Medicolegal Importance of Pregnancy, Delivery & Abortion PDF

Medicolegal Importance of Pregnancy, Delivery & Abortion Dr. Isam ELHASSAN  Conditions in which pregnancy is of medicolegal importance A. CIVIL CIRCUMSTANCES: 1. Inheritance: a widow may allege pregnancy soon after her husband’s death, to inherit her dead husband. 2. Divo...

Medicolegal Importance of Pregnancy, Delivery & Abortion Dr. Isam ELHASSAN  Conditions in which pregnancy is of medicolegal importance A. CIVIL CIRCUMSTANCES: 1. Inheritance: a widow may allege pregnancy soon after her husband’s death, to inherit her dead husband. 2. Divorce: a woman may allege pregnancy to get more alimony for her child. 3. Disputed paternity: When a woman is accused of being pregnant while her husband is away, then the estimation of the duration of pregnancy, here is very important. B. CRIMINAL CIRCUMSTANCES: I. Rape: the accusation will be greater if pregnancy occurred as a result and the girl may ask for compensation. 2. Capital sentence of death: If a female is condemned to capital sentence of death she may allege pregnancy to delay the time of execution. 3. In cases of suicidal attempts, pregnancy could be expected as the motive for suicide.  signs of pregnancy I. Presumptive symptoms & signs of pregnancy: These signs and symptoms are not accepted medicolegally to diagnose pregnancy as they may occur with other conditions. 1. Amenorrhea. 2. Nausea and Vomiting (Morning Sickness). 3. Frequent Urination. 4. Breast Changes: (2nd — 3rd months) (a) Increased firmness and tenderness of the breasts. (b) More prominent and visible veins due to the increased blood supply. (c) Darkening of the areola: the brown part around the nipple. (d) Enlargement of Montgomery glands:, the tiny nodules or sebaceous glands within the areola. (e) Presence of colostrum. 5. Abdominal wall signs: Enlargement of the abdomen (2nd trimester) with Linea nigra in the middle line and stria gravidarum (stretch marks) on the sides. 6. Abdominal enlargement This gradually occurs as the uterus increases in size from below upwards - In the first three months the uterus is a pelvic organ. - After the third month it becomes abdominal. Enlargement of the body of the uterus: 3rd month: the uterus is felt just above the symphysis pubis. 4th month: the fundus is at the junction of the lower 1/3 with the upper 2/3 of the line joining the symphysis pubis to the umbilicus. 5th month: it is at the junction of the lower 2/3 with the upper 1/3 of this line. 6th month it reaches the level of the umbilicus. 7th month it reaches the junction of the lower 1/3 with the upper 2/3 of the line joining the umbilicus to the xiphi-sternum. 8th month it reaches the junction of the lower 2/3 with the upper 1/3 of this line. 9th month it is as high as the xiphoid. 7. Palpable uterine contractions can be felt from 20 weeks. 8. Genital changes: - Dark pigmented vulval mucosa. - The vaginal mucosa becomes violet (originally pink) due to increased vascularity and increased mucous secretion. - The cervix is softened (Hegar’s sign) by the 2month (originally hard as cartilage). - Uterus becomes enlarged, soft, and globular.  II- Sure signs of pregnancy 1. Palpation of fetal parts especially the head and the limbs at 16 weeks. 2. Palpation of fetal movements at 20 weeks. 3.Auscultation of fetal heart sounds. This can be achieved using fetal stethoscope only at 22 weeks. It is audible also with a Doppler at an earlier stage in pregnancy at 12 -14 weeks. The, rate of the fetal heart sounds is 120-140 beats/minute and is of regular rhythm. It should be differentiated from the maternal pulse and from the uterine souffle (which is a soft blowing murmur heard over the uterus due to pulsation of blood through enlarged uterine artery). ▪ Sometimes, the fetal heart sounds are not heard e.g. - When the abdominal wall is very fatty. - When there is excess liquor. - When the fetus is dead in uterus. 4. Pregnancy tests: These tests are based on the presence of human chorionic gonadotropin (HCG) in the urine or blood of pregnant females. A. Urinary Immunological Tests: It is an antigen-antibody reaction. These tests detect HCG 2 weeks after the first missed period. The first urine specimen of the morning is the best one to use. The chorion of the blastocyst secretes human chorionic gonadotrophin. Urine + anti HCG →Agglutination (+ TEST). Disadvantages: false positive result when there is excess luteinizing hormone (LH) both have identical α subunits. Tumors of anterior pituitary or postmenopausal. B. Blood Radioimmunoassay: can detect HCG in the blood 2 days after implantation. Not only this method detect HCG, but it can also measure its quantity. 