penanganan sepsis maternal

PENANGANAN SEPSIS MATERNAL

Made Kornia Karkata

Divisi Fetomaternal Bagian / SMF Obstetri Ginekologi

FakultasKedokteran Universitas Udayana / RSUP Sanglah, Denpasar.

Abstrak.

            Meskipun di Indonesia sudah terdapat penurunan angka kematian ibu (AKI) karena sebab infeksi akan tetapi WHO masih menyatakan bahwa sepsis merupakan salah satu dari lima penyebab kematian ibu terutama di negara sedang berkembang. Sepsis meternal merupakan salah satu kegawatan obstetri yang sangat fatal. Infeksi yang tidak ditanggulangi akan berkembang menjadi bakteremia, sepsis, systemic inflammatory response syndrome (SIRS), severe sepsis dan syok septik yang berakibat kematian ibu.  Infeksi di bidang obstetri misalnya karena: korioamnionitis, post partum endometritis , aborsi septik, infeksi luka episiotomi dan seksio sesaria  serta akibat prosedur invasif penyebab necrotizing fasciitis,, pengikatan servix (cerclage) serta amniosentesis atau akibat toxic shock syndrome. Infeksi bisa juga berasal dari faktor non-obstetri seperti adanya radang apendiks, kholesistitis, infeksi saluran kemih pielonefritis dan pneumonia. Diagnosis sepsis sudah boleh ditegakkan bila ada faktor predisposisi infeksi dan ditemukan minimal dua kriteria SIRS. Manajemen sepsis menyangkut pendekatan tim multidisiplin yang agresif dalam waktu cepat yang melibatkan keahlian fetomaternal, perawatan intensif, ahli anasthesi dan farmasi. Kecepatan melakukan tindakan secara agresif sangatlah penting, golden period nya adalah dalam waktu 6 jam pasien harus sudah mendapatkan penanganan yang cukup dengan didahului pemberian cairan yang cukup serta antibiotika yang tepat. Selanjutnya dilakukan perawatan di ruang intensif dengan pemberian cairan intra vena, peningkatan pemberian oksigen, pemberian obat  vasopresor, obat obat inotropik, kalau perlu tranfusi darah, pemberian ventilasi mekanik dan pemakaian kateter arteri disertai dengan monitoring yang ketat. Pemeriksaan laboratorium yang lengkap harus dikerjakan, termasuk untuk mencari sumber dan jenis infeksi dengan pemeriksaan darah, urin, dahak, sekresi luka atau cairan amnion serta menguji sensitivitasnya terhadap antibiotika.  Agar dihindarkan keadaan yang ”Early Under Treatment and Late Over Treatment” sebab bila pasien sudah jatuh ke dalam MOD dan MOF maka mortalitasnya sangat tinggi dengan menghabiskan banyak biaya. Kalau perlu dapat dilakukan evakuasi sumber infeksi dengan tindakan pembedahan berupa kuret, drainase abses, eksisi jaringan nekrotis bahkan sampai histerektomi.

Kesimpulan : Sepsis maternal merupakan salah satu kegawatan obstetri yang sangat fatal yang memerlukan penanganan intensif yang cepat dan adekuat. Sumber infeksi bisa berasal dari sebab obstetri dan non obstetri. Sumber infeksi non obstetri harus dicari pada saat ante natal dan segera diberi pengobatan adekuat dengan antibiotika yang aman buat fetus. Infeksi yang terjadi saat hamil atau persalinan maka bayi harus segera dilahirkan sesuai dengan indikasi dan persyaratannya. Pada saat persalinan diawasi dengan partograf WHO untuk mencegah partus kasep dan penolong melakukan universal precaution, dan mengurangi tindakan yang manipulatif yang dapat menyebabkan robekan, perdarahan serta mudah terpapar infeksi. Penanganan multidisiplin dengan diagnosis akurat yang cepat, terapi suportif yang adekuat, serta pemilihan anti biotika yang rasional, evakuasi sumber infeksi serta monitoring yang ketat di ruang intensif akan mempengaruhi hasil keluaran sepsis maternal.

Kata kunci : sepsis maternal ; manajemen

 

MATERNAL SEPSIS MANAGEMENT

Made Kornia Karkata
Division of Fetomaternal / Departement of Obstetrics Gynecology
Medical Faculty of Udayana / Sanglah Hospital, Denpasar.

Abstract.

While in Indonesia have been found decline in maternal mortality rate (MMR) because of infection but the WHO is still stating that sepsis is one of the five causes of maternal mortality especially in developing countries. Sepsis is one of the serious fatal obstetrics emergency.  Infections that are not appropriately addressed will develop into bacteriemia, sepsis, systemic inflammatory response syndrome (SIRS), severe sepsis and septic shock that resulted in maternal deaths. Infection in the field of obstetrics such as: chorioamnionitis, postpartum endometritis, septic abortion, wound infection and episiotomy and cesarean section due to invasive procedures causing necrotizing fasciitis, cervix cerclage and amniocentesis or due to toxic shock syndrome. Infection can also come from non-obstetric factors such as acute appendicitis, cholecystitis,  pyelonephritis, urinary tract infection and pneumonia. The diagnosis of sepsis is based on evidence of predisposing factors of infection and found at least two SIRS criteria. Management of sepsis involving a multidisciplinary team approach which is aggressive and quick time response involving fetomaternal expertise, expert in intensive care, anaesthesiologist and pharmacies. Speed ​​to act aggressively is very important, since golden period was within 6 hours the patient should have gotten adequate fluids and appropriate antibiotics. Furthermore, treatment should be continued in intensive care unit with intravenous fluid administration, increasing oxygen delivery, vasopressor drug and, inotropic drugs delivery, blood transfusion administration, provision of mechanical ventilation and the use of arterial catheters as well as close monitoring. The serial  laboratory examination is mandatory, including to seek the source and type of infection by blood tests, urine, sputum, wound secretions or amniotic fluid and tested its sensitivity to antibiotics.Always trying to avoid circumstances that "early under-treatment and late over-treatment" because if the patient had fallen into the MOD and MOF, the mortality is very high with spending a lot of cost. If  necesarry to do evacuations source of infection by applying curette surgery, drainage of abscesses, excision of necrotic-tissue or even to do hysterectomy..

Conclusion: Maternal sepsis is one of the most fatal obstetric crisis that requires quick and adequate intensive treatment. The source of infection can be derived from obstetric and non obstetric causes. Sources of non-obstetric infections should be sought at the time of ante natal care and immediately given adequate antibiotic treatment which is safe for the fetus. Infections that occur during pregnancy or childbirth, the baby should be born in accordance with the indications and requirements. At the time of delivery the helper always practice universal precaution and apply partograph assesment, and reduce the manipulative actions that can cause tearing, bleeding and condition easily exposed to infection. Handling multidisciplinary with a rapid accurate diagnosis, aggressive supportive therapy is adequate, and the selection of a rational antibiotics, evacuation source of infection and close monitoring in intensive care will affect the outcome of maternal sepsis.

Keywords: maternal sepsis; management