Sepsis Puerpuralis

A.Guntur H.

Subbagian Alergi-Imunologi Tropik Infeksi Bagian Ilmu Penyakit Dalam

Fak. Kedokteran UNS. / RSUD.Dr. Moewardi Surakarta
 Introduction
 Generally, a measure used to assess the merits of the
state of obstetric care (maternity care) within a country
or region is maternal death (maternal mortality).

 According to the WHO definition of "maternal

mortality is the death of a woman during pregnancy or
within 42 days after the end of pregnancy in any way,
regardless of the parents of pregnancy and the actions
taken to terminate the pregnancy".
 High mortality rates are generally half a century ago has
three main reasons:
 (1) is still a lack of knowledge about the causes and prevention
of important complications in pregnancy, childbirth, and
childbirth;
 (2) lack of understanding and knowledge about reproductive
health, and
 (3) less prevalence of good obstetric care for all pregnant. One of
which belongs to the important causes of maternal mortality is
puerperal sepsis
 Although Semmelweiss in 1874 already showed that
puerperal sepsis caused by infection and that doctors
and midwives are often the carriers of the infection in
women who are birthing, but still a long way in the
20th century this has not been generally accepted
among doctors.
 Only after the advancement of microbiological sciences
demonstrated that the main cause of the disease are
different types of bacteria (streptococcus), that the germs
are carried by a doctor, midwife, or other personnel who
attended the delivery

 However, the occurrence of sepsis reduction is achieved

with the discovery of new drugs that have antibiotic
functions "Narrow Spectrum" and "Broad Spectrum."
 Definition
 Puerperium is the period that begins after the placenta
was born after 6 weeks (42 days) to return to normal
reproductive or pre-pregnancy state.
 (Patholgic change in the uterine cavity)

 The uterine cavity is normally free of bacteria during

pregnancy.
 Approximately 48 hours postpartum, progressive
necrosis of the endometrial and placental remnants
produces a favorable intrauterine environment for the
multiplication of aerobic and anaerobic bacteria.
 Pathologic change in the uterine cavity
Endomyoparametritis

 Endomyoparametritis is a potentially life-threatening condition.

 It commonly begins with:
 Retention of secundines (placental and amniochorionic
membrane fragments) that block the normal lochial flow,
 Allowing accumulation of intrauterine lochia,
 Which in turn changes the local BH.
 And acts as a culture medium for bacterial growth.
 The body's normal defense mechanisms that
can prevent the occurrence of a progressive
infection, but decreased defense mechanisms
(imunocompromise) enables microorganisms
(bacteria) to invasion into endometrium or
myometrium.

 A rise of temperature of 100.4 ° ​F (38 ° C) or

higher that lasts longer than 2 consecutive
days (not including the first day postpartum)
during the first 10 days postpartum.
 further invasion into the lymphatics of the
parametrium can cause: lymphangitis, pelvic
cellulitis.
 Infection during childbirth have clinical
manifestations increased body temperature (fever),
and increased pain around the uterus and lower
abdomen.
 When developing these infections erratic body
temperature, increased with fluctuations, it is a
sign of Systemic Inflammatory Response
Syndrome occurs (SIRS) onset of sepsis.
 Puerperal sepsis at the time was still significantly
contribute to postpartum maternal morbidity and
mortality.
 Sepsis
 Clinical syndrome that occurs by excessive body
response due to stimuli Microorganisms products.

 SIRS + Infection.
SIRS/SEPSIS : CLINICAL SYNDROM
 Hyperthermi / Hypothermi
(> 38,3 0C / < 35,6 0C )
 Tachypneu ( resp > 20 / mnt )
 Tachycardi ( pulse > 100 / mnt )
 Leukocytosis > 12000 / mm
 Leukopenia < 4000 / mm
 10% > cell immature
 Suspected infection
 Blood Glucose > 120 mg/dL (without diabetes)
 Mental status disorders

Biomarker dini Pct dan Crp (ccm

2003)
 Grade of Sepsis
1. SIRS, caracterized with two or more following symptom :
a. Hyperthermia/ Hypothermia (> 38,3 0C / < 35,6 0C )

b. Tachypnoe ( resp > 20 / mnt )

c. Tachycardia ( pulse > 100 / mnt )

d. Leucocytosis >12000/mm atau Leucopenia < 4000/mm

e. 10% > immature cell

2. SEPSIS
SIRS that has a proven or suspected infection

3. SEVERE SEPSIS
Sepsis with one or more sign of Multi Organ Disfunction syndrome (MODS)/ Multi organ
Failure (MOF), Hypotension, oligouria or anuria.

4. SEPSIS with Hypotension

Sepsis with hypotension ( systolic blood Pressure (SBP) < 90 mmHg or reduced SBP > 40
mmHg).

