The Journal of Maternal-Fetal & Neonatal Medicine
ISSN: 1476-7058 (Print) 1476-4954 (Online) Journal homepage: http://www.tandfonline.com/loi/ijmf20
Electric shock in pregnancy: a review Radmila Sparić, Antonio Malvasi, Lazar Nejković & Andrea Tinelli To cite this article: Radmila Sparić, Antonio Malvasi, Lazar Nejković & Andrea Tinelli (2016) Electric shock in pregnancy: a review, The Journal of Maternal-Fetal & Neonatal Medicine, 29:2, 317-323, DOI: 10.3109/14767058.2014.1000295 To link to this article: http://dx.doi.org/10.3109/14767058.2014.1000295
Published online: 23 Jan 2015.
Submit your article to this journal
Article views: 228
View related articles
View Crossmark data
Citing articles: 1 View citing articles
Full Terms & Conditions of access and use can be found at http://www.tandfonline.com/action/journalInformation?journalCode=ijmf20 Download by: [University of New England]
Date: 30 October 2017, At: 13:41
http://informahealthcare.com/jmf ISSN: 1476-7058 (print), 1476-4954 (electronic) J Matern Fetal Neonatal Med, 2016; 29(2): 317–323 ! 2015 Informa UK Ltd. DOI: 10.3109/14767058.2014.1000295
REVIEW ARTICLE
Electric shock in pregnancy: a review Radmila Sparic´1, Antonio Malvasi2,3, Lazar Nejkovic´4, and Andrea Tinelli3,5 Clinic of Gynecology and Obstetrics, Clinical Center of Serbia, Belgrade, Serbia, 2Department of Obstetrics and Gynecology, Santa Maria Hospital, Bari, Italy, 3Department of Applied Mathematics, International Translational Medicine and Biomodeling Research Group, Moscow Institute of Physics and Technology, Moscow State University, Russia, 4Clinic of Gynecology and Obstetrics ‘‘Narodni Front’’, Belgrade, Serbia, and 5Division of Experimental Endoscopic Surgery, Imaging, Technology and Minimally Invasive Therapy, Department of Obstetrics and Gynecology, Vito Fazzi Hospital, Lecce, Italy
Downloaded by [University of New England] at 13:41 30 October 2017
1
Abstract
Keywords
Objective: The effect of gestational age and other factors that could influence the outcome of an electric shock in pregnancy have not been defined yet. Objective of this study is to provide reliable data on medical issues linked to electric shock in pregnancy. Methods: Authors consulted the most important scientific databases investigating reactions to electric shock in pregnancy, analyzing mechanism of electric shock, gestational age at the time of injury, the post-shock complications, interval from injury to delivery and fetal and maternal outcome. Results: The spectrum of electrical injuries in pregnancy ranges from transient unpleasant sensation with no effect on the fetus to sudden maternal and fetal death. The clinical presentation of the fetal injury may manifest immediately or even postnataly. Reported outcomes include spontaneous abortion, placental abruption, cardiac arrhythmias, fetal burn and intrauterine fetal death. If the pregnancy is continued, decreased fetal movements and asphyxia, pathological fetal heart patterns, intrauterine fetal growth retardation, damage to the fetal central nervous system and oligoamnios can occur. Conclusions: More large prospective observational studies are necessary for a proper insight into the expected outcomes of the electric shock in pregnancy as well as for a final definition of monitoring procedures of such pregnancies.
Electrical injury, electrocution, fetal injury, maternal complications, maternal morbidity, perinatal outcome History Received 24 November 2014 Accepted 16 December 2014 Published online 23 January 2015
Introduction
Materials and methods
The cases of electric shock in pregnancy are very rare, and there are no reliable data on the incidence [1,2]. Maternal injuries may be various, varying from no morbidity at all to severe injuries including the occurrence of serious complications and even death [1–6]. The incidence of fetal injuries caused by maternal electric shock is unknown [3,4,7]. Outcomes of such an injury include spontaneous abortion, placental abruption, cardiac arrhythmias, fetal burn and intrauterine fetal death [2,5]. If the pregnancy is continued, decreased fetal movements and asphyxia, pathological fetal heart patterns, intrauterine fetal growth retardation, damage to the fetal central nervous system and oligoamnios can occur [2,4,7]. The effect of gestational age and other factors, which could influence the susceptibility to electric shock in pregnancy, have not been studied in the literature yet [5].
Authors, to perform the clinical research, consulted the following scientific databases: PubMed (1966–2014), the Cochrane Library, EMBASE (1974–2014), Science Citation Index (1974–2014), The China Journal Fulltext Database (1994–2014), Chinese Scientific Journals Fulltext Database (1989–2014), Chinese Biomedical Literature Database (1978– 2014) and WANFANG database (1980–2014). The following key terms were used to access the records: electrocution in pregnancy, pregnancy and electric shock, electrical injuries in pregnancy, electrical accident, electric current injury, electric shock in pregnancy and brain damage in pregnancy. After identifying the key relevant articles, their references were also looked into. Similarly, other studies that cited them were used to widen the search results. In the inclusion criteria, as types of studies, we included the following: Case report, Reviews and Observational studies, excluding Randomized Controlled Trials for the lack of their presence in literature. For the outcome measures to analyze, the primary effectiveness outcome was as follows: mechanism of electrical shock, gestational age at the time of injury, the post-shock complications, interval from injury to delivery, fetal and maternal outcome.
Address for correspondence: Radmila Sparic´, MD, MSc, Clinic of Gynecology and Obstetrics, Clinical Center of Serbia, Visˇegradska 26, 11000 Belgrade, Serbia. Tel: +381 (0) 66 8301 332. Fax: +381 (0)11 361 5603. E-mail: [email protected]
318
R. Sparic´ et al.
Downloaded by [University of New England] at 13:41 30 October 2017
Epidemiology Electrical injuries have been reported for almost three centuries, while the first reported case of electrocution was in 1879 by Jex-Blake [8]. Scientific investigations of electrical injuries began in 1890s, and the first pathologic information was obtained when electrocution became a means of capital punishment in New York [8]. The most common causes of electric shock are occupational hazards, household appliances and lightning [9]. Other rare causes of electric shock include: injuries occurring during surgical and anesthetic procedures or during hemodialysis and electroconvulsive therapy [9]. Electrocution is also described as a method of suicide and homicide [9]. Electrical injuries are frequent in young males, although more than 20% of them are observed in children [9]. Mortality rate of electrocution in the United States is 0.5–2.5 per 100 000 persons each year [9]. Lightning causes 1000 deaths worldwide each year [10]. Most of the electrocution-related deaths occur in electrical and construction workers [9].
Basic principles of electrical injury The extent of the electrical injury is determined by pathway of the current through the body, nature of the tissues and their resistance to current, as well as type, duration, amperage and voltage of the current [9,11,12]. Type of the injury is crucially influenced by the pathway of the current through the body [13]. Contact of the electrical source with both hands results in transthoracic pathway, which accounts for most of the mortality. Resistance to the current is tissue specific: low for nerves, muscles and blood vessels and high for bone, tendon and fat [11]. Alternating current is more dangerous than the direct current (DC), as it can cause tetanic muscle contraction and the victim may be unable to release the source of electrical energy [9,11,13]. Degree of tissue destruction is proportional to the duration of contact [13]. According to Joule’s law, the heat generated in the tissue is proportional to the amperage squared. Respiratory arrest can occur at an amperage of 20–50 mA, and ventricular fibrillation at 60–120 mA [13]. Voltage is divided into high (exceeding 1000 V) and low voltage (below 1000 V) [9,11,13]. Highvoltage current results in more severe injuries and often throw the victim from the source [9]. Fatal cases have been reported with voltages as low as 46 V, while voltage over 25 V is potentially dangerous [12,14]. Furthermore, factors such as moisture, sweat and ointments reduce the impediment and affect the outcome [9]. While typical household electricity has 110–230 V, lightning strikes can produce 10 million V or more [15]. Lightning strike delivers large amount of DC during a very short period of time [11]. The extent of the lightning injury is even more difficult to predict, mainly due to the difference in the duration of the exposure [13]. Such victims rarely have extensive tissue destruction and massive cutaneous burns [11].
