Contraception and Family Planning — MCQs

Contraception and Family Planning Indian Medical PG Practice Questions and MCQs

Question 221: Mifepristone used for medical abortion is:

A. Anti-estrogen
B. Anti-progesterone (Correct Answer)
C. Anti-folate
D. Prostaglandin derivative

Explanation: **Explanation:** **Mifepristone (RU-486)** is a synthetic steroid that acts as a potent **competitive receptor antagonist** at the progesterone receptor level. Progesterone is essential for the maintenance of pregnancy as it stabilizes the endometrial lining, inhibits uterine contractions, and maintains the cervical plug. By blocking these receptors, Mifepristone leads to decidual necrosis, detachment of the products of conception, and sensitization of the myometrium to prostaglandins. **Analysis of Options:** * **B. Anti-progesterone (Correct):** Mifepristone binds to progesterone receptors with higher affinity than endogenous progesterone, effectively terminating the hormonal support required for pregnancy. * **A. Anti-estrogen:** Drugs like Clomiphene or Tamoxifen are anti-estrogens. Mifepristone has weak anti-estrogenic activity but its primary clinical function is anti-progestational. * **C. Anti-folate:** Methotrexate is an anti-folate (dihydrofolate reductase inhibitor) used in the medical management of ectopic pregnancy, not the standard regimen for intrauterine medical abortion. * **D. Prostaglandin derivative:** Misoprostol (PGE1) is the prostaglandin derivative used in combination with Mifepristone to cause uterine contractions and expulsion of the fetus. **High-Yield Clinical Pearls for NEET-PG:** 1. **Dosage for Medical Abortion:** 200 mg Mifepristone orally, followed 36–48 hours later by 800 mcg Misoprostol (vaginal/oral/sublingual). 2. **Legal Limit:** In India (MTP Act), medical abortion is approved up to **9 weeks (63 days)** of gestation. 3. **Other Uses:** Mifepristone is also used in **Cushing’s Syndrome** (anti-glucocorticoid effect at high doses), emergency contraception, and management of uterine fibroids. 4. **Side Effects:** Heavy bleeding and abdominal cramps are the most common side effects during the procedure.

Question 222: An intrauterine device (IUD) should not be inserted in which of the following conditions?

A. Genital bleeding of unknown origin
B. Postpartum endometritis
C. Suspected cervical malignancy
D. Immediate postpartum period (Correct Answer)

Explanation: **Explanation:** The correct answer is **D. Immediate postpartum period**. This question focuses on the **WHO Medical Eligibility Criteria (MEC)** for contraceptive use. **Why Option D is correct:** According to WHO MEC Category 4 (Absolute Contraindication), an IUD should not be inserted between **48 hours and 4 weeks postpartum**. During this period, the risk of **expulsion** is highest due to uterine involution, and there is an increased risk of perforation. *Note: IUD insertion is safe within the first 48 hours (PPIUD) or after 4 weeks (interval insertion).* **Analysis of Incorrect Options:** * **A & C (Genital bleeding of unknown origin / Suspected cervical malignancy):** These are **Category 4** contraindications for *initiation* of an IUD. However, in the context of this specific question (often sourced from standard textbooks like Dutta), the "Immediate Postpartum Period" (48h–4wks) is highlighted as the specific temporal contraindication regarding the timing of insertion. * **B (Postpartum endometritis):** This is a **Category 4** contraindication. However, it is an infective complication rather than a physiological timing contraindication. **High-Yield NEET-PG Pearls:** * **WHO MEC Category 4 (Absolute Contraindications) for Cu-T:** 1. Pregnancy. 2. Unexplained vaginal bleeding (until evaluated). 3. Current PID or Purulent cervicitis. 4. Gestational Trophoblastic Disease (with high hCG). 5. Cervical or Endometrial Cancer (awaiting treatment). 6. Distorted uterine cavity (Fibroids). 7. Pelvic Tuberculosis. * **Ideal Time for Insertion:** 3–7 days of the menstrual cycle (to rule out pregnancy and ensure an open internal os). * **Most common side effect:** Bleeding (Menorrhagia). * **Most common reason for removal:** Pain and Bleeding.

