Burns Open 1 (2017) 74–77

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Burns Open
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Case Report

The interdisciplinary management of Severe burns in pregnancy

Christoph Wallner a,⇑, Peter Kern b, Norbert Teig c, Marcus Lehnhardt a, Björn Behr a
a
Department of Plastic Surgery, BG University Hospital Bergmannsheil, Ruhr University Bochum, Bürkle-de-la-Camp Platz 1, 44789 Bochum, Germany
b
Clinic for Obstetrics and Gynecology, University Hospital Katholisches Klinikum Bochum St. Elisabeth-Hospital, Ruhr University Bochum, Bleichstraße 15, 44787 Bochum, Germany
c
Department of Neonatology and Pediatric Intensive Care, University Children’s Hospital, Katholisches Klinikum Bochum St. Elisabeth-Hospital, Ruhr University Bochum,
Bleichstraße 15, 44787 Bochum, Germany

a r t i c l e i n f o a b s t r a c t

Article history: Background: Severe burns in pregnant women present an exceedingly challenging situation due to the
Received 15 March 2017 limitation in therapeutic options including pain management and operative care.
Received in revised form 26 April 2017 Case: We present a 30 years old patient, 38th week of pregnancy, who suffered a full thickness skin burns
Accepted 27 April 2017
in 20% total body surface area and an inhalation trauma. In a Level-1 trauma center an interdisciplinary
Available online 8 May 2017
team of plastic surgeons, neonatologists and gynecologists was organized to deliver best patient care.
Conclusion: This case presents a challenging situation with an intubated analgosedated pregnant woman,
Keywords:
limiting treatment options. On admission a prompt cesarean delivery was performed to guard the unborn
Burn
Pregnancy
child. To shorten the hospital stay, a novel Bromelain based enzymatic debridement was performed on
Management the full thickness burn wounds with immediate skin grafting.
Caesarean delivery Ó 2017 Published by Elsevier Ltd. This is an open access article under the CC BY-NC-ND license (http://
creativecommons.org/licenses/by-nc-nd/4.0/).

1. Introduction 2. Clinical case

Burns in pregnant women are rare but due to a lack of experi-
ence, non-existing standardized treatment and limitation in pain
management, therapeutic options can be frustrating. These cir-
cumstances demand special management considerations for the
care provider. The maternal physiological changes in the endocrine
system consequently alter the water distribution in the body. This
fluid shift towards the interstitial space leads to a challenging sit-
uation in the difficult fluid resuscitation in burn victims. In addi-
tion, limiting the medication support during pregnancy and
securing the fetal life is of uttermost importance. In early pregnan-
cies, saving the maternal life is of highest priority but with
advanced fetal age, a cesarean delivery can expand the maternal
life support management while securing the newborn’s life.
The major patient collective of pregnant burns is located in
developing countries. Data collected from those patients show a
significantly higher mortality compared to the general population
[1]. Given the rarity of occurrence and thus lacking data to define
an adequate therapy, we present this case of a burn injury in late
pregnancy and discuss clinical strategies.
⇑ Corresponding author at: Bürkle-de-la-Camp-Platz 1, 44789 Bochum, Germany.
E-mail address: Christoph.wallner@bergmannsheil.de (C. Wallner).
The 30 years old patient, 38th week of pregnancy, suffered a full
thickness skin burn of 20% total body surface area (TBSA) – includ-
ing deep thickness burns of the right foot and superficial thickness
burns of the right dorsal upper arm and the right pelvis –- and an
inhalation trauma, while trying to extinguish burning oil in a pan
with water. In the pre-hospital phase the affected body surface
area was announced to be 40% TBSA. The patient was intubated
and infusion with Ketamine and Fentanyl was started. Prehospital
ventilation support was generated in BIPAP (Biphasic Positive Air-
way Pressure) mode and a FiO2 of 1.00. The referral was prolonged
due to the unavailability of burn centers with concurrent obstetri-
cal facilities. Thus, it took three hours until the patient finally
entered our resuscitation area after helicopter transfer. To maxi-
mize the therapeutic outcome in our trauma hospital, we orga-
nized an interdisciplinary team including obstetricians and
neonatologists from an adjacent hospital. In order to prevent aor-
tocaval compression syndrome the mother was tilted at least 15°
to the left until delivery. A high-normal oxygenation with FiO2 of
>0.40 was administered, a central-venous cannula into the jugular
vein and arterial cannula were inserted. No hypoxemia was mea-
sured throughout the procedure. Portable ultrasound control of
the fetus revealed a regular heart beat and no severe distress.
Given the administration of opioids to the mother, potential sys-
temic shock responses as well as the foreseeable need of a surgical

