- Email: [email protected]
Early burn wound excision in ‘major’ burns with ‘pregnancy’: a preliminary report
Copyright
Bums Vol. 22, No. 3, pp. 234-237, 1996 0 1996 Elsevier Science Ltd for ISBI. All rights reserved Printed in Great Britain 0305-4179196 $15.00 + 0.00
ELSEVIER
030s4179(95)00113-1
Early burn ‘pregnancy’:
wound excision a preliminary
in ‘major’ report
burns
with
M. Prasanna and K. Singh Department
of Plastic Surgery and Bums, Kasturba Medical College and Hospital, Manipal, Karnataka, India
in pregnantpatientsis not uncommon in developing countries.The results of the manugemenf of six pregnantbums pafienfs,admitted during an 18-month period, were analysed. Successful management of burn injuries rangingfrom 25 to 65 per cent TBSA occurred in putienk during the second and third trimesterof pregnancy,using curly burn wound excision and skin grafting in four patients and by lafe skin grafting of a granulating wound in one patient. All five patients delivered live babies with no congenital anomalies. One patient with 60 per cent TBSA burns who was unsuituble for early excision, died of septicaemia. This report suggests the need for early burn wound excision and skin grafting in burns patients with pregnancy, in order to improve maternal and fetal survival. However, in developing countries early surgey is not advisable in patients with extensive burns because of the non-availability of biological skin substitutes. Burn injuy
Bums,Vol. 22,No.3,234-237,1996
Akhtar et al2 found that ‘TBSA burned’ was the only statistically significant (PC 0.001) factor responsible for adverse fetal and maternal outcome, and pregnancy did not alter the maternal outcome. In pregnant patients with major bums, pathophysiological changesdue to bum injury provide a hostile environment for the fetus. Use of ‘judicious surgical therapy’ was suggestedby Deitch l1 to optimize maternal survival after an extensive thermal injury. Akhtar et a1.2in an epidemiological report suggestedadequate shock management and early excision with grafting to reduce mortality figures in burned patients with pregnancy. We present a preliminary clinical report of six pregnant patients with TBSA bums ranging from 25 to 65 per cent, treated by burn wound excision and skin grafting. The aim of this retrospective analysisis to assessthe merits of early excision in pregnant patients with major bums.
Materials
and methods
One hundred and four patients of either sex were admitted
Introduction Bum injuries in pregnant women are more common in developing than developed countriesl’“. Small bums seem to have no effect on pregnancy, but major bums affect both mother and fetus3-5. Various causesof abortion or premature labour in burned patients are: altered hormone levels and the immune relation between fetus, trophoblast and the mother6, release of prostaglandin E2 from burned tissue’, hyponatraemia, acidosis and sepsis6~8,9, hypoxia and hypotensionlO, etc.
to the Bums Centre of Kasturba Hospital, Manipal between September 1992 and March 1994. Six (15 per cent) out of 40 female patients between 15 and 45 years of age were pregnant at the time of admission. The mean age was 30 years, and the extent of burn injuries ranged from 25 to 65 per cent (mean46.6 per cent) TBSA. The gestational age ranged between 21 and 32 weeks(mean24.5 weeks)(TableI). All had flame bums. The common areas afflicted by bums in all patients were abdomen, breasts, arms and thighs. One patient (Case.?) had an associatedinhalation injury. One patient (Case2)
Table I. Patientprofile
Case 1 2 3 4 5 6
Maternal h) 33 30 25 33 35 23
age
Age of gestation (weeks) 23 32 20 21 20 32
(W
Delay in admission 0)
30 25 60 50 50 65
30 20 21 21 264 45
TBSA
burns
Surgical interventions (no.)