Question 223: Which of the following is a barrier type of contraception?

A. Oral Contraceptive Pill (OCP)
B. Intrauterine Contraceptive Device (IUCD)
C. Spermicidal jelly (Correct Answer)
D. Symptothermic method

Explanation: **Explanation:** Barrier methods of contraception work by physically or chemically preventing sperm from entering the uterus and reaching the oocyte. **Spermicidal jelly** is categorized as a **chemical barrier**. It contains surfactants (most commonly **Nonoxynol-9**) that disrupt the sperm cell membrane, immobilizing or killing them before they can ascend the cervix. While often used in conjunction with physical barriers like diaphragms, it is classified under the barrier umbrella in standard gynecological texts. **Analysis of Incorrect Options:** * **A. Oral Contraceptive Pill (OCP):** This is a **hormonal method**. It primarily works by suppressing ovulation via the inhibition of FSH and LH, and secondarily by thickening cervical mucus. * **B. Intrauterine Contraceptive Device (IUCD):** This is an **intrauterine method**. Copper T works by causing a sterile inflammatory response in the endometrium that is spermicidal, while hormonal IUCDs (LNG-IUD) primarily thicken cervical mucus and thin the endometrial lining. * **D. Symptothermic method:** This is a **natural/behavioral method** (Fertility Awareness-Based Method). It involves tracking basal body temperature and cervical mucus changes to identify the fertile window and avoid coitus during that time. **High-Yield NEET-PG Pearls:** * **Physical Barriers:** Condoms (male/female), Diaphragm, Cervical cap, and Vaginal sponge. * **Chemical Barriers:** Foams, jellies, tablets, and soluble films. * **Dual Protection:** Condoms are the only barrier method that provides significant protection against both pregnancy and **STIs/HIV**. * **Failure Rate:** Barrier methods generally have higher typical-use failure rates compared to LARC (Long-Acting Reversible Contraception) like IUCDs.

Question 224: What is the weekly dose of Centchroman?

A. 45 mg
B. 60 mg (Correct Answer)
C. 90 mg
D. 120 mg

Explanation: **Explanation:** **Centchroman (Ormeloxifene)** is a non-steroidal, non-hormonal oral contraceptive pill developed in India (CDRI, Lucknow). It belongs to the class of **Selective Estrogen Receptor Modulators (SERMs)**. 1. **Why 60 mg is correct:** The standard therapeutic dose of Centchroman is **60 mg**. Under the National Family Planning Program (marketed as **Chhaya**), the dosage schedule is: * **First 3 months:** 60 mg twice weekly (e.g., Sunday and Wednesday). * **From the 4th month onwards:** 60 mg once weekly. Since the question asks for the standard weekly dose (maintenance phase), 60 mg is the correct answer. 2. **Analysis of Incorrect Options:** * **30 mg:** This is a sub-therapeutic dose for contraception. * **90 mg & 120 mg:** These are incorrect as they exceed the established weekly maintenance protocol. While 120 mg is the total dose per week during the initial "loading" phase (60 mg x 2), the unit dose remains 60 mg. **High-Yield Clinical Pearls for NEET-PG:** * **Mechanism of Action:** It acts as an estrogen antagonist in the uterus (preventing implantation by altering the endometrium) and as a weak agonist elsewhere. It does not suppress ovulation. * **Indication:** Apart from contraception, it is the drug of choice for **Mastalgia** and **Benign Breast Disease**, and is used in **Abnormal Uterine Bleeding (AUB)**. * **Safety:** It is safe for breastfeeding mothers as it does not affect the quantity or quality of breast milk. * **Side Effect:** The most common side effect is a **prolonged menstrual cycle** (delayed periods) in some women, which is usually self-limiting.

Question 225: Spermicidal jelly acts through which of the following mechanisms?

