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COPING WITH OBSTETRICS SEPSIS - erepo.unud.ac. · PDF file Sepsis adalah ancaman hidup karena disfungsi organ, yang disebabkan disregulasi host terhadap infeksi John R. Barton, MD,

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  • COPING WITH OBSTETRICS SEPSIS

    TJOKORDA GDE AGUNG SUWARDEWA

    PIT FETOMATERNAL YOGYAKARTA

    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 sih dengar, …

    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

    SIRS Temp > 104.4 F

    < 96.8 F RR > 20 HR > 90 WBC > 12.000

    < 4000 > 10% bands

    PCO2 < 2 mmHg

    Mortality rate 20-40% Mortality rate 60%

    SEPSIS

    2 SIRS

    +

    Infeksi jelas /curiga

    SEPSIS BERAT

    SEPSIS

    +

    Tanda-tanda kegagalan organ

    Hipotensi (SBP 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 sepsis Fetal 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 to labor 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 to labor 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 to labor 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

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