Mechanisms of injury There are four theories explaining features of electrical injury, namely electrostatic, vascular, thermal and
J Matern Fetal Neonatal Med, 2016; 29(2): 317–323
mechanical [12,14]. Electrostatic theory postulates that the electrical charges build up in the victim’s body result in electrostatic effects, which produce expansive force of tissues causing waves of decompression under the skin, as is supported by tissue rupture findings on autopsies. Vascular theory claims that vasoconstriction causes acute manifestations, while delayed symptoms are caused by later intimal injury and thrombosis. Thermal theory suggests that pathological findings in the tissues are caused by thermal injury, while mechanical theory proposes violent jarring of the tissue from electrical current. Due to large number of variables influencing the effect of the current through the body, exact pathophysiology of the electrical injury is not well understood yet [13]. It is most likely that all the above-mentioned mechanisms contribute to tissue damage in electrical injuries [14], as no single theory can explain all the pathological changes [12]. Furthermore, preexisting cardiac anomalies and atherosclerosis, decreased skin resistance due to sweating or contact with water, old age, fatigue and hypothyroidism can potentially increase the morbidity [12].
Clinical manifestations of electric shock Electric shocks account for a considerable morbidity and mortality. High-voltage injuries usually are manifested as massive burns requiring prolonged hospital treatment and are associated with multiple complications [13]. Victims with lightning and low-voltage injuries may have little evidence of injury or may be in cardiopulmonary arrest [13]. Immediate death from electric shock is usually caused by ventricular fibrillation or respiratory arrest [10,11]. Mortality from lightning injuries is as high as 70% [10]. Those who survive electric shock and require prolonged hospitalization usually die of pneumonia, sepsis and multisystem organ failure [13]. Cardiovascular system injury includes various forms of arrhythmias and conduction abnormalities, from ectopic beats to asystole, as well as non-specific changes in electrocardiogram [11]. Lightning and high-voltage injuries frequently cause asystole [13]. Cardiac manifestations are caused by direct cell damage, hypoxia due to respiratory arrest or extensive catecholamine release [9]. Due to catecholamine release, hypertension is common in high-voltage injuries [8]. Myocardial injury can also be secondary due to coronary artery spasm induced ischemia [10]. Acute myocardial infarction and late arrhythmias are very rare [13]. Creatine kinase levels may also be elevated, although skeletal muscle damage may cause this rise as well [9,13]. Asphyxia caused by respiratory arrest can also cause cardiac arrest [9]. Vascular complications include major vessel hemorrhage, arterial thrombosis, abdominal aortic aneurisms and deep vein thrombosis [8]. Respiratory system is also very sensitive to electric shock and even low levels of current across the chest are enough to cause respiratory arrest [11]. It can be caused also by damage to the medullary respiratory center by current passing through the brain [9]. Pulmonary edema, pulmonary contusion, pneumothorax and respiratory distress syndrome have been described as well [9,11].
Downloaded by [University of New England] at 13:41 30 October 2017
DOI: 10.3109/14767058.2014.1000295
Both central and peripheral nervous system can be damaged by electrical injury [11]. Central nervous system manifestations include loss of consciousness, which is usually transient if there are no head injuries [13]. The incidence of transient damage to the nervous system is up to 70% [11]. Keraunoparalysis is a specific, reversible, transient paralysis that could be present in victims of the lightning injury [11]. Neurological symptoms of electrical shock also include quadriplegia, paresis, temporary confusion, amnesia and concentration difficulties [9,13]. Seizures may be secondary to trauma of the central nervous system damage or hypoxia. Cerebral venous thrombosis may cause delayed brain injury [9,12]. In high-voltage victims spine fractures may cause a spinal cord injury [13]. In some cases, victims may suffer from long-term physical and psychological consequences [10,11,13,14]. Less usual manifestations include: lower extremity paralysis, blindness, deafness and aphasia, hypoxic encephalopathy, intracerebral hemorrhage, cerebral infarction and damage to the peripheral nerve tissue [13–15]. Peripheral nerve injury may be due to direct thermal injury, vascular damage or even direct action of current on nerve function [8]. Cutaneous burns at points of contact with the electrical source and the ground represent the most devastating injuries [11,13,16]. The most common sites are hands, heels and head [13]. They usually affect 10–25% of the total body surface area and vary from superficial partial-thickness burns to fullthickness burns [13]. Prognosis is poor in cases with infectious complications or renal failure [8,13]. In electrocution victims, burns are present in up to 81% of the cases, more common in high voltage cases [17]. The extent and depth of burns affect the outcome of the injury [11]. Due to the highest electrical resistance of the bones, those show the most severe electrothermal injuries, such as periosteal burns, destruction of bone matrix and osteonecrosis [11]. Violent involuntary muscular contractions may result in long bone and vertebral column fractures and joint dislocations [11,13,15]. Associated blunt trauma may cause skull fractures and cervical spine injuries [13]. In high voltage shocks, muscle necrosis and compartment syndromes are frequent, due to vascular ischemia and muscle edema [13]. Damage to the blood vessels may cause thrombosis and hemorrhage in small muscle arteries [13]. Venous thrombosis following electrical injuries are also reported [13], necessitating limb amputations in considerable number of patients [9]. Renal system may also be affected due to rhabdomyolysis and myoglobinuria causing acute tubular necrosis and consequent renal failure [9,11]. Other possible causes include direct damage to renal vessels and inadequate rehydration. Although rare, pancreas and liver injuries have also been reported, as well as injuries to hollow viscera, such as the small and large intestine, bladder and gallbladder [13]. Other possible consequences include cataracts, tympanic membrane rupture, disruption of the ossicles and mastoid, retinal detachment and optic nerve injury [8,13]. In cases where the victim has been thrown away of the electrical source by forceful muscular contractions, other injuries are possible as well.
Electric shock in pregnancy
319
Pathophysiology of electrical injury in pregnancy There are a number of physiologic changes that occur during pregnancy, which may alter the pathophysiology of electric shock during pregnancy and thus influence the fetal outcome. Therefore, the severity of maternal injury is not predictive for fetal outcome [4]. Uteroplacental vessels and amniotic fluid have low electrical resistance. Fetal skin is much less resistant than the skin postnatally, therefore even less electricity reaching fetus may cause significant harm due to fetal cardiac arrest. There is a little information about electric shocks in pregnancy. The spectrum of such injuries ranges from transient unpleasant sensation with no effect on the fetus to sudden maternal and fetal death. Bearing in mind the lack of clinical data, the effects of the maternal electric shock on the development of the fetus and pregnancy outcome are generally unknown. Even low-voltage electric shock in pregnancy has been reported to cause stillbirth [13]. Exposure to a 100–380 V, 25 mA current for 0.3 seconds could be lethal for the fetus [7]. The crucial factor determining the effect on the fetus are characteristics of the electricity and the pathway of the electric current through the mother’s body, which is most dangerous in cases of vertical flow (hand-to-foot or headto-foot) through the uterus [2–4]. Therefore, minimal injury to the mother may be lethal to the fetus, particularly in cases when the current bypass the maternal heart and travels through the uterus [6]. Fetal exposure to an electric shock may cause a cardiac arrest, which could explain the cessation of fetal movements noted by mothers [7]. A hand-to-hand pathway poses higher risk for mother and is associated with the least risk for fetus [4]. The clinical presentation of the fetal injury may manifest immediately or even postnatally [7].
Literature reports of electric shock in pregnancy Probably the earliest report of lightning injury in pregnancy was published by Schieffer in 1833, with favorable both maternal and neonatal outcome [18]. Electric shocks from lightning strikes of pregnant woman are very rare, with a few cases described in the literature [15,18]. Electric shock in pregnancy may be the cause of vital endangerment for the mother and can lead to severe damage to the fetus [2,3]. The survival rate of the mothers and the fetuses following electric shock varies, but it is considered that there is small likelihood of recovery and survival in cases of electric shock that lead to the loss of consciousness and cardiac and respiratory disorders [19]. The frequency of the fetal death after the mother experiencing an electric shock documented in the literature ranges from 6 to 73% [11]. Such high rate of fetal mortality may be due to publication bias, as most of the minor injuries are unpublished. Published case reports usually highlight adverse outcomes and therefore cannot be used to adequately define true risk [5,19]. In 1965, Rees [18] published a case of favorable maternal and neonatal outcome following lightning injury in early pregnancy, together with a review of four cases of electric shock in pregnancy out which none of the fetuses survived.
