Contraception and Family Planning — MCQs

Contraception and Family Planning Indian Medical PG Practice Questions and MCQs

Question 401: Oral contraceptive pills (OCPs) are contraindicated in which of the following conditions?

A. Heart disease
B. Thromboembolism
C. Breast cancer
D. All of the above (Correct Answer)

Explanation: Combined Oral Contraceptive Pills (OCPs) contain estrogen and progesterone. The estrogen component (Ethinyl Estradiol) is primarily responsible for the major contraindications due to its metabolic effects on coagulation and the cardiovascular system. **Explanation of the Correct Answer:** The correct answer is **D (All of the above)** because each condition represents a Category 4 contraindication (Unacceptable health risk) according to the WHO Medical Eligibility Criteria (MEC): * **Thromboembolism:** Estrogen increases the hepatic synthesis of clotting factors (II, VII, IX, X) and decreases Antithrombin III. This creates a hypercoagulable state, significantly increasing the risk of Deep Vein Thrombosis (DVT) and Pulmonary Embolism. * **Heart Disease:** OCPs can worsen hypertension and increase the risk of myocardial infarction and stroke, especially in women with underlying ischemic heart disease or valvular disease complicated by atrial fibrillation or pulmonary hypertension. * **Breast Cancer:** Estrogen can stimulate the proliferation of breast tissue. OCPs are strictly contraindicated in patients with current or past history of breast cancer as they may promote the growth of hormone-sensitive tumors. **High-Yield Clinical Pearls for NEET-PG:** * **WHO MEC Category 4 (Absolute Contraindications):** * Smokers >35 years old (>15 cigarettes/day). * Migraine with aura (increased stroke risk). * History of CVA or CAD. * Active liver disease (Hepatitis, Cirrhosis, Tumors). * Undiagnosed abnormal uterine bleeding. * **Beneficial Effects:** OCPs are protective against **Ovarian** and **Endometrial** cancers (the "Rule of O&E"). * **Drug Interactions:** Enzyme inducers like **Rifampicin** and **Antiepileptics** (Phenytoin, Carbamazepine) decrease OCP efficacy, leading to breakthrough bleeding or pregnancy.

Question 402: What is the method used to diagnose a misplaced intra-uterine device?

A. Ultrasound
B. X-ray abdomen (erect view)
C. Uterine sound and hysteroscopy
D. All of the above (Correct Answer)

Explanation: **Explanation:** A misplaced Intra-Uterine Device (IUD) occurs when the device is either expelled, embedded in the myometrium, or has perforated the uterus to enter the peritoneal cavity. The diagnosis follows a systematic clinical and radiological approach. 1. **Ultrasound (USG):** This is the **initial investigation of choice**. It is highly effective at determining if the IUD is "in-situ" (within the endometrial cavity) or "eccentric" (displaced or embedded). If the IUD is not visualized on USG, it is considered "lost." 2. **X-ray Abdomen (Erect/AP view):** If USG is empty, an X-ray of the abdomen and pelvis is performed to locate an extra-uterine IUD. Since all modern IUDs (like Cu-T) are radio-opaque, X-ray helps confirm if the device is still within the body (perforated) or has been expelled unnoticed. 3. **Uterine Sound and Hysteroscopy:** A uterine sound can be used clinically to check for the device, but **Hysteroscopy** is the **gold standard** for diagnosing and managing intrauterine displacement or embedding. It allows direct visualization and retrieval of the device if it is still within the uterine cavity. **Why "All of the Above" is correct:** Diagnosis is a multi-step process. While USG is the first step, X-ray is mandatory to rule out translocation into the peritoneal cavity, and hysteroscopy provides definitive diagnosis for complex intrauterine misplacements. **High-Yield Clinical Pearls for NEET-PG:** * **First step/Initial investigation:** Ultrasound. * **To confirm translocation (perforation):** X-ray (if USG is negative). * **Gold Standard for intrauterine IUD:** Hysteroscopy. * **Management of Perforated IUD:** Laparoscopy is the preferred method for removal of a translocated IUD from the peritoneal cavity.