5. Ultrasound scanning of the fetus: The gestational sac can be seen and photographed. An embryo as 5 week after conception can be identified. It helps to diagnose pregnancy, duration, diseases and age of fetus. DURATION OF PREGNANCY This is important in cases of pregnancy in absence of the husband and he is disputing the paternity. The normal duration of pregnancy is 280 days, calculated from the 1st day of last menstrual period , or 40 weeks ± 2 weeks. Diagnosis of pregnancy in dead: The uterus should be examined for wt., length and content. Determination of the age of the fetus. In early pregnancy microscopic examination for chorionic villi is of a value. ❖ Determination of the period of gestation: I. In the living: ▪ Fundal level. ▪ Ultrasonography. ll. In the dead: Through the weight and length of the uterus. Length of the uterus in Calendar month of inches pregnancy 7&6 (2+) 5& 4 10 & 9 (3+) 7 & 6 13 & 12 (4+) 9 & 8 ❖ Artificial Human Insemination: It is a medical procedure to induce pregnancy through instillation of semen into the genital tract of the female, by mean other than sexual intercourse. Types: A.I.H.(Artificial insemination Homologous): The semen is obtained from the spouse. It is recommended in cases of male impotence, hostile vaginal discharge. It is a legal procedure.  A.I.D. (Artificial Insemination Donor): The semen in this type is obtained from a donor. So it is against good morals and religions, and the resulting child is illegal. ❖ Invitro Fertilization (IVF): In which fertilization of the ovum is induced outside the body of the individuals, then the fertilized ovum is embedded in the uterus. In cases of failure of normal fertilization of the ovum (female sterility due to other pathological causes than anovulation). If semen obtained from the husband and the ovum from his wife considered a legal procedure, otherwise it is illegal.  DELIVERY ❖ The medicolegaI conditions in which a female is examined for sign of delivery are: I. Inheritance: When a widow alleges that she delivered an infant to inherit a dead husband. 2. Infanticide: when a woman is suspected to be the mother of a killed newly born infant. 3. Disputed maternity: when two women are alleging to be the mother of a certain child. The age of the fetus must coincide with the date of labor of the woman. 4. In cases of kidnapping of a newly born infant.  ❖ Signs of recent delivery in the living: (within 6 weeks) A. General sign: I. Pallor, exhaustion and rapid pulse. II. Breasts are enlarged and contain colostrum. III. The abdomen is lax and shows striae gravidara and linea nigra. B. Local sign: I. The vulva is congested and swollen, The perineum may show tears or bruising 2. Presence of vaginal discharge “lochia”: It is bloody for the first 4 to 5 days, pinkish for another 5 days then gradually looses all color, becoming white and turbid until its final disappearance in 14 days. 3. The cervix: The internal os closes within 24 hours. The external os is soft and patent and it may show recent tear. It admits 2 fingers for 3-4 days. one finger by the end of the Ist week to close by 2 weeks and becomes button-bole shaped. 4. The uterus starts to decrease in size (involution). Just after delivery it is 2-3 fingers above the umbilicus. After 1 week it becomes midway between the umbilicus and the symphysis pubis. In 2 weeks it becomes a pelvic organ to reach its normal size in 6 weeks.  ❖SIGNS OF RECENT DELIVERY IN THE DEAD: In addition to the above signs, autopsy shows: 1. The involution of the uterus (observed from its length and weight). Soon after delivery, it weighs about 1kg. it contains large clots of blood. - At one week it weighs 500 g. At 2 weeks it weighs 375 g. At 6 weeks it weighs 100 g. 2. The site of the placenta in the uterus appears as a bruised and lacerated area 3. The ovary shows a large corpus luteum. 4. The vagina is dilated, bruised and may be lacerated. 5. There may be signs of episiotomy or perineal tear.  ❖SIGNS OF REMOTE DELIVERY IN THE LIVING A:parous female usually presents certain permanent body changes: 1-Breast is lax, soft and pendulous with enlarged nipple and dark areola. 2. The abdomen is lax and shows striae gravidara and linea nigra. 3. The labia do not completely close the vaginal orifice and there may be scars of old tears in the perineum. 4. The hymen is completely ruptured. 5. The vaginal mucosa is smooth (loss of vaginal rugae “arbora vitae” that are present in nullipara). 6. The external os in multipara is usually transverse (slit-like), fissured and may show old scar. In nullipara it is a small round opening with smooth edges. SIGNS OF REMOTE DELIVERY IN THE DEAD 1- The placental site may show endarteritis obliterans. 2- As in the living. In addition examination of the uterus may differentiate between parous and nulliparous uteri: Differences between parous and nulliparous uterus: Nulliparous Parous Item inch 2 inch 3 Length of uterus Less than double More than double Length of body/cervix Triangular Globular The cavity Thick Thin The uterine wall Rounded narrow Transverse slit External cervical hole with scar os  Criminal abortion (illegal Abortion) ❖ Def. abortion: it is expulsion of the contents of the gravid uterus at any time before full term. ❖ Criminal abortion: induction of abortion due to any reasons other than saving the mother’s life. ❖ Medicolegal conditions in which a female is examined for abortion: A women alleges that she has been aborted after a blow or a kick to inflect more penalty on the assailant. Also, to