Contraception and Family Planning Practice Questions

Q: Which one of the following is the most suitable situation for prescribing progestin only pill?

Lactating mother. ***Lactating mother*** - Progestin-only pills (POPs) are preferred for **breastfeeding mothers** as they do not affect **milk supply** or composition, unlike combined oral contraceptives containing estrogen. - They also eliminate the risk of estrogen exposure to the infant, which is generally avoided during **lactation**. *Young patients* - While young patients can use POPs, there isn't a specific indication making them "most suitable" compared to other contraceptive methods. - Often, combined oral contraceptives are also an appropriate choice for young patients, depending on their individual health profile. *Emergency contraception* - Progestin-only pills are a type of contraception, but they are not the primary or most effective form of **emergency contraception**; dedicated high-dose progestin pills (like levonorgestrel) or copper IUDs are used for this purpose. - Regular POPs are designed for daily use and are not formulated for a single, high-dose emergency contraceptive effect. *Woman with unexplained vaginal bleeding* - **Unexplained vaginal bleeding** is a **contraindication** for starting any hormonal contraceptive, including POPs, until the cause is identified. - It is crucial to rule out serious conditions like **endometrial cancer** or other gynecological pathologies before initiating hormonal therapy.

Q: The highest incidence of ectopic pregnancy amongst contraceptive users is observed with:

Progestasert intrauterine device. ***Progestasert intrauterine device*** - The **Progestasert IUD** (progesterone-releasing) has the **highest failure rate** among IUDs (2-3% per year), meaning more pregnancies occur in users. - When pregnancy does occur with Progestasert, approximately **5-6% are ectopic**, and due to the higher overall failure rate, this results in the **highest absolute incidence** of ectopic pregnancy among contraceptive users. - The progesterone released locally is less effective at preventing pregnancy compared to copper or levonorgestrel-releasing devices. - **Key concept**: The question asks about "highest incidence" (absolute rate among all users), not the highest proportion among pregnancies that occur. *Copper T intrauterine contraceptive device* - While the **proportion** of pregnancies that are ectopic is relatively high with Copper T (3-4% of pregnancies that occur are ectopic), the **absolute incidence** is lower. - Copper T has a very low failure rate (<1% per year), so fewer total pregnancies occur, resulting in fewer ectopic pregnancies overall among users. - Highly effective at preventing intrauterine implantation but not ovulation. *Levonorgestrel intrauterine system* - The **levonorgestrel IUS** has the **lowest failure rate** among IUDs (0.1-0.2% per year). - It suppresses ovulation in some users, thickens cervical mucus, and thins the endometrium. - Results in the **lowest absolute incidence** of ectopic pregnancy due to excellent contraceptive efficacy. *Combined contraceptive pills* - Highly effective at preventing pregnancy by **inhibiting ovulation**. - Very low incidence of ectopic pregnancy because ovulation is suppressed in most users. - When taken correctly, overall pregnancy rates are very low (0.3% per year with perfect use).

Q: Laparoscopic sterilization is not recommended during the period of:

Immediate post partum. ***Immediate post partum*** - The **uterus** is significantly enlarged and **hypervascular** in the immediate postpartum period, increasing the risk of **hemorrhage** and organ injury during laparoscopic sterilization. - The **bowel can be dilated and edematous**, making visualization and manipulation difficult, further complicating the procedure. *Post menstrual* - This period is generally considered **safe and even ideal** for sterilization procedures as the risk of pregnancy is minimal and the uterus is small. - The **uterine size** is at its baseline, which facilitates easier access and manipulation during laparoscopy. *Post first trimester MTP* - This period is considered a suitable time for sterilization, as the **uterus is still relatively small**, and the risks associated with the procedure are low. - It allows for the patient to combine two procedures, thereby reducing the need for multiple hospital visits. *Interval* - The **interval period** (any time not immediately postpartum or post-abortion) is the **most common and often most recommended time** for sterilization. - At this time, the **uterus is non-gravid**, at its baseline size, and easily accessible, leading to a lower risk of complications.

Q: Female sterilization is contraindicated in which of the following well-controlled conditions?