1 1 2 5 3 1
Prasanna
and Singh: Early bum wound
235
excision
Table II. Results
Meternal Case 1 2 3 4 5 6 TE = tangential
Surgery
done
Postburn
TE, SSG TE. SSG Escharotomy, slough, excision, and amputation TE, SSG Slough, excision, SSG TE, SSG excision;
SSG =split
days
4 3 11,14 4,10,14.22.33 19,24,54 7
outcome
Fetal outcome
Hospiral stay (dws)
Survived Survived Died
Survived Survived Aborted
20 24 23
Survived Survived Survived
Survived Survived Survived
44 71 13
skin grafting.
was a primigravida. All were evaluated by an obstetrician within 4 h of admission.The delay between time of injury and admission ranged from 20 h to 264 h. However, on excluding Case5 (having a delay of 264) the mean time delay was 25.4 h. Early fluid resuscitation with the modified Brooke formula was the same as in non-pregnant patients. All patients received tetanus prophylaxis and a combination of intravenous cloxacillin and gentamicin on admission. Broad-spectrum antibiotics such as netilimicin and thirdgeneration cephalosporins were given on suspicion or evidence of septic episodes. All bum wounds were treated with closed dressings with silver suIphadiazine followed by surgery. Four patients (CasesI, 2, 4 and 6) received early tangential excision of the bum wound and skin grafting between days 3 and 7 postbum (TableII). Between 15 and 20 per cent TBSA wound excision and skin grafting was done at the first operation, in all these patients. Wounds over abdomen and breasts were excised first to permit caesareansection and breast feeding subsequently. Case6 only received one operation since she was discharged on request (against medical advice) 1 week after the first operation. Two patients were not fit for early surgery, becauseof inhalation injury and cardiac arrest soon after admission (Case3) and gross wound infection Tn admission(Case5). All surgical procedures were done under general anaesthesia with thiopentone sodium as an induction agent. Endotracheal intubation followed paralysis with pancuronium and maintenance of anaesthesiaby nitrous oxide, oxygen, muscle relaxants and narcotics. Halothane was avoided to permit usage of adrenaline soaks. During surgery, maternal vital signs were monitored using a Nihon Kohden Lifescope 9, and fetal heart sounds were monitored (usingDoppler) by the ariaesthesiologistexcept when the abdomen was the site of surgery. Hourly urine output was also monitored throughout surgery to check the state of body hydration.
Figure 1. Case2 at admission.
Figure 2. Case2 on the day of discharge.
Results In spite of major bums ranging from 25 to 65 per cent TBSA, the survival rate of fetus and mothers was 100 per cent in four patients, who underwent early tangential excision and skin grafting (Figures1-5). Their hospital stay ranged from 13 days (discharged at request) to 44 days (mean 25.2 days) (TubleII). All these four mothers gave birth to live babies with no obvious congential abnormality as evaluated by a neonatologist. Two had normal vaginal delivery, one required outlet forceps and one had a lower segment caesarean section because of placenta previa. Case6 delivered vaginally a premature baby which
weighed 1940 g on day 3 postbum. The baby thrived well in the neonatal intensive care unit. The two pregnant patients with 50 and 60 per cent TBSA bums, who were unfit for early surgery, had a stormy hospital stay. Case3 aborted on day 3 postbum and died of septicaemiaon day 23. Case5 was dischargedafter 71 days in hospital after skin grafting of granulating wounds. In spite of being on a ventilator for 12 days for bronchopneumonia she delivered, vaginally, a healthy baby at term.
236
Bums: Vol. 22, No. 3‘1996
Figure 3. Case 2 on admission.
Figure 5. Case 4 after caesarean section.
Figure 4. Case 4 on the day of discharge.