take a compensation after a transportation accident. A women may notify that a physician brought her into abortion by giving her some abortificient drugs. A women may try to conceal abortion after being charged with it. A dead women after abortion to investigate the case. ❖Methods of induction 1- General violence: Violent exercises. Jumping from a height. Carrying heavy weights. N.B: abortion cannot occur except in women liable to it. 11- Local violence: A- Non professional persons: Instrumental (foreign body) Interference: To disturb the pregnancy sac. Once the sac damaged it will be expelled by uterine contractions. use knitting needle, piece of wood, and all types of instruments as surgical dilator. Vaginal plug containing irritant poisons (arsenic or mercury).  Insertion of a rubber pump usually a Higginson enema syringe to flushing fluid (antiseptic solution as glycerin& iodine)into the cavity of the uterus which separate the sac from the interior of the uterus. ▪ The main complication is air embolism. B- In medically trained people: Introduction of the catheter into the uterus. D& C. Syringe aspiration: through the cervix. Intrauterine injection of hypertonic saline or glucose: in the second trimester. With a long needle amniotic fluid is removed and replaced with a corresponding volume of 20% saline or 50% glucose. In most cases expulsion takes place within 24-48 hours. Dangers of the local violance: Perforation of the uterus, mid vagina, instrument passes through coils of intestine as far as the liver. Sever bleeding and infection. Cervical shock, the mere dilatation of the cervix in un anesthetized patient may trigger a vagal reflex leading to cardiac arrest.  Methods of induction 111-Abortifacient drugs: Classified according to their mode of action: A. Ecbolic: Have specific action on the uterus leading to its contraction e.g. Ergometrine: Its effect is greater late in pregnancy. Excess dosage leads to peripheral vascular spasm and gangrene. Oxytocin: Induces uterine contractions specially late in pregnancy. (posterior lobe of pituitary). Prostaglandins: PGE2 & F2 applied locally in a form of pessaries, it is very effective in triggering contractions.  Potassium Permanganate: Causes local necrosis of the vagina, renal failure. Potassium Iodine locally erodes the cervix. Quinine: The dose required for any effect on the uterus is high which cause metHb & blindness. Lead: It is general protoplasmic poison. B. Drastic purgatives: lead to reflex uterine contraction through the strong irritation of GIT e.g. ▪ Colocynth. ▪ Cantharides. ▪ Caster oil. ▪ Croton oil. ▪ Jalap. C. General protoplasmic poisons: lead to death of ovum and its expulsion e.g. ▪ Arsenic. ▪ Antimony. ▪ Mercury. ▪ Lead oleate. ❖Dangers (Complications) of abortion 1- Neurogenic shock: ▪ Parasympathetic: reflex cardiac inhibition due to touching of the cervix with an instrument, sudden dilatation of the cervix. ▪ sympathetic: due to severe pain due to perforation of the uterus. 2- Haemorrhage: ▪ 1ry: *intrauterine due to retention of some part of ovum or placenta. *intraperitoneal due to perforation of the uterus. ▪ 2ry: occurs due to sepsis. 3- venous air embolism: Air introduced into the uterine veins. 4- Amniotic embolism. 5- Acute poisoning: Rapid absorption of poison from vaginal mucosa (arsenic plug). 6- DIC: As complication of severe post- abortion bleeding. 7- Sepsis: [septicemia or toxemia]: – In instrumental abortion: occurs early in the 1st 3 days – In non instrumental: delayed & occurs after a week or more.  ❖Diagnosis of abortion 1- In the living: Patient’s consent: for examination. History. Signs of pregnancy: breast and abdominal change; pregnancy test remain +ve for 2 weeks after abortion. Signs of generals violence. 1- In the living: Cont. Signs of local violence: ▪ Cervix: os is dilated with recent laceration, bloody discharge ▪ Vagina: irritation or laceration, foreign body as metallic plugs& embryonic tissue as placenta or embryo. 1- In the living: Cont. Laboratory investigation: blood & urine and stools for abortifacient drugs. Products of the abortion: ▪Precipitin test for products. ▪Age of the fetus is estimated and compare with history. ▪Fetus, macerated intrauterine fetal death or not. 2- Diagnosis of abortion In the dead: Signs of living in addition to: Peritoneum: May show peritonitis& perforated or ruptured uterus. GIT: May show irritation due to purgatives.  Vagina: Must be examined for congestion, bruises & presence of foreign body. Cervix: Must be examined for laceration, foreign body, fetal tissue & vulsellum marks. Uterus: Size, content & inflammation of endometrium. ❖ In autopsy: When air embolism is considered pre-autopsy radiology of chest and abdomen must be performed. Air bubbles in the heart, great veins of the thorax can establish the diagnosis of air embolism.  Open the heart chambers under water in the pericardial sac. Frothy contents of the right ventricle is diagnostic for air embolism. In advanced centers where MRI facilities are available for autopsy material, the chance of diagnosis is very much increased.. The end