Downloaded by [University of New England] at 13:41 30 October 2017
320
R. Sparic´ et al.
One of those pregnancies ended in spontaneous abortion: two fetuses were delivered macerated five and six days after the injury, while the fourth fetus developed polyhidramnios and was prematurely delivered and died three days after the delivery. Garcia Gutierrez et al. [15] published their experience with lightning strike in pregnancy and a review of previously published cases. Of 13 cases evaluated, all mothers survived, but fetal mortality rate was 50% (five intrauterine fetal deaths and one neonatal death few hours after the delivery) [15]. Their patient suffered burns without any other type of injury. She was exposed to a direct lightning strike at 18 weeks of gestation with entrance wounds on the scalp and neck and exit wounds in the right lower extremity. She delivered a healthy infant 3030 g of weight, with proper development for 30 months. They concluded that the risk of sequel or fetal death is higher in cases of injuries in the third trimester of pregnancy. Einarson et al. [19] noted that, in most cases, accidental electric shock in pregnancy occurring during everyday life does not represent major fetal risk. In this prospective controlled cohort Canadian study, in only 10% of cases the path of electric current was hand to foot through the uterus. Of 31 pregnant women, 28 delivered healthy infants, two had spontaneous abortions, while one child had a ventricular septal defect that closed spontaneously. Leiberman et al. [20] reviewed six pregnants who experienced electric shock at home. For all, the current went from hand to foot, with favorable maternal outcome in all cases. Three of the fetuses were stillborn, within three days to 12 weeks after the shock, with intrauterine growth retardation. One fetus was normal, and two had oligohydramnios. By examining the placenta and cord, cited authors noted that there are no specific signs of damage in such cases. Fatovich [7] describes 15 pregnant women who experienced electric shock and concludes that the fetal death occurred in 73% of the cases. Both Jaffe et al. [16] and Mazor and Leiberman [21] described cases of spontaneous abortion in the first trimester of pregnancy few hours and two days after the accident. Steer [22] described a case of delayed fetal death following electric fence injury in the first trimester. Sparic´ et al. [1] described a case of electric shock in 14 weeks of pregnancy and attempt of prolongation of the pregnancy until fetal maturity is reached. Despite the multidisciplinary treatment in the intensive care unit, perimortem cesarean section (CS) at 24 week’s gestation ended in the delivery of 450 g stillborn neonate. On the contrary, Toongsuwan [23] described a case of postmortem CS 15 min after maternal death at 38 weeks of pregnancy ending in delivery of live neonate, who showed normal physical and mental development at the age of eight. Awwad et al. [4] described a case of electric shock in 28 week’s gestation ending in term delivery at 38 week’s gestation without fetal or maternal sequel. Although woman had tetany, the patient did not lose her consciousness, and the flow of the current was estimated to be hand-to-hand. Yoong [2] published a case of electric shock that occurred in a woman while fixing the plug of her iron. She was thrown away for approximately 5 m. She was
J Matern Fetal Neonatal Med, 2016; 29(2): 317–323
delivered the next day by emergency CS, which revealed large placental abruption. The baby died 24-h later, despite resuscitation. Strong et al. [6] described a case of electric shock experienced in pregnant at 30 weeks gestation when a 110 V DC wire touched the power-saw she was using. A few hours later, she experienced decreased fetal movements and repetitive spontaneous fetal heart decelerations. Following diagnosis of fetal distress, she underwent an emergency CS. A live baby was delivered and transferred to the neonatal intensive care unit. Both fetal and maternal outcome were favorable. Anguenot [24] described a case of maternal electric shock transmitted in a vertical trajectory in 34 weeks’ gestation, which was followed by fetal distress two weeks later. She was delivered by emergency CS with delivery of a 3190 g with cord blood pH values of 7.13 and 7.25. The neonate required intensive care unit treatment and had a nonfunctioning left kidney due to antenatal renal vein thrombosis. At two years of age, except atrophic kidney, child’s development was found to be satisfactory. A short summary of electric shock in pregnancy reports is listed in Table 1.
Surveillance Women who suffered electric shock in pregnancy, even if it was a minor one, require a complete obstetric evaluation [7]. There is no confirmation that any kind of management can impact the outcome of the pregnancy after electric shock without mechanical trauma [3]. The majority of authors agree that there are no indications for the fetal monitoring before the 20 weeks of gestation [3,19]. In cases of injuries after the 20 weeks of gestation, it is important to consider fetal condition as well [6]. Thus, it is advisable to carry out cardiotocographic monitoring for four hours after the injury; a 24-h electrocardiographic and cardiotocographic monitoring is advisable in cases of maternal loss of consciousness and electrocardiogram abnormalities, as well as in cases of cardiovascular disorders of the mother [3,5,6,11]. Mechanical trauma, which occurs in cases of even a very week electric shock, can be significantly influential, as the result of violent involuntary muscular contractions [3]. This kind of traumatism can cause placental abruption. Therefore, pregnant women should have an urgent ultrasound scan, even in cases of apparently minor shocks [3]. Doppler exam is advisable two weeks after the injury to check for late fetal death [19]. Although there is no protocol for prenatal monitoring or obstetric approach in such cases, fetal monitoring for oligohidramnios and fetal growth restriction is reasonable for the rest of the pregnancy [1]. In cases of abdominal trauma, it would be reasonable for Rh (D) negative women should receive prophylaxis. Furthermore, having in mind that electrical burns are prone to tetanus [8], those with burns should receive tetanus immunization on the basis of their immunization history. In cases when a pregnant patient has sustained an injury that has led to serious brain damage after the 24 weeks of gestation, and when no improvement of the patient’s condition is anticipated, each case must be considered separately
9–38 weeks
No data available 13 weeks
Electric shock to dry hand from a kitchen electric appliance with worn insulation connected to a 220 V AC while wearing rubber slippers Minor electric shock while using hair dryer, current did not travel through abdomen 110 V DC wire touch in the power-saw
Fifteen victims (one DC injury and 14 household AC)
Thirteen cases
220 V
Awwad et al. [4] Case report
Goldman et al. [5] Case report
Fatovich [7] Review of case reports published in English literature of pregnant woman exposed to electric shock
Garcia Gutierrez et al. [15] Case report and literature review on lightning injuries in pregnancy Jaffe et al. [16] Case report
Strong Jr et al. [6] Case report
Electric shock whilst mending the wiring of the plug of her iron
Yoong [2] Case report
No data in the article
23 weeks
Few hours
No data available
Few hours-21 weeks
Few hours
10 weeks
28 weeks
30 weeks
Less than 24 h
10 weeks
Interval from injury to delivery
32 weeks
14 weeks
Woman suffered electric shock while blow-drying her hair in the bath
Sparic´ et al. [1] Case report
Gestational age (weeks)
Mechanism of electrocution
Author (ref) Type of publication
Table 1. Short summary of the electric shock in pregnancy reports.
Absent fetal movement, repetitive spontaneous fetal hart decelerations, emergency CS delivery of live baby 715 g, discharged home at eight weeks of age Fetal mortality 73% (11 cases): three spontaneous abortions, four stillborns; two neonatal deaths-one with burn marks, two dead macerated infants, two cases of oligohydramnios with live neonate, one case of live IUGR neonate and one normal neonate Fetal mortality rate 50% (five intrauterine fetal deaths and one neonatal death few hours after the delivery) Fetal death and spontaneous abortion
Stillborn neonate weighing 450 g delivered emergency CS 5 min after mother’s death (autopsy diagnosed intrauterine asphyxia as the cause of fetal death) Placental abruption, 2240 g dead fetus delivered by an emergency CS indicated with fetal bradycardia. Apgar score 0 at 9 min. Although resuscitated, the baby died 24 h after the delivery Fetal hypo activity, change in fetal movement pattern, irregular fetal heart rhythm and missed beats Live newborn weighing 3120 g with Apgar scores of 8 and 10 at one and five minutes No data in the article
Fetal outcome
Downloaded by [University of New England] at 13:41 30 October 2017
Maternal outcome
Not available
All mothers survived
(continued )
No maternal death; none experienced loss of consciousness one mother received electrical burn; several were thrown back from the current source
No loss of consciousness, elevated creatinine phosphokinase and myoglobinuria
No data in the article
Tetany but no loss of consciousness
Mother in persistent vegetative state following shock, her general condition deteriorated 10 weeks after the accident and died due to respiratory arrest Mother ‘‘thrown across the room’’ approximately five meters, no loss of consciousness, felt ‘‘tingly’’ for several minutes
DOI: 10.3109/14767058.2014.1000295
Electric shock in pregnancy 321
2 weeks
38 weeks 34 weeks
No data
2 days
Three stillbirths, two cases of oligohydramnios and one normal fetus Fetal death and spontaneous abortion Live infant with normal physical and mental development at the age of eight Fetus weighing 3190 g delivered by CS performed for fetal distress, postnataly treated in the neonatal intensive care unit and diagnosed with antenatal renal vein thrombosis with satisfactory development at two years of age
All four fetuses died: two were ceased moving immediately after the injury and the pregnancies ended in spontaneous delivery of dead macerated neonates, one died due to the spontaneous abortion in the first trimester and fourth died three days after the delivery and had burn marks on the body Twenty-eight healthy newborns (94%), two spontaneous abortions (one and two weeks after the injury), one baby had muscular-type ventricular septal defect that closed spontaneously during early childhood
Fetal outcome
Mother fell on her knees after shock without loosing consciousness
Maternal death
No data
Not available
Two women had tetany and one had electric burns
Not available
Maternal outcome
R. Sparic´ et al.
AC, alternating current; DC, direct current; and V, Volt.
