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COPING WITH OBSTETRICS SEPSIS
TJOKORDA GDE AGUNG SUWARDEWA
PIT FETOMATERNALYOGYAKARTA
2017
TUJUAN PEMBELAJARAN
Untuk mengatasi sepsis obstetri, diharapkan mengingat kembali:
• Apa itu sepsis?
• Bagaimana sepsis itu terjadi?
• Apa faktor risiko dan penyebabnya?
• Bagaimana tatalaksana sepsis?
Sering sihdengar, …
tapi?
PENDAHULUAN
• Sepsis: keadaan gawat-darurat yang timbul akibat
respon tubuh terhadap infeksi.
• Sepsis tetap menjadi penyebab kematian utama
karena infeksi (Merinoff Symposium 2010: National Guidline of Sepsis)
• Maternal sepsis jarang terjadi, namun sepsis
merupakaan masalah yang serius dan tidak ada tendensi
menurun (RCOG. Bacterial Sepsis in Pregnancy. Green-top Guideline 64A. April, 2012)
• Sampai saat ini sepsis masih dapat diatasi dengan
pencegahan.
EPIDEMIOLOGI • Maternal sepsis di dunia, > 5 juta/tahun, dan 75000 kematian maternal2.
• Di USA, Eropah, Inggris, antara 0.4 ̶ 1,0 /1000 populasi.
• Risiko kematian maternal:
– Di negara kaya 2,1%,
– Di negara miskin 11,6%2 .
• Angka di Indonesia?
• Sequele 0,1– 0,6/1000 kelahiran:
PID, oklusi tuba, infertilitas,
nyeri kronis di pelvis*..
2. Jeroen van Dillen, Joost Zwart, Joke Schutte and Jos van Roosmalen. 2013. Maternal sepsis: epidemiology, etiology and outcome
*Arulkumaran N, Singer M. Puerperal sepsis. Best Pract Res Clin Obstet Gynaecol. 2013 Dec;27(6):893-902.
PATOFISIOLOGI
APA ITU SEPSIS?
RCOG. Bacterial Sepsis in Pregnancy. Green-top Guideline 64A April 2012
Persistent of hypoperfusion
despite ample fluid replacement
SIRSTemp > 104.4 F
< 96.8 FRR > 20HR > 90WBC > 12.000
< 4000> 10% bands
PCO2 < 2 mmHg
Mortality rate 20-40% Mortality rate 60%
SEPSIS
2 SIRS
+
Infeksijelas /curiga
SEPSISBERAT
SEPSIS
+
Tanda-tandakegagalan organ
Hipotensi (SBP<90)
Lactate > 4 mmol
SYOK SEPTIK
SEPSIS BERAT
with persistent:
Hypotension
Sign of end organ damaged
Lactate > 4 mmol
Sepsis adalah ancaman hidup karena disfungsi organ, yang disebabkan disregulasi
host terhadap infeksi
John R. Barton, MD, and Baha M. Sibai, MD. Severe Sepsis and Septic Shock in Pregnancy
CARA DIAGNOSIS
FAKTOR RISIKO
Community risk factors
Low socioeconomic status
Lack of adequate healthcare
Untrained birth attendant
Maternal risk factors
Anemia
Poor nutrition
Existing infection
Primiparity
Multiple pregnancy
Obecity
Birthing condition risk factors
Cesarean section
Multiple vaginal exams (>5)
Unhygienic conditions
Prolonged rupture of membranes
Prolonged labor
Multiple obstetric maneuver
Retained product of conception
PENGARUH SEPSIS
Hypoperfusion, acute tubular necrosis
Confusion, coma, somnolence, fever
Hypotension, increased CO,Myocardial depression,Tachyarrhythmia
Hypoxemia, diffuse infiltrates
Thrombocytopenia, leukocytosis, Consumtive coagulopathy
CNS EFFECT
CARDIOVASCULAR
PULMONARY
KIDNEYS
HEMATOLOGIC
Preterm bierth, neonatal sepsisFetal hypoxia, fetal/neonatal death
PERINATAL
John R. Barton, MD, and Baha M. Sibai, MD. Severe Sepsis and Septic Shock in Pregnancy
TATALAKSANA
PATOGENESIS
GOAL RESUSITASI
JANGAN LUPA INTERVENSI OBSTETRI UNTUK KESEJAHTERAN JANIN
Goal and normal values in pregnancy
TATALAKSANA
KOMPLIKASIFAKTOR RISIKO
KAUSA SEPSIS
Community risk factors-Low social-economic-Lack of adequate healthcare-Untrained birth attendant
Maternal risk factors-Anemia-Poor nutrition
Birthing condition risk factors-Cesarean Section-Multiples examinations-Unhygienic conditions-Prolonged PRM and labor-Multiples obstetrical maneuvers -Retained product of conceptions
Genital tract infections- Endometritis- Chorioamnionitis
Mastitis
Incidental infections- Respiratory infections
Others: related tolabor and birth- Urinary tract infection
Maternal-ICU-Lung edem-ARDS-Acute renal failure-Shock liver-Septic embilies-Myocardial & cerebral ischemic-DIC- Death
Perinatal-Preterm birth-Neonatal sepsis-Perinatal hypoxia & acidosis-Fetal or neonatal death
TERBAIK PENCEGAHAN PRIMER
Rekomendasi WHO:
• Pemeriksaan VT dengan interval 4 jam pada kasus
yang rutin dan risiko rendah
• Rekomendasi WHO untuk pemberian antibiotika:
– Persalinan dengan GBS, untuk mencegah neonatus
GBS
– Preterm Prelabor Rupture of the Membrane
(PPROM)
– Profilaksis sebelum plasenta manual
WHO. 2015. WHO recommendations for prevention and treatment of maternal peripartum infections.