None of the above. ***None of the above*** - **Well-controlled** chronic conditions like diabetes mellitus, heart disease, or hypertension generally do **not contraindicate female sterilization** according to WHO Medical Eligibility Criteria (MEC). - Sterilization is a **permanent contraception method** that is often the most appropriate option for women with stable medical conditions who have completed their families. - The key principle is that these conditions must be **well-controlled** and stable at the time of the procedure. *Diabetes mellitus* - **Well-controlled diabetes** is WHO MEC Category 1-2 (no restriction or advantages generally outweigh risks) for female sterilization. - Women with **poorly controlled diabetes** should have their condition optimized before surgery to minimize perioperative risks, but this is not an absolute contraindication. - The risks of pregnancy in diabetic women typically exceed the minimal surgical risks of sterilization. *Heart disease* - **Well-managed stable heart disease** does not preclude female sterilization, though cardiac function should be assessed pre-operatively. - Most stable cardiac conditions are WHO MEC Category 2-3, with individualized assessment based on functional status. - For women with significant heart disease, avoiding pregnancy (which carries substantial cardiovascular burden) is often more important than avoiding a brief surgical procedure. *Hypertension* - **Controlled hypertension** is WHO MEC Category 1-2 for female sterilization and is not a contraindication. - Blood pressure should be optimized before surgery, and anesthetic management adjusted accordingly. - The cardiovascular stress of pregnancy far exceeds that of a sterilization procedure in hypertensive women.

Q: Absolute contraindication for the use of OCPs is:

Thromboembolism. ***Thromboembolism*** - A **current or past history of thromboembolism** (e.g., DVT, pulmonary embolism) is an **absolute contraindication (WHO MEC Category 4)** for combined oral contraceptive pills (OCPs) due to the significantly increased risk of recurrent thrombotic events. - Exogenous **estrogen** in OCPs increases the synthesis of clotting factors (II, VII, IX, X, fibrinogen) and decreases anticoagulant proteins (protein S, antithrombin), thereby promoting a hypercoagulable state. - Even a remote history of VTE makes OCPs absolutely contraindicated. *Diabetes* - Diabetes **with vascular complications** (retinopathy, nephropathy, neuropathy) or diabetes of >20 years duration is a contraindication (WHO MEC Category 3/4). - However, **uncomplicated diabetes without vascular disease** is not an absolute contraindication for OCPs. - Among the options listed, thromboembolism is the clearest absolute contraindication. *Epilepsy* - Epilepsy itself is **not a contraindication** for OCPs (WHO MEC Category 1). - However, some **enzyme-inducing antiepileptic drugs** (phenytoin, carbamazepine, phenobarbital, topiramate) can reduce OCP efficacy by increasing hepatic metabolism of contraceptive hormones. - In such cases, higher-dose OCPs, alternative methods, or non-enzyme-inducing AEDs should be considered. *Hypertension* - **Severe or uncontrolled hypertension** (≥160/100 mmHg) or hypertension with vascular disease is an absolute contraindication (WHO MEC Category 4). - **Adequately controlled and monitored hypertension** is a relative contraindication (WHO MEC Category 3), not an absolute one. - Among the given options, thromboembolism represents a clearer and more universally accepted absolute contraindication.

Q: For a 40 year old hypertensive woman, which one of the following is not recommended for contraception?

NuvaRing. ***NuvaRing*** - **NuvaRing** is a **combined hormonal contraceptive** that releases both estrogen and progestin. - **Estrogen-containing contraception** is generally **contraindicated** or used with caution in women with uncontrolled hypertension due to an increased risk of **cardiovascular events** such as stroke and myocardial infarction. *IUCD* - **Intrauterine contraceptive devices (IUCDs)**, both copper and levonorgestrel-releasing, are considered **safe** and highly effective for women with hypertension. - They do not contain systemic hormones or contain only progestin, which has a minimal impact on blood pressure. *Minipill* - The **minipill** is a **progestin-only oral contraceptive**. - **Progestin-only contraceptives** are safe for women with hypertension as they do not carry the same cardiovascular risks associated with estrogen. *LNG IUD (LNg IUD)* - The **levonorgestrel-releasing intrauterine device (LNG IUD)** is a **progestin-only contraceptive**. - It is **safe** for women with hypertension because the progestin is primarily local, and it does not contain estrogen, thereby avoiding cardiovascular risks.

Q: For a woman who has had unprotected intercourse two days ago, which one of the following emergency contraceptive methods is LEAST preferred as first-line emergency contraception?