Anguenot [24] Case report
Woman suffered electric shock while mowing her lawn in bare feet by accidentally grasping a unprotected area of her lawn mower’s electric cable sheath
15 min post mortem
9 weeks
220 V
3 days to 21 weeks
Mazor & Leiberman [21] Case report Toongsuwan [23] Case report
20–40 weeks
No data
4–36 weeks (average 18.8 ± 10.1 weeks)
Thirty-one women (28 exposed to electric shock by home appliances – 110 V, two exposed to an electrified fence with high voltage, one touched a telephone line with very low voltage – 2 V) 10% of cases current crossed uterus Six victims of household AC
Einarson et al. [19] Prospective cohort study
Leiberman et al. [20] Report of six cases
5 days to 4 weeks
13–38 weeks
Four pregnant woman who experienced electric shock
Rees [18] Report of four cases published from 1933 to 1957
Interval from injury to delivery
Gestational age (weeks)
Mechanism of electrocution
Author (ref) Type of publication
Table 1. Continued
Downloaded by [University of New England] at 13:41 30 October 2017
322 J Matern Fetal Neonatal Med, 2016; 29(2): 317–323
Electric shock in pregnancy
Downloaded by [University of New England] at 13:41 30 October 2017
DOI: 10.3109/14767058.2014.1000295
and explained in detail to the closest relatives. If mother is being kept alive for the purpose of reaching fetal viability, the primary goal is to achieve adequate uteroplacental circulation, due to the absence of the autoregulation of the uterine blood vessels, bearing in mind that the maternal hypotension may lead to fetal hypoperfusion, hypoxia and neurological damage. Apart from the risk of prematurity, the risk of further intrauterine development of the fetus in life sustaining pregnant should be taken into consideration. Recommendations on providing cardio-respiratory support, enteral and parenteral diet and the treatment of the complications in life sustaining pregnant patients have been published [25]. Fetal cardiotocographic monitoring in such cases should be carried out on a daily basis after the 24 weeks of gestation [1]. It is impossible to make a conclusion regarding the probability to success in the preservation of pregnancy and the expected prevalence or a favorable outcome considering the fetus in such cases. Progressive hemodynamic instability is the most common indication for the termination of pregnancy [1]. Other causes that may necessitate the delivery are fetal asphyxia or intrauterine growth retardation and achievement of adequate fetal lung maturity [1]. Mother’s condition could be additionally worsened by nosocomial infections caused by therapeutic procedures and intensive care unit treatment. Literature provides reports of such unsuccessful attempts, but such data are scarce [1].
Management The mainstay for management of electrical injuries in pregnancy is prevention, as majority of the electric shocks are preventable. Misuse and improper maintenance or handling of household appliances and electrical equipment at workplace can be avoided by proper health education of pregnants emphasizing on electrical safety. Women who suffered electric shock in pregnancy, even if it was a minor one, require a complete obstetric evaluation. In cases of severe maternal injury, multidisciplinary treatment is required at the major trauma center with appropriate obstetric service.
Future research The effect of electric shock on the pregnancy outcome has yet to be defined. Therefore, more large prospective observational studies are necessary for a proper insight into the expected outcomes and for a final definition of monitoring procedures of such pregnancies.
Declaration of interest The authors report no declarations of interest.
323
References 1. Sparic´ R, Berisavac I, Kadija S, et al. Accidental electrocution in pregnancy. Int J Gyn Obstet 2014;126:181–2. 2. Yoong AF. Electrical shock sustained in pregnancy followed by placental abruption. Postgrad Med J 1990;66:563–4. 3. Fish RM. Electric injury, part III: cardiac monitoring indications, the pregnant patient, and lightning. J Emerg Med 2000;18:181–7. 4. Awwad J, Hannoun A, Fares F, Ghazeeri G. Accidental electric shock during pregnancy: reflection on a case. AJP Rep 2013;3: 103–4. 5. Goldman RD, Einarson A, Koren G. Electric shock during pregnancy. Can Fam Physician 2003;49:297–8. 6. Strong Jr TH, Gocke SE, Levy AV, Newel GJ. Electrical shock in pregnancy: a case report. J Emer Med 1987;5:318–33. 7. Fatovich DM. Electric shock in pregnancy. J Emerg Meg 1993;11: 175–7. 8. Kobernick M. Electrical injuries: pathophysiology and emergency management. Ann Emerg Med 1982;11:633–8. 9. Lederer W, Wiedermann FJ, Cerchiari E, Baubin MA. Electricityassociated injuries I: outdoor management of current-induced casualties. Resuscitation 1999;43:69–77. 10. Soar J, Perkins GD, Abbas G, et al. European Resuscitation Council Guidelines for resuscitation 2010 Section 8. Cardiac arrest in special circumstances: electrolyte abnormalities, poisoning, drowning, accidental hypothermia, hyperthermia, asthma, anaphylaxis, cardiac surgery, trauma, pregnancy, electrocution. Resuscitation 2010;81:1400–33. 11. Spies C, Trohman RG. Narrative review: electrocution and lifethreatening electrical injuries. Ann Intern Med 2006;145:531–7. 12. Patel A, Lo R. Electric injury with cerebral venous thrombosis. Case report and review of the literature. Stroke 1993;24:903–5. 13. Cooper MA, Price TG. Electrical and lightning injuries. [Internet]. Available from: https://www.uic.edu/labs/lightninginjury/Electr& Ltn.pdf [last accessed 12 Oct 2014]. 14. Gallati CP, Silberstein HJ, Meyers SP. Hemorrhage of a cavernous malformation associated with accidental electrocution: case report and review of the literature. Surg Neurol Int 2012;3:166. 15. Garcia Gutierrez JJ, Melendez J, Torrero JV, et al. Lightning injuries in a pregnant woman: a case report and review of the literature. Burns 2005;31:1045–9. 16. Jaffe R, Fejgin M, Ben Adaret N. Fetal death in early pregnancy due to electric current. Acta Obstet Gynecol Scand 1986;65:283. 17. Karger B, Suggeler O, Brinkmann B. Electrocution-autopsy study with emphasis on ‘‘electrical petechiae’’. Forensic Sci Int 2002; 126:210–13. 18. Rees WD. Pregnant woman struck by lightning. BMJ 1965;1: 103–4. 19. Einarson A, Bailey B, Inocencion G, et al. Accidental electric shock in pregnancy: a prospective cohort study. Am J Obstet Gynecol 1997;176:678–81. 20. Leiberman JR, Mazor M, Molcho J, et al. Electrical accidents during pregnancy. Obstet Gynecol 1986;67:861–3. 21. Mazor M, Leiberman JR. Abortion causes by electrical current. Arch Gynecol Obstet 1987;241:71–2. 22. Steer RG. Delayed fetal death following electrical injury in the first trimester. Aust N Z J Obstet Gynaecol 1992;32:377–8. 23. Toongsuwan S. Post mortem caesarean section following death by electrocution. Aust N Z J Obstet Gynaecol 1972;12:265–6. 24. Anguenot JL. Antenatal renal vein thrombosis after accidental electric shock in a pregnant woman. J Ultrasound Med 1999;18: 779–81. 25. Powner DJ, Bernstein IM. Extended somatic support for pregnant women after brain death. Crit Care Med 2003;31:1241–9.
