Contraception and Family Planning Practice Questions

Q: The contraceptive choice for a 38 year old woman with chronic hypertension and history of dysmenorrhea and menorrhagia (malignancy ruled out) is:

Levonorgestrel intrauterine device. ***Levonorgestrel intrauterine device*** - The **Levonorgestrel IUD** is an excellent choice as it provides effective contraception while also treating menorrhagia and dysmenorrhea due to its local progesterone release. - It is safe for women with **hypertension** as it is a **non-estrogen-containing method**, avoiding the increased risk of thrombotic events associated with estrogen. *Copper intrauterine device* - While an effective non-hormonal contraceptive, the **copper IUD** can worsen **dysmenorrhea** and **menorrhagia**, which are existing concerns for the patient. - It does not offer any therapeutic benefits for her heavy and painful periods. *Sterilization* - Although it provides permanent and highly effective contraception, **sterilization** does not address the patient's symptoms of **dysmenorrhea** and **menorrhagia**. - It is an irreversible procedure and typically considered when no further childbearing is desired and symptomatic relief is not a primary concern for the contraceptive method itself. *Combined oral contraceptive pills* - **Combined oral contraceptive pills (COCs)** are generally contraindicated or used with caution in women with uncontrolled **hypertension** due to the estrogen component, which can increase the risk of cardiovascular events, including thrombosis. - While COCs can improve dysmenorrhea and menorrhagia, the cardiovascular risks in a 38-year-old with chronic hypertension outweigh these benefits.

Q: A 26 year old P2L2 has just had delivery. What are the contraceptive choices she has at present? 1. Post placental insertion of IUCD 2. Post partum ligation 3. Oral contraceptive pill 4. Lap ligation Select the correct answer using the code given below:

1 and 2 only. **1 and 2 only** - **Post-placental insertion of an IUCD** (Intrauterine Contraceptive Device) is a safe and effective immediate contraception option after delivery, as the cervix is still dilated, facilitating insertion. - **Postpartum ligation** (tubal ligation) is a common and highly effective permanent contraception method that can be performed shortly after delivery, often before discharge from the hospital. *2 only* - This option is incomplete as **post-placental IUCD insertion** is also a viable and often preferred immediate post-delivery contraceptive choice. - Limiting options to only postpartum ligation overlooks another readily available and effective method. *1, 2 and 4* - This option includes **lap ligation**, which typically refers to a laparoscopic procedure and is usually not performed immediately postpartum due to the enlarged uterus and increased vascularity, making it less ideal than ligation performed via mini-laparotomy shortly after delivery. - While laparoscopic approaches are possible later, **postpartum mini-laparotomy ligation** (which '2' likely refers to in this context) is the more immediate and common surgical approach. *1 and 3* - This option includes **oral contraceptive pills**, which are generally not recommended for immediate use in the postpartum period, especially for breastfeeding mothers, due to the potential impact on lactation and an increased risk of thromboembolism in the initial weeks after delivery. - **Progestin-only pills** can be considered later in the postpartum period, but combined oral contraceptives are typically delayed.

Q: Which one of the following statements regarding contraception is NOT true?

Vaginal ring is a barrier method. ***Vaginal ring is a barrier method*** - The **vaginal ring** (e.g., NuvaRing) is a **hormonal contraceptive** that releases estrogen and progestin, not a barrier method. - Its mechanism of action involves **inhibiting ovulation** and altering cervical mucus, unlike barrier methods that physically block sperm. *Copper T can be inserted just after delivery* - The **Copper T (IUD)** can be safely inserted immediately after delivery, ideally within **48 hours**, as a **postpartum IUD insertion**. - This timing is often preferred as the cervix is still dilated, and the woman is already in a healthcare setting. *Implanon is a hormonal contraceptive* - **Implanon** (now Nexplanon) is indeed a **hormonal contraceptive**, containing etonogestrel, a progestin. - It is an implantable rod that provides **long-acting reversible contraception (LARC)** for up to three years. *Copper T can be used as post coital contraception* - The **Copper T IUD** is highly effective as **emergency contraception** when inserted within **5 days** of unprotected intercourse. - It works by preventing fertilization or implantation, making it more effective than emergency contraceptive pills.

Q: Which one of the following IUDs is associated with a low pregnancy rate (0.2 per 100), less number of ectopic pregnancies and lower menstrual blood loss?

