Forensic Medicine Related to Pregnancy and Trauma

Medicolegal Importance of Pregnancy, Delivery & Abortion

• Civil Circumstances:
  • Inheritance: A widow may claim pregnancy shortly after her husband's death to inherit his estate.
  • Divorce: A woman might claim pregnancy to receive greater alimony for her child.
  • Disputed Paternity: Accurate pregnancy duration estimation is crucial when a woman is accused of being pregnant while her husband is away, challenging paternity.

Criminal Circumstances

• Rape: A pregnancy arising from rape strengthens the accusation, and the victim may seek compensation.
• Capital Punishment: A pregnant female condemned to death penalty may use pregnancy to delay the execution.
• Suicide Attempts: Pregnancy might be a factor in cases of attempted suicide.

Signs of Pregnancy

• Presumptive Signs: These are not definitive medical proof, as they can occur in other non-pregnancy conditions.

  • Amenorrhea
  • Nausea and Vomiting (Morning Sickness)
  • Frequent Urination

• Breast Changes (2nd-3rd Months):

  • Increased firmness and tenderness
  • More prominent and visible veins
  • Darkening of the areola
  • Enlargement of Montgomery glands
  • Presence of colostrum

• Abdominal Wall Signs:

  • Abdomen enlargement evident in the 2nd trimester;
  • Linea nigra in the middle
  • Stria gravidarum (stretch marks) visible on the sides

• Uterine Enlargement:

  • 3rd month: uterus palpable just above the symphysis pubis
  • 4th month: fundus at the junction of lower 1/3 and upper 2/3 of line connecting symphysis pubis to the umbilicus
  • 5th month: fundus at the junction of lower 2/3 and upper 1/3
  • 6th month: fundus reaches the umbilicus level
  • 7th month: fundus reaches the junction of lower 1/3 and upper 2/3 line connecting the umbilicus to the xiphisternum
  • 8th month: fundus reaches the junction of lower 2/3 and upper 1/3
  • 9th month: fundus reaches the level of the xiphoid process

• Other Genital Changes:

  • Dark pigmented vulva
  • Vaginal mucosa becomes violet (from originally pink) due to increased vascularity and mucous secretion
  • Softening of the cervix (Hegar’s sign), originally firm as cartilage , by the 2nd month
  • Uterus enlarged, soft, and globular

• Palpable Uterine Contractions: Can be felt after 20 weeks

• Sure Signs:

  • Palpation of fetal parts, specifically the head and limbs (16 weeks)
  • Palpation of fetal movements (20 weeks)
  • Auscultation of fetal heart sounds (22 weeks, can also be detected via Doppler at earlier stages, between 12-14 weeks).
  • Key points to differentiation include rhythm (120-140 beats per minute), and distinctness from maternal pulse and uterine souffle.

• Fetal Heart sounds' Absence: Possible reasons for absence of fetal heart sounds include fatty abdominal wall, excess amniotic fluid, or fetal death.

• Pregnancy Tests: Based on the presence of human chorionic gonadotropin (hCG) in urine or blood.

  • Urinary Immunological Tests: Antigen-antibody reaction detecting hCG 2 weeks after missed period. Morning urine is optimal.
  • Blood Radioimmunoassay: Detects hCG 2 days after implantation, quantifies hCG levels.

• Ultrasound Scanning:

  • Visualizes the gestational sac and embryo (as early as 5 weeks).
  • Aids in pregnancy duration assessment, fetal disease identification, and age determination.

• Duration of Pregnancy:

  • The typical gestation period is 280 days (40 weeks ± 2 weeks), calculated from the first day of the last menstrual period.

• Dead Cases Exam Diagnostic Points:

  • Examine the uterus for weight, length, and contents.
  • Determine fetal age.
  • Perform microscopic examination of chorionic villi in early pregnancy.

• Gestational Period Determination:

  • Living individuals: Fundal level and ultrasound are used.
  • Dead individuals: Uterine weight and length are used to gauge the period of gestation (see chart for specific measurements and correlates)

• Artificial Insemination:

  • A medical procedure to induce pregnancy by inserting semen into the female genital tract beyond sexual intercourse.
    • Homologous (A.I.H.): Uses semen from the spouse, useful in cases of male infertility or hostile vaginal conditions.
    • Donor (A.I.D.): Utilizes a donor's semen, ethically contentious, with resulting offspring being unlawful.

