Contraception and Family Planning Practice Questions

Q: Which of the following neoplasms has been associated with the use of oral contraceptives?

Hepatic adenoma. **Explanation:** The correct answer is **Hepatic Adenoma**. Combined Oral Contraceptive Pills (COCPs) contain synthetic estrogen and progesterone. Estrogen, in particular, has a trophic effect on hepatocytes and the hepatic vasculature. Long-term use of COCPs is a well-established risk factor for the development of **Hepatic Adenoma** (a benign but potentially serious liver tumor). These tumors are highly vascular and carry a risk of spontaneous rupture and life-threatening intraperitoneal hemorrhage, especially during pregnancy or continued pill use. **Analysis of Incorrect Options:** * **Ovarian Cancer:** COCPs are actually **protective** against epithelial ovarian cancer. The suppression of "incessant ovulation" reduces the risk by approximately 50% after 5 years of use, and this protection persists for decades after discontinuation. * **Endometrial Cancer:** COCPs are **protective** against endometrial cancer. The progestogen component counteracts the proliferative effect of estrogen on the endometrium, reducing the risk by about 50%. * **Breast Cancer:** While there is a slight, transient increase in the relative risk of breast cancer diagnosis during current use (which returns to baseline 10 years after stopping), the association is less definitive and less "classically" linked in exam scenarios compared to the specific association with hepatic adenoma. **High-Yield NEET-PG Pearls:** * **Cancers Decreased by COCPs:** Ovarian, Endometrial, and Colorectal cancer. * **Cancers Increased by COCPs:** Cervical cancer (risk increases with >5 years of use) and Hepatic Adenoma. * **Management of Hepatic Adenoma:** Small adenomas (<5 cm) may regress upon discontinuation of COCPs; larger ones may require surgical resection due to the risk of rupture or malignant transformation to Hepatocellular Carcinoma (HCC).

Q: What is the recommended pressure range employed during suction evacuation in MTP?

400-600 mm Hg. ### Explanation **Suction Evacuation (Vacuum Aspiration)** is the gold standard surgical method for Medical Termination of Pregnancy (MTP) in the first trimester (up to 12 weeks). **1. Why 400-600 mm Hg is Correct:** To effectively detach and aspirate the products of conception (decidua and chorionic tissue) from the uterine wall, a negative pressure of **400–600 mm Hg** (or 60–80 kPa) is required. This range provides sufficient suction to empty the uterus quickly while minimizing the risk of trauma to the myometrium. **2. Analysis of Incorrect Options:** * **A (200-400 mm Hg):** This pressure is generally **insufficient** to dislodge the gestational sac and placental tissue, leading to incomplete evacuation and increased procedure time. * **C & D (600-1000 mm Hg):** Pressures exceeding 600 mm Hg are **excessive**. High negative pressure increases the risk of uterine perforation, Asherman syndrome (due to over-denudation of the basal layer of the endometrium), and cervical injury. **3. Clinical Pearls for NEET-PG:** * **Cannula Size Rule:** The size of the Karman cannula (in mm) should correspond to the weeks of gestation (e.g., an 8 mm cannula for 8 weeks of pregnancy). * **Manual Vacuum Aspiration (MVA):** Uses a handheld syringe (60cc) that creates a constant vacuum of approximately **600 mm Hg**. * **Signs of Completion:** The procedure is complete when "gritty" sensations are felt against the cannula, bubbles appear in the tube, and the uterus contracts around the cannula. * **MTP Act Update:** Remember that under the MTP (Amendment) Act 2021, the upper gestation limit for termination has been increased to **24 weeks** for specific categories of women.

Q: What is the most preferable contraceptive device for a female with Rheumatic Heart Disease who has completed her family?

Tubal ligation. **Explanation:** The primary concern in managing contraception for a patient with **Rheumatic Heart Disease (RHD)** is preventing unintended pregnancy, which poses a high risk of cardiac decompensation due to the physiological hemodynamic changes of pregnancy. **Why Tubal Ligation is Correct:** For a woman who has **completed her family**, permanent sterilization via **Tubal Ligation** is the most preferable method. It offers the highest efficacy (lowest failure rate) without the hormonal risks or infection concerns associated with other methods. In RHD patients, it is ideally performed during a stable cardiac period. It provides a "one-time" solution to the high-risk threat of future pregnancies. **Analysis of Incorrect Options:** * **IUCD (Option A):** Generally avoided in RHD patients due to the risk of **Pelvic Inflammatory Disease (PID)** and subsequent **Subacute Bacterial Endocarditis (SABE)**. Additionally, the vasovagal response during insertion can trigger cardiac arrhythmias in susceptible patients. * **Norplant (Option C):** While highly effective, progestin-only implants are usually reserved for those spacing pregnancies. For someone who has completed their family, permanent methods are superior. * **Barrier Method (Option D):** These have a high **user-failure rate**. In RHD, a contraceptive failure leading to pregnancy can be life-threatening; therefore, low-efficacy methods are not preferred. **High-Yield Clinical Pearls for NEET-PG:** * **WHO Eligibility Criteria:** For RHD, sterilization is Category 2 (benefits outweigh risks), but IUCD is often Category 3/4 if there is a high risk of endocarditis. * **Prophylaxis:** If an IUCD must be used or surgery performed, **antibiotic prophylaxis** is mandatory to prevent SABE. * **OCPs:** Combined Oral Contraceptive Pills are **contraindicated** in RHD with complications (like atrial fibrillation or valve replacement) due to the increased risk of thromboembolism.