Yuzpe regimen. ***Yuzpe regimen*** - The **Yuzpe regimen** uses higher doses of combined oral contraceptive pills, leading to more side effects like nausea and vomiting and generally lower efficacy compared to newer methods. - It involves taking two doses of estrogen and progestin, making it less convenient and less effective, especially after **48 hours**, compared to progestin-only or ulipristal acetate pills. *Levonorgestrel 1.5 mg* - **Levonorgestrel (LNG)** 1.5 mg, taken as a single dose, is a highly effective and widely recommended first-line emergency contraceptive within **72 hours** of unprotected intercourse. - It primarily works by **inhibiting or delaying ovulation**, without causing significant side effects in most women. *LNG IUD* - While an **LNG IUD** can be used as emergency contraception, it is not typically considered a first-line *oral* method; it is placed by a healthcare provider and can provide long-term contraception. - It is effective if inserted within **5 days** of unprotected intercourse, making it a highly effective option that also offers ongoing contraception. *Ulipristal acetate* - **Ulipristal acetate (UPA)** is a highly effective emergency contraceptive, even up to **120 hours (5 days)** after unprotected intercourse. - It works by delaying or inhibiting ovulation and is generally more effective than levonorgestrel, especially when taken more than **72 hours** post-coitally.

Q: Which one of the following is not a contraindication for prescribing combined oral contraceptive pills?

Pelvic inflammatory disease. ***Pelvic inflammatory disease*** - **Pelvic inflammatory disease (PID)** is NOT a contraindication for combined oral contraceptive pills (COCs). - According to **WHO Medical Eligibility Criteria**, PID is classified as **Category 1** (no restriction) for COC use. - COCs do not worsen PID and may actually provide some **protective effect** against ascending genital tract infections. - PID concerns are primarily relevant for **IUD insertion**, not oral contraceptive use. *Viral hepatitis* - **Active viral hepatitis** is a contraindication (WHO Category 3-4) for COCs. - COCs are metabolized in the **liver**, and use during active hepatitis can exacerbate liver damage. - **Severe or acute liver disease** impairs hormone metabolism, increasing risks of adverse effects. *Well-controlled hypertension* - **Hypertension** is generally a contraindication for COCs depending on severity and vascular complications. - **Well-controlled hypertension without vascular disease** is WHO Category 3 (risks usually outweigh benefits). - **Uncontrolled hypertension** (≥160/100 mmHg) or hypertension with vascular disease is **Category 4** (absolute contraindication). - Estrogen in COCs can further elevate blood pressure and increase cardiovascular risks. *Thromboembolic disease* - History of **thromboembolic disease** (DVT, PE, stroke) is an **absolute contraindication** (WHO Category 4) for COCs. - Estrogen in COCs increases synthesis of **clotting factors** (I, VII, X) and decreases anticoagulant proteins, significantly raising **venous thromboembolism risk**.

Q: LNG-20 (Mirena) is a third generation intra uterine device. What are the advantages of its use? 1. Low uterine pregnancy rates 2. Prevents anemia 3. Long effective life of 5 years 4. No effect on incidence of ectopic pregnancy Select the correct answer using the code given below:

1, 2 and 3. ***1, 2 and 3*** - LNG-20 (Mirena) significantly reduces the risk of **uterine pregnancy** due to its local progestin release, which thins the endometrium and thickens cervical mucus. - It often leads to **reduced menstrual blood loss** or even amenorrhea, thereby preventing or improving **anemia** in many users. - Mirena is effectively contraceptive for **up to 5 years**, providing a long-acting reversible contraceptive option. *1, 2 and 4* - While LNG-20 offers low uterine pregnancy rates and can prevent anemia, it **does not eliminate the risk of ectopic pregnancy** and may slightly increase its relative incidence if pregnancy occurs. - Therefore, the statement "no effect on incidence of ectopic pregnancy" is incorrect. *1, 3 and 4* - Although LNG-20 provides low uterine pregnancy rates and a 5-year effective life, the claim of "no effect on incidence of ectopic pregnancy" is **inaccurate**. - LNG-IUDs reduce overall pregnancy risk but if conception does occur, it's more likely to be ectopic than with no contraception. *2, 3 and 4* - LNG-20 does prevent anemia and has a long effective life, but it **does not have no effect on ectopic pregnancy incidence**; rather, it shifts the proportion of pregnancies that are ectopic if contraception fails. - It also provides low uterine pregnancy rates, making the exclusion of statement 1 incorrect.