A. Acrosomal enzyme action
B. Cervical enzyme alteration
C. Inhibition of glucose uptake by sperms
D. Disruption of the sperm cell membrane (Correct Answer)

Explanation: **Explanation:** **Mechanism of Action (Correct Answer: D)** Spermicides are chemical barrier contraceptives that primarily act by **disrupting the sperm cell membrane**. The most common active ingredient used globally is **Nonoxynol-9**, a surfactant. These agents lower the surface tension at the sperm cell membrane, leading to increased permeability, loss of intracellular components, and physical fragmentation of the lipid bilayer. This effectively kills the sperm (spermicidal) or immobilizes it, preventing it from reaching the ovum. **Analysis of Incorrect Options:** * **A & B:** Spermicides do not primarily target specific acrosomal or cervical enzymes. While the acrosomal cap may be damaged as part of the overall membrane disruption, it is a secondary effect rather than the primary biochemical mechanism. * **C:** Inhibition of glucose uptake is a metabolic pathway disruption. Spermicides act as physical-chemical detergents on the cell surface rather than interfering with internal metabolic or glycolytic pathways. **High-Yield Clinical Pearls for NEET-PG:** * **Active Ingredient:** Nonoxynol-9 is the most frequently tested agent. * **Failure Rate:** When used alone, spermicides have a high failure rate (Typical use: ~28%). They are most effective when used in combination with mechanical barriers like condoms or diaphragms. * **STI Risk:** Contrary to older beliefs, Nonoxynol-9 does **not** protect against HIV/STIs. In fact, frequent use can cause vaginal/rectal epithelial irritation, potentially **increasing** the risk of HIV transmission. * **Application:** They must be placed high in the vagina near the cervix at least 10–15 minutes before intercourse to be effective.

Question 226: All of the following are considered procedures for female sterilization, EXCEPT?

A. Mini-lap tubal ligation
B. Laparoscopic tubal ligation
C. Laparoscopic puerperal sterilization (Correct Answer)
D. Hysteroscopic tubal occlusion

Explanation: **Explanation:** The core concept behind this question lies in the timing and physiological constraints of postpartum sterilization. **Why Option C is the correct answer:** **Puerperal sterilization** refers to tubal ligation performed within the first week (usually 24–48 hours) after delivery. During the early puerperium, the uterus is an abdominal organ (enlarged), and the fallopian tubes are easily accessible via a small sub-umbilical incision. Therefore, **Mini-laparotomy** is the preferred and standard method for puerperal sterilization. **Laparoscopy is contraindicated** in the immediate puerperium because the enlarged uterus increases the risk of injury during trocar insertion, and the increased vascularity of the pelvic organs poses a higher risk of bleeding. **Analysis of other options:** * **A. Mini-lap tubal ligation:** The most common method used in mass sterilization camps and for postpartum (puerperal) sterilization. It involves a small abdominal incision (Pomeroy’s technique is most common). * **B. Laparoscopic tubal ligation:** The gold standard for **interval sterilization** (performed 6 weeks after delivery). It uses Falope rings or Filshie clips. * **C. Hysteroscopic tubal occlusion:** A non-incisional method (e.g., Essure, though now largely discontinued) where micro-inserts are placed into the fallopian tubes via the cervix. **High-Yield NEET-PG Pearls:** * **Ideal time for Puerperal Sterilization:** 24–48 hours postpartum (not before 24 hours to allow for neonatal assessment). * **Preferred Technique:** Pomeroy’s method (Modified) is the most popular due to its simplicity and efficacy. * **Failure Rates:** Failure is highest in laparoscopic clips and lowest in surgical excision (Pomeroy). * **Interval Sterilization:** Best performed during the follicular phase of the menstrual cycle.

Question 227: At what gestational age is RU-486, an anti-progesterone drug used in the induction of abortion, most effectively used?

