Intrauterine Devices — MCQs
The best method of evacuation of a missed abortion in uterus of more than 12 weeks:
A teenage girl presented with irregular cycles and increased facial hair. Her ovaries showed increased volume. Which of the following are used in the first line treatment? 1. Laparoscopic ovarian drilling 2. Anti-androgens 3. Lifestyle modifications 4. Combined oral contraceptive pills
Which of the following is the most common cause of perforation of uterus in non-pregnant state?
A pregnant lady delivers a healthy baby via normal delivery. What is the earliest time at which an intrauterine contraceptive device (IUCD) can be inserted?
A pregnant woman presents with an IUD in place, and the thread is clearly visible. She wishes to continue the pregnancy. What is the most appropriate next step?
Which IUD is preferred for menorrhagia?
The most common complication of intrauterine contraceptive devices is:
What is the pathophysiological mechanism behind the increased risk of pelvic inflammatory disease with intrauterine device (IUD) insertion?
Copper T is ideally inserted at-
Which of the following are examples of LARC (Long Acting Reversible Contraceptives) ? 1. Copper-T 380A 2. Implants 3. LNG-IUS Select the correct answer using the code given below :
Intrauterine Devices Indian Medical PG Practice Questions and MCQs
Question 1: The best method of evacuation of a missed abortion in uterus of more than 12 weeks:
- A. Intramuscular prostaglandin (15 methyl PGF2a)
- B. Oxytocin infusion
- C. Suction evacuation
- D. Prostaglandin E1 vaginal misoprostol followed by evacuation of the uterus (Correct Answer)
Explanation: ***Prostaglandin E1 vaginal misoprostol followed by evacuation of the uterus*** - For **missed abortions** beyond 12 weeks of gestation, **misoprostol** (a prostaglandin E1 analogue) is highly effective in inducing cervical ripening and uterine contractions. - This step facilitates the subsequent **evacuation of retained products of conception** (ERPC) via suction or manual vacuum aspiration, a safer approach than direct instrumental evacuation in a less softened cervix. *Intramuscular prostaglandin (15 methyl PGF2a)* - While intramuscular prostaglandins can induce uterine contractions, **15-methyl PGF2a** is associated with significant gastrointestinal side effects like nausea, vomiting, and diarrhea. - Its use often results in a less controlled induction compared to vaginal misoprostol, which offers better patient tolerance and titration. *Oxytocin infusion* - **Oxytocin** is primarily used to induce labor in viable pregnancies or to manage postpartum hemorrhage; its effectiveness in inducing uterine contractions for missed abortion before term is limited. - The uterus typically lacks sufficient oxytocin receptors to respond effectively to an infusion for expulsion of a missed abortion before the third trimester. *Suction evacuation* - **Direct suction evacuation** beyond 12 weeks of gestation without prior cervical preparation carries a higher risk of cervical injury and uterine perforation. - The larger fetal size and less pliable cervix at this stage necessitate a controlled induction to reduce complications associated with instrumental removal.