Question 403: Tubectomy in a patient who has recently delivered is best done after:

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

Explanation: **Explanation:** The timing of postpartum sterilization (Tubectomy) is critical due to the physiological changes in the uterus and the risk of infection. **Why 1 week is the correct answer:** Postpartum tubectomy is ideally performed **between 24 hours and 7 days (1 week)** after delivery. During the first week, the fundus of the uterus is still high (near the umbilicus), making the fallopian tubes easily accessible via a small sub-umbilical mini-laparotomy incision. Waiting until the end of the first week allows the patient to stabilize hemodynamically and ensures the newborn is healthy before performing a permanent procedure. **Analysis of Incorrect Options:** * **Immediately (Option D):** Performing surgery immediately after delivery is avoided due to the high risk of postpartum hemorrhage, hemodynamic instability, and the potential for increased infection. * **48 hours (Option A):** While often practiced for convenience, the "best" window extends up to a week. If done too early (within hours), the risk of reactionary hemorrhage is higher. * **2 weeks (Option C):** By 2 weeks, the uterus has undergone significant involution and descended into the true pelvis. This makes the tubes difficult to reach via a simple sub-umbilical incision, increasing the technical difficulty of the surgery. **High-Yield Clinical Pearls for NEET-PG:** * **Pomeroy’s Method:** The most common surgical technique used for postpartum tubectomy. * **Interval Sterilization:** If not done within the first week, it should be deferred for **6 weeks** (post-puerperium) to allow complete uterine involution. * **Laparoscopic Sterilization:** This is **contraindicated** in the immediate postpartum period due to the large, vascular uterus and is instead the preferred method for *interval* sterilization. * **Failure Rate:** The failure rate of tubectomy is approximately 0.5 per 100 women.

Question 404: Which contraceptive method is not an interceptive?

A. Cu-T
B. Norplant (Correct Answer)
C. RU-486
D. OC pills

Explanation: ### Explanation The core concept here is the definition of **Interception**. Interception (or post-coital contraception) refers to methods that act **after** fertilization but **before** implantation. They prevent the blastocyst from attaching to the uterine wall. **Why Norplant is the correct answer:** **Norplant** is a progestogen-only subdermal implant. Its primary mechanism of action is the **prevention of ovulation** (by suppressing LH surge) and thickening of cervical mucus to prevent sperm penetration. Since it is a long-acting reversible contraceptive (LARC) used *before* intercourse occurs, it is a primary contraceptive, not an interceptive. **Analysis of incorrect options:** * **Cu-T (Copper-T):** When used as emergency contraception within 5 days of unprotected intercourse, it acts as an interceptive by causing a sterile inflammatory response in the endometrium, making it hostile for a fertilized ovum to implant. * **RU-486 (Mifepristone):** This is an anti-progestational agent. It prevents implantation by blocking progesterone receptors in the endometrium or, if implantation has occurred, causes decidual breakdown. It is a potent interceptive. * **OC Pills:** High-dose Oral Contraceptive pills (specifically the Yuzpe regimen) can be used as emergency contraception. They act by delaying ovulation or altering the endometrium to prevent implantation, thus qualifying as interceptive. **High-Yield Clinical Pearls for NEET-PG:** * **Most effective emergency contraceptive:** Copper-T (failure rate <0.1%). * **Drug of choice for emergency contraception:** Levonorgestrel (LNG) 1.5 mg single dose (within 72 hours). * **Mifepristone dose for emergency contraception:** 10 mg to 25 mg (low dose). * **Interception vs. Abortion:** Interception acts *before* implantation (6th day); Abortion acts *after* implantation.

Question 405: What is the best contraceptive method for a newly married, healthy couple?

