Double Jeopardy: Managing Burns in the Obstetric Patient

You and your partner are working on a Friday afternoon when the tones drop. Dispatch tells you that your needed at a residence for a patient involved in a house fire. When you arrive on scene, you see a double story house that is fully engulfed in flames. The fire department tells you that your patient is with first responders in the next driveway over at the neighbors house.

When you get to the patient, you find a 26 year old female who tells you she is 24 weeks and 4 days pregnant. She has 2nd and 3rd degree thermal burns to her face anterior arms and legs and anterior chest and abdomen. She tells you she was lighting a fire in the wood stove and something exploded. She was able to get herself out of the house and to the neighbors where they called 911.

As you're doing your assessment you find that her airway sounds stridor, breathing is shallow at 24, heart rate is 137 and regular. She tells you she is in a significant amount of pain, 8/10, and it's becoming more and more difficult to breathe.

What are you going to do?

OB Burns

Caring for a burn patient who is also pregnant is going to be a rare event in your career. However, it is something that you could encounter and could potentially be one of the most critical and fragile patients you will have to provide treatment to. One study I read found that any thermal burn greater than 30% body surface area (BSA) the fetus died and anything greater than 70% BSA both the mother and the fetus died. Fetal survival is also dependent on gestational age. Any BSA greater than 30% and the fetus is viable; labor should be induced or a cesarian section can be done once the mother has been stabilized. If the fetus is not viable, continued monitoring of the fetus is recommended. Maternal survival will be dependent on the total body surface burn and how well she is resuscitated. Any treatments and interventions we provide in the clinical setting we practice in will have a huge effect on these patients and hopefully decrease their morbidity and mortality. 

Airway Management

Just like any other patient, oxygenation is king, and if we’re not oxygenating mom, we’re not oxygenating the baby. If the patient loses the ability to protect their own airway, your next steps will depend on your scope of practice. For BLS providers, it's appropriate to use basic airway adjuncts like NPAs and OPAs, along with suctioning and BVM ventilation, to support breathing and oxygenation. Supraglottic airways can serve as a valuable bridge while transporting the patient to definitive care or awaiting the arrival of ALS or Critical Care support.

A big concern is whether the burned area involves the structures of the airway or if there are inhalation injuries. Don’t waste any time securing an airway before any additional swelling or edema occurs. When intubating, have a smaller tube available if you can’t get the correct size through the cords. It would be beneficial to utilize a bougie as an introducer if you do need to switch to a smaller tube. Lastly, have the surgical cricothyrotomy kit out and be prepared to cut the neck if you’re in a can’t ventilate, can’t oxygenate, can’t intubate situation.

If you’re planning to perform RSI, it’s important to choose your induction and paralytic medications thoughtfully. One interesting consideration with Succinylcholine is its altered behavior in pregnant patients. By the third trimester, plasma volume increases by about 40% to 50%, which leads to a dilutional decrease in plasma pseudocholinesterase levels. Since this enzyme is responsible for breaking down Succinylcholine, reduced levels mean the drug isn’t metabolized as quickly. As a result, more Succinylcholine remains active in the bloodstream for longer, prolonging paralysis.

Etomidate, Fentanyl, and Rocuronium are great choices for intubation, they are safe for use in pregnancy. Another consideration is the use of Ketamine. Ketamine has bronchodilation effects which could be beneficial if the patient has any inhalation injuries with bronchospasm. Another benefit of Ketamine is the ability to maintain hemodynamic stability. Be aware though, Ketamine could have the potential to increase uterine tone and cause fetal distress.

Fluid Resuscitation

Fluid resuscitation is going to be important for this patient and the fetus. The American College of Obstetrics and Gynecology doesn't recommend a specific fluid resuscitation guide or formula for thermal burns. They maintain the focus should be to provide the appropriate amount of fluid to maintain adequate perfusion to the mother and the fetus. Monitoring fetal well being along with urinary output will determine if the patient has received an adequate amount of resuscitation. One study mentioned that maintaining a urinary output of 1ml/kg/hour is the goal. It was also stated they utilized the Parkland Formula for fluid resuscitation and in order to maintain the urinary output the fluids had to be increased by 150%.