• In Vitro Fertilization (IVF): Fertilizing an ovum outside the body and then placing the embryo in the uterus. Lawful if the sperm and egg are from the parents, and unlawful if sperm and/or egg are from a donor.

• Delivery:

  • Conditions requiring examination: Inheritance claims by widows, infanticide accusations, disputed maternity cases, kidnapping cases

• Signs of Recent Delivery (in the living, within 6 weeks):

  • General Signs: Pallor, exhaustion, rapid pulse, enlarged breasts containing colostrum, lax abdomen showing striae gravidarum and linea nigra.
  • Local Signs: Congested and swollen vulva, perineal tears or bruising, vaginal discharge ("lochia"; initially bloody, then pinkish, and finally white and turbid, lasting 14 days), a softer cervix), and a uterus that descends to a midpoint between the umbilicus and pubic symphysis within a week.

• Signs of Recent Delivery (in the dead):

  • Uterus demonstrates involution, showing reduced size and diminished weight, containing blood clots and reduced substance amount in the womb after delivery..
  • Laceration or bruising around the site of the placenta
  • Enlargment of the corpus luteum organ of the ovary
  • Dilated, bruised, and potentially lacerated vagina
  • Signs of episiotomy or perineal tears

• Signs of Remote Delivery (in the living):

  • Breast changes: lax, soft, pendulous breasts; enlarged nipples; dark areola.
  • Abdominal changes: lax abdomen; striae gravidarum; linea nigra.
  • Vaginal changes: labia do not completely close the vaginal orifice; possible scarring on the perineum.
  • Hymen ruptured
  • Vaginal mucosa smooth (loss of vaginal rugae or folds)

• Signs of Remote Delivery (in the dead): -Endarteritis obliterans evident at the placental site.

• Differences between parous and nulliparous uteri: (see chart for detailed comparison)

• Criminal Abortion:

  • Expulsion of pregnancy contents before full term, due to reasons beyond saving the woman's life.

• Conditions Requiring Abortion Examination:

  • Injuries resulting in alleged abortion.
  • Taking of medication for abortion.
  • Concealment of abortion after the accusation.
  • Post-abortion death necessitating examination.

• Methods of Abortion Induction:

  • General Violence: Violent exercises, jumping from a height, lifting heavy objects.
  • Local Violence (Non-professional): Instruments (knitting needles, wood), inserting foreign objects, using irritants (arsenic, mercury).
  • Local Violence (Professional): Catheter introduction, D&C; injecting hypertonic solutions, removing amniotic fluid and replacing it with a saline/glucose solution.
  • Abortifacient Drugs: • Ecbolics: Have specific action on the uterus leading to contraction (Ergometrine, Oxytocin, Prostaglandins PGE2 & F2, or Potassium Permanganate, Quinine or Lead) with varied effects and risks, such as vascular spasms and gangrene • Drastic purgatives (e.g. Colocynth, cantharides, castor oil, croton oil, jalap) • General prototoplasmic poisons (e.g. arsenic, antimony, mercury, lead oleate)

• Abortion Dangers (Complications):

  • Neurogenic shock (parasympathetic or sympathetic).
  • Hemorrhage (primary/secondary to retained products, sepsis)
  • Venous air embolism
  • Amniotic embolism
  • Acute poisoning
  • Disseminated Intravascular Coagulation (D.I.C)
  • Sepsis

• Abortion Diagnosis (Living Patients):

  • Consent of the patient
  • Patient history
  • Signs of pregnancy
  • Signs of general and local violence
  • Investigations (blood, urine, stools)
  • Products of abortion (precipitin test, fetal age determination)

-Abortion Diagnosis (Dead Patients): -Examine Peritoneum, GIT, Vagina, and Cervix, and Uterus as per the mentioned observations

• Autopsy Consideration for Air Embolism: Radiological examinations of the chest and abdomen pre-autopsy are required. Detection of air bubbles in the heart and major thoracic veins confirms the diagnosis.