A. Barrier method
B. Intrauterine contraceptive device (IUCD)
C. Oral contraceptive pills (Correct Answer)
D. Natural methods

Explanation: **Explanation:** The choice of contraception for a newly married couple depends on efficacy, reversibility, and the need for "spacing." **Why Oral Contraceptive Pills (OCPs) are the best choice:** Combined Oral Contraceptive Pills (COCPs) are considered the **ideal first-line method** for newly married, healthy couples. They offer high efficacy (Pearl Index of 0.1 with perfect use), are independent of the coital act, and are **rapidly reversible**. Upon discontinuation, ovulation usually resumes within 1–2 months, making them perfect for couples who wish to delay their first pregnancy but want to conceive shortly after stopping the medication. **Analysis of Incorrect Options:** * **Barrier Methods (Condoms):** While they provide protection against STIs, they have a higher "typical use" failure rate compared to hormonal methods. They are often less preferred by couples seeking maximum contraceptive reliability. * **Intrauterine Contraceptive Device (IUCD):** These are generally preferred for **multiparous women** (spacing between children). In nulliparous women (newly married), there is a slightly higher risk of expulsion and a theoretical risk of Pelvic Inflammatory Disease (PID), which could impact future fertility. * **Natural Methods:** These (e.g., rhythm method, withdrawal) have the highest failure rates and require high motivation and regular cycles, making them unreliable for couples who strictly want to avoid early pregnancy. **Clinical Pearls for NEET-PG:** * **Ideal Candidate for OCPs:** Young, non-smoking, healthy women. * **Centchroman (Saheli):** A non-steroidal, once-a-week pill developed in India (CDRI, Lucknow); it is a SERM and is often a high-yield alternative in Indian exams. * **Contraindications for OCPs:** History of thromboembolism, undiagnosed vaginal bleeding, breast cancer, and heavy smokers >35 years. * **Non-contraceptive benefits of OCPs:** Reduced risk of ovarian and endometrial cancers, and improvement in dysmenorrhea/acne.

Question 406: Oral contraceptive pills provide protection against which of the following cancers?

A. Hepatic
B. Ovary (Correct Answer)
C. Cervix
D. Breast

Explanation: Combined Oral Contraceptive Pills (COCPs) exert a significant protective effect against certain gynecological cancers, primarily through the suppression of ovulation and the induction of a progestational state. ### **Explanation of the Correct Answer** **B. Ovary:** COCPs reduce the risk of **Epithelial Ovarian Cancer** by approximately 40–50%. The underlying mechanism is the **"Incessant Ovulation Theory."** By suppressing FSH and LH, COCPs prevent ovulation, thereby reducing repetitive trauma to the ovarian epithelium and lowering local inflammatory mediators. This protection begins after 3–6 months of use, increases with duration, and persists for up to 15–30 years after discontinuation. ### **Explanation of Incorrect Options** * **A. Hepatic:** COCPs are actually associated with an increased risk of benign liver tumors, specifically **Hepatic Adenomas**. They do not provide protection against hepatocellular carcinoma. * **C. Cervix:** Long-term use of COCPs (>5 years) is associated with a **slight increase** in the risk of Cervical Cancer, likely due to increased susceptibility to HPV or changes in the transformation zone. * **D. Breast:** The relationship is controversial, but most studies suggest a **minimal transient increase** in breast cancer risk during use, which returns to baseline 10 years after stopping. ### **High-Yield Clinical Pearls for NEET-PG** * **Dual Protection:** COCPs protect against both **Ovarian** and **Endometrial** cancer (the latter due to the progestogen-induced thinning of the lining). * **Colorectal Cancer:** COCPs also significantly reduce the risk of colorectal cancer (by ~15–20%). * **Benign Conditions:** They provide protection against Benign Breast Disease (fibroadenomas/cysts) and Pelvic Inflammatory Disease (PID) by thickening cervical mucus. * **Contraindication:** History of breast cancer is a Category 4 (absolute) contraindication for COCP use.

Question 407: What is the drug used for first-trimester abortion?