A. 50 days (Correct Answer)
B. 72 days
C. 88 days
D. 120 days

Explanation: **Explanation:** **RU-486 (Mifepristone)** is a synthetic steroid with potent anti-progestational activity. It works by competitively binding to progesterone receptors, leading to decidual necrosis, cervical softening, and increased uterine sensitivity to prostaglandins. **Why 50 days is correct:** While various international guidelines (like the WHO or FDA) approve medical abortion up to 63–70 days, clinical efficacy is highest in the very early stages of pregnancy. In the context of standard medical examinations like NEET-PG, Mifepristone is considered most effective when used within **7 weeks (49–50 days)** of gestation. During this window, the success rate of medical abortion (when combined with Misoprostol) is approximately 95–98%. Beyond 50–63 days, the failure rate and the risk of incomplete abortion increase significantly. **Analysis of Incorrect Options:** * **72 days and 88 days:** These fall into the late first trimester. While medical management is possible, the risk of heavy bleeding and incomplete expulsion increases, often requiring surgical intervention (D&C). * **120 days:** This represents the second trimester (~17 weeks). At this stage, Mifepristone is used only as a *pre-treatment* to prime the cervix 24–48 hours before inducing labor with prostaglandins, rather than as a primary abortifacient. **Clinical Pearls for NEET-PG:** * **Mechanism:** Competitive progesterone antagonist; also has anti-glucocorticoid and anti-androgenic activity. * **MTP Act (India) Update:** Medical abortion is legally permitted up to **9 weeks (63 days)** of gestation. * **Standard Regimen:** 200 mg Mifepristone orally, followed 36–48 hours later by 800 mcg Misoprostol (vaginal/sublingual/buccal). * **Contraindications:** Ectopic pregnancy, chronic adrenal failure, long-term corticosteroid therapy, and known allergy to prostaglandins.

Question 228: What is the most common side effect of mifepristone?

A. Fever
B. Diarrhea (Correct Answer)
C. Headache
D. Rash

Explanation: **Explanation:** Mifepristone is a selective progesterone receptor modulator (SPRM) used primarily for medical termination of pregnancy (MTP). While it is generally well-tolerated, it has a distinct side effect profile. **1. Why Diarrhea is Correct:** The most common side effect associated with mifepristone administration is **gastrointestinal upset**, specifically **diarrhea**. This occurs due to the drug’s secondary effects on the gastrointestinal tract and its interaction with prostaglandin pathways. While abdominal pain and cramping are also frequent, they are often attributed to the subsequent administration of Misoprostol; however, even when used alone, mifepristone frequently induces nausea and diarrhea. **2. Analysis of Incorrect Options:** * **A. Fever:** Fever and chills are very common side effects of **Misoprostol** (a PGE1 analogue), not Mifepristone. In NEET-PG, it is crucial to differentiate between the two drugs in the MTP regimen. * **C. Headache:** While reported by some patients, it is a non-specific symptom and occurs much less frequently than GI disturbances. * **D. Rash:** Skin rashes or allergic reactions are rare adverse effects and are not considered characteristic of the drug. **3. High-Yield Clinical Pearls for NEET-PG:** * **Mechanism of Action:** Mifepristone acts as an anti-progestogen by blocking receptors, leading to decidual breakdown and sensitization of the myometrium to prostaglandins. * **MTP Dosage:** The standard WHO/RCOG regimen is **200 mg Mifepristone orally**, followed 24–48 hours later by **800 mcg Misoprostol** (vaginal/sublingual/buccal). * **Contraindication:** Chronic adrenal failure (due to its anti-glucocorticoid activity) and uncontrolled asthma. * **Key Distinction:** If the question asks for the most common side effect of the *combined* MTP regimen, the answer is usually **pain/cramping** or **bleeding**. If asking specifically for Mifepristone, think **GI upset (Diarrhea/Nausea)**.

Question 229: Oral contraceptive pills are contraindicated in all except?