Question 2: A teenage girl presented with irregular cycles and increased facial hair. Her ovaries showed increased volume. Which of the following are used in the first line treatment? 1. Laparoscopic ovarian drilling 2. Anti-androgens 3. Lifestyle modifications 4. Combined oral contraceptive pills
- A. 2,3,4 (Correct Answer)
- B. 1,2,3
- C. 1,2,4
- D. 1,3,4
Explanation: ***2,3,4 (Correct Answer)*** - **Lifestyle modifications (3)** are the foundational first-line intervention for all PCOS patients, particularly those who are overweight or obese, as they improve insulin sensitivity, reduce androgen levels, and improve both metabolic and reproductive outcomes. - **Combined oral contraceptive pills/COCs (4)** are the first-line pharmacological treatment for menstrual irregularity and hyperandrogenism in PCOS when fertility is not desired. They regulate cycles, suppress ovarian androgen production, and reduce hirsutism and acne. - **Anti-androgens (2)** such as spironolactone are used in first-line management of moderate-to-severe hirsutism and acne in PCOS, typically in combination with COCs. They block androgen receptors or inhibit androgen synthesis, providing additional benefit for hyperandrogenic symptoms like the increased facial hair in this patient. *1,2,3* - **Laparoscopic ovarian drilling (1)** is a second-line surgical treatment reserved for anovulatory infertility in PCOS patients who fail to respond to ovulation induction with clomiphene citrate. It is NOT a first-line treatment for menstrual irregularity and hirsutism. - While lifestyle modifications (3) and anti-androgens (2) are appropriate first-line components, the inclusion of ovarian drilling makes this combination incorrect as a first-line approach. *1,2,4* - **Laparoscopic ovarian drilling (1)** is an invasive procedure indicated only as second-line therapy for specific cases of anovulatory infertility, not for initial management of irregular cycles and hirsutism. - Although anti-androgens (2) and COCs (4) are appropriate first-line pharmacological treatments, the inclusion of ovarian drilling excludes this from being a correct first-line treatment combination. *1,3,4* - This combination includes two appropriate first-line treatments: **lifestyle modifications (3)** and **combined oral contraceptive pills (4)**. - However, **laparoscopic ovarian drilling (1)** is a second-line or third-line surgical intervention for very specific indications (anovulatory infertility resistant to medical management), making this combination incorrect as a first-line approach for this clinical presentation.
Question 3: Which of the following is the most common cause of perforation of uterus in non-pregnant state?
- A. Dilatation and curettage (Correct Answer)
- B. Laparoscopy
- C. IUCD
- D. Carcinoma Endometrium
Explanation: ***Dilatation and curettage*** - **Dilatation and curettage (D&C)** is the most frequent iatrogenic cause of uterine perforation in the non-pregnant state due to the blind nature of the procedure, especially in cases of uterine anatomical variations or reduced uterine wall integrity. - The risk of perforation is higher in postmenopausal women due to **atrophic, thinned uterine walls**, and in procedures performed for conditions like endometrial hyperplasia or polyps. *Laparoscopy* - While laparoscopic procedures involve inserting instruments into the abdomen, **uterine perforation during laparoscopy itself is rare**, as it usually involves instrumentation *outside* the uterus unless direct uterine manipulation or hysteroscopy is part of the procedure. - Laparoscopy more commonly results in complications like bowel or vascular injury due to trocar insertion, rather than uterine perforation. *IUCD* - **Intrauterine contraceptive device (IUCD)** insertion can cause uterine perforation, but it is less common than with D&C, with an estimated incidence of 1-2 per 1000 insertions. - Perforation during IUCD insertion is typically an immediate event, whereas D&C-related perforations can occur at any stage of the curettage. *Carcinoma Endometrium* - **Endometrial carcinoma** does not typically cause spontaneous uterine perforation, though it can weaken the uterine wall, making it more susceptible to perforation during diagnostic or therapeutic procedures like D&C. - Perforation directly attributable to the carcinoma itself without instrumental intervention is exceedingly rare.
Question 4: A pregnant lady delivers a healthy baby via normal delivery. What is the earliest time at which an intrauterine contraceptive device (IUCD) can be inserted?
- A. Within 48 hours (Correct Answer)
- B. After 6 weeks
- C. After 3 months
- D. After 1 month
Explanation: ***Within 48 hours*** - **Immediate postpartum insertion** (within 48 hours of delivery) is considered safe and effective, with high client satisfaction and continuation rates. - While there's a slightly higher risk of **expulsion** compared to later insertions, it provides immediate contraception for women who might not return for follow-up. *After 6 weeks* - This is a common time for postpartum check-ups and a traditional window for IUCD insertion, after the uterus has largely involuted. - However, it is not the **earliest possible time**, as immediate postpartum insertion is also an option. *After 3 months* - Delaying IUCD insertion until three months postpartum is unnecessarily late if the woman desires contraception sooner. - This longer delay could increase the risk of an **unintended pregnancy** during the interim. *After 1 month* - Insertion at one month postpartum is also a safe option, after early uterine involution. - However, similar to the six-week option, it is not the **earliest possible time** for insertion.
