During the first 6 months of lactation, which amongst the following contraceptives is not advisable?
Oral contraceptives may provide protection against the following malignancies except :
The following drugs are effective in the management of menorrhagia except :
What is the commonest cause of Vulvo-Vaginal Fistula in developing countries ?
A 28-year old woman comes with infertility. Husband's semen analysis is normal. Endometrial biopsy shows secretory changes with no evidence of tuberculosis. On hysterosalpingography both tubes show tubal blockage. What should be the next step in management?
Which of the following statements is true for maternal rubella infection?
Contraindications for medical abortions are all except :
A woman dies from a heart disease six days after delivery. This would come under the category of :
In a woman using an intrauterine contraceptive device (IUCD) an unexpected pregnancy occurs and the IUCD threads are visible. What is the reason to recommend removal of the device ?
Success of tubal re-canalization is best with :
UPSC-CMS 2013 - Obstetrics and Gynecology UPSC-CMS Practice Questions and MCQs
Question 21: During the first 6 months of lactation, which amongst the following contraceptives is not advisable?
- A. Norplant
- B. DMPA
- C. Progestin only pills
- D. Combined oral contraceptive pills (Correct Answer)
Explanation: ***Combined oral contraceptive pills*** - **Combined oral contraceptive pills (COCs)** contain both **estrogen** and **progestin**, and the synthetic estrogen component can potentially reduce breast milk supply, which is critical during the initial 6 months of breastfeeding. - Estrogen may also alter the composition of breast milk, and there's a theoretical concern about **estrogen excretion into breast milk** affecting the newborn during this vulnerable period. *Norplant* - **Norplant** (levonorgestrel implants) contains only **progestin**, which is generally considered safe for use during breastfeeding from 6 weeks postpartum. - Progestin-only contraceptives do not significantly affect milk supply or infant health. *DMPA* - **DMPA (depot medroxyprogesterone acetate)** is an injectable contraceptive containing only **progestin**. It is considered safe and effective during breastfeeding, typically from 6 weeks postpartum. - It does not negatively impact milk production or infant growth and development. *Progestin only pills* - **Progestin-only pills (POPs)** are safe for use during breastfeeding, usually initiated immediately postpartum or from 6 weeks. - They do not contain estrogen, thereby avoiding the concerns associated with combined oral contraceptives regarding milk supply and infant exposure.
Question 22: Oral contraceptives may provide protection against the following malignancies except :
- A. Cervical cancer (Correct Answer)
- B. Endometrial cancer
- C. Ovarian cancer
- D. None of the options
Explanation: ***Cervical cancer*** - Oral contraceptives (OCPs) are associated with an **increased risk of cervical cancer**, particularly with prolonged use, due to their potential influence on the immune response to **HPV infection**. - OCPs do not provide protection against cervical cancer; instead, they are considered a **risk factor** in its development. *Endometrial cancer* - OCPs, especially with their progestin component, offer significant **protection against endometrial cancer** by counteracting unopposed estrogen effects on the endometrium. - This protective effect is evident after just a few years of use and can persist for decades after discontinuation. *Ovarian cancer* - Oral contraceptive use is well-established to **reduce the risk of ovarian cancer**, with the protective effect increasing with longer duration of use. - This protection is thought to be mediated by the **suppression of ovulation**, thereby reducing the continuous trauma to the ovarian surface epithelium. *None of the options* - This option is incorrect because OCPs do provide protection against several malignancies, specifically endometrial and ovarian cancers, but actually increase the risk of cervical cancer.