LNG-20 (Mirena). ***LNG-20 (Mirena)*** - This **levonorgestrel-releasing IUD** (Mirena) has a very low pregnancy rate (0.2 per 100 women-years). - It significantly **reduces menstrual blood loss** and cramps and is associated with a lower risk of ectopic pregnancies compared to copper IUDs because it thins the endometrial lining, making implantation less likely. *Cu T-380A* - The **Cu T-380A copper IUD** has a slightly higher pregnancy rate (around 0.6-0.8 per 100 women-years) compared to Mirena. - It is known to **increase menstrual blood loss** and dysmenorrhea, which is contrary to the question's criteria. *ML-Cu 375* - The **Multiload Cu 375** is another type of copper IUD, with a pregnancy rate similar to or slightly higher than the TCu-380A. - Like other copper IUDs, it typically **increases menstrual flow** and may worsen menstrual pain. *Progestasert* - **Progestasert** was an early progesterone-releasing IUD that had a higher failure rate and a shorter lifespan (1 year) compared to newer LNG-IUDs. - While it aimed to reduce menstrual blood loss, its **overall efficacy and duration of action** were inferior to the LNG-20 system.

Q: Which of the following is/are required for a registered medical practitioner to qualify for performing Medical Termination of Pregnancy (MTP), as per revised rules of MTP Act? 1. Certified for assisting at least 25 MTP in an authorized centre 2. Diploma or degree in Obstetrics and Gynaecology 3. House surgeon training for 6 months in Obstetrics and Gynaecology 4. Certified training for 6 months in laparoscopic surgeries Select the correct answer using the code given below:

1, 2 and 3. ***1, 2 and 3*** - As per the **MTP (Amendment) Act 2021 and Rules**, a registered medical practitioner (RMP) can perform MTP if they meet **any one** of the following qualifications: - Assisted at least **25 MTPs** in an authorized center - Hold a **diploma or degree in Obstetrics and Gynaecology** - Completed **house surgeon training for 6 months** in Obstetrics and Gynaecology in a recognized institution - All three statements (1, 2, and 3) represent valid pathways for qualification under the MTP Act, making this the correct answer. *2 only* - While a **diploma or degree in Obstetrics and Gynaecology** is indeed a valid qualification, it is not the *only* pathway recognized by the MTP Act. - Other pathways including practical experience (25 MTPs) and house surgeon training are equally valid qualifications. *1 only* - Assisting at least **25 MTPs** in an authorized center is a valid standalone qualification under the MTP Act. - However, this option is incorrect because statements 2 and 3 are also valid qualifications, not just statement 1 alone. *1, 2 and 4* - **Certified training for 6 months in laparoscopic surgeries** is **not a requirement** for performing MTP under the MTP Act. - While surgical skills are valuable, laparoscopic surgery training is not specifically mandated for MTP qualification, which primarily involves medical and surgical abortion procedures that don't necessarily require laparoscopic techniques.

Q: Which one of the following is NOT a contraindication for use of Mini pill?

Breast feeding. ***Breastfeeding*** - **Mini-pills**, which contain only progestin, are **safe for use during breastfeeding** as they do not significantly affect milk production or infant health. - They are often the **preferred hormonal contraceptive** for nursing mothers. - WHO Category 1 (no restriction) for breastfeeding women. *Pregnancy* - **Pregnancy** is a **contraindication** for any hormonal contraceptive, including the mini-pill. - The purpose of contraception is to **prevent pregnancy**, making its presence a clear reason not to start or continue the method. - WHO Category 4 (unacceptable health risk). *Thromboembolic disease* - **History of thromboembolic disease is NOT an absolute contraindication** for progestin-only pills (mini-pills). - Unlike combined oral contraceptives that contain estrogen, **mini-pills do not significantly increase the risk of thrombosis** as they lack the estrogen component responsible for clotting effects. - WHO Category 2 (advantages generally outweigh risks) for history of VTE. - This makes mini-pills a **safer alternative** for women with previous thromboembolism who need hormonal contraception. *History of breast cancer* - A **history of breast cancer** is a **contraindication** for hormonal contraceptives, including mini-pills, because steroid hormones can promote the growth of hormone-sensitive cancers. - Current breast cancer: WHO Category 4; past breast cancer with no evidence of disease for 5 years: WHO Category 3. - Alternative non-hormonal contraception methods are recommended in such cases.

Q: Contraindications for insertion of IUDs are all EXCEPT:

During cesarean section. ***During cesarean section*** - Immediate post-placental IUD insertion during cesarean section is **safe and effective** with proper technique and uterine assessment - This timing improves continuation rates by avoiding a separate office visit - WHO and ACOG guidelines support this practice, making it **NOT a contraindication** *Trophoblastic disease* - Gestational trophoblastic disease is a **contraindication** due to increased risk of uterine perforation - IUD insertion can mask disease recurrence and interfere with hCG monitoring - Must wait until complete resolution and hCG normalization *Suspected pregnancy* - IUD insertion in a pregnant uterus can cause **miscarriage, infection, or perforation** - Pregnancy must be **ruled out** before insertion - This is an **absolute contraindication** *Severe dysmenorrhea* - **Copper IUDs** are relatively contraindicated as they can worsen menstrual cramps and bleeding - However, **levonorgestrel-releasing IUDs (LNG-IUS)** are actually therapeutic for dysmenorrhea - As a general contraindication listing (without specifying IUD type), severe dysmenorrhea is traditionally considered a contraindication primarily for copper IUDs

