featuresvirginityDefloration 1.Basic differenceNo experience of sexual intercourseHave experience of sexual intercourse 2.hymenIntactTorn except in false virgin 3.introitusDoes not admit more than tip of little finger, it is painful May admit 2 fingers, it is painless 4.vagina.Marked rugosity on wall Full length of a finger cannot be admitted Rugosity diminishes Full length of finger can be admitted 5.Fossa navicularisLess conspicuousMore conspicuous after sexual intercourse 6.FourchetteIntactHealed tear 7.Labia minoraSmaller pinkish, covered with majora enlarged, pigmented, not covered 8.Labia majoraThick, fleshy, both majora are in close apposition Less fleshy, not in full apposition 9.BreastsSmaller, firm, pinkish smaller areola, and small nipple Larger, flabby, pendulous, wider areola, large and raised nipple
Trauma or Accident Surgical operation or Gynaecological examination Sanitary tampons Foreign body – sola pith (APTAE VARIS) Scratching due to irritation from uncleaniness Masturbation Ulceration – d/t diphtheria, fungus, etc. Other conditions which may affect signs of virginity
False Virgins Hymen is intact but the woman has had sexual intercourse.
Point of difference True virginFalse virgin 1.Basic differenceThe woman has no experience of sexual intercourse Has experience of sexual intercourse 2.HymenNot ruptured. It is thin flap of tissue of regular shape and appearance Not ruptured. It is thick, fleshy or fibrous elastic with folds 3.IntroitusDoes not admit more than the tip of little finger, it is painful May admit 2 fingers, it is not painful 4.Vagina.Marked rugosity on wall Full length of a finger cannot be admitted Rugosity diminishes Full length of finger can be admitted
5.Fossa navicularis Less conspicuousMore conspicuous after sexual intercourse 6.FourchetteIntactHealed tear 7.Labia minoraSmaller pinkish, covered with majora enlarged, pigmented, not covered 8.Labia majoraThick, fleshy, both majora are in close apposition Less fleshy, not in full apposition 9.BreastsSmaller, firm, pinkish smaller areola and small nipple Larger, flabby, pendulous, wider areola, large and raised nipple
Medico legal importance of virginity In Civil cases : 1.Nullity of marriage 2.Divorce 3.Defamation of character 4.Rape
Pregnancy It is a physiological condition develops in a female with in her child bearing age due to fertilisation of ova by spermatozoa results in developing embryo or foetus in the uterus till its birth. Signs of pregnancy in living: 1.Presumptive signs 2.Probable signs 3.Positive or conclusive signs
Presumptive signs of pregnancy Amenorrhoea Morning sickness Changes in breasts Changes in the Vagina Urinary disturbances- increased frequency of micturition Chloasma - 24 th week Quickening - 16 – 20 weeks Linea nigra - 20 th week Striae gravidarum Sympathetic change -increased salivation -PICA (perverted appetite) -irritable temper.
Changes in Breasts : Breasts enlarged & nodular(2 nd month) Surface veins prominent Areola enlarged, pigmented with prominent Montgomery’s tubercles (2 nd month). Nipples enlarged Colostrum (3 rd month). Changes in Vagina : Jackquemier’s sign or Chadwick’s sign: violet or bluish discolouration of vaginal mucosa (after 4 th week).
PROBABLE SIGNS OF PREGNANCY Enlargement of abdomen Height of uterus. Palmer’s sign- regular rhythmic contractions of uterus at 4 th to 8 th week.
Goodell’s sign -softening of cervix at 4 th month Osiander’s sign – increase pulsation felt through lateral fornices at 8 th week ‘Piskacek’s sign – asymmetrical enlargement of uterus if there is lateral implantation. Goodell’s sign
PROBABLE SIGNS OF PREGNANCY Braxton-hick’s sign -After weeks of pregnancy Ballottement: internal and external (during 4 th and 5 th month) Uterine soufflé at end of 4 th month Biological tests : Presence of gonadotropins in pregnant woman’s blood and their excretion in urine External ballottement Internal ballottement
Immunological tests : a)Inhibition (Indirect) Latex slide test b)Direct Latex slide test Haemagglutination inhibition test. RIA and ELISA
POSITIVE SIGNS OF PREGNANCY Auscultation of foetal heart sounds- positive after wks Palpation of foetal part Feeling foetal movements Radiograph of foetus -after 3 months USG : 6 wks - Gestational sac 7 wks - Embryo 10 wks - Heart beat 14 wks - Head and Thorax Presence of foetal cells in mother’s blood.