Question 23: The following drugs are effective in the management of menorrhagia except :
- A. Progestational agents
- B. Prostaglandins (Correct Answer)
- C. Non-steroidal anti-inflammatory drugs
- D. Anti-fibrinolytic drugs
Explanation: ***Prostaglandins*** - Prostaglandins, particularly **PGE2** and **PGF2α**, are generally associated with **increased uterine contractions** and **vasodilation**, which can worsen menstrual bleeding rather than reduce it. - While cyclooxygenase inhibitors (NSAIDs) work by inhibiting prostaglandin synthesis, exogenous prostaglandins themselves are not used to treat menorrhagia and can exacerbate it. *Progestational agents* - Progestins help to **stabilize the endometrium**, reducing excessive bleeding by inducing decidualization and limiting endometrial growth. - They can be administered orally, via injection, or through an **intrauterine device (IUD)** like the levonorgestrel-releasing IUD (Mirena), which is highly effective. *Non-steroidal anti-inflammatory drugs* - NSAIDs reduce menorrhagia by **inhibiting prostaglandin synthesis** in the endometrium, which leads to reduced vasodilation and uterine contractions. - They also help alleviate associated **dysmenorrhea** (menstrual pain). *Anti-fibrinolytic drugs* - These drugs, such as **tranexamic acid**, work by **inhibiting plasminogen activation**, thereby preventing the breakdown of fibrin clots within the uterus. - This promotes clot stability and reduces menstrual blood loss significantly.
Question 24: What is the commonest cause of Vulvo-Vaginal Fistula in developing countries ?
- A. Carcinoma of bladder
- B. Injury during hysterectomy
- C. Radiotherapy for treatment of carcinoma cervix
- D. Obstructed labour (Correct Answer)
Explanation: ***Obstructed labour*** - **Prolonged obstructed labor** causes **ischemic necrosis** of the tissues between the vagina and the bladder or rectum due to continuous pressure from the fetal head, leading to a fistula. - This is the **most common cause** of vulvo-vaginal fistulas in developing countries, often due to limited access to emergency obstetric care like C-sections. *Carcinoma of bladder* - While bladder carcinoma can cause fistulas, they are more typically **vesicovaginal fistulas** and are less common than those resulting from obstructed labor in developing countries. - Fistulas due to malignancy often involve **tissue destruction** and may be associated with prior radiation therapy. *Injury during hysterectomy* - Iatrogenic injury during a **hysterectomy** can lead to a fistula, but this is more common in developed healthcare settings with higher rates of surgical interventions. - This cause is less prevalent globally compared to the widespread issue of obstructed labor in resource-limited regions. *Radiotherapy for treatment of carcinoma cervix* - **Radiotherapy** for cervical carcinoma can cause **radiation-induced necrosis** and lead to fistulas, particularly **rectovaginal** or **vesicovaginal** types. - While a significant cause in cancer patients, it is not the commonest overall cause in developing countries compared to the sheer volume of cases resulting from obstructed labor.
Question 25: A 28-year old woman comes with infertility. Husband's semen analysis is normal. Endometrial biopsy shows secretory changes with no evidence of tuberculosis. On hysterosalpingography both tubes show tubal blockage. What should be the next step in management?
- A. IVF
- B. Diagnostic laparoscopy and chromo-pertubation (Correct Answer)
- C. Tuboplasty
- D. ICSI
Explanation: ***Diagnostic laparoscopy and chromo-pertubation*** - This procedure directly visualizes the fallopian tubes and surrounding pelvic structures, allowing for definitive confirmation of tubal blockage and identification of potential causes like **endometriosis** or **adhesions**. - **Chromo-pertubation** involves injecting a dye through the cervix to assess tubal patency and identify the exact location and nature of the blockage. *IVF* - While IVF is a viable option for tubal factor infertility, it is generally considered after a more thorough diagnostic workup, especially when the cause of blockage is unknown and potentially treatable. - Proceeding directly to IVF without assessing the possibility of surgical correction might be premature and miss an opportunity for natural conception or a less invasive intervention. *Tuboplasty* - **Tuboplasty** is a surgical procedure to repair or reconstruct damaged fallopian tubes. - However, its success depends on the extent of damage and the specific type of blockage, which can only be determined after a diagnostic evaluation like laparoscopy. *ICSI* - **ICSI (Intracytoplasmic Sperm Injection)** is a specialized form of IVF primarily used for severe male factor infertility, not tubal blockage, especially when the husband's semen analysis is normal. - While ICSI can be part of an IVF cycle, it's not the primary next step for diagnosing or treating tubal blockage in a woman with normal male factor.