Discussion Resuscitation of pregnant burn patients necessitates a balance between the physiological changesof pregnancy and the pathophysiological changes of bums. Maternal
cardiovascular status alters considerably throughout pregnancy, and additionally the stressof major bum injuries demands immediate measuresto prevent maternal and fetal complications. One patient with 50 per cent TBSA bums and a 5 month pregnancy (Case3) had a cardiac arrest on admission,i.e. 21 h after burns. Although shewas revived, intrauterine fetal death could not be avoided. This patient was unsuitable for early surgicalwound closure and died of septicaemiaon day 23 postbum. This emphasizes that early and efficient resuscitative measuresare essential for a good prognosis in burns patients with pregnancy. Induction of labour in order to improve maternal6 survival is unphysiological becauseburn injury is pathological and pregnancy is physiological. We feel strongly that expediting bum wound healing by early surgery helps to normalize the mother’s physiological status with the progression of pregnancy to term. To date published reports of early bum wound excision and skin grafting in pregnant patients are limited to only two out of 16 patients by Gang et a1.12,and both patients had burns of less than 10 per cent TBSA. In the present study, all four pregnant patients with major bums ranging from 25 to 65 per cent TBSA who underwent early tangential excision of bum wound and skin grafting had 100 per cent maternal and fetal survival. With the exception of Case3 who aborted, all the other women delivered live babies. One patient who delivered prematurely during month 8 of pregnancy (Case6) on day 3 postbum underwent tangential excision and skin grafting successfully. The baby also thrived well following intensive neonatal care. In comparison with non-pregnant women of reproductive age, septic shock may be commoner and more
Prasanna
and Singh: Early burn wound
excision
devastating to the pregnant patient sustaining a major bum13,14.Since early wound closure minimizes septic complications, early wound excision and skin grafting should have a very important place in the management of burned pregnant patients. Administration of antibiotics and analgesicsto pregnant patients with bums can be minimized by early surgery, becauseit prevents repeated septic episodesand painful dressings.Logically, therefore, even small deep dermal or full thickness depth bums should be excised early and skin grafted in pregnant patients using suitable anaesthesia.We found that timely administration of selected broadspectrum antibiotics helped the mothers to combat sepsis. Fortunately, most antibiotics are well tolerated by the fetus. However, tetracycline, chloramphicol and sulphonamides should be avoided“‘. The use of large doses of powerful antibiotics could be life-saving, despite the risk of resistance,superinfection and teratogenesi?. In this study, cloxacillin, aminoglycosides and cephalosporins were used. All the babies born to bums patients in this report were clinically normal, probably because none of the mothers were in the first trimester of pregnancy when burned. An additional advantage of early surgical wound closure of abdomen was well appreciated in Case4 who had to undergo a caesareansection because of placenta p&via (Figtrre5). A review of patients with old bums and pregnancy by Matthew? showed occasional problems due to densescarring over the abdomen and the absenceof the nipple areola complex. In this report it was observed that all the pregnant bums patients had the abdomen and breastsaffected by the bums, probably becausethey were bending towards the fire flames.In India ground level fires are used for cooking and/or worshipping. Early surgery in all thesepatients provided them with stableskin over these crucial areasat the earliest possible time. The quality of wound healing is far superior after early excision and skin grafting, than after secondary intention healing. Good and early healing of the abdominal wound helped: (a) pain-free stretching of the abdominal skin during the developing pregnancy to term; (b) abdominal obstetric supervision of the growing fetus; and (c) performing caesareansection if required. Early surgery of the breast wound prevents infection and sloughing of nipples. All our patients in the present study successfully suckled their newborn babies. The delicately balanced haemodynamic status in these patients required the utmost care in administration of anaesthetic agents, intravenous fluids and other drugs. Intraoperative maintenance of a minimum of I mg/kg/h urine volume and 100 per cent oxygen saturation are desirable. Dietch in 1985” rightly mentioned that the avoidance of hypotension and hypoxia during anaesthesia is more important than the anaesthetic agent used. All patients in this study received pain relief on admissionand in the postoperative period by continuous intravenous or subcutaneous opioid infusion using the Bard PCA I pump, or by Graseby syringe pump in dosage prescribed by the pain specialist, with no harmful effect either to the fetus or the newborn. FellerI attributed the nationwide decreasedmortality and hospital stay of burned patients in the USA to ‘early burn wound closure’. In India early bum wound excision and skin grafting helped reduce mortality, morbidity and hospital stay in burns patients16.The favourable maternal and fetal prognosis in the present report suggests that
237 early bum wound excision and skin grafting is indicated in ‘pregnant bums patients’ also, because it restores the normal physiological status of the mother (and therefore the fetus) by early healing of the bum wounds. However, in view of the non-availability of cadaver homograft and artificial skin in India, early excision should not be done in extensively burned patients16.
Conclusion The results of ‘early’ wound excision in four pregnant patients with major bums were encouraging, in view of 100 per cent maternal and fetal survival, perhaps due to early restoration of haemodynamic status and healing of bum wounds. Early wound healing over critical areassuch as the abdomen and breasts permitted caesareansection when needed, and breast feeding in all. Safe anaesthesia was possible in all patients, with careful avoidance of hypotension and hypoxia.
