Pelayanan

Ginekologi dalam Pandemi Covid 19:

Bagaimana peran FKTP

Budi Wiweko
wiwekobudi@yahoo.co.id
budi.wiweko@gmail.com

Academic Health System Universitas Indonesia - Indonesian Medical Education and Research Institute
Faculty of Medicine Universitas Indonesia
Dr. Cipto Mangunkusumo General Hospital
Jakarta

Inspiring and empowering society

The branch of medical science that deals with
the health maintenance and diseases of
women, especially of the reproductive
organs.

Inspiring and empowering society

• In vitro

•
fertilization
Pre implantation REPRODUCTIVE HEALTH
diagnosis
• Fetal “ from WOMB to TOMB ”
programming • Ectopic
• Implantation • Pregnancy
pregnancy • Osteoporosis
• Metabolic • Severe pre-
• Prenatal • Climacteric
syndrome (PCOS) eclampsia
diagnosis • Disorders of • Metabolic
• Endometriosis • High risk • Preterm birth
sex • Post partum syndrome
• Recurrent pregnancy development • Malignancy
miscarriages hemorrhage
(pre- • Menstrual • Urogenital
• Infection • Contraception
eclampsia, disturbances tract
• Malignancy
preterm, • Puberty • Abnormal
IUGR, etc) • Abnormal
• Contraception uterine uterine
• Fetal • Malignancy bleeding
bleeding
programming

Infertility Fetus Adolescent Adult Menopause

Wiweko et al. Ina-Repromed, 2012

Inspiring and empowering society

Polycystic ovary syndrome (PCOS)

Inspiring and empowering society

Endometriosis
The presence of endometrial like tissue outside uterine cavity
 KELUHAN ENDOMETRIOSIS

INFERTILITAS NYERI

NYERI PADA ENDOMETRIOSIS

Nyeri pelvik merupakan keluhan

tersering
• Dismenorea
• Dispareunia
• Diskezia
• Disuria

Inspiring and empowering society

 Perdarahan uterus abnormal (PUA)
Gangguan haid berupa kelainan dalam hal frekuensi, keteraturan, lama dan jumlah darah
yang disebabkan oleh faktor fisiologis, patologis, atau iatrogenik

Fraser I. Hum Reprod Update, vol 8, 2002

Mohan S et al. Best Pract Res Clin Obstet Gynecol, vol. 21, No. 6, pp. 891–903, 2007

Polip Kista
endometrium Mioma uteri
endometriosis

Inspiring and empowering society

KLASIFIKASI PERDARAHAN UTERUS ABNORMAL

STRUKTURAL NON STRUKTURAL

Munro et al. Int J Obstet Gynecol, 2011

Inspiring and empowering society

Ectopic Pregnancy
The implantation of the blastocyst (fertilized ovum) outside the endometrial lining of
the uterine cavity

blastocyst implanted in the fallopian tube

Inspiring and empowering society

Pre Cervical Cancer Lesion

Pap Smear Test

Inspiring and empowering society

Shut down or delays of contraception during COVID-19
will disproportionately impact the most vulnerable
populations, including women and girls in low-income
and middle-income countries, and lead to considerable
and preventable death and lifelong disability.

Inspiring and empowering society

COVID-19 may fundamentally change women’s contraceptive use, thus altering the range of
supplies that will be required in the near term.

Global Health: Science and Practice 2020 | Volume 8 | Number 2

Inspiring and empowering society

Summary of Assumptions Used for COVID-19 Disruption Scenarios

Global Health: Science and Practice 2020 | Volume 8 | Number 2

Inspiring and empowering society

Potential Short-Term Changes in Contraceptive Method Mix During
COVID-19 Disruptions in Kenya and Nigeria

Global Health: Science and Practice 2020 | Volume 8 | Number 2

Inspiring and empowering society

Cumulative Number of Pills Dispensed Over 6 months in Kenya and Nigeria Under
Different COVID-19 Disruption Scenarios, April to September 2020

Global Health: Science and Practice 2020 | Volume 8 | Number 2

Inspiring and empowering society

Progestin only pill (POP)

It can be continued in Covid-19 positive women both asymptomatic and symptomatic.

In the case women are hospitalised and contraceptives are suspended, women should be
informed that menses may occur.

Re-initiation of a POP can be performed immediately after recovery. Efficacy is not

guaranteed for the first 7 days and in this period a condom should be used.

Inspiring and empowering society

LARCs (IUD, IUS, Implant)

They can be continued in Covid-19 positive women both asymptomatic and symptomatic.
There is no need to remove a LARC. In case the system is exhausted and needs to be replaced,
removal and replacement should be post-poned considering that these systems are licenced for
a period inferior to their effective duration.

