The Baby or the Burn? Balancing Maternal and Fetal Needs During Burn Resuscitation With Active Labor

Introduction: Pregnant patients with an acute injury present challenges to healthcare teams; one with a burn poses unique challenges when considering the balance of fluid resuscitation with a tendency toward extravasation due to hematologic changes in pregnancy, along with managing a patient in dual hyperdynamic states. When a patient presents in active labor, burn resuscitation is complicated by hemodynamic changes related to the pregnancy and active labor, and we must account for fetal responses in relation to a massive burn. We discuss the unique challenges presented when admitting a laboring woman with a significant burn injury.


Description: She presented to our ED a 56% TBSA from an outdoor fire and was intubated prior to transfer. Per report, she was estimated to be 38 weeks pregnant. She was evaluated in the ED by the trauma, burn, and OB teams. The OB team noted that she was in active labor, as was evident by exam and regular uterine contractions on tocometry monitoring. In-depth discussions were held regarding the most appropriate admission location for this patient (Labor & Delivery or Burn ICU); she was ultimately admitted to the L&D unit with close involvement of the Burn ICU team. We initiated her burn resuscitation based on our institutional guidelines. Central access was obtained, both for burn fluid resuscitation and for potential need of blood products for obstetrical hemorrhage. She was closely monitored by both teams and ultimately proceeded to a c-section within 6 hours of admission due to fetal distress. Post-delivery, she was admitted to the burn unit. She underwent burn surgery on HD #2, was discharged on HD #20, and her baby was discharged home without incident.


Discussion: Robust literature exists regarding care for pregnant trauma patients balancing needs of both mother and fetus; such literature is lacking in burn care. In this case, our patient and her fetus were cared for simultaneously, however turning the L&D unit into a Burn ICU room presented logistical challenges with many frustrations among the multiple disciplines involved. This situation highlighted both an institutional and larger specialty need for standardized approaches to laboring women that require both the immediate availability of the OB team as well as critical care trained providers.