Community risk factors-Low social-economic-Lack of adequate healthcare-Untrained birth attendant
Maternal risk factors-Anemia-Poor nutrition
Birthing condition risk factors-Cesarean Section-Multiples examinations-Unhygienic conditions-Prolonged PRM and labor-Multiples obstetrical maneuvers -Retained product of conceptions
• Antibiotika profilaksis rutin direkomendasi
pada ruptura perineum tingkat IV.
• Pencucian vagina dengan povidone-
iodine segera sebelum SC.
• Antibiotik profilaksis direkomendasi untuk
tindakan SC berencana atau
emergensi
• Antibiotika profilaksis diberikan sebelum
insisi kulit.
• Cephalosporin atau Penicillin dosis
tunggal merupakan pilihan.
WHO. 2015. WHO recommendations for prevention and treatment of maternal peripartum infections.
PENCEGAHAN PRIMER
Birthing condition risk factors-Cesarean Sectiion-Multiples examinations-Unhygienic conditions-Prolonged PRM and labor-Multiples obstetrical maneuvers -Retained product of conceptions
PENCEGAHAN SEKUNDER
KOMPLIKASIFAKTOR RISIKO
KAUSA SEPSIS
Community risk factors-Low social-economic-Lack of adequate healthcare-Untrained birth attendant
Maternal risk factors-Anemia-Poor nutrition
Birthing condition risk factors-CS-Multiples examinations-Unhygienic conditions-Prolonged PRM and labor-Multiples obstetrical maneuvers -Retained product of conceptions
Genital tract infections- Endometritis- Chorioamnionitis
Mastitis
Incidental infections- Respiratory infections
Others: related tolabor and birth- Urinary tract infection
Maternal-ICU-Lung edem-ARDS-Acute renal failure-Shock liver-Septic embilies-Myocardial & cerebral ischemic-DIC- Death
Perinatal-Preterm birth-Neonatal sepsis-Perinatal hypoxia & acidosis-Fetal or neonatal death
PENCEGAHAN SEKUNDER
KOMPLIKASIFAKTOR RISIKO
KAUSA SEPSIS
Community risk factors-Low social-economic-Lack of adequate healthcare-Untrained birth attendant
Maternal risk factors-Anemia-Poor nutrition
Birthing condition risk factors-CS-Multiples examinations-Unhygienic conditions-Prolonged PRM and labor-Multiples obstetrical maneuvers -Retained product of conceptions
Genital tract infections- Endometritis- Chorioamnionitis
Mastitis
Incidental infections- Respiratory infections
Others: related tolabor and birth- Urinary tract infection
Maternal-ICU-Lung edem-ARDS-Acute renal failure-Shock liver-Septic embolies-Myocardial & cerebral ischemic-DIC- Death
Perinatal-Preterm birth-Neonatal sepsis-Perinatal hypoxia & acidosis-Fetal or neonatal death
MIKROORGANISME PATOGEN YANG SERING
Jeffrey E Gotts , Michael A Matthay. Sepsis: pathophysiology and clinical management
TERAPI ANTIMIKROBIAL
1. RCOG. Bacterial Sepsis in Pregnancy. Green-top Guideline 64A April 2012
PILIHAN ANTIMIKROBIAL TERGANTUNG SENSITIVITAS KUMAN DAN PENGARUHNYA TERHADAP ORGAN TUBUH
TERAPI ANTIMIKROBIAL
• Dimulai dari terapi empiris dengan satu/lebih antibiotika berspektrum
luas.