Usually any method is active for an additional year. Because the efficacy of progestin medicated
LARCs progressively declines women that need to replace these systems should be advised to
add a POP or to add the use of condoms.

Inspiring and empowering society

Estro-Progestin combined contraceptives (Oral, Patch, Ring)

• They can be continued in asymptomatic Covid-19 positive women.

• They can be continued in Covid-19 positive women with cough and fever.
• When severe pneumonia, in bed immobilisation, and increased thromboembolic risk
require stopping treatment, women should be advised that menses are likely to occur.
• Re-initiation of an E-P contraceptive can be performed immediately after recovery. Efficacy
is not guaranteed for the first 7 days and in this period a condom should be used.

Inspiring and empowering society

Women who want to start contraception
• In case it is not possible to collect an appropriate medical history consider to
prescribe a POP until the woman consults a physician.
• Contraindications to POP are very few, and it can be prescribed without medical
evaluation, following a negative pregnancy test.
• Initiation can also be immediate, but efficacy is not guaranteed for the first 7 days.

Women who breast-feed

• A POP can be offered to breastfeeding women, following a negative pregnancy
test.
• Initiation can be immediate, but efficacy is not guaranteed for the first 7 days

Inspiring and empowering society

Estrogens stimulate the humoral response to viral infections, while testosterone and pro-
gesterone give an immune suppression of both innate and cell-mediated immune
responses.

We hypothesise that estrogens, in particular estradiol but also synthetic estrogen such as
ethinylestradiol, could protect women from the most serious complications of COVID-19.

Inspiring and empowering society

The use of medications that keep hormonal levels high and stable, such as combined hormonal
contraceptive, could therefore play a protective role.

These potential benefits overtake the thrombotic risk in healthy women.

As stated by the World Health Organization, all modern methods of contraception were safe to
use during the COVID-19 pandemic.

Inspiring and empowering society

1. Hormone therapy or hormonal contraceptives should be continued, unless the woman is
severely ill, a condition in which hormonal balance is probably not so crucial. In the other
conditions, the possibility that hormone withdrawal may accelerate COVID-19
progression cannot be excluded, and withdrawal should be avoided.
2. Shifting from oral to transdermal oestrogens (patch, gel, spray) may be considered, but is
not mandatory.

Inspiring and empowering society

3. In case of disease progression from a simple flu to more severe symptoms, it seems wise to
rely on expertise of specialists who will consider the need of adding heparin, useful as
anticoagulant, anti-inflammatory and immune modulator.
4. In order to start or restart therapy, it is probably useful to use transdermal instead of oral
oestrogens.
5. In the case that hormone therapy is discontinued, it should be remembered that withdrawal
bleedings may occur.

Inspiring and empowering society

The purpose of this guidance document is to clarify that the Department considers sexual and reproductive
health services as essential services, however the ultimate decision on when such services must occur is
between a patient and clinical provider. These services include but are not limited to:

1. Birth control, including Long Active Reversible Contraceptives, such as IUDs;

2. Fertility services, including infertility treatment and procedures;
3. Gynecological surgeries to address acute complications related to conditions, such as fibroids or
endometriosis;
4. Abortion services;
5. Obstetrical care, such as vaginal and cesarean deliveries;
6. Evaluation, diagnosis, and treatment of sexually transmitted diseases;
7. Evaluation for gynecologic and breast cancer, when medically indicated based on patient history and / or
physical exam.

Inspiring and empowering society

 Family Planning Healthy menopause

Adolescent Adult Peri conception Pregnant women

Menstrual cycle Marriages Pre marital screening Early neonate

Puberty and sex Immunization Biological age

differentiation
Pre natal screening
Smoking
Reproductive hormone Children

Environmental
Reproduction

Nutrition

Contraception

HUMAN CAPITAL DEVELOPMENT

 TAKE HOME MESSAGES

1. Konseling dan edukasi mengenai pelayanan kesehatan reproduksi merupakan tugas utama
FKTP.
2. Pelayanan ginekologi fokus pada pemeliharaan organ reproduksi perempuan.
• Gangguan ovulasi: deteksi dini
• Endometriosis: deteksi dini dan pengobatan nyeri
• Perdarahan uterus abnormal: deteksi dini dan pengobatan kedaruratan
• Kanker serviks: deteksi dini
3. Pelayanan kontrasepsi aman untuk tetap dilakukan sesuai kriteria kelayakan medik.
4. Konsep perencanaan keluarga adalah merencanakan, menyiapkan dan menjaga kehamilan
dengan baik.

Inspiring and empowering society

Inspiring and empowering society