Signs of pregnancy in Dead Products of conception Enlarged Uterus & other uterine change. Corpus luteum
Medicolegal importance of pregnancy In Civil cases : Nullity of marriage Inheritance of property Higher maintenance allowance in case of divorce Compensation cases Illegitimate baby Maternity leave Compensation case if allegation of pregnancy against unmarried woman or widow.
In Criminal cases : Execution of death sentence. Advantage during trial in court. It is positive proof in a trial of rape. An unmarried pregnant woman bring a charge of criminal breach of trust against a man. Adultery. In criminal abortion and to foeticide or infanticide. Motive for suicide or murder.
1. Uterine soufflé may be heard by auscultation at the end of- a)10wks b)12wks c)14wks d)16wks 2. Foetal parts can be detected by X ray usually by- a)8wks b)12wks c)14wks d)16wks
3. A pregnant woman sentenced to death cannot be hanged till- a)Delivery b)Delivery and attainment of 6 months of age by new born c)Delivery and one year after that d)None of the above 4. Pseudocyesis is found in- a)Young married woman b)Aged unmarried girl c)Menopausal ladies d)Adolescent girl
5. Impregnation of an ovum discharged from a previous ovulation has been developed is called- a)Fecundation b)Superfecundation c)Super foetation d)None of the above 6. Which of the following statements is true for virgo intacta- a)Breasts are large and nodular b)Labia majora not apposed with each other c)Fossa navicularis is disappeared d)Labia minora completely covered by labia majora
DELIVERY Definition : Expulsion of products of conception from within the uterus at term.
Signs of Recent delivery in Living : General appearances of indisposition : Woman looks pale, exhausted and ill. Breasts : Enlarged, full, firm, tense. Darkening of areola. Prominent Montgomery tubercles. Surface veins are prominent. Striae are seen. Colostrum can be squeezed out for 2-3 days after delivery.
Abdomen : Striae gravidarum (pink) Lineae albicantes (silvery white) Linea nigra (black) External genitalia : Labia are tender, swollen and lacerated. Fourchette is ruptured. Perineum is lacerated. Internal os begins to close within 24 hrs External os is patent admitting two fingers initially and later one finger with difficulty at the end of a week. Vaginal discharge known as Lochia ( for 2-3 weeks) : During first 4-5 days -lochia rubra (red) During the next 4 days -lochia serosa (pale or serous) After 9th day -lochia alba (yellowish grey or turbid)
Signs of Recent delivery in Living : Extent of signs depends upon whether the woman is primiparous or multiparous Breast: pendulous Hyperpigmentation present Montgomery's tubercles are prominent Stria are present Abdomen: abdominal wall is lax Linea albicantes Linea nigra
Signs of Remote delivery in Living : External genitalia: labia are lax Vaginal rugae are lost Fourchette is lost Hymen: carunculae myrtiformis Os in Nulliparous:- Internal os is well defined - External os is rounded and orifice closed Os in Multiparous:-Internal os is not well defined External os is transverse irregular and may admit a tip of finger
Sign of Recent delivery in the Dead : Same as are found in living Additional findings are found in uterus and its appendages Uterus is firm and returns to a permanent reduced size Placental site can be identified by its dark colour and coarse granular appearance and covered with blood clots, lymph and decidua. Ovaries and fallopian tubes are congested Histopathological examination: - trophoblastic cells and chorionic villi are present in endometrium - one large corpus luteum is present in one ovary
Signs of Remote delivery in Dead : Same as are found in remote delivery in living Additional findings are present in uterus and its appendages Uterus is concave inwards. Fundus is above the line of fallopian tube Length of body is twice the length of cervix in multiparous and it is equal in nulliparous. External os is enlarged, irregular and patulous and admits tip of finger Internal os is not well defined Arbor vitae: lost in parous woman
Different measures immediatelyAfter3daysAfter1 weekafter2weeksafter3weeks Outer length20cm17cm14cm12cm10cm Outer breadth13-14cm10cm8cm7cm6cm Thickness5cm 4cm3cm2.5cm Inner length15cm12cm10cm8cm7cm Weight1kg7oogm500gm300gm80-100gm Dia of the site of placental attachment 10cm7cm4cm2.5cm1.5cm
Point of differencesnulliparousparous size7cm x 5cm x 2 cm10cm x 6cm x 2.5cm weight40 gm gm Ratio between Body/CervixEqual2:1 Upper surface of fundusLess convexMore convex Uterine cavityconvexconcave Scar for placental attachmentabsentpresent External osroundtransverse Internal osCircular, well definedIll defined, margin wrinkled
Abortion Definition : “Termination of pregnancy due to premature expulsion of product of conception at any time from the uterus.”