Q: Indications for removal of IUDs are all EXCEPT:

Cyclical menstrual bleeding. ***Cyclical menstrual bleeding*** - **Normal cyclical menstrual bleeding** is an expected physiological event and not an indication for IUD removal. - While IUDs can alter menstrual patterns (e.g., heavier or lighter bleeding), typical cyclical bleeding that is not excessively heavy, painful, or prolonged usually does not warrant removal. *Pregnancy with IUD* - If a **pregnancy occurs with an IUD in situ**, especially in the first trimester, the IUD should ideally be removed to reduce the risk of spontaneous abortion, preterm labor, or infection. - Removal is especially crucial if the strings are visible and accessible; if not, close monitoring is necessary. *Flaring up of salpingitis* - **Salpingitis (pelvic inflammatory disease - PID)** is a serious infection that can be exacerbated or initiated by the presence of an IUD, particularly during insertion or in individuals with pre-existing infections. - A confirmed or suspected flare-up of salpingitis necessitates IUD removal to control the infection and prevent further complications like infertility or ectopic pregnancy. *Perforation of uterus* - **Uterine perforation** is a serious complication that can occur during IUD insertion and requires immediate removal of the device. - Depending on the extent of perforation, it may lead to pain, hemorrhage, infection, or damage to surrounding organs.

Q: What is the pathophysiological mechanism behind the increased risk of pelvic inflammatory disease with intrauterine device (IUD) insertion?

Introduction of vaginal bacteria during insertion procedure. ***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.

Q: 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?

Within 48 hours. ***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 1

The contraceptive choice for a 38 year old woman with chronic hypertension and history of dysmenorrhea and menorrhagia (malignancy ruled out) is:

Accepted Answer

Levonorgestrel intrauterine device

Answer

Copper intrauterine device

Answer

Sterilization

Answer

Combined oral contraceptive pills

Question 2

A 26 year old P2L2 has just had delivery. What are the contraceptive choices she has at present?

1. Post placental insertion of IUCD
2. Post partum ligation
3. Oral contraceptive pill
4. Lap ligation

Select the correct answer using the code given below:

Accepted Answer

1 and 2 only

Answer

2 only

Answer

1, 2 and 4

Answer

1 and 3

Question 3

Which one of the following statements regarding contraception is NOT true?

Accepted Answer

Vaginal ring is a barrier method

Answer

Copper T can be inserted just after delivery

Answer

Implanon is a hormonal contraceptive

Answer

Copper T can be used as post coital contraception

Question 4

Which one of the following IUDs is associated with a low pregnancy rate (0.2 per 100), less number of ectopic pregnancies and lower menstrual blood loss?

Accepted Answer

LNG-20 (Mirena)

Answer

Cu T-380A

Answer

ML-Cu 375

Answer

Progestasert

Question 5

Which of the following is/are required for a registered medical practitioner to qualify for performing Medical Termination of Pregnancy (MTP), as per revised rules of MTP Act?

1. Certified for assisting at least 25 MTP in an authorized centre

2. Diploma or degree in Obstetrics and Gynaecology

3. House surgeon training for 6 months in Obstetrics and Gynaecology

4. Certified training for 6 months in laparoscopic surgeries

Select the correct answer using the code given below:

Accepted Answer

1, 2 and 3

Answer

2 only

Answer

1 only

Answer

1, 2 and 4

Question 6

Which one of the following is NOT a contraindication for use of Mini pill?

Accepted Answer

Breast feeding

Answer

Pregnancy

Answer

Thromboembolic disease

Answer

History of breast cancer

Question 7

Contraindications for insertion of IUDs are all EXCEPT:

Accepted Answer

During cesarean section

Answer

Trophoblastic disease

Answer

Suspected pregnancy

Answer

Severe dysmenorrhea

Question 8

Indications for removal of IUDs are all EXCEPT:

Accepted Answer

Cyclical menstrual bleeding

Answer

Pregnancy with IUD

Answer

Flaring up of salpingitis

Answer

Perforation of uterus

Question 9

What is the pathophysiological mechanism behind the increased risk of pelvic inflammatory disease with intrauterine device (IUD) insertion?

Accepted Answer

Introduction of vaginal bacteria during insertion procedure

Answer

Inhibition of local immune responses by copper

Answer

Direct trauma to endometrial tissue

Answer

Enhancement of bacterial adhesion by IUD string

Question 10

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?

Accepted Answer

Within 48 hours

Answer

After 6 weeks

Answer

After 3 months

Answer

After 1 month

Contraception and Family Planning — MCQs

Contraception and Family Planning — MCQs

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