References I JainML, Garg AK. Bumswith pregnancy- a review of 2.5 cases.Burns1993;19: 166. 2 Akhtar MA, Mulawkar PM, Kulkami HR. Bums in pregnancy:effect on maternalandfetal outcome.Bums1994;20: 351. 3 Champagnie ML. And a baby wasborn. Burns 1978; 4: 285. 4 Matthews RN. Bumsin pregnancy- a preliminarycommunication.Br] Plasf Surg 1981;34: 231. 5 Stilwell JH. A majorbum in early pregnancywith maternal survival and pregnancyprogressingto term. Br 1 Plusf Swg 1982;35: 33. 6 Mathews RN. Obstetric implicationsof bumsin pregnancy. Br ] Obsfef Gynaecol 1982;89: 603. 7 ShrivastavaS,BangRL. Burnsduringpregnancy.Bum 1988; 14: 228. 8 Stage HA. Severe burns in the pregnant patient. O&feet Gynecol 1973; 42: 259.
9 Taylor JW,Plunkett GD, McManus WF et al. Thermalinjury during pregnancy.Obsfef Gynecol 1976;47: 434. 10 BhatRV, Vyas KD. Bumsin pregnancy.] Obsfef Gynecol India 1974;24: 264. 11 Deitch EA, RightmireDA, Clothier J et al. Managementof bumsin pregnantwomen.Swg Gynecol Obsfet 1985;161: 1. 12 Gang RK, BajecJ, Tahboub M. Management of thermal injury in pregnancy-an analysisof 16 patients.Bums 1992; l&317. 13 Shemitz JT. Pregnant patients with bums. Am J Obsfef Gynecol 1971; 110: 57.
14 Ying-bei 2, Ying-jie Z, XueweiW. Bumsduring pregnancyan analysisof 24 cases.Burns 1982;8: 286. 15 FellerI, Tholen D, CornellRG. Improvementsin bum care, 1965to 1969.JAMA 1980; 244: 2078. 16 Prasanna M, SinghK, KumarP.Early tangentialexcisionand skin grafting asa routine method of bum wound management - an experiencefrom a developing country. Bums 1994;20:446. Paper accepted after revision 31 July 1995. Correspondence should be addressed fo: Dr Mita Prasanna, Department of PlasticSurgery and Bums,KasturbaMedical College, Manipal-576119,Kamataka,India.
Bums Vol. 22, No. 3, pp. 234-237, 1996 0 1996 Elsevier Science Ltd for ISBI. All rights reserved Printed in Great Britain 0305-4179196 $15.00 + 0.00
ELSEVIER
030s4179(95)00113-1
Early burn ‘pregnancy’:
wound excision a preliminary
in ‘major’ report
burns
with
M. Prasanna and K. Singh Department
of Plastic Surgery and Bums, Kasturba Medical College and Hospital, Manipal, Karnataka, India
in pregnantpatientsis not uncommon in developing countries.The results of the manugemenf of six pregnantbums pafienfs,admitted during an 18-month period, were analysed. Successful management of burn injuries rangingfrom 25 to 65 per cent TBSA occurred in putienk during the second and third trimesterof pregnancy,using curly burn wound excision and skin grafting in four patients and by lafe skin grafting of a granulating wound in one patient. All five patients delivered live babies with no congenital anomalies. One patient with 60 per cent TBSA burns who was unsuituble for early excision, died of septicaemia. This report suggests the need for early burn wound excision and skin grafting in burns patients with pregnancy, in order to improve maternal and fetal survival. However, in developing countries early surgey is not advisable in patients with extensive burns because of the non-availability of biological skin substitutes. Burn injuy
Bums,Vol. 22,No.3,234-237,1996
Akhtar et al2 found that ‘TBSA burned’ was the only statistically significant (PC 0.001) factor responsible for adverse fetal and maternal outcome, and pregnancy did not alter the maternal outcome. In pregnant patients with major bums, pathophysiological changesdue to bum injury provide a hostile environment for the fetus. Use of ‘judicious surgical therapy’ was suggestedby Deitch l1 to optimize maternal survival after an extensive thermal injury. Akhtar et a1.2in an epidemiological report suggestedadequate shock management and early excision with grafting to reduce mortality figures in burned patients with pregnancy. We present a preliminary clinical report of six pregnant patients with TBSA bums ranging from 25 to 65 per cent, treated by burn wound excision and skin grafting. The aim of this retrospective analysisis to assessthe merits of early excision in pregnant patients with major bums.