A. Oral mifepristone (Correct Answer)
B. Intra-amniotic saline
C. Extra-amniotic ethacridine lactate
D. Oxytocin infusion

Explanation: **Explanation:** Medical management of first-trimester abortion (up to 10 weeks or 70 days of gestation) primarily involves a combination of **Mifepristone** and **Misoprostol**. **Why Mifepristone is correct:** Mifepristone (RU-486) is an anti-progestational agent. It works by blocking progesterone receptors in the decidua, leading to decidual breakdown, cervical softening, and increased uterine sensitivity to prostaglandins. In the first trimester, the standard WHO and GOI protocol is **200 mg Oral Mifepristone** followed 24–48 hours later by **800 mcg Misoprostol** (vaginal, buccal, or sublingual). **Why other options are incorrect:** * **Intra-amniotic saline:** This is a hypertonic solution used historically for **second-trimester** induction. It is now largely obsolete due to risks of hypernatremia and maternal coagulopathy. * **Extra-amniotic ethacridine lactate:** This was a common method for **mid-trimester** (13–20 weeks) abortion. It acts as a local irritant to induce contractions but has been replaced by safer prostaglandin regimens. * **Oxytocin infusion:** Oxytocin is ineffective in the first trimester because the uterus lacks sufficient oxytocin receptors at this early stage. It is primarily used for labor induction at term or managing second-trimester losses after cervical ripening. **High-Yield Clinical Pearls for NEET-PG:** * **MTP Act 2021 Update:** Medical abortion is legal up to **24 weeks** under specific conditions, but the Mifepristone+Misoprostol "Medical Abortion Pack" is specifically validated for use up to **9 weeks (63 days)** in many clinical settings, though evidence supports use up to 10 weeks. * **Mechanism of Misoprostol:** It is a PGE1 analogue that causes uterine contractions and cervical ripening. * **Side Effects:** The most common side effect of Mifepristone is heavy bleeding; for Misoprostol, it is diarrhea and shivering.

Question 408: Previous ectopic pregnancy is a contraindication for which type of contraception?

A. Copper-containing IUD
B. Depot medroxyprogesterone acetate
C. Levonorgestrel-releasing IUS (Correct Answer)
D. Progestin-containing subdermal implant

Explanation: **Explanation:** The core concept in this question revolves around the **Medical Eligibility Criteria (MEC)** for contraceptive use. According to the WHO and CDC guidelines, a history of previous ectopic pregnancy is categorized as **MEC Category 3** (Risks outweigh benefits) for the **Levonorgestrel-releasing Intrauterine System (LNG-IUS)**. **Why LNG-IUS is the correct answer:** While all IUDs significantly reduce the *absolute* risk of any pregnancy (including ectopic), if a pregnancy does occur with an LNG-IUS in situ, the *relative* risk of it being ectopic is higher. The LNG-IUS primarily works by thickening cervical mucus and thinning the endometrium, but it can also cause partial suppression of ovulation and decrease tubal motility via local progesterone effect. In a patient with a damaged fallopian tube (from a previous ectopic), this further reduction in ciliary action and tubal motility increases the risk of a recurrent ectopic pregnancy. **Analysis of Incorrect Options:** * **Copper-containing IUD:** While also an IUD, it is generally considered MEC Category 1 or 2 for previous ectopic pregnancy. It does not have the hormonal effect on tubal motility seen with progestins. * **DMPA (Injectable) & Subdermal Implants:** These are highly effective systemic contraceptives that consistently inhibit ovulation. By preventing ovulation entirely, they provide the highest level of protection against both intrauterine and ectopic pregnancies (MEC Category 1). **High-Yield Clinical Pearls for NEET-PG:** * **Absolute Contraindications (MEC 4) for IUDs:** Current PID, unexplained vaginal bleeding, gestational trophoblastic disease, and distorted uterine cavity. * **Ectopic Risk:** The contraceptive method with the *highest* relative risk of ectopic pregnancy (if failure occurs) is the **Progesterone-only Pill (POP)** and **LNG-IUS**. * **Best Protection:** The best protection against ectopic pregnancy is a method that reliably inhibits ovulation (e.g., OCPs, Implants).

Question 409: Which of the following is NOT a method of contraception during lactation?