Question 26: Which of the following statements is true for maternal rubella infection?
- A. The primary infection is responsible for birth defects (Correct Answer)
- B. 24% incidence of congenital infection if acquired during the last month of pregnancy
- C. It leads to abortions before 16 weeks of gestation
- D. It causes blindness with recurrent infection
Explanation: ***The primary infection is responsible for birth defects*** - **Primary maternal rubella infection** during pregnancy is the primary cause of congenital rubella syndrome, as the virus can cross the placenta and infect the developing fetus. - The risk and severity of **birth defects** are highest when the mother is infected during the first trimester. *24% incidence of congenital infection if acquired during the last month of pregnancy* - While rubella infection late in pregnancy can still lead to fetal infection, the incidence of **congenital rubella syndrome** is significantly lower in the last trimester (typically less than 1%) compared to the first trimester. - The reported incidence of 24% is excessively high for an infection acquired in the **last month of pregnancy**. *It leads to abortions before 16 weeks of gestation* - While **rubella infection** can increase the risk of spontaneous abortion, especially if acquired early in pregnancy, it is not the *only* or *guaranteed* outcome. Many infected pregnancies continue to term with varying degrees of fetal compromise. - The statement suggests a direct and absolute causal link to abortion before 16 weeks, which is too definitive. *It causes blindness with recurrent infection* - **Congenital rubella syndrome** can cause ocular defects such as **cataracts**, **glaucoma**, and **retinopathy**, which can lead to blindness. - However, rubella infection typically confers **lifelong immunity**, making **recurrent infection** extremely rare and thus not a common mechanism for causing blindness.
Question 27: Contraindications for medical abortions are all except :
- A. Uncontrolled seizure disorder
- B. Hemoglobin less than 8 gm%
- C. Age more than 35 years (Correct Answer)
- D. Undiagnosed adnexal mass
Explanation: ***Age more than 35 years*** - Age alone, including being over 35 years old, is **not a contraindication** for a medical abortion. - The decision for medical abortion is based on health status, gestational age, and patient choice, not primarily on age. *Uncontrolled seizure disorder* - An **uncontrolled seizure disorder** can be a relative contraindication due to the stress and potential risks associated with the abortion process, which could trigger seizures. - Prostaglandins used in medical abortion can sometimes **increase uterine contractions and pain**, which may exacerbate a seizure disorder. *Hemoglobin less than 8 gm%* - A **hemoglobin level less than 8 gm%** indicates significant anemia, which increases the risk of complications from blood loss during a medical abortion. - Patients with severe anemia may require **blood transfusion** if significant bleeding occurs, making medical abortion less safe. *Undiagnosed adnexal mass* - An **undiagnosed adnexal mass** can be a contraindication because it might mask an **ectopic pregnancy**, for which medical abortion drugs are not effective and could be dangerous. - It also raises concerns about potential **complications or rupture** of the mass during the abortion process.
Question 28: A woman dies from a heart disease six days after delivery. This would come under the category of :
- A. Direct maternal death
- B. Unclassified death
- C. Indirect maternal death (Correct Answer)
- D. Medical (non-maternal) death
Explanation: ***Indirect maternal death*** - An **indirect maternal death** is defined as one resulting from a pre-existing disease or a disease that developed during pregnancy, which was not due to direct obstetric causes but was aggravated by the physiological effects of pregnancy. - Heart disease in this context, especially when occurring six days postpartum, is often a pre-existing condition exacerbated by pregnancy-related cardiovascular demands, fitting this definition. *Direct maternal death* - **Direct maternal deaths** are those resulting from obstetric complications of the pregnant state, from interventions, omissions, incorrect treatment, or from a chain of events resulting from any of these. - Examples include severe hemorrhage, pre-eclampsia/eclampsia, or obstructed labor, which are not described in this scenario. *Unclassified death* - An **unclassified death** is assigned when there is insufficient information to determine the cause of death as direct, indirect, or coincidental. - In this case, the cause of death (heart disease) is known, making classification possible. *Medical (non-maternal) death* - This category usually refers to deaths from medical conditions **unrelated to or unaggravated by pregnancy**. - While heart disease is a medical condition, its occurrence six days postpartum strongly suggests that the physiological changes of pregnancy played a significant role in its exacerbation or presentation, thereby classifying it as a maternal death rather than a coincidental non-maternal death.