Question 5: A pregnant woman presents with an IUD in place, and the thread is clearly visible. She wishes to continue the pregnancy. What is the most appropriate next step?
- A. Leave the IUD inside
- B. Remove gently (Correct Answer)
- C. MTP (Medical Termination of Pregnancy)
- D. Cesarean section
Explanation: ***Remove gently*** - When the **IUD thread is visible**, gentle removal is recommended if the woman wishes to **continue the pregnancy**, as this significantly reduces the risk of miscarriage and infection. - Leaving an **IUD in situ** during pregnancy increases risks of **septic miscarriage**, **preterm delivery**, and **chorioamnionitis**. *Leave the IUD inside* - Leaving an **IUD in place** during pregnancy increases the risks of **septic miscarriage**, **chorioamnionitis**, and **preterm labor**. - The presence of the IUD can also lead to **placental complications** and difficulties with fetal development. *MTP (Medical Termination of Pregnancy)* - MTP is an option for unintended pregnancies but is not the most appropriate first step when the patient explicitly **wishes to continue the pregnancy**. - MTP would be considered if the patient chose to terminate, but the question states she wants to continue. *Cesarean section* - **Cesarean section** is a mode of delivery and is not an appropriate initial intervention for an early pregnancy with an **IUD in situ**. - The removal of an IUD from an early pregnancy does not necessitate a cesarean section.
Question 6: Which IUD is preferred for menorrhagia?
- A. NOVA T
- B. Cu IUD
- C. Mirena (Correct Answer)
- D. Gynefix
Explanation: ***Mirena*** - The **Mirena** IUD contains **levonorgestrel**, a progestin, which significantly reduces menstrual blood loss by causing endometrial atrophy. - It is FDA-approved for the treatment of **menorrhagia** and is highly effective in reducing heavy menstrual bleeding. *NOVA T* - **NOVA T** is a **copper IUD**, which can actually *increase* menstrual blood loss and dysmenorrhea, making it unsuitable for menorrhagia. - Copper IUDs work primarily by inducing a **local inflammatory reaction** in the uterus that is spermicidal and prevents fertilization. *Cu IUD* - Like NOVA T, **copper IUDs (Cu IUDs)** are known to exacerbate **heavy menstrual bleeding** and cramping. - They are used for contraception but are generally contraindicated in women with pre-existing menorrhagia. *Gynefix* - **Gynefix** is a frameless copper IUD designed to reduce the side effects of traditional T-shaped copper IUDs. - While it may cause less cramping than other copper IUDs, it still contains copper and can **increase menstrual flow**, making it a poor choice for menorrhagia.
Question 7: The most common complication of intrauterine contraceptive devices is:
- A. Bleeding (Correct Answer)
- B. Ectopic pregnancy
- C. Backache
- D. Cervical stenosis
Explanation: ***Bleeding*** - **Irregular bleeding** and **heavier menstrual periods (menorrhagia)** are the most common reasons for IUD discontinuation. - This is particularly true for **non-hormonal copper IUDs**, which can increase menstrual blood loss and dysmenorrhea. *Ectopic pregnancy* - While IUDs significantly reduce the overall risk of pregnancy, if a pregnancy does occur with an IUD in place, there is a **higher relative risk** that it will be **ectopic**. - However, the **absolute number** of ectopic pregnancies is low due to the high effectiveness of IUDs in preventing pregnancy altogether. *Backache* - Backache is **not a common complication** directly attributed to IUD use. - It could be a general discomfort but isn't specifically caused by the device itself or its mechanism of action. *Cervical stenosis* - **Cervical stenosis** is a narrowing of the cervical canal, which is **not typically caused by IUD insertion or presence**. - More commonly, it results from **surgical procedures** on the cervix, infection, or radiation.
Question 8: What is the pathophysiological mechanism behind the increased risk of pelvic inflammatory disease with intrauterine device (IUD) insertion?