Q: Tubectomy is commonly performed at which site of fallopian tube?

Isthmus. ***Isthmus*** - The **isthmus** is the **most common site** for tubectomy (tubal ligation) procedures. - It is the preferred location because it is **narrow, straight, and easily accessible** during surgery, making ligation technically simpler. - The isthmus has **relatively less blood supply** compared to other parts of the tube, reducing the risk of bleeding. - Common techniques like the **Pomeroy method** and **Parkland technique** are typically performed at the isthmus. - The narrow diameter ensures **complete occlusion** and reduces the risk of recanalization. *Ampulla* - The **ampulla** is the widest and longest portion of the fallopian tube, located between the isthmus and infundibulum. - It is **rarely chosen** for tubectomy because its wider lumen makes complete occlusion more difficult. - The ampulla has **higher vascularity**, increasing the risk of bleeding during surgery. - Greater risk of **incomplete blockage** and potential for recanalization. *Infundibulum* - The **infundibulum** is the funnel-shaped distal end with fimbriae that opens into the peritoneal cavity. - This site is **almost never used** for tubectomy due to its proximity to the ovary and technical difficulty. - Risk of damage to the fimbriae and ovarian blood supply. *Cornua* - The **cornua** (interstitial portion) passes through the uterine wall. - While sometimes used, it is **less common** than the isthmus due to increased technical difficulty. - Cornual resection carries higher risk of **uterine perforation** and **bleeding** from the uterine vessels. - May be chosen in specific clinical scenarios but not the standard first choice.

Question 1

Which one of the following is the most suitable situation for prescribing progestin only pill?

Accepted Answer

Lactating mother

Answer

Young patients

Answer

Emergency contraception

Answer

Woman with unexplained vaginal bleeding

Question 2

The highest incidence of ectopic pregnancy amongst contraceptive users is observed with:

Accepted Answer

Progestasert intrauterine device

Answer

Combined contraceptive pills

Answer

Levonorgestrel intrauterine system

Answer

Copper T intrauterine contraceptive device

Question 3

Laparoscopic sterilization is not recommended during the period of:

Accepted Answer

Immediate post partum

Answer

Post menstrual

Answer

Interval

Answer

Post first trimester MTP

Question 4

Female sterilization is contraindicated in which of the following well-controlled conditions?

Accepted Answer

None of the above

Answer

Diabetes mellitus

Answer

Heart disease

Answer

Hypertension

Question 5

Absolute contraindication for the use of OCPs is:

Accepted Answer

Thromboembolism

Answer

Diabetes

Answer

Epilepsy

Answer

Hypertension

Question 6

For a 40 year old hypertensive woman, which one of the following is not recommended for contraception?

Accepted Answer

NuvaRing

Answer

IUCD

Answer

Minipill

Answer

LNG IUD (LNg IUD)

Question 7

For a woman who has had unprotected intercourse two days ago, which one of the following emergency contraceptive methods is LEAST preferred as first-line emergency contraception?

Accepted Answer

Yuzpe regimen

Answer

Levonorgestrel 1.5 mg

Answer

LNG IUD

Answer

Ulipristal acetate

Question 8

Which one of the following is not a contraindication for prescribing combined oral contraceptive pills?

Accepted Answer

Pelvic inflammatory disease

Answer

Viral hepatitis

Answer

Well-controlled hypertension

Answer

Thromboembolic disease

Question 9

LNG-20 (Mirena) is a third generation intra uterine device. What are the advantages of its use?

1. Low uterine pregnancy rates
2. Prevents anemia
3. Long effective life of 5 years
4. No effect on incidence of ectopic pregnancy

Select the correct answer using the code given below:

Accepted Answer

1, 2 and 3

Answer

1, 2 and 4

Answer

1, 3 and 4

Answer

2, 3 and 4

Question 10

Tubectomy is commonly performed at which site of fallopian tube?

Accepted Answer

Isthmus

Answer

Infundibulum

Answer

Ampulla

Answer

Cornua

Contraception and Family Planning — MCQs

Contraception and Family Planning — MCQs

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