ABORTION

(Medicolegal Aspects)
Col Dr Mohammad Asif Shahab
DEFINITION:
ABORTION: The expulsion of the products
of conception or termination of pregnancy
in the1st trimester (within 3 months) is
called abortion.
Miscarriage: The expulsion of the products
of conception or termination of pregnancy
in the second trimester (3-7 months) is
called miscarriage.
Premature Labour: The expulsion of the
products of conception or termination of
pregnancy in the 3rd trimester (7-9)
months) is called Premature Labour. All
above are medical definitions
LEGAL DEFINITION OF ABORTION
The expulsion of products of conception
or termination of pregnancy at any period
before full-term is called abortion (without
good faith)
According to Islamic law the abortion
definition.
ISQAT-I-HAML: SEC 338 A PPC
► Who ever causes a women with child whose
organ have not been formed to miscarry, if
such a miscarriage is not caused in good faith
for purpose of saving life or providing her
necessary treatment is said to cause ISQAT-I-
HAML.
► A women causing herself ISQAT-I-HAML is also
punishable
► ISQAT-I-HAML with the consent of women is 3
years imprisonment & without the consent 10
ISQAT-I-JANIN (Sec 338 B PPC)
► Who ever causes a women with child whose
organs have developed, to miscarry without
good faith is called ISQAT-I-JANIN.
► A women causing herself to miscarry is also
punishable under this section
► If child was born dead (1/2 the of diyat)
► If child was born alive but died by an act of
offender (Full diyat)
► Imprisonment for 7 years
► If more than one child separate diyat for each.
► If during miscarriage, hurt is caused to
women, separate punishment for hurt
TYPES OF ABORTION
A) Natural or Spontaneous Abortion or
Accidental Abortion
B) Artificial or Induced Abortion
Legal or justified Abortion
Illegal or criminal Abortion
CRIMINAL ABORTION
a) ISQAT-I-HAML (b) ISQAT-I-JANIN
 LEGAL OR JUSTIFIED ABORTION
a) Therapeutic ground
b) Eugenic ground (substantial reason)
c) Humanitarian ground (zina-bil-jabar victim)
d) Social grounds (Failure of contraceptives)
e) Environmental ground (Myocardial infarction patient)
CAUSES OF ABORTION
1) Natural or spontaneous abortion
a) General Diseases (high fever due to infections)
b) Diseases of the genital organs e.g. Inflammation,
Displacement, fibroid, tumors and congenital mal
formation of uterus.
c) Sudden shock, fear, joy, sorrow and reflex irritation
d) Accidental fall or blow on abdomen
e) Death of the fetus or degeneration of placenta
CAUSES OF THERAPEUTIC ABORTION
1) Heart failure, MI, Active and advance TB,
uncontrolled and severe diabetes mellitus.
2) Severe hypertension with heart or kidney
failure nephrotic syndrome
3) Pulmonary hypertension
4) Hepatic failure, acute hepatitis or
pancreatitis
5) Toxaemia of pregnancy
6) Hydatid form mole or acute hydramnios
7) Uterine hemorrhage
8) Malignant neoplasm of genital tract or
uterus
9) Irreducible prolapsed uterus
10) Threatened insanity
CAUSES OF EUGENIC ABORTION
a) Viral infections like German measles, chicken
pox, hepatitis (risk for child especially in 1st
trimester)
b) X-Ray and other radiation exposure of
pregnant mother
c) Use of catatonic drug like LSD or thalidomide
by mother.
d) When parents have some inheritable mental
disease or chromosomal abnormality.
CAUSES OF CRIMINAL ABORTION
1) To get rid of illegal pregnancy may be married
women or unmarried women, widow etc,
2) To conceal the crime
3) As differences/quarrel with the husband
4) For cosmetic purpose as in dancer and singers
5) For professional purpose as in prostitutes
METHODS OF ARTIFICIAL ABORTION
A) DRUGS (ABORTIFICIANT)
1) Acting directly on the uterus e.g. ergot,
quinine, pituitary extract and prostaglandins
(Embolic)
2) Causing increase menstrual flow
(Emmenagogue) eg synthetic, estrogen, oil of
swain, borax etc
3) Drugs acting indirectly on the uterus
a) Emetics eg Tartar
b) Purgatives eg castor oil
c) Essential oils eg turpentine
d) Metals eg lead
B) MECHANICAL VIOLENCE
a) Local b) General
GENERAL VIOLENCE:
Directly on uterus or indirectly by promoting
congestion of the pelvic organ
1) VIOLENT EXERCISES: Jumping, cycling,
playing tennis, golf, football, horse riding,
running up and down, lifting, heavy weight etc
2) Application of severe pressure on the abdomen.
eg blows or kicks on abdomen.
3) Cupping on hypo gastric region
4) Taking very hot and cold baths alternately
5) Massage of uterus per abdomen
6) Applying leaches on perineum or vulva
LOCAL VIOLENCE TO GENITAL ORGANS
a) Local irritation by local irritants
b) Dilatation of cervix with or without rupture of
membranes by following methods.
