the management of
pregnant women. The correct judgment of pregnant week
is crucial. If the gestational week is uncertain and prenatal
examination is not performed routinely, the measurement
of the physical indexes of the fetus, including the
biparietal diameter, head circumference, and height of the femur
using B-mode ultrasound, will be useful for the
assessment of gestational age and maturity of the fetus. If the
fetus is still immature, continuation of pregnancy could be
considered under close monitoring, but the fetus is under
the risk of drug toxicity due to the treatment strategies.
Much literature has indicated that septicemia and sepsis
are the main causes of death in pregnant women [8,13],
and the administration of antibiotics is inevitable. The US
Food and Drug Administration (FDA) has divided
antibiotics into five grades (A, B, C, D, and X) according to the
possible side effects for the fetus. Penicillins, macrolides,
cephalosporins, lincomycin, and clindamycin belong to
grade B drugs, which are safe for pregnant women and
could be used during pregnancy. Quinolones,
itraconazole, and fluconazole belong to grade C drugs, and animal
experiments have revealed negative influences on the
fetus; therefore, they are selected only when potential
benefits exceed potential risks. Silver sulfadiazine could be
absorbed from the wounds, and the absorption amount is
related to the applied area and duration. Research had
reported that the average Ag+ concentration in the blood
reaches 190 ng/mL at 10 days after application for patients
with <35% TBSA, and the Ag+ was observed to deposit in
the liver and kidneys . Extensive area application of
silver sulfadiazine should be avoided for pregnant women
with burns because absorption of sulfonamides is related
to kernicterus. In our case, silver sulfadiazine was applied
after the fetus was delivered. Additionally, imipenem was
given after cesarean delivery.
Pregnancy causes tremendous neurological and
endocrine changes, including an activated
renin-angiotensinaldosterone system  and an increased level of cortisol
and the catecholamine adrenaline [16,17]. Heart disease
and heart failure following pregnancy-induced
hypertension [18,19] and gestational diabetes  are not
uncommon in pregnant women. It is reasonable to presume that
severe burns might aggravate the pathological changes of
gravida and result in a deteriorative outcome based on the
current knowledge on pathological changes for pregnancy
and severe burns. Because related reports and research are
scarce, the collection and summarization of more clinical
data are needed.
In summary, the timely termination of pregnancy at the
early stage after injury and appropriate modification of
the volume of solution for fluid resuscitation based on
vital signs and urine output of the patient are two
pivotal elements for the success of this case. However, the
exact status of hemodynamics, including the heart
function and circulation volume, remained uncertain due to
the deficiency in invasive monitoring. The collection of
more precise data will be very helpful for the
decisionmaking concerning pregnant women with a severe burn
injury in the future.
Written informed consent was obtained from the patient
for publication of this case report and any accompanying
images. A copy of the written consent is available for
review by the Editor of this journal.
YS collected the clinical data, performed the statistical analysis, and drafted
the manuscript. XZ formulated the clinical treatment programs and helped to
draft the manuscript. B-GH and W-KW participated in the clinical treatment. YL
revised the manuscript for important intellectual content and the translation. All
authors read and approved the final manuscript.
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