Materials
and methods
One hundred and four patients of either sex were admitted
Introduction Bum injuries in pregnant women are more common in developing than developed countriesl’“. Small bums seem to have no effect on pregnancy, but major bums affect both mother and fetus3-5. Various causesof abortion or premature labour in burned patients are: altered hormone levels and the immune relation between fetus, trophoblast and the mother6, release of prostaglandin E2 from burned tissue’, hyponatraemia, acidosis and sepsis6~8,9, hypoxia and hypotensionlO, etc.
to the Bums Centre of Kasturba Hospital, Manipal between September 1992 and March 1994. Six (15 per cent) out of 40 female patients between 15 and 45 years of age were pregnant at the time of admission. The mean age was 30 years, and the extent of burn injuries ranged from 25 to 65 per cent (mean46.6 per cent) TBSA. The gestational age ranged between 21 and 32 weeks(mean24.5 weeks)(TableI). All had flame bums. The common areas afflicted by bums in all patients were abdomen, breasts, arms and thighs. One patient (Case.?) had an associatedinhalation injury. One patient (Case2)
Table I. Patientprofile
Case 1 2 3 4 5 6
Maternal h) 33 30 25 33 35 23
age
Age of gestation (weeks) 23 32 20 21 20 32
(W
Delay in admission 0)
30 25 60 50 50 65
30 20 21 21 264 45
TBSA
burns
Surgical interventions (no.)
1 1 2 5 3 1
Prasanna
and Singh: Early bum wound
235
excision
Table II. Results
Meternal Case 1 2 3 4 5 6 TE = tangential
Surgery
done
Postburn
TE, SSG TE. SSG Escharotomy, slough, excision, and amputation TE, SSG Slough, excision, SSG TE, SSG excision;
SSG =split
days
4 3 11,14 4,10,14.22.33 19,24,54 7
outcome
Fetal outcome
Hospiral stay (dws)
Survived Survived Died
Survived Survived Aborted
20 24 23
Survived Survived Survived
Survived Survived Survived
44 71 13
skin grafting.
was a primigravida. All were evaluated by an obstetrician within 4 h of admission.The delay between time of injury and admission ranged from 20 h to 264 h. However, on excluding Case5 (having a delay of 264) the mean time delay was 25.4 h. Early fluid resuscitation with the modified Brooke formula was the same as in non-pregnant patients. All patients received tetanus prophylaxis and a combination of intravenous cloxacillin and gentamicin on admission. Broad-spectrum antibiotics such as netilimicin and thirdgeneration cephalosporins were given on suspicion or evidence of septic episodes. All bum wounds were treated with closed dressings with silver suIphadiazine followed by surgery. Four patients (CasesI, 2, 4 and 6) received early tangential excision of the bum wound and skin grafting between days 3 and 7 postbum (TableII). Between 15 and 20 per cent TBSA wound excision and skin grafting was done at the first operation, in all these patients. Wounds over abdomen and breasts were excised first to permit caesareansection and breast feeding subsequently. Case6 only received one operation since she was discharged on request (against medical advice) 1 week after the first operation. Two patients were not fit for early surgery, becauseof inhalation injury and cardiac arrest soon after admission (Case3) and gross wound infection Tn admission(Case5). All surgical procedures were done under general anaesthesia with thiopentone sodium as an induction agent. Endotracheal intubation followed paralysis with pancuronium and maintenance of anaesthesiaby nitrous oxide, oxygen, muscle relaxants and narcotics. Halothane was avoided to permit usage of adrenaline soaks. During surgery, maternal vital signs were monitored using a Nihon Kohden Lifescope 9, and fetal heart sounds were monitored (usingDoppler) by the ariaesthesiologistexcept when the abdomen was the site of surgery. Hourly urine output was also monitored throughout surgery to check the state of body hydration.
Figure 1. Case2 at admission.
Figure 2. Case2 on the day of discharge.