1) Self instrumentation
2) Abortion sticks
3) Syringing fluids in vagina and uterus under pressure
4) Dilatation of cervix by metallic dilators
5) Dilatation and curettage (D&C)
6) Rupture of membranes
7) Electric current application to genital organ
 SIGNS AND SYMPTOMS OF CRIMINAL
ABORTION
A) GENERAL SIGNS/SYMPTOMS
Anxious look & exhausted, pallor
face, uneasy gait and H/O frequent pad
change. Low BP, weak pulse.
B) SPECIFIC S/SYMPTOMS
1) Enlarged and tender uterus on palpation per abdomen
2) Os of cervix patulous and dilated
3) Tags of membranes are coming out in bleeding per
vaginal
4) Per vaginal lochial discharge
5) Signs of pregnancy and delivery (recent) on breast and
abdomen
6) Signs of poisoning may be present
7) Signs of local trauma
8) Signs of hypo volumic shock
9) Increased gonadotropic hormones in urine
COMPLICATIONS OF CRIMINAL ABORTION
1) IMMEDIATE COMPLICATION
Neurogenic shock or Vagal inhibition
2) EARLY COMPLICATIONS
a) Haemorrhage & shock
b) Air embolism
c) Fat or amniotic embolism
d) Perforation of uterus
e) Local sepsis or septicemia
3) LOCAL COMPLICATIONS
a) Tetanus
b) Prolapse uterus
c) Threatened & repeated abortion
d) Sterility due to adhesion of tissues
e) Renal failure
f) Menorrhagia
g) Leucorrhoea
CAUSES OF DEATH IN CRIMINAL ABORTION
1) IMMEDIATE OR SUDDEN CAUSES
Vagal inhibition due to intense pain
(Neurogenic shock)
2) EARLY CAUSES OF DEATH
a) Air or Fat embolism (20 min to 1 hour)
b) Haemorrhagic shock
c) Perforation of uterus and peritonitis
d) Septic shock due to septicemia
e) Poisoning due to drugs & chemicals used
for abortion
3) LATE CAUSES OF DEATH
a) Tetanus
b) Renal or hepatic failure
 DIFFERENCE OF NATURAL ABORTION AND
CRIMINAL ABORTION
Features Natural Abortion Criminal Abortion
Cause Natural Criminal
Genital tract injuries Not usually May be present
Foreign body in Nil May be present
genital tract
Sepsis Not usually Frequent may be
present
Signs of violence on Nil May be present
abdomen
Toxic drugs effects Nil May be present
Foetal injuries Nil May be present
 AUTOPSY FINDINGS OF
CRIMINAL ABORTION
1) Signs of pregnancy
2) Signs of recent delivery
3) Signs of violence (local & general)
4) Signs of poisoning (local or general or both)
5) Signs of haemorrhagic shock
6) Signs of septic shock
7) Signs of air& fat embolism
 MEDICO LEGAL ASPECT OF CRIMINAL
ABORTION
1) Whether abortion is criminal or natural
2) Cause of abortion (Drug, poison or
instrument or other violence)
3) Age of deceased
4) Whether abortion is homicidal, suicidal,
accidental or natural
5) Whether abortion is by un-skilled, semi-
skilled or skilled abortionist
PREGNANCY
Growth of fertilized ovum in the uterus is
called pregnancy.
SIGNS OF PREGNANCY
a) Presumptive sings
b) Probable signs
C) Positive or conclusive signs
A) PRESUMPTIVE SIGNS
1) Suppression of menstruation
2) Morning sickness
3) Sympathetic disturbances
4) Changes in breast
5) Pigmentation of skin ie linea Nigra
6) Quickning (After 4 months)
7) Changes in vagina (jacquemier’s signs or
Chadwick sign)
8) Urinary disturbances ie increase frequency
of urine
B) PROBABLE SIGNS OF PREGNANCY
a) CHANGES IN ABDOMEN:
Progressive enlargement of abdomen the
upper level of gravid uterus at different periods
of pregnancy is as follow :
1) Up to first 3 months in pelvic cavity
2) Fourth month just above the symphysis pubis.
3) Fifth month: Mid way between symphysis
pubis & navel.
4) Sixth month: At the level of navel or umbilicus
5) Seventh month: Midway between navel &
xiphisternum
6) Eighth month: At the level of xiphisternum
7) Later parts of ninth month & there after
xiphisternum
 Positive or conclusive signs of pregnancy
1) Hearing the fetal heart sounds between 4th
or 5th month
● 160/min at 5th month
● 120/ min at 9th month
2) Feeling of fetal movements and parts: (after
4th month)
3) Radiograph of the fetus after 4th month
possible
4) Ultra sonography
► Fetal heart sound 12th week
► Fetal head size, body growth and
physical abnormalities
 SIGNS OF PREGNANCY IN DEAD
1) Presence of an ovum or fetus in the uterus
2) Uterine change: Increase in size
3) Corpus luteum
MEDICO LEGAL ASPECTS OF PREGNANCY
1) Excuse to avoid court attendance as a witness
2) A convicted women take plea to avoid hard labour or
execution
3) Claim for more share from property of deceased
husband
4) She can claim damage of pregnancy by Zina-Bil-jabar.
