BURNS IN PREGNANCY

Napoli B., D'Arpa N., Masellis M., Graziano R. Divisione i C!ir"r#ia Plas$i%a e &erapia elle Us$ioni, 'spe ale Civi%o, Paler(o, I$al) Divisione 's$e$ri%ia e Gine%olo#ia, 'spe ale Civi%o, Paler(o

SUMMARY. Two cases are reported of bums in pregnancy. After a survey of the literature and a discussion of the incidence of bums in pregnancy, the physiopathology of spontaneous uterine activity is considered together with aspects of the treatment of bums and obstetric management in relation to maternal and foetal prognosis.

Introduction and survey of the literature Texts on obstetrics do not deal with bums in pregnancy nor is the topic considered in books devoted to the treatment of bums. Tables I and II present the authors and cases present in the literature in papers, covering the problem.

Case n"(*er 1 2 3 4 5 6 7 8 9 10 11 12 13
*'!a#e#' +',n$ian' rigin

A"$!or Mulla Ryan Merger Tica Schmitz Stage Bhatt* Tayl r !ham"agnie Si#m n$i %ing&ei'() Stil*ell Matthe*#

Year 1958 1962 1963 1969 1971 1973 1974 1976 1977 1979 1981 1982 1982

Perio o+ s$" ) 1961-69 1963-72 1967-71 1950-74 1956-78 -

N"(*er o+ %ases 1 2 2 1 6 3 28 19 1 1 24 1 16

Ma$ernal ea$! 1 0 0 0 0 0 20 7 0 0 2 0 6

,oe$al ea$! 1 0 0 1 2 1 23 7 0 0 5 1 8

Table I - Summary table of authors and cases until 1 !"

#esides the description of individual cases or limited series of cases collected over protracted periods, we find works based on case histories from various bums centres. $atthews discusses %& cases based partly on a 'uestionnaire sent to all bums centres in the () *1+ cases, and partly on the previous literature *-. cases,, and provides data regarding works by Sismondi et al., /ingbei 0. et al., and Stilwell1 his work thus presents an almost complete survey of the literature up to 1 !".

Case n"(*er 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29
*'!a#e#' +',n$ian' rigin

A"$!or Ray&urn -eitch .my Bartle Sri/a#ta/a Benineir !heah R $e Ma& gunge 0ang 1ain* .2htar* l ann /ich !ale++i 3ra#anna* Sar2ar*

Year 1984 1985 1985 1988 1988 1988 1989 1990 1990 1992 1993 1994 1994 1994 1996 1996

Perio o+ s$" ) 1964-81 1978-83 1950-84 1955-75 1984-87 1970-86 1981-87 1986-87 1972-81 1984-89 1986-91 1991-93 1988-93 1992-94 1993-95

N"(*er o+ %ases 30 11 11 42 8 8 9 33 7 8 25 50 5 1 6 20

Ma$ernal ea$! 8 0 3 3 0 2 2 8 1 1 5 35 1 0 1 0

,oe$al ea$! 12 3 6 20 2 3 2 13 2 3 9 36 2 0 1 12

Table II - Summary table of authors and cases after 1 !"

The characteristics of later papers untilthe present day are however no different. 2aybum et al. report -& cases studied over an 1!-yr period in three American university bums centres1 Arny et al. also describe -& cases, 1 of which had however already described by Taylor et al. some years previously1 3ang et al. reported 1+ cases, half of which had already been presented by Srivastava et al. 4ases previously described and collections of cases from other centres have contributed to the overall number of observations that have made it possible to establish the