Results In spite of major bums ranging from 25 to 65 per cent TBSA, the survival rate of fetus and mothers was 100 per cent in four patients, who underwent early tangential excision and skin grafting (Figures1-5). Their hospital stay ranged from 13 days (discharged at request) to 44 days (mean 25.2 days) (TubleII). All these four mothers gave birth to live babies with no obvious congential abnormality as evaluated by a neonatologist. Two had normal vaginal delivery, one required outlet forceps and one had a lower segment caesarean section because of placenta previa. Case6 delivered vaginally a premature baby which
weighed 1940 g on day 3 postbum. The baby thrived well in the neonatal intensive care unit. The two pregnant patients with 50 and 60 per cent TBSA bums, who were unfit for early surgery, had a stormy hospital stay. Case3 aborted on day 3 postbum and died of septicaemiaon day 23. Case5 was dischargedafter 71 days in hospital after skin grafting of granulating wounds. In spite of being on a ventilator for 12 days for bronchopneumonia she delivered, vaginally, a healthy baby at term.
236
Bums: Vol. 22, No. 3‘1996
Figure 3. Case 2 on admission.
Figure 5. Case 4 after caesarean section.
Figure 4. Case 4 on the day of discharge.
Discussion Resuscitation of pregnant burn patients necessitates a balance between the physiological changesof pregnancy and the pathophysiological changes of bums. Maternal
cardiovascular status alters considerably throughout pregnancy, and additionally the stressof major bum injuries demands immediate measuresto prevent maternal and fetal complications. One patient with 50 per cent TBSA bums and a 5 month pregnancy (Case3) had a cardiac arrest on admission,i.e. 21 h after burns. Although shewas revived, intrauterine fetal death could not be avoided. This patient was unsuitable for early surgicalwound closure and died of septicaemiaon day 23 postbum. This emphasizes that early and efficient resuscitative measuresare essential for a good prognosis in burns patients with pregnancy. Induction of labour in order to improve maternal6 survival is unphysiological becauseburn injury is pathological and pregnancy is physiological. We feel strongly that expediting bum wound healing by early surgery helps to normalize the mother’s physiological status with the progression of pregnancy to term. To date published reports of early bum wound excision and skin grafting in pregnant patients are limited to only two out of 16 patients by Gang et a1.12,and both patients had burns of less than 10 per cent TBSA. In the present study, all four pregnant patients with major bums ranging from 25 to 65 per cent TBSA who underwent early tangential excision of bum wound and skin grafting had 100 per cent maternal and fetal survival. With the exception of Case3 who aborted, all the other women delivered live babies. One patient who delivered prematurely during month 8 of pregnancy (Case6) on day 3 postbum underwent tangential excision and skin grafting successfully. The baby also thrived well following intensive neonatal care. In comparison with non-pregnant women of reproductive age, septic shock may be commoner and more
Prasanna
and Singh: Early burn wound
excision
devastating to the pregnant patient sustaining a major bum13,14.Since early wound closure minimizes septic complications, early wound excision and skin grafting should have a very important place in the management of burned pregnant patients. Administration of antibiotics and analgesicsto pregnant patients with bums can be minimized by early surgery, becauseit prevents repeated septic episodesand painful dressings.Logically, therefore, even small deep dermal or full thickness depth bums should be excised early and skin grafted in pregnant patients using suitable anaesthesia.We found that timely administration of selected broadspectrum antibiotics helped the mothers to combat sepsis. Fortunately, most antibiotics are well tolerated by the fetus. However, tetracycline, chloramphicol and sulphonamides should be avoided“‘. The use of large doses of powerful antibiotics could be life-saving, despite the risk of resistance,superinfection and teratogenesi?. In this study, cloxacillin, aminoglycosides and cephalosporins were used. All the babies born to bums patients in this report were clinically normal, probably because none of the mothers were in the first trimester of pregnancy when burned. An additional advantage of early surgical wound closure of abdomen was well appreciated in Case4 who had to undergo a caesareansection because of placenta p&via (Figtrre5). A review of patients with old bums and pregnancy by Matthew? showed occasional