• Terapi empiris jangan lebih dari 3–5 hari.
• Korioamnionitis Simple regimen seperti Ampicillin dan
Gentamycin sekali sehari sebagai first-line antibiotics (WHO).
• Endometritis postpartum direkomendasi kombinasi Clindamycin
dan Gentamicin sebagai pilihan pertama (WHO).
• Antibiotika diberikan dalam 1 jam sejak terdiagnosis sepsis berat
dan syok septik
International Guidelines for Management of Severe Sepsis and Septic Shock. 2013. The Surviving Sepsis Campaign is a collaboration of the European Society of Intensive Care Medicine and the Society of Critical Care Medicine.
WHO. 2015. WHO recommendations for prevention and treatment of maternal peripartum infections.
o Pencukuran rambut tidak direkomendasi untuk menurunkan risiko
infeksi luka operasi.
o Hindari penggunaan larutan antiseptik pada luka, karena sitotoksik
pada jaringan granulasi yang baru.
o Keringkan kulit luka, baru ditutup, dan biarkan biarkan jangan diganggu
sampai 5 hari, kecuali ada eksudat di bawah penutup. Bebat
hendaknya dibuka pada hari ke 5/6.
PERAWATAN LUKA OPERASI
1. Guideline for Obstetric Abdominal Wound Care (GL778) October 20152. The Royal Marsden Manual of Clinical Nursing Procedures 7thEdition; Chapter 48 Wound Management, Wiley Blackwell 2008 3. Nice Clinical Guideline 74, Surgical Site Infection, October 2008 www.nice.org.uk/guidance/CG74
NO! YES!
PERAWATAN LUKA OPERASI
Pada wanita dengan BMI is >35kg/m2, hendaknya dipakaikan
bebat spesial dengan intruksi khusus pada kemasannya.
Jika bebat menjadi kotor atau longgar dan perlu diganti, maka;
• Pakai tehnik asepsis tanpa sentuhan untuk melepas atau
mengganti bebat.
• Pergunakan normal saline steril untuk membersihkan luka
sampai 48 jam pasca operasi.
• Sarankan bahwa, mandi aman setelah 24 jam pasca operasi,
tetapi hindari jangan sampai bebat robek..
• Pergunakan bebat interaktif untuk luka operasi.
1. Guideline for Obstetric Abdominal Wound Care (GL778) October 20152. The Royal Marsden Manual of Clinical Nursing Procedures 7thEdition; Chapter 48 Wound Management, Wiley Blackwell 2008 3. Nice Clinical Guideline 74, Surgical Site Infection, October 2008 www.nice.org.uk/guidance/CG74
PERAWATAN LUKA OPERASI
Terapi antibiotika
• Jika dicurigai infeksi luka operasi (selulitis),
berikan antibiotika.
• Pilih antibiotika yang mencakup kebanyakan
organisme penyebab. Pertimbangkan resistensi
dan tes sensitivitas.
1. Guideline for Obstetric Abdominal Wound Care (GL778) October 20152. The Royal Marsden Manual of Clinical Nursing Procedures 7thEdition; Chapter 48 Wound Management, Wiley Blackwell 2008 3. Nice Clinical Guideline 74, Surgical Site Infection, October 2008 www.nice.org.uk/guidance/CG74
PESAN DIBAWA PULANG
• Ingat 6 langkah dalam 1 jam pertama
• Pertahankan MAP ≥ 65 mmHg dan laktat ≤ 2 mmol/L
• Berikan antibiotika secara empirik sebelumkultur ada, maksimal 3-5 hari.
• Antisipasi faktor risiko dan tatalaksanaselama persalinan berlangsung sangatpenting.
• Perawatan luka operasi harusmemperhatikan tehnik, asepsis, dan bahan.
• Jangan lupa viabilitas dan kesejahteraanjanin di samping kesejahteraan ibu.
PENDAHULUAN
WHO. 2015. WHO recommendations for prevention and treatment of maternal peripartum infections.
Faktor risiko sepsis maternal adalah:
– Kondisi ibu yang sudah ada sebelumnya(malnutrisi, DM, kegemukan, anemia berat, BV,
infeksi streptokokus grup B).
– Kondisi yang diprakarsai oleh persalinan
dan kelahiran (prolonged rupture of membranes,
multiple vaginal examinations, manual removal of
the placenta, and caesarean section).