5. SEPTIC SHOCK
septic shock as subset of severe sepsis difined as sepsis-induced hypotension persistently
despite adequate fluid resuscitation along with the presence of tissue hypoperfusion.
 Diagnosis
 Good ananemsa to eliminate other causes of fever are caused by the
purpurium.
 Physical examination.
 Laboratory investigations:
 Aerobic and anaerobic cultures should be obtained from the blood,
endocervix, and uterine cavity,
 Urine specimens for culture
 Complete blood
 CTS or abdominal pelvic ultrasound scan.
 Management Sepsis
 di HCU (High Care Unit) Penyakit Dalam RSUD
Dr.Moewardi Surakarta

A. NONMEDIKAMENTOSA
B. MEDIKAMENTOSA
 NONMEDIKAMENTOSA

 Total bed rest, the position depending on the condition

of the patient's illness
 Oxygenation 3-4 lt
 DC Plug
 If the patient is unconscious or inadequate intake and
gastro intestinal massive bleeding, plug NGT for
bleeding and evacuation sonde diet.
 MEDIKAMENTOSA

I. Fluid resuscitation
 Changes in sepsis hemodynamic
 capillary permeability 
 Liquid come out  interstitial space
 Reduced intravascular fluid
 Dilation of blood vessels  resistance ↓
 decreased blood pressure  shock
 Restoration of intravascular volume
 Colloid + crystalloid
Goal of fluid resuscitation:
        - Improvement of blood volume
        - Optimizing Cardiac Output
        - Reduce the risk of pulmonary edema
        - Correction of acidosis
 Antibiotik
- Cephalosphorin
- Cephalosphorin +  Lactam inhibit
Emperik
- Sesuai pola kuman dirumah sakit
setempat

Gram (+) Gram (-)

Cephalosphorin
72 jam C.  Lactam inhibit
Aminoglycosida

METRONIDAZOL
72 jam
- Vancomycin Carbapenim
Sensitivitas - Teicoplanim
Imepenim
Test

Fungus : Fluconazol
Parasite
Virus
Guntur, 2002
 ANTIBIOTIC
ANTIBIOTIC

 Blood culture obtained prior to antibiotic administration

 From the time of presentation, broad spectrum antibiotics administered
within 3 hours for ED admissions and 1 hours for non-ED ICU
admissions. Intensive Care Med (2010) 36:222–231
DOI 10.1007/s00134-009-1738-3

Culture Available
Culture Not Available

Deescalation
Empirical Treatment
broad spectrum antibiotics

Combination Definite / Rational

Therapy
III. Nutrisi Enteral – IMUNONUTRISI

• Imunonutrisi - omega 3 Folat

- L. arginin B12
- Nukleutida Vit E
• respons imun MALT
GALT
• perfusi splanikus
INSTALASI GIZI RSUD Dr. MOEWARDI SURAKARTA
Tabel ZONDE LENGKAP

Items analyzed : Code

   
150 gram wortel 298
150 gram tempe kedelai murni 111
40 gram hati sapi 139
40 gram tepung beras 49
90 gram tepung susu skim 365
120 gram gula pasir 393
75 gram telur ayam 147
20 gram margarine 369

Guntur, 2001
Weight : 685 Gram (24.2 oz) Water weight : 329 G
Calories 1515 Vitamin B6 Mg
Protein 81.7 G Vitamin B12 Mcg
Carbohydrates 228 G Folacin Mcg
Dietary Fiber G Pantothenic Mg
Fat-Total 343 G Vitamin C 27.7 Mg
Fat-Saturated G Vitamin E Mg
Fat-Mono G Calcium 1477 Mg
Fat-Poly G Copper Mg
Cholesterol Mg Iron 21.8 Mg
Vit A-Carotene RE Magnesium Mg
Vit A-Preformed RE Phosphorus 1552 Mg
Vit A-Total 36710 RE Potassium Mg
Thiamin-B1 887 Mg Selenium Mcg
Ribloflavin-B2 Mg Sodium Mg
Niacin-B3 Mg Zine Mg
Calories from protein : 21% Poly/Sat = 0.0 : 1
Calories from carbohydrates : 59% Sod/Pot = 0.0 : 1
Guntur, 2001
Calories from fats : 20% Ca/Phos = 0.0 : 1
IV. SUPLEMENTATIF THERAPY

- Strategy and Anti Exotoxin endotoxin

      - Monoclonal antibody
      - Corticosteroids
      - Strategy Anti Mediator
      - Neutralization of NO
      - CVVH
      - Herbal Treatment
      - Intra Venus Immuno Globulin (IVIG)
 Imunopatogenesis
C3a, C5a LPS
Kortikosteroid APC
IMUNOCOM
LPS bp SUPER ANTIGEN

C7a MHC II
CD 14
TLR 4 CD 4+ TCR
IL - 10
IFN - IL - 4
TLR2 TH - 1 TH - 2 IL - 5 B cell
IL - 6
CSF Ig
IL 8
SEPSIS
IL 6 IL-2
IL -1 N
Compl.
TNF - CD 8+
MOD
NK
PAI-1 PGE 2 NO ICAM -1

SHOCK
SEPTIC
(Guntur, 2006)
Management Sepsis
Underlying Treatment

Better (+)

•Resuscitation
Underlying •AB + Underlying Diseases
Diseases + Sepsis •Immunonutrition
•Suplementatif

Worst (-)
MODS-MOF
Septic-Shock
72% - 80% die > 72 hr

Guntur, 2000 30% - 80% ARDS

 Conclusions
 At purpuralis, frequent infections causing sepsis.
 Need to be careful, because it has a high mortality rate.
 Precision / accuracy for detecting "purpuralis infection"
to sepsis.
 Immediately take action in accordance with a protocol
that has been done as these above.