A. Lactational amenorrhea method
B. Intrauterine device (IUD)
C. Oral contraceptive pills (OCPs) (Correct Answer)
D. Progestin-only pills (Minipills)

Explanation: **Explanation:** The correct answer is **C. Oral contraceptive pills (OCPs)**. In the context of lactation, "OCPs" typically refers to **Combined Oral Contraceptive Pills (COCs)** containing both estrogen and progesterone. Estrogen is known to **suppress prolactin levels**, which leads to a significant decrease in the quantity and quality of breast milk. Therefore, COCs are generally avoided during the first 6 months of breastfeeding to prevent interference with infant nutrition. **Analysis of Options:** * **A. Lactational Amenorrhea Method (LAM):** A natural method based on the physiological suppression of ovulation by high prolactin levels. It is effective for up to 6 months if the mother is exclusively breastfeeding and remains amenorrheic. * **B. Intrauterine Device (IUD):** Both Cu-T and LNG-IUS are safe during lactation. They do not affect milk production. Postpartum IUCD (PPIUCD) can be inserted within 48 hours of delivery or after 6 weeks (involution). * **D. Progestin-only pills (POPs/Minipills):** These are the **contraceptives of choice** for breastfeeding mothers who desire oral hormonal contraception. Unlike estrogen, progestins do not affect milk volume or composition. **High-Yield Clinical Pearls for NEET-PG:** * **Timing of COCs:** According to WHO Medical Eligibility Criteria (MEC), COCs are MEC Category 4 (unacceptable risk) before 3 weeks postpartum and Category 3 (risks outweigh benefits) between 3 weeks to 6 months if breastfeeding. * **DMPA (Injectable):** Can be safely started 6 weeks postpartum in lactating women. * **Ideal Contraceptive:** Progestin-only methods (POPs, Implants) or Non-hormonal methods (Barrier, IUDs) are preferred during lactation.

Question 410: What is the typical cutoff time for Continuous Umbilical Transfusion (CuT)?

A. 1 minute
B. 2 minutes (Correct Answer)
C. 3 minutes
D. 4 minutes

Explanation: **Explanation:** The question refers to the timing of **Delayed Cord Clamping (DCC)**, often associated with the physiological process of placental transfusion. In modern obstetric practice, the "typical cutoff" or the optimal duration for DCC in a term neonate is generally accepted as **2 minutes**. **1. Why 2 minutes is correct:** Placental transfusion is a time-dependent process. Approximately 25% of the total placental blood volume is transferred to the infant within the first 15–30 seconds, and roughly **90% of the transfusion is completed by the end of 2 minutes**. Waiting for 2 minutes ensures the neonate receives an additional 80–100 ml of blood, significantly increasing iron stores and reducing the risk of iron-deficiency anemia in infancy without significantly increasing the risk of neonatal respiratory distress or symptomatic polycythemia. **2. Analysis of Incorrect Options:** * **1 minute (Option A):** While DCC is defined by many guidelines (like WHO) as occurring between 1–3 minutes, 1 minute is often considered the minimum threshold. At 1 minute, the transfusion is incomplete compared to the 2-minute mark. * **3 minutes (Option C):** Although beneficial, most of the physiological blood transfer has already occurred by 2 minutes. Waiting until 3 minutes provides diminishing returns and may unnecessarily delay neonatal resuscitation if required. * **4 minutes (Option D):** There is no significant clinical evidence suggesting additional benefits to waiting 4 minutes; it may increase the theoretical risk of hyperbilirubinemia requiring phototherapy. **High-Yield Clinical Pearls for NEET-PG:** * **WHO Recommendation:** Clamping should not be performed earlier than 1 minute after birth. * **Benefits of DCC:** Increased hemoglobin levels at birth and improved iron stores for up to 6 months. * **Preterm Benefit:** In preterm infants, DCC reduces the need for blood transfusions and decreases the incidence of Intraventricular Hemorrhage (IVH) and Necrotizing Enterocolitis (NEC). * **Contraindication:** DCC is contraindicated in cases of fetal distress, birth asphyxia requiring immediate resuscitation, or maternal hemodynamic instability (e.g., severe PPH).

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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