Q: Which of the following is NOT an absolute contraindication for IUCD users?

HIV infection. The correct answer is **C. HIV infection**. ### **Explanation** According to the **WHO Medical Eligibility Criteria (MEC)** for contraceptive use, HIV infection is categorized as **MEC Category 2** (benefits generally outweigh risks) for both initiation and continuation of an Intrauterine Contraceptive Device (IUCD). It is **not** an absolute contraindication. Women with HIV, including those on Antiretroviral Therapy (ART) who are clinically well, can safely use IUCDs. The risk of pelvic infection is not significantly higher in these patients compared to HIV-negative women, provided they do not have an active AIDS-defining illness (MEC 3 for initiation). ### **Why other options are wrong:** * **Undiagnosed vaginal bleeding (MEC 4):** This is an absolute contraindication because the bleeding could be due to an underlying malignancy (e.g., cervical or endometrial cancer) or pregnancy complications, which must be ruled out before insertion. * **Suspected pregnancy (MEC 4):** Insertion of an IUCD during pregnancy can lead to septic abortion, miscarriage, or preterm labor. Pregnancy must always be excluded. * **Pelvic Inflammatory Disease (PID) (MEC 4):** Current or active PID is an absolute contraindication for initiation. Inserting an IUCD during an active infection can exacerbate the condition and lead to tubal damage or infertility. ### **High-Yield Clinical Pearls for NEET-PG:** * **MEC Category 4 (Absolute Contraindications):** Undiagnosed vaginal bleeding, current PID, suspected pregnancy, copper allergy (for Cu-T), and distorted uterine cavity (fibroids). * **IUCD & HIV:** If a woman develops AIDS while using an IUCD, she can continue using it (MEC 2), but initiation in a patient with AIDS who is not on ART is MEC 3. * **Ideal Candidate:** A parous woman in a stable monogamous relationship with no history of PID. * **Most common side effect:** Bleeding (menorrhagia); **Most common reason for removal:** Pain and bleeding.

Q: Which of the following is a true statement about the minipill?

Irregular vaginal bleeding may be a side effect.. The **Minipill**, or Progestogen-Only Pill (POP), is a contraceptive containing only a low dose of progestin without estrogen. ### **Explanation of Options** * **A. Irregular vaginal bleeding (Correct):** This is the most common side effect of POPs. Unlike combined pills, which provide a predictable withdrawal bleed due to the estrogen component stabilizing the endometrium, POPs often cause endometrial thinning and breakthrough spotting. Approximately 40% of users experience irregular bleeding, spotting, or amenorrhea. * **B. Combination with OCPs:** This is incorrect. The minipill is an alternative to Combined Oral Contraceptive Pills (COCPs), especially for women who have contraindications to estrogen (e.g., history of thromboembolism or hypertension). * **C. Use during lactation:** This is incorrect. The minipill is the **contraceptive of choice for lactating mothers**. Unlike estrogen, which suppresses milk production, progestins do not affect the quantity or quality of breast milk. * **D. Ectopic pregnancy:** This is incorrect. While the minipill reduces the absolute risk of pregnancy, if a woman *does* conceive while taking it, there is a **higher relative risk** that the pregnancy will be ectopic because progestins decrease fallopian tube motility. ### **High-Yield NEET-PG Pearls** * **Mechanism of Action:** Primarily works by **thickening cervical mucus** (preventing sperm penetration) and making the endometrium unfavorable for implantation. It does not consistently inhibit ovulation (ovulation occurs in ~60% of cycles). * **Strict Timing:** The minipill must be taken at the **same time every day**. A delay of more than **3 hours** is considered a "missed pill," requiring backup contraception for 48 hours. * **Ideal Candidate:** Lactating women, smokers over 35, and women with cardiovascular risks.

Q: A pregnant woman with an intrauterine contraceptive device (IUCD) in situ, where the IUCD tail is visible, what is the next recommended course of action?