correct procedures to be observed as regards bums, i.e. in the mother, and as regards pregnancy, i.e. in the foetus, in relation to the stage of pregnancy. #efore proceeding any further, however, a word of warning is necessary - 4hampagnie5 published his case twice, while and /ingbei et al. published their ". cases no fewer than three times. Incidence The literature on bums in pregnancy is indeed limited, but the incidence of the phenomenon, as calculated by the various authors in relation to the total number of female burn patients of reproductive age, does not appear to be low, while the incidence in early pregnancy is unknown in the absence of routine pregnancy testing on admission. Apart from the &.+6 reported from 7srael by #enmeir et al., Taylor et al. calculated an incidence of 86, a rate also found by Amy et al.in later years *+.86, 9ort :ouston,, while the rate of 8. 6 reported by Srivastava et al. was confirmed by 3ang et al. *8.!6, )uwait,. The highest of all burn incidences in pregnancy was found in 7ndia, ranging from 86, calculated by Akhtar *;agpur,, to 1-.-6, reported by <ain *#hilai,, and 1%6 reported by =rasanna *)arnataka,. This high incidence reflects the fact that of the -8 cases reported in the literature between 1 %! and the present day that have come to our attention, 1" *-.6, occurred in 7ndia (Tables I, II,. 7n 7taly only two cases have ever been reported in the literature *Sismondietal. and 4aleffi et al.,. >e supplement these two cases and the international literature with two other cases that have come to our attention in recent years. Clinical cases Case 1 ?e =.A., age - yr, first 'uarter pregnancy *.th week of amenorrhoea,, suffered full-thickness skin burns in #SA -&6 on + <une 1 .. @n "% August 1 . the patient was subAected in general anaesthesia to free skin graft and discharged on 1- September 1 .. The patient originally opted for a voluntary abortion, which gave us a certain degree of freedom of action in the management of the pregnancy, but she later decided for religious reasons to carry the child to term. @n " $arch 1 % she was delivered of a foetus presenting a serious cardiac malformation. The child died a few days after birth. Case 2 2.7., age "& yr,, third 'uarter pregnancy *--rd week of amenorrhoea,, suffered full-thickness skin bums in "&6 #SA on "! ?ecember 1 %. The treatment of the bums and the management of the pregnancy culminated in a surgical operation two weeks after the patientBs admission. @n 1" <anuary 1 +, after prophylaxis for hyaline membrane disease, the patient was subAected to a caesarian section. The foetus presented in podalic position *buttocks variety,. The foetus, of female sex, weighed ".. kg and was alive and well, with Apgar ! at minute 1 and 1& at minute %. 7mmediately after closure of the abdominal wall, the patient was subAected to free skin graft in the burned areas *9igs. 1--,. @n obAective examination the baby showed nothing pathological in the various organs and systems but was kept in hospital in view of her prematurity. After a normal obstetric and surgical course the patient was dismissed on "- <anuary 1 +.

Fig. 1 - Cxtraction of foetus.

Fig.

- =atient after caesarian section.

Fig. ! - The living and viable foetus.

"iscussion A. Thermal trauma and spontaneous uterine activity The onset of labour in a premature delivery shortly after a serious burn was in the past thought to be triggered by the endocrine function, and in particular by that of the secretion of adrenocortical hormones related to stress. Dater observations confirmed that slight bums had no effect on the course of pregnancy, while bums of at least -%6 T#SA were capable of provoking early labour and the loss of the foetus following intrauterine death within a week of the bum. #oth spontaneous miscarriage and premature delivery were subse'uently thought to be related to the synthesis and release of prostaglandins *responsible for early uterine contractions, from the skin in the burn area. Dater, however, the correct importance was attributed both to maternal shock, which determines a considerable reduction in the uterine blood flow and causes foetal hypoxia, and to pleuropulmonary complications, especially in cases of inhalation lesions with grave reduction of maternal =&" and conse'uently, as in this case, foetal hypoxia. Table III presents the events that as a result of foetal hypoxia and acidosis determine spontaneous uterine activity. The condition of hypotension and acute respiratory insufficiency is thus accompanied by septicaemia. This can lead to complications in the foetus, even some time after the bum, owing to the fact that the foetus may be able to tolerate the early phases of maternal sepsis but is notably affected in the advanced phases, when the mother is decompensated and her cardiovascular system collapses.

Table III - Cvents determining spontaneous uterine activity

As the maternal intravascular space is in a state of e'uilibrium with the amniotic li'uid, the reduction of this li'uid during serious hypovolaemia can cause the intrauterine death of the foetus. The onset of spontaneous uterine contractions is also favoured by the release from bacteria and the placenta of an enEyme, phospholipase A, which is necessary for the conversion of arachidonic acid into prostaglandin. 7t has recently been shown that there is a considerable reduction in plasma levels of 18#-oestradiol in pregnant burned women who had either an abortion or a still birth in the first week post-bum. #. Burns treatment - its influence on the course of pregnancy and the foetus #l. 3eneral treatment. 2esuscitation treatment in the burned pregnant woman is no different from that in the nonpregnant burned woman. The prevention of hypovolaemic shock by ade'uate early fluid therefore re'uires that the uterine blood flow should be able maintain foetus tissue =@" levels within the normal range. 7t has been recommended that a 'uantity of fluid should be administered that is sufficient to maintain the motherBs blood pressure within the normal range and a diuresis of -&-+& mlFh. The maintenance of arterial pressure levels at normal values is essential at all stages of the burn disease. ?iuretics and anti-hypertension drugs should therefore be avoided whenever possible. Cpisodes of hypotension should be avoided also in the event of surgical operations. 7t is recommended that surgery should be performed with intraoperative maintenance of a minimum of 1 mlFkgFh of urine volume and 1&&6 oxygen saturation. Since extensive surface bums are fre'uently associated with an increased rate of arterial shunting and hypoxia, it becomes necessary to administer oxygen. A pregnant patientBs oxygenation can