Medical termination of pregnancy (MTP)act 1971 Came into force in 1972 Amendments in 1975, 2002 and 2003 Grounds for MTP: Therapeutic : risk to pregnant woman Eugenic : risk to the child to be born Humanitarian : pregnancy caused by rape Socioeconomic : pregnancy due to failure of contraceptive, Unwanted pregnancy with low SE status Environemental: no one to help from society
Duration of pregnancy for MTP Below 12 weeks :only one medical officer alone can take decision for MTP Between 12 to 20 weeks: decision is taken by two medical officers for MTP After 20 weeks: MTP can not be done, except in emergency conditions. (In emergency conditions decision can be taken by only a single doctor.)
Places for MTP Any government or semi-government hospital Any non-government hospital approved by government or CMO or district health officer
Qualification and Experience of doctors for MTP Up to 12 weeks: By any RMP who has performed at least 25 cases of MTP and out of which 5 have been performed independently in an approved place. By doctor with any of the following: -PG degree or diploma in OBG -6 month of house surgency in OBG -Experience of one year or more in OBG at any hospital In emergency cases: By any RMP, at any place, irrespective of duration of pregnancy.
Consent Only consent of pregnant woman is necessary No need to obtain consent from her husband In case of minor (less than 18 year of age),and mentally ill woman, consent from guardian is required
Common methods of MTP Medical : mifepristone and misoprostol Dilatation and curettage (D&C) Vacuum aspiration technique or surgical abortion Intra-embryonic instillation of PG Extra-embryonic instillation of hypertonic saline Surgical
Complications Immediate: Haemorrhagic shock Perforation of uterus, perineum or intestine Laceration of cervix or vagina Incomplete abortion Embolism Thrombophlebitis
Criminal Abortion : Abortion done against the provision of MTP act.
Sec.312 IPC: Criminal abortion with the consent of patient Punishment to both for upto 3 year,and +/- fine If the woman is quick with child then may extend upto 7years Sec 313 IPC: if abortion done without her consent Punishment upto 10 years and fine Sec 314 IPC:if woman dies by this act Punishment upto 10 years and fine Legal aspects of criminal abortion:
Sec 315 IPC : Any act with the intent to prevent the child being born alive or cause its death before birth Punishment : upto 10 years and/or fine. Sec 316 IPC : any act which cause death of quick unborn child amount to culpable homicide Imprisionment upto 10 years and fine
Methods adopted for criminal abortion I. Abortifacient drugs Drugs acting directly on the Uterus Irritants of Genito-Urinary tract Irritants of GI tract Drugs having poisonous effect on Body II. General violence III. Local violence
I. Abortifacient drugs: 1. Drugs acting directly on the Uterus : A.ECBOLICS : (I ncrease Uterine Contraction) Eg. Ergot Hydrastis canadensis Quinine Lead ( lead oleate or lead plaster) Decoction of cotton root bark Nitrobenzol Picrotoxin and strychnine
B. EMMENAGOGUES : (Increase Menstrual Flow) Eg. :- savin borex apiol rue laburum oestrogen sanguinarin caulophyllin hallebore
2. Irritants of Genito-urinary tract: Oil of pennyroyal Oil of tansy Oil of turpentine Cantharides KMnO 4
4.Drugs having poisonous effect on Body: Inorganic: Pb, Cu, Fe,Hg, Sb Organic: cantharides, unripe fruits of papaya and pine apple, juice of calotropis, bark of plumbago rosea, methi,saffron
II. General violence: Intensional 1. Severe pressure on abdomen: by blow, kick, jumping or kneeling 2.Violent exercise: horse riding, cycling, jumping from height, severe jolting, carrying or lifting heavy weights 3.Cupping 4. Very hot and cold bath alternately
III. Local violence : Syringing: by Higginson’s syringe Syringe aspiration Vacuum aspiration Rupture of membrane Use of laminaria tent /slippery elm Abortion sticks Utus paste (thymol, iodine, salt of mercury) Electric current Air insufflations
CAUSE OF DEATH AND DANGERS OF CRIMINAL ABORTION A. Cause of Rapid death: Haemorrhage Perforation Vagal shock Fat embolism Air embolism
B. Cause of delayed death Peritonitis Local infection getting complicated Tetanus Septicaemia Pyaemia
C. Remote causes : Renal failure Meningitis Endocarditis Pneumonitis Hepatitis D. Toxic effects of Abortifacient drugs: - causing early or delayed deaths
Duties of doctor in suspected criminal abortion Doctor must ask the patient to make a statement about the criminal abortion. If she refuses, he should not pursue the matter, but inform the police. He should keep all the information secret to maintain professional secrecy. He must arrange to record the dying declaration in case woman’s condition is serious. If woman dies, he must not issue the death certificate, but should inform police for post-mortem examination. Any foreign materials collected from genitals should be kept preserved.