problems due to densescarring over the abdomen and the absenceof the nipple areola complex. In this report it was observed that all the pregnant bums patients had the abdomen and breastsaffected by the bums, probably becausethey were bending towards the fire flames.In India ground level fires are used for cooking and/or worshipping. Early surgery in all thesepatients provided them with stableskin over these crucial areasat the earliest possible time. The quality of wound healing is far superior after early excision and skin grafting, than after secondary intention healing. Good and early healing of the abdominal wound helped: (a) pain-free stretching of the abdominal skin during the developing pregnancy to term; (b) abdominal obstetric supervision of the growing fetus; and (c) performing caesareansection if required. Early surgery of the breast wound prevents infection and sloughing of nipples. All our patients in the present study successfully suckled their newborn babies. The delicately balanced haemodynamic status in these patients required the utmost care in administration of anaesthetic agents, intravenous fluids and other drugs. Intraoperative maintenance of a minimum of I mg/kg/h urine volume and 100 per cent oxygen saturation are desirable. Dietch in 1985” rightly mentioned that the avoidance of hypotension and hypoxia during anaesthesia is more important than the anaesthetic agent used. All patients in this study received pain relief on admissionand in the postoperative period by continuous intravenous or subcutaneous opioid infusion using the Bard PCA I pump, or by Graseby syringe pump in dosage prescribed by the pain specialist, with no harmful effect either to the fetus or the newborn. FellerI attributed the nationwide decreasedmortality and hospital stay of burned patients in the USA to ‘early burn wound closure’. In India early bum wound excision and skin grafting helped reduce mortality, morbidity and hospital stay in burns patients16.The favourable maternal and fetal prognosis in the present report suggests that
237 early bum wound excision and skin grafting is indicated in ‘pregnant bums patients’ also, because it restores the normal physiological status of the mother (and therefore the fetus) by early healing of the bum wounds. However, in view of the non-availability of cadaver homograft and artificial skin in India, early excision should not be done in extensively burned patients16.
Conclusion The results of ‘early’ wound excision in four pregnant patients with major bums were encouraging, in view of 100 per cent maternal and fetal survival, perhaps due to early restoration of haemodynamic status and healing of bum wounds. Early wound healing over critical areassuch as the abdomen and breasts permitted caesareansection when needed, and breast feeding in all. Safe anaesthesia was possible in all patients, with careful avoidance of hypotension and hypoxia.
References I JainML, Garg AK. Bumswith pregnancy- a review of 2.5 cases.Burns1993;19: 166. 2 Akhtar MA, Mulawkar PM, Kulkami HR. Bums in pregnancy:effect on maternalandfetal outcome.Bums1994;20: 351. 3 Champagnie ML. And a baby wasborn. Burns 1978; 4: 285. 4 Matthews RN. Bumsin pregnancy- a preliminarycommunication.Br] Plasf Surg 1981;34: 231. 5 Stilwell JH. A majorbum in early pregnancywith maternal survival and pregnancyprogressingto term. Br 1 Plusf Swg 1982;35: 33. 6 Mathews RN. Obstetric implicationsof bumsin pregnancy. Br ] Obsfef Gynaecol 1982;89: 603. 7 ShrivastavaS,BangRL. Burnsduringpregnancy.Bum 1988; 14: 228. 8 Stage HA. Severe burns in the pregnant patient. O&feet Gynecol 1973; 42: 259.
9 Taylor JW,Plunkett GD, McManus WF et al. Thermalinjury during pregnancy.Obsfef Gynecol 1976;47: 434. 10 BhatRV, Vyas KD. Bumsin pregnancy.] Obsfef Gynecol India 1974;24: 264. 11 Deitch EA, RightmireDA, Clothier J et al. Managementof bumsin pregnantwomen.Swg Gynecol Obsfet 1985;161: 1. 12 Gang RK, BajecJ, Tahboub M. Management of thermal injury in pregnancy-an analysisof 16 patients.Bums 1992; l&317. 13 Shemitz JT. Pregnant patients with bums. Am J Obsfef Gynecol 1971; 110: 57.
14 Ying-bei 2, Ying-jie Z, XueweiW. Bumsduring pregnancyan analysisof 24 cases.Burns 1982;8: 286. 15 FellerI, Tholen D, CornellRG. Improvementsin bum care, 1965to 1969.JAMA 1980; 244: 2078. 16 Prasanna M, SinghK, KumarP.Early tangentialexcisionand skin grafting asa routine method of bum wound management - an experiencefrom a developing country. Bums 1994;20:446. Paper accepted after revision 31 July 1995. Correspondence should be addressed fo: Dr Mita Prasanna, Department of PlasticSurgery and Bums,KasturbaMedical College, Manipal-576119,Kamataka,India.