ISSN: 1476-7058 (Print) 1476-4954 (Online) Journal homepage: http://www.tandfonline.com/loi/ijmf20
Electric shock in pregnancy: a review Radmila Sparić, Antonio Malvasi, Lazar Nejković & Andrea Tinelli To cite this article: Radmila Sparić, Antonio Malvasi, Lazar Nejković & Andrea Tinelli (2016) Electric shock in pregnancy: a review, The Journal of Maternal-Fetal & Neonatal Medicine, 29:2, 317-323, DOI: 10.3109/14767058.2014.1000295 To link to this article: http://dx.doi.org/10.3109/14767058.2014.1000295
Published online: 23 Jan 2015.
Submit your article to this journal
Article views: 228
View related articles
View Crossmark data
Citing articles: 1 View citing articles
Full Terms & Conditions of access and use can be found at http://www.tandfonline.com/action/journalInformation?journalCode=ijmf20 Download by: [University of New England]
Date: 30 October 2017, At: 13:41
http://informahealthcare.com/jmf ISSN: 1476-7058 (print), 1476-4954 (electronic) J Matern Fetal Neonatal Med, 2016; 29(2): 317–323 ! 2015 Informa UK Ltd. DOI: 10.3109/14767058.2014.1000295
REVIEW ARTICLE
Electric shock in pregnancy: a review Radmila Sparic´1, Antonio Malvasi2,3, Lazar Nejkovic´4, and Andrea Tinelli3,5 Clinic of Gynecology and Obstetrics, Clinical Center of Serbia, Belgrade, Serbia, 2Department of Obstetrics and Gynecology, Santa Maria Hospital, Bari, Italy, 3Department of Applied Mathematics, International Translational Medicine and Biomodeling Research Group, Moscow Institute of Physics and Technology, Moscow State University, Russia, 4Clinic of Gynecology and Obstetrics ‘‘Narodni Front’’, Belgrade, Serbia, and 5Division of Experimental Endoscopic Surgery, Imaging, Technology and Minimally Invasive Therapy, Department of Obstetrics and Gynecology, Vito Fazzi Hospital, Lecce, Italy
Downloaded by [University of New England] at 13:41 30 October 2017
1
Abstract
Keywords
Objective: The effect of gestational age and other factors that could influence the outcome of an electric shock in pregnancy have not been defined yet. Objective of this study is to provide reliable data on medical issues linked to electric shock in pregnancy. Methods: Authors consulted the most important scientific databases investigating reactions to electric shock in pregnancy, analyzing mechanism of electric shock, gestational age at the time of injury, the post-shock complications, interval from injury to delivery and fetal and maternal outcome. Results: The spectrum of electrical injuries in pregnancy ranges from transient unpleasant sensation with no effect on the fetus to sudden maternal and fetal death. The clinical presentation of the fetal injury may manifest immediately or even postnataly. Reported outcomes include spontaneous abortion, placental abruption, cardiac arrhythmias, fetal burn and intrauterine fetal death. If the pregnancy is continued, decreased fetal movements and asphyxia, pathological fetal heart patterns, intrauterine fetal growth retardation, damage to the fetal central nervous system and oligoamnios can occur. Conclusions: More large prospective observational studies are necessary for a proper insight into the expected outcomes of the electric shock in pregnancy as well as for a final definition of monitoring procedures of such pregnancies.
Electrical injury, electrocution, fetal injury, maternal complications, maternal morbidity, perinatal outcome History Received 24 November 2014 Accepted 16 December 2014 Published online 23 January 2015
Introduction
Materials and methods
The cases of electric shock in pregnancy are very rare, and there are no reliable data on the incidence [1,2]. Maternal injuries may be various, varying from no morbidity at all to severe injuries including the occurrence of serious complications and even death [1–6]. The incidence of fetal injuries caused by maternal electric shock is unknown [3,4,7]. Outcomes of such an injury include spontaneous abortion, placental abruption, cardiac arrhythmias, fetal burn and intrauterine fetal death [2,5]. If the pregnancy is continued, decreased fetal movements and asphyxia, pathological fetal heart patterns, intrauterine fetal growth retardation, damage to the fetal central nervous system and oligoamnios can occur [2,4,7]. The effect of gestational age and other factors, which could influence the susceptibility to electric shock in pregnancy, have not been studied in the literature yet [5].
Authors, to perform the clinical research, consulted the following scientific databases: PubMed (1966–2014), the Cochrane Library, EMBASE (1974–2014), Science Citation Index (1974–2014), The China Journal Fulltext Database (1994–2014), Chinese Scientific Journals Fulltext Database (1989–2014), Chinese Biomedical Literature Database (1978– 2014) and WANFANG database (1980–2014). The following key terms were used to access the records: electrocution in pregnancy, pregnancy and electric shock, electrical injuries in pregnancy, electrical accident, electric current injury, electric shock in pregnancy and brain damage in pregnancy. After identifying the key relevant articles, their references were also looked into. Similarly, other studies that cited them were used to widen the search results. In the inclusion criteria, as types of studies, we included the following: Case report, Reviews and Observational studies, excluding Randomized Controlled Trials for the lack of their presence in literature. For the outcome measures to analyze, the primary effectiveness outcome was as follows: mechanism of electrical shock, gestational age at the time of injury, the post-shock complications, interval from injury to delivery, fetal and maternal outcome.
Address for correspondence: Radmila Sparic´, MD, MSc, Clinic of Gynecology and Obstetrics, Clinical Center of Serbia, Visˇegradska 26, 11000 Belgrade, Serbia. Tel: +381 (0) 66 8301 332. Fax: +381 (0)11 361 5603. E-mail: [email protected]
318
R. Sparic´ et al.
Downloaded by [University of New England] at 13:41 30 October 2017
Epidemiology Electrical injuries have been reported for almost three centuries, while the first reported case of electrocution was in 1879 by Jex-Blake [8]. Scientific investigations of electrical injuries began in 1890s, and the first pathologic information was obtained when electrocution became a means of capital punishment in New York [8]. The most common causes of electric shock are occupational hazards, household appliances and lightning [9]. Other rare causes of electric shock include: injuries occurring during surgical and anesthetic procedures or during hemodialysis and electroconvulsive therapy [9]. Electrocution is also described as a method of suicide and homicide [9]. Electrical injuries are frequent in young males, although more than 20% of them are observed in children [9]. Mortality rate of electrocution in the United States is 0.5–2.5 per 100 000 persons each year [9]. Lightning causes 1000 deaths worldwide each year [10]. Most of the electrocution-related deaths occur in electrical and construction workers [9].
Basic principles of electrical injury The extent of the electrical injury is determined by pathway of the current through the body, nature of the tissues and their resistance to current, as well as type, duration, amperage and voltage of the current [9,11,12]. Type of the injury is crucially influenced by the pathway of the current through the body [13]. Contact of the electrical source with both hands results in transthoracic pathway, which accounts for most of the mortality. Resistance to the current is tissue specific: low for nerves, muscles and blood vessels and high for bone, tendon and fat [11]. Alternating current is more dangerous than the direct current (DC), as it can cause tetanic muscle contraction and the victim may be unable to release the source of electrical energy [9,11,13]. Degree of tissue destruction is proportional to the duration of contact [13]. According to Joule’s law, the heat generated in the tissue is proportional to the amperage squared. Respiratory arrest can occur at an amperage of 20–50 mA, and ventricular fibrillation at 60–120 mA [13]. Voltage is divided into high (exceeding 1000 V) and low voltage (below 1000 V) [9,11,13]. Highvoltage current results in more severe injuries and often throw the victim from the source [9]. Fatal cases have been reported with voltages as low as 46 V, while voltage over 25 V is potentially dangerous [12,14]. Furthermore, factors such as moisture, sweat and ointments reduce the impediment and affect the outcome [9]. While typical household electricity has 110–230 V, lightning strikes can produce 10 million V or more [15]. Lightning strike delivers large amount of DC during a very short period of time [11]. The extent of the lightning injury is even more difficult to predict, mainly due to the difference in the duration of the exposure [13]. Such victims rarely have extensive tissue destruction and massive cutaneous burns [11].