Remove the IUCD. ### Explanation The management of a pregnancy with an intrauterine contraceptive device (IUCD) in situ depends primarily on the **visibility of the strings**. **Why Option B is Correct:** When a woman becomes pregnant with an IUCD and the strings are visible, the standard of care is **immediate removal of the IUCD**. Leaving the device in situ significantly increases the risk of: 1. **Septic Abortion:** A 20-fold increase in risk. 2. **Spontaneous Abortion (SAB):** The risk of SAB is approximately 50% if left in situ, which reduces to about 20–25% if the device is removed early. 3. **Preterm Labor and Chorioamnionitis:** Increased risk in the second and third trimesters. **Why Other Options are Incorrect:** * **Options A & C:** Continuing the pregnancy without intervention or just monitoring is dangerous due to the high risk of life-threatening pelvic sepsis and miscarriage. * **Option D:** Pregnancy termination is not medically mandated. If the woman desires to continue the pregnancy, the IUCD should be removed, and the pregnancy can proceed. The IUCD itself is **not teratogenic**. **High-Yield Clinical Pearls for NEET-PG:** * **Strings NOT visible:** Perform an ultrasound. If the IUCD is intra-decidual, **do not** attempt removal, as it may disrupt the gestational sac. * **Ectopic Risk:** While IUCDs are highly effective, if a pregnancy *does* occur, the **relative risk** of it being an ectopic pregnancy is higher (though the absolute risk is lower than in non-contraceptive users). * **Teratogenicity:** There is no evidence of increased congenital malformations in babies born with an IUCD in situ. * **Management Summary:** Strings visible $\rightarrow$ Pull/Remove; Strings not visible $\rightarrow$ Leave it alone and monitor.

Q: Which is the most likely complication of an intrauterine device (IUD)?

Hypofibrinogenemia. **Explanation:** The correct answer is **Hypofibrinogenemia**. While this may seem counterintuitive compared to common side effects like bleeding or pain, it is a recognized systemic complication associated with the chronic inflammatory response triggered by an IUD. **1. Why Hypofibrinogenemia is correct:** Intrauterine devices, particularly non-medicated ones, induce a local sterile inflammatory reaction in the endometrium. This leads to an increase in vascular permeability and the release of lysosomal enzymes and plasminogen activators. The chronic increase in **fibrinolytic activity** within the uterine cavity can lead to the systemic consumption of fibrinogen, resulting in hypofibrinogenemia. This is often the underlying mechanism for the increased menstrual blood loss (menorrhagia) seen in IUD users. **2. Why other options are incorrect:** * **Sterility:** IUDs do not cause permanent sterility. Fertility returns immediately upon removal. While Pelvic Inflammatory Disease (PID) can lead to tubal factor infertility, the IUD itself is not a cause of sterility. * **Cervical tear:** This is a rare mechanical complication that may occur during the *insertion* process (usually due to the tenaculum), but it is not a complication of the device itself. * **None of the above:** Incorrect, as hypofibrinogenemia is a documented hematological association. **High-Yield NEET-PG Pearls:** * **Most common side effect of IUD:** Bleeding (Menorrhagia). * **Most common cause for IUD removal:** Bleeding. * **Second most common cause for removal:** Pain. * **Mechanism of action (Cu-T):** Primarily spermicidal (due to sterile inflammatory response and Cu ions). * **Ideal time for insertion:** Within 10 days of the start of menstruation (to ensure the patient is not pregnant and the cervix is slightly dilated).

Question 1

Which of the following neoplasms has been associated with the use of oral contraceptives?

Accepted Answer

Hepatic adenoma

Answer

Breast cancer

Answer

Ovarian cancer

Answer

Endometrial cancer

Question 2

What is the recommended pressure range employed during suction evacuation in MTP?

Accepted Answer

400-600 mm Hg

Answer

200-400 mm Hg

Answer

600-800 mm Hg

Answer

800-1000 mm Hg

Question 3

What is the most preferable contraceptive device for a female with Rheumatic Heart Disease who has completed her family?

Accepted Answer

Tubal ligation

Answer

Intrauterine contraceptive device (IUCD)

Answer

Norplant

Answer

Barrier method

Question 4

All of the following are features of post-tubal ligation syndrome except?

Accepted Answer

All the above

Answer

Abnormal menstrual bleeding

Answer

Dysmenorrhea

Answer

Dyspareunia

Question 5

Which of the following is NOT an absolute contraindication for IUCD users?

Accepted Answer

HIV infection

Answer

Undiagnosed vaginal bleeding

Answer

Suspected pregnancy

Answer

Pelvic inflammatory disease

Question 6

Which of the following is a true statement about the minipill?

Accepted Answer

Irregular vaginal bleeding may be a side effect.

Answer

It is used in combination with oral contraceptive pills.

Answer

It cannot be used during lactation.

Answer

It prevents ectopic pregnancy.

Question 7

A pregnant woman with an intrauterine contraceptive device (IUCD) in situ, where the IUCD tail is visible, what is the next recommended course of action?

Accepted Answer

Remove the IUCD

Answer

Continue the pregnancy without intervention

Answer

Continue the pregnancy with watchful monitoring

Answer

Remove the IUCD and terminate the pregnancy

Question 8

Which is the most likely complication of an intrauterine device (IUD)?

Accepted Answer

Hypofibrinogenemia

Answer

Sterility

Answer

Cervical tear

Answer

None of the above

Question 9

What is the contraceptive method of choice in lactating mothers?

Accepted Answer

Progesterone-only pills

Answer

Barrier method

Answer

Combined oral contraceptive pills

Answer

Lactational amenorrhea

Question 10

What is the best method of contraception for a commercial sex worker?

Accepted Answer

Barrier methods

Answer

Intrauterine contraceptive device (IUCD)

Answer

Oral contraceptive pills (OCP)

Answer

Permanent sterilization

Contraception and Family Planning — MCQs

Contraception and Family Planning — MCQs

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