- A. Inhibition of local immune responses by copper
- B. Introduction of vaginal bacteria during insertion procedure (Correct Answer)
- C. Direct trauma to endometrial tissue
- D. Enhancement of bacterial adhesion by IUD string
Explanation: ***Introduction of vaginal bacteria during insertion procedure*** - The **insertion process itself** can introduce bacteria from the vagina and cervix into the uterine cavity, leading to an **ascending infection**. - This risk is primarily associated with the **first 2-3 weeks post-insertion**, after which the risk significantly decreases and is not directly related to the IUD's presence. *Inhibition of local immune responses by copper* - **Copper IUDs** actually induce a **local inflammatory response** in the endometrium, which is part of their contraceptive mechanism. - This inflammation helps to prevent sperm survival and ovum implantation, rather than inhibiting immune responses. *Direct trauma to endometrial tissue* - While insertion can cause minor trauma, this **trauma itself does not directly cause PID** but rather provides a potential entry point for bacteria if disinfection protocols are not meticulously followed. - The risk of infection is primarily from the introduction of bacteria rather than the tissue damage. *Enhancement of bacterial adhesion by IUD string* - Although the **IUD string** could theoretically serve as a pathway for bacteria, studies have not definitively shown it to be a significant independent risk factor for PID beyond the initial insertion period. - The primary risk factor is the **bacterial translocation during the insertion procedure**, not ongoing bacterial ascent via the string.
Question 9: Copper T is ideally inserted at-
- A. Just before menstruation
- B. On the 26th day
- C. Just after menstruation (Correct Answer)
- D. On the 14th day
Explanation: ***Just after menstruation*** - The **endometrium is thin** immediately after menstruation, making insertion easier and reducing the risk of pain and perforation. - Inserting it after menstruation also helps to ensure the woman is **not pregnant** at the time of insertion, as the uterus has shed its lining. *Just before menstruation* - The endometrium is typically **thicker and more vascular** just before menstruation, increasing the risk of bleeding and pain during insertion. - There is a higher possibility of **early pregnancy**, which would contraindicate IUD insertion. *On the 26th day* - The 26th day of the menstrual cycle is usually in the **luteal phase**, when the endometrium is highly vascularized and receptive, which could increase discomfort and bleeding during insertion. - This timing also carries a **higher risk of pregnancy**, making IUD insertion potentially hazardous if not confirmed otherwise. *On the 14th day* - The 14th day typically corresponds to the **ovulation period**, making it a high-risk time for conception if protection has not been used. - The uterus is also more sensitive during ovulation, potentially leading to increased discomfort or complications during insertion.
Question 10: Which of the following are examples of LARC (Long Acting Reversible Contraceptives) ? 1. Copper-T 380A 2. Implants 3. LNG-IUS Select the correct answer using the code given below :
- A. 1, 2 and 3 (Correct Answer)
- B. 1 and 3 only
- C. 1 and 2 only
- D. 2 and 3 only
Explanation: ***1, 2 and 3*** - **Long-acting reversible contraceptives (LARCs)** include all methods that are effective for an extended period, do not require daily attention, and are reversible. The **Copper-T 380A intra-uterine device (IUD)**, **subdermal implants**, and the **levonorgestrel-releasing intra-uterine system (LNG-IUS)** all fit this description. - These methods are highly effective due to minimal user error and provide contraception for several years, making them ideal for long-term birth control. *1 and 3 only* - This option incorrectly excludes **implants**, which are a well-established and highly effective form of LARC, offering contraception for up to three years. - While Copper-T 380A and LNG-IUS are indeed LARCs, the exclusion of implants makes this option incomplete. *1 and 2 only* - This option incorrectly excludes the **levonorgestrel-releasing intra-uterine system (LNG-IUS)**, which is an increasingly popular and effective LARC, providing contraception for up to five years. - The LNG-IUS is a hormonal LARC often used for both contraception and managing heavy menstrual bleeding. *2 and 3 only* - This option incorrectly excludes the **Copper-T 380A IUD**, which is a non-hormonal LARC. - The Copper-T 380A is one of the most widely used LARCs globally, offering highly effective contraception for up to ten years.
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