often be improved by nursing her in a semi-sitting position. $aternal =@" values of less than +& ram :g during the pleuropulmonary complications that are often secondary to inhalation have been considered critical, and it has therefore been recommended that ventilatory support should be initiated as soon as possible. This is all the more necessary because inhaled carbon monoxide can also cross the placental barrier to compete for binding sites on foetal haemoglobin, provoking foetal cardiac oedema, and also affect cardiac development .7f the respiratory complication is bronchopneumonia, it is necessary to use antibiotic treatment, if possible selecting drugs that the foetus can tolerate. The same applies to cases of suspected and manifest sepsis. #". Docal treatment. The local treatment of burns in pregnant women is not simple, because of the limitations imposed by the state of pregnancy. 4hloramphenicol, either in powder form *4hemicetine, or as an ointment in association with collagenase *lruxol,, is among the drugs to be avoided throughout pregnancy since it is teratogenous if administered during the first period of pregnancy and responsible for neonatal pathology if used during the final period *grey syndrome,. 3entamicin *3entalyn cream, gentalyn ointment, is an aminoglycoside capable of passing through the placenta after absorption through bums. 7f used after the 1.th week of pregnancy it can cause lesions in the !th pair of cranial nerves, with vestibular and acoustic damage. The fulltemi foetus has been found to present antibiotic concentrations analogous to those of the mother. 7n addition to ototoxicity aminoglycosides are responsible for nephrotoxicity. 2ifamycin SG *2ifocyn for local use, is absolutely to be avoided in the last period of pregnancy because its interference with bilimbin metabolism can cause indirect hyperbilirubinaemia, with the risk of kemicterus. Sulpha drugs *silver sulphadiaEine-Sofargen, are suspected of potential teratogenous activity if administered before the 1.th week of pregnancy and of retarding growth, determining low birth weight if subse'uently administered. Sulpha drugs administered at the term of pregnancy are responsible for kernicterus. Salicylates *salicylate vaseline, exert an anti-prostaglandin action and may therefore have a protective effect on pregnancy. 9or the same reason they should not be used in the final period of pregnancy because they prolong gestation and delay spontaneous delivery. There is little evidence regarding the possibility that salicylates have a teratogenous effect, although the birth weight of babies born to women subAected to chronic administration of salicylates has been reported to be below average. An increase in perinatal mortality has also been reported. These results have not however been confirmed in other studies. =ovidone-iodine *lodoten, is widely used for bums cleansing. 7t must however be avoided in pregnant women since large amounts of iodine can be absorbed through the burn wound. (se of povidone-iodine is inadvisable in bums exceeding "&6 T#SA because the iodine passing through the placenta can be absorbed in sufficient 'uantities to affect thyroid functions and cause metabolic acidosis. 7t is thus clear that the state of pregnancy considerably reduces use of the commonest protocols for the topical treatment of burns. Cven the local use of antibiotics that are normally administered systemically presents considerable difficulties. The only antibiotics that can be considered safe in pregnancy are the penicillins and cephalosporins, while vancomycin, one of the most fre'uently used and most active antistaphylococcal drugs, is considered to be potentially teratogenous and ciprophloxacin may possibly damage articular cartilages in undeveloped organisms.