Mechanisms of injury There are four theories explaining features of electrical injury, namely electrostatic, vascular, thermal and
J Matern Fetal Neonatal Med, 2016; 29(2): 317–323
mechanical [12,14]. Electrostatic theory postulates that the electrical charges build up in the victim’s body result in electrostatic effects, which produce expansive force of tissues causing waves of decompression under the skin, as is supported by tissue rupture findings on autopsies. Vascular theory claims that vasoconstriction causes acute manifestations, while delayed symptoms are caused by later intimal injury and thrombosis. Thermal theory suggests that pathological findings in the tissues are caused by thermal injury, while mechanical theory proposes violent jarring of the tissue from electrical current. Due to large number of variables influencing the effect of the current through the body, exact pathophysiology of the electrical injury is not well understood yet [13]. It is most likely that all the above-mentioned mechanisms contribute to tissue damage in electrical injuries [14], as no single theory can explain all the pathological changes [12]. Furthermore, preexisting cardiac anomalies and atherosclerosis, decreased skin resistance due to sweating or contact with water, old age, fatigue and hypothyroidism can potentially increase the morbidity [12].
Clinical manifestations of electric shock Electric shocks account for a considerable morbidity and mortality. High-voltage injuries usually are manifested as massive burns requiring prolonged hospital treatment and are associated with multiple complications [13]. Victims with lightning and low-voltage injuries may have little evidence of injury or may be in cardiopulmonary arrest [13]. Immediate death from electric shock is usually caused by ventricular fibrillation or respiratory arrest [10,11]. Mortality from lightning injuries is as high as 70% [10]. Those who survive electric shock and require prolonged hospitalization usually die of pneumonia, sepsis and multisystem organ failure [13]. Cardiovascular system injury includes various forms of arrhythmias and conduction abnormalities, from ectopic beats to asystole, as well as non-specific changes in electrocardiogram [11]. Lightning and high-voltage injuries frequently cause asystole [13]. Cardiac manifestations are caused by direct cell damage, hypoxia due to respiratory arrest or extensive catecholamine release [9]. Due to catecholamine release, hypertension is common in high-voltage injuries [8]. Myocardial injury can also be secondary due to coronary artery spasm induced ischemia [10]. Acute myocardial infarction and late arrhythmias are very rare [13]. Creatine kinase levels may also be elevated, although skeletal muscle damage may cause this rise as well [9,13]. Asphyxia caused by respiratory arrest can also cause cardiac arrest [9]. Vascular complications include major vessel hemorrhage, arterial thrombosis, abdominal aortic aneurisms and deep vein thrombosis [8]. Respiratory system is also very sensitive to electric shock and even low levels of current across the chest are enough to cause respiratory arrest [11]. It can be caused also by damage to the medullary respiratory center by current passing through the brain [9]. Pulmonary edema, pulmonary contusion, pneumothorax and respiratory distress syndrome have been described as well [9,11].
Downloaded by [University of New England] at 13:41 30 October 2017
DOI: 10.3109/14767058.2014.1000295
Both central and peripheral nervous system can be damaged by electrical injury [11]. Central nervous system manifestations include loss of consciousness, which is usually transient if there are no head injuries [13]. The incidence of transient damage to the nervous system is up to 70% [11]. Keraunoparalysis is a specific, reversible, transient paralysis that could be present in victims of the lightning injury [11]. Neurological symptoms of electrical shock also include quadriplegia, paresis, temporary confusion, amnesia and concentration difficulties [9,13]. Seizures may be secondary to trauma of the central nervous system damage or hypoxia. Cerebral venous thrombosis may cause delayed brain injury [9,12]. In high-voltage victims spine fractures may cause a spinal cord injury [13]. In some cases, victims may suffer from long-term physical and psychological consequences [10,11,13,14]. Less usual manifestations include: lower extremity paralysis, blindness, deafness and aphasia, hypoxic encephalopathy, intracerebral hemorrhage, cerebral infarction and damage to the peripheral nerve tissue [13–15]. Peripheral nerve injury may be due to direct thermal injury, vascular damage or even direct action of current on nerve function [8]. Cutaneous burns at points of contact with the electrical source and the ground represent the most devastating injuries [11,13,16]. The most common sites are hands, heels and head [13]. They usually affect 10–25% of the total body surface area and vary from superficial partial-thickness burns to fullthickness burns [13]. Prognosis is poor in cases with infectious complications or renal failure [8,13]. In electrocution victims, burns are present in up to 81% of the cases, more common in high voltage cases [17]. The extent and depth of burns affect the outcome of the injury [11]. Due to the highest electrical resistance of the bones, those show the most severe electrothermal injuries, such as periosteal burns, destruction of bone matrix and osteonecrosis [11]. Violent involuntary muscular contractions may result in long bone and vertebral column fractures and joint dislocations [11,13,15]. Associated blunt trauma may cause skull fractures and cervical spine injuries [13]. In high voltage shocks, muscle necrosis and compartment syndromes are frequent, due to vascular ischemia and muscle edema [13]. Damage to the blood vessels may cause thrombosis and hemorrhage in small muscle arteries [13]. Venous thrombosis following electrical injuries are also reported [13], necessitating limb amputations in considerable number of patients [9]. Renal system may also be affected due to rhabdomyolysis and myoglobinuria causing acute tubular necrosis and consequent renal failure [9,11]. Other possible causes include direct damage to renal vessels and inadequate rehydration. Although rare, pancreas and liver injuries have also been reported, as well as injuries to hollow viscera, such as the small and large intestine, bladder and gallbladder [13]. Other possible consequences include cataracts, tympanic membrane rupture, disruption of the ossicles and mastoid, retinal detachment and optic nerve injury [8,13]. In cases where the victim has been thrown away of the electrical source by forceful muscular contractions, other injuries are possible as well.
Electric shock in pregnancy
319
Pathophysiology of electrical injury in pregnancy There are a number of physiologic changes that occur during pregnancy, which may alter the pathophysiology of electric shock during pregnancy and thus influence the fetal outcome. Therefore, the severity of maternal injury is not predictive for fetal outcome [4]. Uteroplacental vessels and amniotic fluid have low electrical resistance. Fetal skin is much less resistant than the skin postnatally, therefore even less electricity reaching fetus may cause significant harm due to fetal cardiac arrest. There is a little information about electric shocks in pregnancy. The spectrum of such injuries ranges from transient unpleasant sensation with no effect on the fetus to sudden maternal and fetal death. Bearing in mind the lack of clinical data, the effects of the maternal electric shock on the development of the fetus and pregnancy outcome are generally unknown. Even low-voltage electric shock in pregnancy has been reported to cause stillbirth [13]. Exposure to a 100–380 V, 25 mA current for 0.3 seconds could be lethal for the fetus [7]. The crucial factor determining the effect on the fetus are characteristics of the electricity and the pathway of the electric current through the mother’s body, which is most dangerous in cases of vertical flow (hand-to-foot or headto-foot) through the uterus [2–4]. Therefore, minimal injury to the mother may be lethal to the fetus, particularly in cases when the current bypass the maternal heart and travels through the uterus [6]. Fetal exposure to an electric shock may cause a cardiac arrest, which could explain the cessation of fetal movements noted by mothers [7]. A hand-to-hand pathway poses higher risk for mother and is associated with the least risk for fetus [4]. The clinical presentation of the fetal injury may manifest immediately or even postnatally [7].
Literature reports of electric shock in pregnancy Probably the earliest report of lightning injury in pregnancy was published by Schieffer in 1833, with favorable both maternal and neonatal outcome [18]. Electric shocks from lightning strikes of pregnant woman are very rare, with a few cases described in the literature [15,18]. Electric shock in pregnancy may be the cause of vital endangerment for the mother and can lead to severe damage to the fetus [2,3]. The survival rate of the mothers and the fetuses following electric shock varies, but it is considered that there is small likelihood of recovery and survival in cases of electric shock that lead to the loss of consciousness and cardiac and respiratory disorders [19]. The frequency of the fetal death after the mother experiencing an electric shock documented in the literature ranges from 6 to 73% [11]. Such high rate of fetal mortality may be due to publication bias, as most of the minor injuries are unpublished. Published case reports usually highlight adverse outcomes and therefore cannot be used to adequately define true risk [5,19]. In 1965, Rees [18] published a case of favorable maternal and neonatal outcome following lightning injury in early pregnancy, together with a review of four cases of electric shock in pregnancy out which none of the fetuses survived.