http://dx.doi.org/10.1016/j.burnso.2017.04.003
2468-9122/Ó 2017 Published by Elsevier Ltd.
This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).
 C. Wallner et al. / Burns Open 1 (2017) 74–77 75

intervention with respect to the relatively low risks associated
with a caesarean delivery at this advanced stage of pregnancy for
the fetus, the team decided to perform a caesarean delivery at
37 + 1/7 completed weeks of gestation. The male fetus presented
in breech position, weighed 2950 g and was alive. A neonatal team
consisting of a neonatologist, an anesthesiologist, and two nurses
cared for the newborn in an adjacent room. The child was com-
pletely hypotonic and showed no respiratory efforts, possibly due
to side effects of large doses of ketamine and fentanyl given for
the burn injury during the prolonged transport. Bag-and-mask
ventilation was necessary for the first 12 min, but intubation could
be avoided, muscle tone normalized during the consecutive two
hours. Apgar-scores were 1-4-4 after 1, 5, and 10 min, respectively.
After stabilization the child was transferred to the neonatal inten-
sive care unit of the adjacent hospital. It was discharged home
3 days later without sequelae.
Immediately following the cesarean delivery, a dressing change
and mechanical debridement of the burn wounds were performed
(Fig. 1). 2b° and 3° burns of the lower extremities, the right dorsal
elbow and the right flank were diagnosed. Postoperatively,

Fig. 1. Deep thickness burns of the right foot. (a) Admission record status showing deep thickness burns on the right foot and lower leg. (b) Wound status after burn blister
removal. (c) Wound after Bromelain based enzymatic debridement on the first day after trauma revealing a vital wound bed with intact vascularization dermal (toes and
proximal forefoot) and subdermal (distal forefoot). (d) Postoperative result (2 months) after split thickness skin grafting without any additional debridement.