@ther commonly used antibiotics *7mipenem, teicoplanin, should be avoided in the absence of ade'uate information about their safety during pregnancy unless they are absolutely necessary and their advantages outweigh any possible risk. These considerations are also valid with reference to the parenteral use of the above-mentioned drugs in the event of infective respiratory complications or sepsis. Tetracyclines are not widely used in bums but it should not be forgotten that they are contra-indicated during pregnancy because of their varying effects on foetal growth, bones, teeth, and the immune system. >ith regard to local treatment, if the medication is performed under anaesthesia it is important to avoid the use of ketamine, which increases the excitability of the myometrium because it is capable of triggering effective contractions1 also, when the pregnancy is near term and delivery is imminent, ketamine may cause respiratory depression in the neonate. #-. Surgical treatment. 7n view of the difficulties related to local medical treatment, early surgical therapy assumes vital importance. This is because early surgical facilitates healing of the wounds and thus improves prognosis in both mother and neonate. Carly coverage of the bums also minimiEes septic complications and the need to administer antibiotics1 in addition, it reduces painful medications and the necessity of analgesic drugs. The treatment comprises early tangential excision and split-thickness skin-grafting --8 days postbuni in the deeper burned areas *but not more than 1%-"&6 T#SA at one operation,. >ounds over the abdomen and breast have to be treated first. 3ood early healing of the abdominal wound favoursH

pain-free stretching of the abdominal skin during the developing pregnancy to term abdominal obstetric supervision of the growing foetus performance of caesarian section if re'uired

Carly surgery of the breast wound prevents infection and sloughing of nipples and permits subse'uent breast feeding. C. bstetric management of the pregnant !oman !ith burns 7f it is known that a burned female is pregnant, it is important to establish as precisely as possible the exact stage of pregnancy at the time of the burn accident. This must be based upon the menstrual history and foetal ultrasound examination. The gestational period is in fact one of the factors determining obstetric procedures *no intervention, protection of pregnancy by tocolithic treatment, induction andFor acceleration of labour,. @ther factors are the severity of the burn and foetal viability, which must be confirmed immediately. Such biophysical measurements as foetal muscle tone, limb motion and breathing patterns, placental morphology, and amniotic fluid volume may be visualiEed in order to assess foetal health. >ith regard to the stage of gestation, foetuses delivered before ". weeks generally will not survive, while those delivered after -" weeks will do well with modem neonatal intensive care if born without hypoxia or birth trauma. The most difficult to manage are foetuses of between ". and -" weeksB gestational age, where e" utero survival is difficult to predict. 7n such cases, therefore, when pre-term labour occurs, tocolysis procedures are initiated. 7n the light of the findings of 2yan et al. *relative to two patients with respectively +%6 and 8&6 T#SA bums presenting first-'uarter pregnancy who survived and had full-term deliveries,, it

was long believed that pregnancy improved prognosis in the mother. :owever, the findings of $atthews indicated that a more advanced state of pregnancy *"nd--rd 'uarter, in women with over %&6 T#SA bums had an unfavourable effect unless delivery was immediate, as the burn created an unfavourable environment for the foetus1 in bums in less than .&6 T#SA pregnancy and its continuation had no effect on prognosis in the mother and every attempt had to be made to interrupt inception of labour if the foetus was too immature to survive. Table I# presents a protocol that has recently been proposed. 7ts presenters do not suggest that the protocol should be applied rigidly in all cases but rather that it should be regarded as a useful general guideline.

&o$al *"rn

A#e o+ #es$a$ion 5ir#t'trime#ter

Mana#e(en$ 6 ' &#tetric'inter+erence 6 ' &#tetric'inter+erence

4'30

Sec n$'trime#ter Thir$'trime#ter 5ir#t'trime#ter

M re'than'36'*2# ,n$uce'la& ur'7'cae#arian'#ecti n 8e##'than'36'*2#' ! n#er/ati/e'a""r ach'an$'m nit ring' +'heart'rate 5 etal'm nit ring'&y'ultra# un$'3-4'*2# 5 etal'm nit ring'e/ery'3-4'*2#)'T c lytic'thera"y M re'than'32'*2#' -eli/er'+ etu#'*ithin'48'h 8e##'than'36'*2# !are+ul'+ etal'm nit ring Terminate'"regnancy Terminate'"regnancy ,+'&a&y'i#'/ia&le ,n$uce'la& ur'7'cae#arian'#ecti n'*ithin'24h 6 'acti/e'inter/enti n'u"'t '4'*2#'7'm nit ring' +' + etu#' +'haem c agulati n'+act r# 6 'treatment 6 'treatment !ae#arian'#ecti n'a#'an'emergency'"r ce$ure'at'the' earlie#t

30-50

Sec n$'trime#ter Thir$'trime#ter 5ir#t'trime#ter Sec n$'trime#ter

50-70 Thir$'trime#ter

,ntrauterine'$eath

5ir#t'trime#ter 9'70 Sec n$'trime#ter Thir$'trime#ter

5r m'0ang'et'a8'1992)