Downloaded by [University of New England] at 13:41 30 October 2017
320
R. Sparic´ et al.
One of those pregnancies ended in spontaneous abortion: two fetuses were delivered macerated five and six days after the injury, while the fourth fetus developed polyhidramnios and was prematurely delivered and died three days after the delivery. Garcia Gutierrez et al. [15] published their experience with lightning strike in pregnancy and a review of previously published cases. Of 13 cases evaluated, all mothers survived, but fetal mortality rate was 50% (five intrauterine fetal deaths and one neonatal death few hours after the delivery) [15]. Their patient suffered burns without any other type of injury. She was exposed to a direct lightning strike at 18 weeks of gestation with entrance wounds on the scalp and neck and exit wounds in the right lower extremity. She delivered a healthy infant 3030 g of weight, with proper development for 30 months. They concluded that the risk of sequel or fetal death is higher in cases of injuries in the third trimester of pregnancy. Einarson et al. [19] noted that, in most cases, accidental electric shock in pregnancy occurring during everyday life does not represent major fetal risk. In this prospective controlled cohort Canadian study, in only 10% of cases the path of electric current was hand to foot through the uterus. Of 31 pregnant women, 28 delivered healthy infants, two had spontaneous abortions, while one child had a ventricular septal defect that closed spontaneously. Leiberman et al. [20] reviewed six pregnants who experienced electric shock at home. For all, the current went from hand to foot, with favorable maternal outcome in all cases. Three of the fetuses were stillborn, within three days to 12 weeks after the shock, with intrauterine growth retardation. One fetus was normal, and two had oligohydramnios. By examining the placenta and cord, cited authors noted that there are no specific signs of damage in such cases. Fatovich [7] describes 15 pregnant women who experienced electric shock and concludes that the fetal death occurred in 73% of the cases. Both Jaffe et al. [16] and Mazor and Leiberman [21] described cases of spontaneous abortion in the first trimester of pregnancy few hours and two days after the accident. Steer [22] described a case of delayed fetal death following electric fence injury in the first trimester. Sparic´ et al. [1] described a case of electric shock in 14 weeks of pregnancy and attempt of prolongation of the pregnancy until fetal maturity is reached. Despite the multidisciplinary treatment in the intensive care unit, perimortem cesarean section (CS) at 24 week’s gestation ended in the delivery of 450 g stillborn neonate. On the contrary, Toongsuwan [23] described a case of postmortem CS 15 min after maternal death at 38 weeks of pregnancy ending in delivery of live neonate, who showed normal physical and mental development at the age of eight. Awwad et al. [4] described a case of electric shock in 28 week’s gestation ending in term delivery at 38 week’s gestation without fetal or maternal sequel. Although woman had tetany, the patient did not lose her consciousness, and the flow of the current was estimated to be hand-to-hand. Yoong [2] published a case of electric shock that occurred in a woman while fixing the plug of her iron. She was thrown away for approximately 5 m. She was
J Matern Fetal Neonatal Med, 2016; 29(2): 317–323
delivered the next day by emergency CS, which revealed large placental abruption. The baby died 24-h later, despite resuscitation. Strong et al. [6] described a case of electric shock experienced in pregnant at 30 weeks gestation when a 110 V DC wire touched the power-saw she was using. A few hours later, she experienced decreased fetal movements and repetitive spontaneous fetal heart decelerations. Following diagnosis of fetal distress, she underwent an emergency CS. A live baby was delivered and transferred to the neonatal intensive care unit. Both fetal and maternal outcome were favorable. Anguenot [24] described a case of maternal electric shock transmitted in a vertical trajectory in 34 weeks’ gestation, which was followed by fetal distress two weeks later. She was delivered by emergency CS with delivery of a 3190 g with cord blood pH values of 7.13 and 7.25. The neonate required intensive care unit treatment and had a nonfunctioning left kidney due to antenatal renal vein thrombosis. At two years of age, except atrophic kidney, child’s development was found to be satisfactory. A short summary of electric shock in pregnancy reports is listed in Table 1.
Surveillance Women who suffered electric shock in pregnancy, even if it was a minor one, require a complete obstetric evaluation [7]. There is no confirmation that any kind of management can impact the outcome of the pregnancy after electric shock without mechanical trauma [3]. The majority of authors agree that there are no indications for the fetal monitoring before the 20 weeks of gestation [3,19]. In cases of injuries after the 20 weeks of gestation, it is important to consider fetal condition as well [6]. Thus, it is advisable to carry out cardiotocographic monitoring for four hours after the injury; a 24-h electrocardiographic and cardiotocographic monitoring is advisable in cases of maternal loss of consciousness and electrocardiogram abnormalities, as well as in cases of cardiovascular disorders of the mother [3,5,6,11]. Mechanical trauma, which occurs in cases of even a very week electric shock, can be significantly influential, as the result of violent involuntary muscular contractions [3]. This kind of traumatism can cause placental abruption. Therefore, pregnant women should have an urgent ultrasound scan, even in cases of apparently minor shocks [3]. Doppler exam is advisable two weeks after the injury to check for late fetal death [19]. Although there is no protocol for prenatal monitoring or obstetric approach in such cases, fetal monitoring for oligohidramnios and fetal growth restriction is reasonable for the rest of the pregnancy [1]. In cases of abdominal trauma, it would be reasonable for Rh (D) negative women should receive prophylaxis. Furthermore, having in mind that electrical burns are prone to tetanus [8], those with burns should receive tetanus immunization on the basis of their immunization history. In cases when a pregnant patient has sustained an injury that has led to serious brain damage after the 24 weeks of gestation, and when no improvement of the patient’s condition is anticipated, each case must be considered separately
9–38 weeks
No data available 13 weeks
Electric shock to dry hand from a kitchen electric appliance with worn insulation connected to a 220 V AC while wearing rubber slippers Minor electric shock while using hair dryer, current did not travel through abdomen 110 V DC wire touch in the power-saw
Fifteen victims (one DC injury and 14 household AC)
Thirteen cases
220 V
Awwad et al. [4] Case report
Goldman et al. [5] Case report
Fatovich [7] Review of case reports published in English literature of pregnant woman exposed to electric shock
Garcia Gutierrez et al. [15] Case report and literature review on lightning injuries in pregnancy Jaffe et al. [16] Case report
Strong Jr et al. [6] Case report
Electric shock whilst mending the wiring of the plug of her iron
Yoong [2] Case report
No data in the article
23 weeks
Few hours
No data available
Few hours-21 weeks
Few hours
10 weeks
28 weeks
30 weeks
Less than 24 h
10 weeks
Interval from injury to delivery
32 weeks
14 weeks
Woman suffered electric shock while blow-drying her hair in the bath
Sparic´ et al. [1] Case report
Gestational age (weeks)
Mechanism of electrocution
Author (ref) Type of publication
Table 1. Short summary of the electric shock in pregnancy reports.
Absent fetal movement, repetitive spontaneous fetal hart decelerations, emergency CS delivery of live baby 715 g, discharged home at eight weeks of age Fetal mortality 73% (11 cases): three spontaneous abortions, four stillborns; two neonatal deaths-one with burn marks, two dead macerated infants, two cases of oligohydramnios with live neonate, one case of live IUGR neonate and one normal neonate Fetal mortality rate 50% (five intrauterine fetal deaths and one neonatal death few hours after the delivery) Fetal death and spontaneous abortion
Stillborn neonate weighing 450 g delivered emergency CS 5 min after mother’s death (autopsy diagnosed intrauterine asphyxia as the cause of fetal death) Placental abruption, 2240 g dead fetus delivered by an emergency CS indicated with fetal bradycardia. Apgar score 0 at 9 min. Although resuscitated, the baby died 24 h after the delivery Fetal hypo activity, change in fetal movement pattern, irregular fetal heart rhythm and missed beats Live newborn weighing 3120 g with Apgar scores of 8 and 10 at one and five minutes No data in the article
Fetal outcome
Downloaded by [University of New England] at 13:41 30 October 2017
Maternal outcome
Not available
All mothers survived
(continued )
No maternal death; none experienced loss of consciousness one mother received electrical burn; several were thrown back from the current source
No loss of consciousness, elevated creatinine phosphokinase and myoglobinuria
No data in the article
Tetany but no loss of consciousness
Mother in persistent vegetative state following shock, her general condition deteriorated 10 weeks after the accident and died due to respiratory arrest Mother ‘‘thrown across the room’’ approximately five meters, no loss of consciousness, felt ‘‘tingly’’ for several minutes
DOI: 10.3109/14767058.2014.1000295
Electric shock in pregnancy 321
2 weeks
38 weeks 34 weeks
No data
2 days
Three stillbirths, two cases of oligohydramnios and one normal fetus Fetal death and spontaneous abortion Live infant with normal physical and mental development at the age of eight Fetus weighing 3190 g delivered by CS performed for fetal distress, postnataly treated in the neonatal intensive care unit and diagnosed with antenatal renal vein thrombosis with satisfactory development at two years of age
All four fetuses died: two were ceased moving immediately after the injury and the pregnancies ended in spontaneous delivery of dead macerated neonates, one died due to the spontaneous abortion in the first trimester and fourth died three days after the delivery and had burn marks on the body Twenty-eight healthy newborns (94%), two spontaneous abortions (one and two weeks after the injury), one baby had muscular-type ventricular septal defect that closed spontaneously during early childhood
Fetal outcome
Mother fell on her knees after shock without loosing consciousness
Maternal death
No data
Not available
Two women had tetany and one had electric burns
Not available
Maternal outcome
R. Sparic´ et al.
AC, alternating current; DC, direct current; and V, Volt.