Question 29: In a woman using an intrauterine contraceptive device (IUCD) an unexpected pregnancy occurs and the IUCD threads are visible. What is the reason to recommend removal of the device ?
- A. To prevent the risk of subsequent septic abortion and preterm labour (Correct Answer)
- B. To prevent post partum haemorrhage
- C. To prevent congenital abnormality of the newborn
- D. To prevent perforation
Explanation: ***To prevent the risk of subsequent septic abortion and preterm labour*** - Retaining an IUCD during pregnancy significantly increases the risk of **septic abortion** and **preterm labor** due to the presence of a foreign body in the uterus. - Removing the IUCD when threads are visible can reduce these risks (reducing spontaneous abortion risk from ~50% to ~30%), although there's a small risk of miscarriage associated with the removal procedure itself. *To prevent post partum haemorrhage* - This is not a primary reason for IUCD removal during an ongoing pregnancy. **Postpartum hemorrhage** is typically related to uterine atony, placental abnormalities, or trauma during delivery. - While an IUCD might rarely interfere with uterine contraction, its removal during pregnancy is not specifically aimed at preventing postpartum hemorrhage. *To prevent congenital abnormality of the newborn* - An IUCD does not cause **congenital abnormalities** or **birth defects** in the fetus; its mechanism of action is primarily **preventing fertilization** through local spermicidal effects and interference with sperm-egg interaction. - Exposure to an IUCD does not have a teratogenic effect on fetal development. *To prevent perforation* - **Uterine perforation** is a rare complication that usually occurs during IUCD insertion, not during an ongoing pregnancy with an already in-situ device. - While an IUCD could potentially migrate or embed deeper, preventing perforation is not the primary or most urgent reason for its removal in the context of an unexpected pregnancy.
Question 30: Success of tubal re-canalization is best with :
- A. Laparoscopic ring application (Correct Answer)
- B. Uchida's technique
- C. Fimbriectomy
- D. Pomeroy's technique
Explanation: ***Laparoscopic ring application (Falope ring/Tubal clips)*** - Mechanical occlusion methods (clips and rings) cause **minimal tissue destruction**, typically affecting only **2-3 cm** of the fallopian tube. - The tubal segments remain relatively **healthy and undamaged**, with minimal scarring and fibrosis. - Reversal success rates are **highest at 70-90%** due to the preservation of tubal architecture and length. - These methods are considered the **most reversible** form of tubal sterilization. *Pomeroy's technique* - Involves excision of a tubal loop (approximately 3-4 cm) with ligation, causing moderate tissue damage. - The cut ends heal by scarring, and some tubal length is permanently lost. - Reversal success rates are moderate at **60-70%**. - More tissue damage than clip/ring methods but still reasonably reversible. *Uchida's technique* - Involves separating the serosa from the muscularis, ligating and excising a **larger segment** of the tube (4-5 cm). - Creates more extensive tissue damage with greater tubal length loss. - Reversal success rates are lower at **40-50%** due to the complexity and extent of tissue disruption. *Fimbriectomy* - Involves complete removal of the **fimbrial end** of the fallopian tube, which is essential for ovum pickup. - Even if re-anastomosis is technically successful, the **absence of fimbriae** results in extremely poor functional outcomes. - Reversal success rates are very poor at **<20%**, making this the least reversible sterilization method.