Table I# $ @bstetric management of the pregnant burned woman

2egarding the manner of delivery *vaginal route, caesarian section,, spontaneous vaginal delivery is generally preferred, although obstetric considerations affect the choice of route and the timing of the delivery1 serial foetal sonography and electronic heart rate monitoring, by means of cardiotocographic recording, identifies foetal stress at an early stage and may permit timely intervention, preventing intrauterine death. 7n a critically burned woman with a living and near-term pregnancy, foetal salvage by caesarian section appears Austifiable. >hen there are obstetric indications for a caesarian section, this can be performed even when the lower abdominal wall is part of the burned area. Conclusion Although the relevant literature is limited, the incidence of bums in pregnancy does not appear to be low, especially in developing countries such as 7ndia where bums constitute a social disease. As hypovolaemia causes a reduction in uterine blood flow and in the amniotic fluid, the overcoming of maternal shock is of fundamental importance for foetal prognosis. At a later stage the drop in pressure related to septic episodes and the reduction of maternal =@" secondary to pulmonary complications. :ypovolaemia and hypoxia are in fact the cause of the spontaneous uterine contractions that lead to abortion or premature delivery after intrauterine death of the foetus. An important role is played by the synthesis and release of prostaglandin both by the burned skin and as a result of dehydration, if not appropriately corrected. The general and topical treatment of bums in the pregnant woman has to take into account the embryonal, foetal, and perinatal toxicity of the pharmacological therapy employed, since what is beneficial for the mother may be harmful for the child. =articularly difficult therapeutic courses have been found to cause serious malformations1 and even the infusion of hypertonic glucose solutions can lead to secondary hyperinsulaemia with foetal macrosornia. 7n order to reduce pharmacological therapy to the minimum possible and to accelerate the burn healing process *and thus improve prognosis,, the maAority of authors are favourable to early surgical intervention. @bstetric management of pregnancy in the burned woman re'uiresH

monitoring of the pregnancy by fre'uent ultrasound scanning, daily measuring of the blood clotting factor, and, where possible, cardiotocographic monitoring. 7ntrauterine death of the foetus may be preceded by a reduction of 18!-oestradiol and C, levels1 calculation of the stage of gestation and the gravity of the burn1 obstetric treatment must be =-Aated to these two parameters choice of method of delivery *vaginal route, caesarian section,.

R%SUM%. Des Auteurs dIcrivent deux cas de brJlures pendant la grossesse. AprKs avoir examinI la littIrature relative et discutI lBincidence du phInomKne, ils approfondissent la physiopathologie de lBactivitI utIrine spontanIe et les aspects 'ui concernent soit le traitement des brJlures soit la gestion obstItricale en fonction du pronostic maternofItale.

&I&'I()RA*+Y 1. ". -. $atthews 2LH @bstetric implications of bums in pregnancy. #r. <. @bstet. 3ynaec., ! H +&-- , 1 !". Sismondi 9., 3alletto D., #ormioli $.H (stioni in gravidanEa. $in. 3in., -1H %.1-., 1 8 . a, /ingbei 0., Luewi >., /ingAie 0., /onghua S.H #ums during pregnancyH Analysis of ". cases. 4hin. $ed. <., .H 1"--+, 1 !1. b, /ingbei 0., /ingAie 0., Luewi >.H #urn inAury during pregnancyH Analysis of ". cases. #ums, !H "!+- , 1 !1. c, Luewi >., /ingbei 0., /ingAie 0.H #ums during pregnancyH Analysis of ". cases. #ull. 4lin. 2ev. #urn 7nA., "H 1%-1+, 1 !%. Stilwell <.:.H A maAor burn in early pregnancy with survival and pregnancy progressing to term. #r. <. =last. Surg., -%H ---%, 1 !". 2ayburn >., Smith #., 9eller 7., Garner $., 4ruikshank ?.H $aAor bums during pregnancyH Cffect on fetal well-being. @bstet. 3ynecol., +-H - "-%, 1 !.. Amy #.>., $c$anus >.9., 3oodwin 4.>., $ason A., =ruitt #.A., ArH Thermal inAury in the pregnant patient. Surg. 3ynec. @bst., 1+1H "& -1", 1 !%. Taylor <.>., =lunkett 3.?., $c$anus >.9., =ruitt #.A., ArH Thermal inAury during pregnancy. @bstet. 3ynec., .8H .-.-!, 1 8+. 3ang 2.)., #aAee <., Tahboub $.H $anagement of thermal inAury in pregnancyH An analysis of 1+ patients. #ums, 1!H -18-"&, 1 ". Srivastava S., #ang 2.D.H #ums during pregnancy. #ums, 1.H ""! -", 1 !!.