Anguenot [24] Case report
Woman suffered electric shock while mowing her lawn in bare feet by accidentally grasping a unprotected area of her lawn mower’s electric cable sheath
15 min post mortem
9 weeks
220 V
3 days to 21 weeks
Mazor & Leiberman [21] Case report Toongsuwan [23] Case report
20–40 weeks
No data
4–36 weeks (average 18.8 ± 10.1 weeks)
Thirty-one women (28 exposed to electric shock by home appliances – 110 V, two exposed to an electrified fence with high voltage, one touched a telephone line with very low voltage – 2 V) 10% of cases current crossed uterus Six victims of household AC
Einarson et al. [19] Prospective cohort study
Leiberman et al. [20] Report of six cases
5 days to 4 weeks
13–38 weeks
Four pregnant woman who experienced electric shock
Rees [18] Report of four cases published from 1933 to 1957
Interval from injury to delivery
Gestational age (weeks)
Mechanism of electrocution
Author (ref) Type of publication
Table 1. Continued
Downloaded by [University of New England] at 13:41 30 October 2017
322 J Matern Fetal Neonatal Med, 2016; 29(2): 317–323
Electric shock in pregnancy
Downloaded by [University of New England] at 13:41 30 October 2017
DOI: 10.3109/14767058.2014.1000295
and explained in detail to the closest relatives. If mother is being kept alive for the purpose of reaching fetal viability, the primary goal is to achieve adequate uteroplacental circulation, due to the absence of the autoregulation of the uterine blood vessels, bearing in mind that the maternal hypotension may lead to fetal hypoperfusion, hypoxia and neurological damage. Apart from the risk of prematurity, the risk of further intrauterine development of the fetus in life sustaining pregnant should be taken into consideration. Recommendations on providing cardio-respiratory support, enteral and parenteral diet and the treatment of the complications in life sustaining pregnant patients have been published [25]. Fetal cardiotocographic monitoring in such cases should be carried out on a daily basis after the 24 weeks of gestation [1]. It is impossible to make a conclusion regarding the probability to success in the preservation of pregnancy and the expected prevalence or a favorable outcome considering the fetus in such cases. Progressive hemodynamic instability is the most common indication for the termination of pregnancy [1]. Other causes that may necessitate the delivery are fetal asphyxia or intrauterine growth retardation and achievement of adequate fetal lung maturity [1]. Mother’s condition could be additionally worsened by nosocomial infections caused by therapeutic procedures and intensive care unit treatment. Literature provides reports of such unsuccessful attempts, but such data are scarce [1].
Management The mainstay for management of electrical injuries in pregnancy is prevention, as majority of the electric shocks are preventable. Misuse and improper maintenance or handling of household appliances and electrical equipment at workplace can be avoided by proper health education of pregnants emphasizing on electrical safety. Women who suffered electric shock in pregnancy, even if it was a minor one, require a complete obstetric evaluation. In cases of severe maternal injury, multidisciplinary treatment is required at the major trauma center with appropriate obstetric service.
Future research The effect of electric shock on the pregnancy outcome has yet to be defined. Therefore, more large prospective observational studies are necessary for a proper insight into the expected outcomes and for a final definition of monitoring procedures of such pregnancies.
Declaration of interest The authors report no declarations of interest.
323
References 1. Sparic´ R, Berisavac I, Kadija S, et al. Accidental electrocution in pregnancy. Int J Gyn Obstet 2014;126:181–2. 2. Yoong AF. Electrical shock sustained in pregnancy followed by placental abruption. Postgrad Med J 1990;66:563–4. 3. Fish RM. Electric injury, part III: cardiac monitoring indications, the pregnant patient, and lightning. J Emerg Med 2000;18:181–7. 4. Awwad J, Hannoun A, Fares F, Ghazeeri G. Accidental electric shock during pregnancy: reflection on a case. AJP Rep 2013;3: 103–4. 5. Goldman RD, Einarson A, Koren G. Electric shock during pregnancy. Can Fam Physician 2003;49:297–8. 6. Strong Jr TH, Gocke SE, Levy AV, Newel GJ. Electrical shock in pregnancy: a case report. J Emer Med 1987;5:318–33. 7. Fatovich DM. Electric shock in pregnancy. J Emerg Meg 1993;11: 175–7. 8. Kobernick M. Electrical injuries: pathophysiology and emergency management. Ann Emerg Med 1982;11:633–8. 9. Lederer W, Wiedermann FJ, Cerchiari E, Baubin MA. Electricityassociated injuries I: outdoor management of current-induced casualties. Resuscitation 1999;43:69–77. 10. Soar J, Perkins GD, Abbas G, et al. European Resuscitation Council Guidelines for resuscitation 2010 Section 8. Cardiac arrest in special circumstances: electrolyte abnormalities, poisoning, drowning, accidental hypothermia, hyperthermia, asthma, anaphylaxis, cardiac surgery, trauma, pregnancy, electrocution. Resuscitation 2010;81:1400–33. 11. Spies C, Trohman RG. Narrative review: electrocution and lifethreatening electrical injuries. Ann Intern Med 2006;145:531–7. 12. Patel A, Lo R. Electric injury with cerebral venous thrombosis. Case report and review of the literature. Stroke 1993;24:903–5. 13. Cooper MA, Price TG. Electrical and lightning injuries. [Internet]. Available from: https://www.uic.edu/labs/lightninginjury/Electr& Ltn.pdf [last accessed 12 Oct 2014]. 14. Gallati CP, Silberstein HJ, Meyers SP. Hemorrhage of a cavernous malformation associated with accidental electrocution: case report and review of the literature. Surg Neurol Int 2012;3:166. 15. Garcia Gutierrez JJ, Melendez J, Torrero JV, et al. Lightning injuries in a pregnant woman: a case report and review of the literature. Burns 2005;31:1045–9. 16. Jaffe R, Fejgin M, Ben Adaret N. Fetal death in early pregnancy due to electric current. Acta Obstet Gynecol Scand 1986;65:283. 17. Karger B, Suggeler O, Brinkmann B. Electrocution-autopsy study with emphasis on ‘‘electrical petechiae’’. Forensic Sci Int 2002; 126:210–13. 18. Rees WD. Pregnant woman struck by lightning. BMJ 1965;1: 103–4. 19. Einarson A, Bailey B, Inocencion G, et al. Accidental electric shock in pregnancy: a prospective cohort study. Am J Obstet Gynecol 1997;176:678–81. 20. Leiberman JR, Mazor M, Molcho J, et al. Electrical accidents during pregnancy. Obstet Gynecol 1986;67:861–3. 21. Mazor M, Leiberman JR. Abortion causes by electrical current. Arch Gynecol Obstet 1987;241:71–2. 22. Steer RG. Delayed fetal death following electrical injury in the first trimester. Aust N Z J Obstet Gynaecol 1992;32:377–8. 23. Toongsuwan S. Post mortem caesarean section following death by electrocution. Aust N Z J Obstet Gynaecol 1972;12:265–6. 24. Anguenot JL. Antenatal renal vein thrombosis after accidental electric shock in a pregnant woman. J Ultrasound Med 1999;18: 779–81. 25. Powner DJ, Bernstein IM. Extended somatic support for pregnant women after brain death. Crit Care Med 2003;31:1241–9.