Patient Destination

When choosing a destination for the pregnant burn patient, it’s important to carefully consider the patient’s immediate and anticipated clinical needs, as well as the capabilities of the available receiving facilities. If you (and your patient) are fortunate enough to have a facility with both comprehensive burn and maternal/fetal capabilities available, the decision is much simpler. However, if you’re forced to choose between one or the other, that decision becomes more challenging. 

Heat-damaged tissue releases prostaglandins, which can lead to the onset of labor. For some, vaginal birth may be achievable; however, those who are significantly pre-term or have other complications might require more complex resources. Even without spontaneous onset of labor, high BSA injuries to the mother can necessitate delivery of the fetus, often via cesarean section, to maximize outcomes for both mom and baby. It’s also important to identify any compounding traumatic injuries that may exist, especially in the setting of blast injuries or following a traffic accident - in these cases, the need for trauma services may supersede the need for specialized burn care. Finally, it is crucial to factor in the overall stability of the patient and time to destination. 

In the acute setting, optimizing resuscitation of the mother will also give the fetus its best chance at survival. However, in the setting of critical injury and challenging resuscitation, or if imminent death of the mother is expected, there are other treatment options that might be considered.

Peri-Mortem Cesarean Delivery / Resuscitative Hysterectomy

Peri-mortem cesarean delivery (PCMD) is indicated in the setting of maternal cardiac arrest and if fetal age supports viability outside the uterus (gestational age >20-23 weeks, depending on source). PCMD is ideally performed within five minutes of maternal cardiac arrest and aims to minimize hypoxic injury to the fetus. This can also help optimize maternal resuscitation efforts by relieving compression on the aorta and promoting venous return of blood to the heart.

ECMO

Extracorporeal membrane oxygenation (ECMO) may also be indicated in the setting of severe burn injury. This will most often be venous-venous (VV) cannulation to support recovering lung tissue post-inhalation injury. Pregnant patients can be supported on ECMO, although hemodynamic changes that occur during pregnancy do present unique challenges. If gestation is > 24 weeks, and especially in the presence of maternal cardiac compromise, delivery of the fetus is likely / recommended if feasible in order to optimize care for both mother and baby.

Note on Psychological Wellness

Caring for a pregnant burn patient can be challenging - not just in a clinical or logistical sense, but also emotionally and psychologically. Especially in the event of maternal and/or fetal demise, these encounters can result in acute psychological stress. Recognizing these emotions, fostering open discussion and debrief among the crew, and prioritizing provider wellbeing are essential.

References

Agarwal, P. “Thermal Injury in Pregnancy: Predicting Maternal and Fetal Outcome.” Indian Journal of Plastic Surgery, vol. 38, no. 02, July 2005, pp. 95–99, www.bioline.org.br/pdf?pl05019, https://doi.org/10.4103/0970-0358.19774. Accessed 24 June 2022.

Haghighi, Mohammad, et al. “The Utero-Tonic Effects of Low Dose Intravenous Ketamine in Cesarean Section under Spinal Anesthesia; a Randomized Double-Blind Clinical Trial.” PubMed, vol. 14, no. 2, 1 Jan. 2023, pp. 218–225, https://doi.org/10.22088/cjim.14.2.218. Accessed 8 May 2025.

Mendez-Figueroa, H., Dahlke, J., Vrees, R., & Rouse, D. (2013). Trauma in pregnancy: an updated systematic review. American Journal of Obstetrics and Gynecology, 209(1), 1–10. https://doi.org/10.1016/j.ajog.2013.01.021

Rahal, A.A., Alboudi, S., Haidar, I.A. and Alhassanieh, A. (2020) Acute Burns in Pregnancy. Open Journal of Obstetrics and Gynecology, 10, 1702-1707. https://doi.org/10.4236/ojog.2020.10120154

Roderique EJ, Gebre-Giorgis AA, Stewart DH, Feldman MJ, Pozez AL. Smoke inhalation injury in a pregnant patient: a literature review of the evidence and current best practices in the setting of a classic case. J Burn Care Res. 2012 Sep-Oct;33(5):624-33. doi: 10.1097/BCR.0b013e31824799d2. PMID: 22293595.