.. %. +. 8. !. .

1&. a, 4hampagnie $.D.H And a baby was bom. ;ursing $irror, 1.%H 1+-18, 1 88. b, 4hampagnie $.D.H And a baby was bom. #ums, .H "!%, 1 8!. 11. #enmeir =., Sagi A., 3reber #., #ibi 4., :auben ?., 2osenberg D., #en-/a'ar /, $ather ?.H #ums during pregnancyH @ur experience. #ums, 1.H "---+, 1 !!. 1". Akhtar $.A., $ulawkar =.$., )ulkami :.2.H #ums in pregnancyH Cffect on maternal and fetal outcomes. #ums, "&H -%1-%, 1 .. 1-. <ain $.D., 3arg A.).H #ums with pregnancy - a review of "% cases. #ums, 1 H 1++-8, 1 -.

1.. =rasanna $., Singh ).H Carly burn wound excision in maAor bums with pregnancyH A preliminary report. #ums, ""H "-.-8, 1 +. 1%. 4aleffi C., #occhi A., Toschi S., =apadia 9.H ;atural skin graft expansionH @ur experience with a four months pregnant burn patient. Ann. $edit. #ums 4lub, 8H 1%&-", 1 .. 1+. $ulla ;.H Dabor following severe thermal bums. A case report. Am. <. @bstet. 3ynec., 8+H 1--!-.1, 1 %!. 18. SchmitE <.T.H =regnant patients with bums. Am. <. @bstet. 3ynaec., 1H %8, 1 81. 1!. Stage A.:.H Severe bums in the pregnant patient. @bstet. 3ynecol., ."H "% -+", 1 8-. 1 . loannovich <., )astana ?., Alexakis ?., Tsoutsos ?., =anayotou =.H =regnancy and bumsH Cxperience from five cases. Ann. $edit. #ums 4lub, 8H 1.1-", 1 .. "&. Sarkar T., 2oychowdury S.H =lasma 18-beta oestradiol estimation in bums during pregnancy. 7ndian <. #umsH . -%", April, 1 +.

"1. ?eitch C.A., 2ightmire ?.A., 4lothuer <., #lass ;.H $anagement of bums in pregnant women. Surg. 3ynec. @bstet., 1+1H 1-., 1 !%. "". =andya ;.H #ums in pregnancy. 7ndian <. #umsH .1-., April 1 ..

"-. #assetti ?.H M4hermoterapici antinfettivi e loro impiego raEionaleM. Dibreria (niversitaria, 3enoa, 1 !". ".. =aroli C.H M9armacologia clinica. TossicologiaM. SocietA Cditrice (niverso, 2ome, 1 !%. "%. 3oodman and 3ilmanH MDe basi farmacologiche della terapiaM. Cditoriale 3rasso, #ologna, 1 !". "+. Turner 3., 4ollins C.H 9etal effects of regular salicylate ingestion in pregnancy. Dancet, "H --!- , 1 8%. "8. Shapiro S.T., $onson 2.2., )aufman ?.>., Siskind G., :emonen @.=., Slone ?.H =erinatal mortality and birthweight in relation to aspirin taken during pregnancy. Dancet, 1H 1-8%-+, 1 8+. "!. Agolini 3., $icali 3., 2aitano A.H Antisettici e chemioterapici nella terapia topica delle ustioni. 2iv. 7tal. 4hir., -&H "---+8, 1 !. " . 2yan 2.9., Dongenecker 4.3., Gincent 2.>.H Cffects on pregnancy on healing bums. S. 9orum Am. 4oll. Surgeons, 1-H .!--%, 1 +". -&. 2yan 2.9., Dongenecker 4.3., Gincent 2.>., #ergeron <.$.H 9urther observations on the effects of pregnancy on healing of bums. =last. 2econstr. Surg., --H "+ -81, 1 +.. -1. $erger 2., #arrat <., ;icolas <.H 4ontribution N 1B+tude des bAllures graves au cours de la grossesse. 3ynecol. @bstet. *=aris,, +"H 1&1+, 1 +-. -". @b-3yn 4ollected Detters, Series G777, 1 ++. --. Sawhney 4.=., AhuAa 2.#., 3oel A.H #urns in 7ndiaH Cpidemiology and problems in management. 7ndian <. #ums, 1H 1, 1 -.