Fig. 2. Superficial thickness burns of the right dorsal upper arm and the right pelvis. (Upper row) Wound status at admission of partial thickness burns of the right dorsal
upper arm (a) and the right pelvis (b). (Lower row) Status 2 months after trauma.
76 C. Wallner et al. / Burns Open 1 (2017) 74–77
Fig. 3. Multidisciplinary team approach of plastic surgeons, anesthetists, gynecol-
ogists and neonatologists. (a) Caesarean delivery with gynecologists and plastic
surgeons before initial debridement of the burn wounds. (b) Initial examination of
the newborn by the neonatologist.
analgosedation was changed to a combination of the short-acting
Isofluran and Sufentanil in order to accelerate an early extubation
and reduce the risk of ventilator-associated infections. In the same
night of admission (6 h post injury) the patient was extubated after
weaning in BIPAP (Biphasic Positive Airway Pressure) and then in
CPAP (Continuous Positive Airway Pressure) mode. After extubation,
non-steroidal antiphlogistics were combined with Naloxon and
Oxycodon for analgesia. On the fourth day the patient was trans-
ferred to the regular ward. 20 International Units Oxytocin were
administered per 24 h for the first two days. Fluid resuscitation
was adjusted to the urine output of a minimum of 1 ml/kg/h (Fig. 2).
On the third day after admission, an enzymatic debridement
based on Bromelain was performed on the lower right leg with
regional anesthesia and unveiled a vital wound. 24 h later (fourth
day after admission) a split thickness skin graft was harvested from
the right thigh and transplanted as mesh graft (1:1.5) to the
Bromelain-debrided area without any further debridement. Five
days later the padded dressings on the skin graft where removed
and showed an almost 100% take of the graft, despite some small
areas of hematoma. All other wounds were treated conservatively.
A daily transport of the patient to the neonatology unit was
organized to keep interruption of bonding to the newborn as small
as possible. During that time, breastfeeding was supported. Six
days after burn injury the newborn was transferred to the mother
to support bonding. In the meantime, intensive physiotherapy,
wound care and midwifery support were granted. Twenty days
after admission the patient was discharged with healed wounds
(Fig. 3).
3. Discussion and review of literature
Deep burns cause physiological and emotional devastating inju-
ries. During pregnancy this requires additional special treatment
considerations in an extended multidisciplinary team. Due to the
low incidence and a lack of management guidelines, therapy
among different centers is highly volatile and experience is shared
with case reports or small series.
One priority in burn victims is set to fluid resuscitation. During
pregnancy, a hyperdynamic cardiovascular state is given and the
total body plasma volume is expanded. Due to an increase in the
maternal female hormone balance the capillary permeability is
already increased and accelerates the fluid loss. Thus, the risk of
a hypovolemic shock is increased and can lead to placental insuffi-
ciency [2]. However the resuscitation management is not different
from that in the non-pregnant woman [3]. A sufficient blood pres-
sure will maintain an adequate blood supply to the maternal
uterus. Hypotensive episodes should be avoided during surgery.
The use of diuretics should be reduced to a compelling necessity
[1]. An inhalation trauma may cause carbon monoxide intoxication
with a transplacental transfer and hypoxia, which in turn can cause
placental insufficiency and an oxygen deficit in the fetus. In
extended burns and smoke inhalation prolonged maternal hypoxia
was observed and might cause hypoxic-ischemic injury to the fetal
brain with subsequent permanent deficits [2]. Thus, ventilator
assistance should not be delayed when smoke inhalation is clini-
cally suspected.
Fetal outcome is highly dependent on fetal age and the extent of
the maternal burn injury. During the second trimester, the ex utero
survival is poor and a tocolysis should be considered when applica-
ble. Magnesium sulfate may be a better choice than b-mimetics
due to reduced vasodilatory effects [2]. A consensus in the litera-
ture was found that in case of maternal distress and during the
third trimester an early caesarean delivery is indicated [2,3].
Neonatal aspects have to be considered when determining a pre-
mature caesarean delivery. Furthermore the delivery of the fetus
allows a more aggressive pain and surgical management. In the
presented case, the decision for a caesarean delivery was therefore
readily and concordantly made, given the low risks for the new-
born as opposed to the prolonged exposure to opioids in utero as
well as the increased risks for the mother upon continuation of
the pregnancy.
Nevertheless, pharmacological consultation on breastfeeding
limitations and precautions is mandatory. Pain management dur-
ing pregnancy is generally limited. Secondly, most doctors from
other specialties than obstetrics are afraid of administering pain
medications due to their lack of experience. Studies do not show
any evidence of increased teratogenic effects of opioids [4]. NSAIDs
(nonsteroidal anti-inflammatory drugs) do not show any terato-
genic effects, however in late pregnancy a substantial increase in
the risk of premature ductal closure is observed [5]. Beside
unaffecting the APGAR-Score due to the use of Sufentanil during
child birth there was no higher teratogenic rate demonstrated
[6,7]. Therefore an extended pain management in acute burns with
Sufentanil may be a good choice.
Inhalational sedation with AnaConDaÒ (Anaesthetic Conserving
Device) enabled a short and flexible sedation with no withdrawal
symptoms and a low concentration considering the expected short
sedation period in late pregnancy. However, isoflurane exposure is
not indicated for longer sedation periods in pregnant patients. High
isoflurane levels may cause amongst others postnatal memory
learning deficits [8].
An early enzymatic debridement with Bromelain allowed to
shorten the demarcation process and subsequently the total hospi-
tal stay. So far no data is available on the use of this enzymes dur-
ing pregnancy or women in childbed. The low local application
dose and the galenics of the Bromelain based enzymatic debride-
ment were considered not to affect the fetus.
An early bonding was pushed by providing a daily transport of
the mother to the NICU in another hospital (newborn intensive
 C. Wallner et al. / Burns Open 1 (2017) 74–77
care unit), continuous breastfeeding by supporting milk pumping
and the logistic actions to accommodate a newborn in Level-1
trauma center without pediatricians nor obstetricians. A daily
attendance of a midwife was organized and the staff was trained
to support the mother during the postnatal stay.
This case underlines the importance of a transdisciplinary team
work and the high flexibility required to offer the best treatment.
An early involvement of all necessary disciplines allows the opti-
mization of the patient’s course.
4. Conclusion
Although the literature on burns in pregnant patients is limited
to case series and case reports, the incidence doesn’t appear to be
low. Consensus on some treatment schemes exists but no guideli-
nes are given. This case report shows an individual approach to
shorten the separation time between the newborn and the mother.
Additionally, we tried to optimize the whole perinatal care of both
patients. This claim demands a strong interdisciplinary communi-
cation and collaboration especially considering the limitation of a
gynecological and neonatal linkage in a trauma hospital.
Contribution of each author
Christoph Wallner: Conception and Preparation of manuscript,
involvement in treatment of the case, proofreading
Peter Kern: Conception and Preparation of manuscript, involve-
ment in treatment of the case, proofreading
Norbert Teig: Conception and Preparation of manuscript,
involvement in treatment of the case, proofreading
Marcus Lehnhardt: Conception and Preparation of manuscript,
involvement in treatment of the case, proofreading
Björn Behr: Conception and Preparation of manuscript, involve-
ment in treatment of the case, proofreading
77
Synopsis
An Interdisciplinary Management of Severe Burns in Pregnancy
with a Bromelain based enzymatic debridement shows an effective
method to treat burn wounds.
Conflicts of interest
None.
No funding received for this work.
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