Examination of Living individual Requisition from the concerned authority Identification of female Written informed consent A female must be present Brief history Clothing must be examined Clinical examination: sign of ill health, GIT disturbances, exhaustion Local examination Laboratory investigations
Examination of Dead body Sudden death of a woman of child bearing age should give rise the suspicion of criminal abortion if: 1.The deceased was pregnant and deeply cyanosed 2.Instrument to procure the abortion or abortifacient drugs are found at scene of death. 3.Underclothing appears to be disturbed after death. 4.Fluid,soapy material or blood coming out of vagina.
Following points should be proved to convict the abortionist: 1.The dead woman was pregnant 2.The accused was responsible for the act which resulted in the interruption of pregnancy 3.The accused acted for purpose of procuring illegal abortion 4.Death occurred as a result of attempt to interrupt the pregnancy
Medical evidence of Abortion In a Living victim : Breasts-pigmented Colostrum Linea nigra and albicans may present Congestion of labia majora and minora Tags of membrane may be present in uterus Swab taken from cervical canal may show chemical used HCG in urine up to 7 days Aborted material, if available,should be subjected to visual or histological examination.
Medical evidence of abortion In a dead victim (autopsy findings) Face may appear pale. Undergarment may show blood clots and fragments of product of conception. Congestion of labia and post. commissure Signs of peritonitis. Vaginal fluid for chemical analysis. In case of suspected air embolism X-ray & CT-Scan. Uterus and ovary may also be sent for chemical analysis to detect abortifacients.
Factor suggestive of Spontaneous / natural Abortion Blighted embryo Degenerative change of chorionic villi Hydatidiform mole Attenuated trophoblastic layer and myxomatous avascular stroma Macerated foetus and placenta Foetal abnormalities
Questions 1.In India MTP act was first introduced in a B.1966 C.1971 D MTP act extends all over India,except, the city/state a.Delhi b.Mumbai c.Chennai d.Jammu and kashmir
Questions(contd) 3.under MTP act one doctor can terminate the pregnancy upto A. six weeks B. twelve weeks C. Twenty weeks D. Twenty weeks 4.if criminal abortion is performed with the consent of the woman,the doctor will be charged under section A.310IPC B.312IPC C.313IPC D.320IPC
Questions (contd) 5. Age of pregnant woman to give consent in MTP act is A.12years B.16years C.18years D.21years 6.Injection of soap water into vagina during criminal abortion can cause A.Air embolism B.fat embolism C.neurogenic shock D.peritonitis
Questions (contd) 7.Intra-amniotic injection of prostaglandins is successful in causing abortion in the A. First trimester B. Second trimester C. Third trimester D. After viability of fetus 8. If criminal abortion is performed without the consent of woman, the doctor will be charged under section A.310IPC B.312IPC C.313IPC D.320IPC
Questions (contd) 9. Under MTP act pregnancy can be terminated at any stage on the ground of A. Eugenic B. Therapeutic C. Social D. Humanitarian 10 Consent required for termination of pregnancy,in an adult woman is A. Husband and herself B. mother C. Mother D. Herself only