5) She can blackmail the friends for marriage on ground
of pregnancy by him
6) When unmarried women a widow or a wife living
apart from husband is defamed she may like to
vindicate herself
7) When Women is accused of criminal abortion,
infanticide concealment of birth or pregnancy she may
like to vindicate herself or defend herself.
 DELIVERY
DEFINITION: Expulsion of infant or
neonate or products of conception at full
term
1) Signs of Recent Delivery in living
2) Signs of Remote Delivery in living
3) Signs of Recent Delivery in Dead
4) Signs of Remote Delivery in Dead
5) Signs of Recent Delivery in the
living
A) GENERAL APPEARANCE
► Probable pallor look, exhausted
physically & ill looking
► Pulse is rapid & weak or low BP & slight
increase in temperature
► After pains are present for 4-5 days. These
signs are absent in strong & healthy women
► Breasts are enlarged, tense and knotty.
Montgomery’s tubercle are present. Sliver
lines abdomen are seen. Surface veins are
dilated. On squeezing breast or mammary
glands colostrum can be ejected for 10 days
after delivery. It is replaced by milk thereafter
► Abdomen is lax and show linea nigra &
abdicans
► Vulva bruised & gaping
► Vagina is roomy, the fourchette & posterior commissure
destroyed & perineum may be ruptured.
► Uterus enlarged, hard & tender on palpation
► Fundus below the umbilicus & in 2-3 weeks it become pelvic
organ and reaches its original size in about 6 weeks.
► Cervix is soft & patulous or its edge are torn or lacerated
► The internal os & external os is soft & patulous and begins to
close in first 24 hours
► The external os closed in 2 weeks
► Vaginal discharge or lochia has peculiar colour, odour or smell
► Its contains red cells, WBC, decidous debris, vaginal epithelium
► During first 3 days, blood stained (lochia rubra)
► Next 3 days (4-6 days), It is paler & serous (lochia serosa)
► In 7-10 days is yellowish green and then white (lochia alba) and
disappears in about 15 days
B) SIGNS OF RECENT DELIVERY IN DEAD
● All signs mentioned in recent delivery in living
● After full term delivery the size of uterus
decreases towards normal in about 6 weeks as
following.
1) JUST AFTER FULL TERM DELIVERY:
Uterus size 22-23 cm long, 5 cm thick &
contains large blood clots & weight 900 gm.
2) AFTER 2-3 DAYS: 18 cm long, 4 cm thick &
weight 600 gm
3) AFTER 7 DAYS: 12-15 cm long, 3 cm thick &
weight 450 gm
4) AFTER 14 DAYS: 10-12 cm long, 3 cm thick &
wt. 300 gm
5) AT THE END OF 6 WEEKS: It reaches normal
size ie 7-8 cm long, 5cm breath, 2 cm thick &
wt. 100 gm
6) PLACENTAL SITES: Can be
determined 15 cm in diameters & contain
clotted blood, lymph & portions of
decidua (just after full term delivery)
7) At the end of 2nd week: Diameter of
placental site is 3-4 cm
8) Blood vessels opening: can be identified
up to 8-9 weeks after delivery
9) Ovaries & fallopian tubes: initially
congested & become normal in few days
10) Histological in doubt
11) Endothelium show trophoblastic
epithelium, ovaries show corpus luteum.
C) SIGNS OF REMOTE DELIVERY IN THE LIVING
1) Permanent sign of previous pregnancy
2) Breasts are lax, pendulous and soft linea
albican are present nipples enlarged with dark
areola around, Montgomery tubercles are
present. Milk can be squeezed from nipples.
Abdominal walls: Are lax and linea albicans &
linea nigra
Perineum: Ruptured scar formed
Hymen: Ruptured (loss of virginity)
Vaginal canal: open & gaping & Non ruggose
condition of its walls
SURE SIGN OF DELIVERY (REMOTE)
Internal os: Not well defined
External os: Transverse, irregular, fissured &
admit the tip of the finger.
 SIGNS OF REMOTE DELIVERY IN DEAD
1) Signs of previous pregnancy
2) Uterus: Larger, thicker and heavier than
nulliparous uterus, the walls are concave from
inside forming wider and rounded cavity as
compared to nulliparous uterus whose walls are
convex on inner aspect, triangular in shape or of
less capacity.
TOP OF FUNDUS OF UTERUS: Is convex & higher level
than that of broad ligaments as compared in nulliparous
women, it is at the level of broad ligaments.
BODY OF UTERUS: Is twice the length of cervix but in
nulliparous these are of same length.
ARBOR VITAE: (Mucosal folds in the cannel of uterine
cervix) which extends form internal or to external os.
Edges of the cervix: Scar formation due to previous
tears and lacerations caused during previous delivery.
INTERNAL & EXTERNAL OS: The internal os is not well
defined & external os in enlarged.
Histology of cut section of uterus: Show end arteries ob
literans can be seen in blood vessels for years.
MEDICO LEGAL ASPECT OF DELIVERY
1) Alleged abortion or infanticide
2) Feigned delivery
3) Concealment of birth
4) Legitimacy of child
5) Disputed charity
6) Blackmail cases
THANK YOU
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