A. Intermittent vaginal bleeding
B. Uterine fibroids (Correct Answer)
C. History of thromboembolism
D. Cardiac abnormalities

Explanation: **Explanation:** Combined Oral Contraceptive Pills (COCPs) contain estrogen and progesterone, which significantly influence systemic physiology. Understanding their contraindications is crucial for NEET-PG. **Why Uterine Fibroids is the Correct Answer:** Uterine fibroids are **not** a contraindication for COCPs. In fact, COCPs are often used as a medical management strategy for fibroids to control the associated heavy menstrual bleeding (menorrhagia). While estrogen can theoretically stimulate fibroid growth, low-dose modern pills do not typically cause significant enlargement and provide the benefit of cycle regulation. **Analysis of Incorrect Options (Contraindications):** * **Intermittent Vaginal Bleeding:** Undiagnosed abnormal vaginal bleeding is an absolute contraindication. COCPs can mask the symptoms of underlying malignancies (like endometrial or cervical cancer) which must be ruled out before starting hormonal therapy. * **History of Thromboembolism:** Estrogen increases the synthesis of clotting factors in the liver and decreases anticoagulants like Protein S. A history of DVT or pulmonary embolism is a Category 4 contraindication (unacceptable health risk) due to the high risk of recurrence. * **Cardiac Abnormalities:** Conditions such as ischemic heart disease, complicated valvular disease, or severe hypertension are contraindications because the estrogen component increases the risk of stroke and myocardial infarction. **High-Yield Clinical Pearls for NEET-PG:** * **WHO Medical Eligibility Criteria (MEC) Category 4 (Absolute Contraindications):** Smoker >35 years (≥15 cigarettes/day), History of Thromboembolism, Migraine with aura, Breast cancer (current), and Liver tumors. * **Benefit:** COCPs are **protective** against Ovarian and Endometrial cancers. * **Drug Interaction:** Rifampicin is the most potent inducer of hepatic enzymes that decreases COCP efficacy.

Question 230: Tubectomy in a heart patient who has recently delivered is best done after which period?

A. 48 hours
B. 1 week (Correct Answer)
C. 2 weeks
D. Immediately

Explanation: **Explanation:** The timing of postpartum sterilization (Tubectomy) in a cardiac patient is governed by the physiological changes in hemodynamics following delivery. **Why 1 week is the correct answer:** Immediately after delivery, there is a significant **autotransfusion** of blood from the uteroplacental circulation back into the systemic circulation. This, combined with the relief of inferior vena cava compression, leads to a massive increase in cardiac output (up to 60-80% above pre-labor levels). In a patient with heart disease, this period carries the highest risk of **congestive heart failure and pulmonary edema**. By **one week**, the hemodynamic status stabilizes, the blood volume begins to normalize, and the immediate risk of cardiac decompensation subsides, making it the safest time for surgery. **Analysis of Incorrect Options:** * **Immediately / 48 hours:** These are the standard times for a routine "Mini-lap" tubectomy in healthy women. However, in cardiac patients, this coincides with the peak of hemodynamic instability and fluid shifts, making anesthesia and surgery life-threatening. * **2 weeks:** While safe, it is unnecessarily delayed. By one week, the patient is usually stable enough for the procedure, and delaying further increases the risk of the patient being lost to follow-up or the uterus involuting too deep into the pelvis for an easy sub-umbilical incision. **High-Yield Clinical Pearls for NEET-PG:** * **Peak risk period:** The first 24–48 hours postpartum is the most dangerous period for a cardiac patient. * **Ideal Contraception:** While sterilization is an option, the **Progestogen-only Pill (POP)** or **Lactational Amenorrhea Method (LAM)** are safe immediate options. **IUCDs** (like Cu-T) should be used with caution due to the risk of vasovagal attacks during insertion in certain cardiac conditions (e.g., Mitral Stenosis). * **Anesthesia:** Local anesthesia with sedation is preferred over general anesthesia for postpartum tubectomy in stable cardiac patients.

Practice by Chapter

Natural Family Planning Methods

Practice Questions

Barrier Methods

Practice Questions

Hormonal Contraceptives

Practice Questions

Intrauterine Devices

Practice Questions

Emergency Contraception

Practice Questions

Permanent Contraception Methods

Practice Questions

Contraception in Special Populations

Practice Questions

Contraceptive Counseling

Practice Questions

Side Effects and Complications of Contraceptives

Practice Questions

Future Contraceptive Technologies

Practice Questions

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