CAUSES OF SEVERE SEPSIS AND SEPTIC SHOCK IN PREGNANCY AND PUERERIUM
Acute pyelonephritis Retained product of conception-Septic abortion-Conservative management of placenta acreta
Neglected chorioamnionitis or endomyometritis- Uterine microabscess or necrotizing myometritis-Gas gangren-Pelvic abscess
Pneumonia -Bacterial -Viral
Unrecognized or inadequatetreated necrotizing faciitis-Abdominal incision -Episiotomy-Perineal laceration
Intraperitoneal etiology-Ruptured appendicitis-Bowel infarction -Acute cholecystitis-Necrotizing pancreatitis
SEPSIS
John R. Barton, MD, and Baha M. Sibai, MD. Severe Sepsis and Septic Shock in Pregnancy
Sofa score ≥ 2
Mervyn,Singer.,Clifford, S. D., Christopher, WS,. et al JAMA. 2016;315(8):801-810.
KERUSAKAN ORGAN
apabila
WHO RECOMMENDATIONS
WHO. 2015. WHO recommendations for prevention and treatment of maternal peripartum infections.
WHO RECOMMENDATIONS
WHO. 2015. WHO recommendations for prevention and treatment of maternal peripartum infections.
WHO RECOMMENDATIONS
WHO. 2015. WHO recommendations for prevention and treatment of maternal peripartum infections.
SEPSIS MANAGEMENT
X
X Y
Y
TREATMENT
THANKS YOU
DEFINITIONS
Infection : is defined as a pathological process caused by invasion of normally sterile tissue or fluid or body cavity by pathogenic or potentially pathogenic micro-organisms.
Sepsis: is the clinical syndrome defined by the presence of both infection and the systemic inflammatory response syndrome (SIRS
Severe sepsis: refers to sepsis complicated by organ dysfunction. (9) In the 8th Edition of the ICD-10-AM/ACHI/ACS1 this is extended to include organ failure.
Septic shock: is defined as severe sepsis with circulatory shock with signs of organ dysfunction or after 30mls/kg isotonic fluid has been administered to reverse any hypovolaemia and are persistent systolic blood pressure <90 mmHg, MAP < 65 mmHg, decrease by 40mmHg from baseline and/or lactate >4 mmol/l.
DEFINITIONS
Previous DefinitionsSIRS : two the following
– Temperature > 380 C or < 360 C
– Heart rate > 90 beats/min
– Respiratory rate > 20 breaths/min or arterial CO2 pressure < 32 mmHg.
– WBC count > 12 x 109/L or < 4 x 109/L
SEPSIS: SIRS with infection (presumed or proven)
SEVERE SEPSIS: sepsis with evidence of acute organ dysfunction
(hypotension, lactic acidosis, reduced urine output, reduced PaO/FIO2 ratio,
raised creatinine or bilirubin, Thrombocytopenias, raised international
normalized ratio)
SEPTIC SHOCK: sepsis with persistent hypotension after fluid resuscitation.
DIAGNOSIS CRITERIAS
THE SEPSIS CASCADE
Bacterial product and component
Activation of coagulationand complement systemTissue factor releaseFibrinolytic activity
TNF-αIL-1IL-6PAFNOetc
Neutrophil activation,agregation, anddegranulationRelease of O2 radical
and Proteases
Platelet activationagregation
Metabolism ofarachidonic acid, Release of
Tromboxane A2,PGS, and LTS
T-cell release ofIL-2 INF-γGM-CSF
Endothelial damaged
Tissue injury
Organ dysfunctions Adv. Neonatal care 2004. W B Saunders
Macrophage
COMMON CAUSES OF MATERNAL SEPSIS
DEFINITION
PATHOPHYSIOLOGY
SERTIFIKAT------ Certificate ------
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HKFM., ." .".'. .. '. \''' .'~,'.. ' .~.~'..
\,._,1 , I .'.' ,...\ .. . diberikon kepodc:
appreciation for
Pertemuan IImiah Tahunan Fetomaternal ke 18THE 18thANNUAL MATERNAL FETAL MEIDICINE
SCIENTIFIC MEETINGMaternal Medicine meets Fetal Medicine:
Optimizing Practice of Maternal Fetal Medicine in IndonesiaThe "lana Hotel & Convention Center Yogyakarta. march n"- is" ~017
Dr. dr. Poedjo Hartono, SpOG(K)Ketua PBPOGI
Prof. Dr. dr. Erry Gumilar Dachlan, SpOG(K)Ketua HKFM