5featuresvirginityDefloration1.Basic differenceNo experience of sexual intercourseHave experience of sexual intercourse2.hymenIntactTorn except in false virgin3.introitusDoes not admit more than tip of little finger, it is painfulMay admit 2 fingers , it is painless4.vagina.Marked rugosity on wallFull length of a finger cannot be admittedRugosity diminishesFull length of finger can be admitted5.Fossa navicularisLess conspicuousMore conspicuous after sexual intercourse6.FourchetteHealed tear7.Labia minoraSmaller pinkish, covered with majoraenlarged, pigmented, not covered8.Labia majoraThick, fleshy, both majora are in close appositionLess fleshy, not in full apposition9.BreastsSmaller, firm, pinkish smaller areola, and small nippleLarger, flabby, pendulous, wider areola, large and raised nipple
6Other conditions which may affect signs of virginity Trauma or AccidentSurgical operation or Gynaecological examinationSanitary tamponsForeign body – sola pith (APTAE VARIS)Scratching due to irritation from uncleaninessMasturbationUlceration – d/t diphtheria , fungus, etc.
7False VirginsHymen is intact but the woman has had sexual intercourse.
8Point of difference True virgin False virgin 1.Basic difference The woman has no experience of sexual intercourseHas experience of sexual intercourse2.HymenNot ruptured. It is thin flap of tissue of regular shape and appearanceNot ruptured. It is thick , fleshy or fibrous elastic with folds3.IntroitusDoes not admit more than the tip of little finger, it is painfulMay admit 2 fingers, it is not painful4.Vagina.Marked rugosity on wallFull length of a finger cannot be admittedRugosity diminishesFull length of finger can be admitted
95.Fossa navicularisLess conspicuousMore conspicuous after sexual intercourse6.FourchetteIntactHealed tear7.Labia minoraSmaller pinkish, covered with majoraenlarged, pigmented, not covered8.Labia majoraThick, fleshy, both majora are in close appositionLess fleshy, not in full apposition9.BreastsSmaller, firm, pinkish smaller areola and small nippleLarger, flabby, pendulous, wider areola, large and raised nipple
10Medico legal importance of virginity In Civil cases:Nullity of marriageDivorceDefamation of characterRape
11Pregnancy Signs of pregnancy in living: Presumptive signs 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:Presumptive signsProbable signsPositive or conclusive signs
12Presumptive signs of pregnancy AmenorrhoeaMorning sicknessChanges in breastsChanges in the VaginaUrinary disturbances- increased frequency of micturitionChloasma th weekQuickening – 20 weeksLinea nigra th weekStriae gravidarumSympathetic change -increased salivation-PICA (perverted appetite)-irritable temper.
13Changes in Breasts : Changes in Vagina : Breasts enlarged & nodular(2nd month)Surface veins prominentAreola enlarged, pigmented with prominent Montgomery’s tubercles (2nd month).Nipples enlargedColostrum (3rd month).Changes in Vagina :Jackquemier’s sign or Chadwick’s sign: violet or bluish discolouration of vaginal mucosa (after 4th week).
14PROBABLE SIGNS OF PREGNANCY Enlargement of abdomenHeight of uterus.Palmer’s sign- regular rhythmic contractions of uterus at 4th to 8th week.
17Goodell’s sign -softening of cervix at 4th month Osiander’s sign – increase pulsation felt through lateral fornices at 8th week‘Piskacek’s sign – asymmetrical enlargement of uterus if there is lateral implantation.Goodell’s sign
18PROBABLE SIGNS OF PREGNANCY Braxton-hick’s sign -After weeks of pregnancyBallottement: internal and external (during 4th and 5th month)Uterine soufflé at end of 4th monthBiological tests : Presence of gonadotropins in pregnant woman’s blood and their excretion in urineExternal ballottementInternal ballottement
19Immunological tests : Inhibition (Indirect) Latex slide test Haemagglutination inhibition test.RIA and ELISA
20POSITIVE SIGNS OF PREGNANCY Auscultation of foetal heart sounds- positive after wksPalpation of foetal partFeeling foetal movementsRadiograph of foetus -after 3 monthsUSG : 6 wks - Gestational sac7 wks - Embryo10 wks - Heart beat14 wks - Head and ThoraxPresence of foetal cells in mother’s blood.
21Signs of pregnancy in Dead Products of conceptionEnlarged Uterus & other uterine change.Corpus luteum
22Medicolegal importance of pregnancy In Civil cases:Nullity of marriageInheritance of propertyHigher maintenance allowance in case of divorceCompensation casesIllegitimate babyMaternity leaveCompensation case if allegation of pregnancy against unmarried woman or widow.
23In 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 acharge of criminal breach of trust against a man.Adultery.In criminal abortion and to foeticide or infanticide.Motive for suicide or murder.
26QUESTIONS1. Uterine soufflé may be heard by auscultation at the end of-10wks12wks14wks16wks2. Foetal parts can be detected by X ray usually by-8wks
273. A pregnant woman sentenced to death cannot be hanged till- DeliveryDelivery and attainment of 6 months of age by new bornDelivery and one year after thatNone of the above4. Pseudocyesis is found in-Young married womanAged unmarried girlMenopausal ladiesAdolescent girl
285. Impregnation of an ovum discharged from a previous ovulation has been developed is called- FecundationSuperfecundationSuper foetationNone of the above6. Which of the following statements is true for virgo intacta-Breasts are large and nodularLabia majora not apposed with each otherFossa navicularis is disappearedLabia minora completely covered by labia majora
29DELIVERYDefinition :Expulsion of products of conception from within the uterus at term.
30Signs 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.
31Abdomen: External genitalia : 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 hrsExternal os is patent admitting two fingers initially and later one finger withdifficulty 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)
32Signs of Recent delivery in Living : Extent of signs depends upon whether the woman is primiparous or multiparousBreast: pendulousHyperpigmentation presentMontgomery's tubercles are prominentStria are presentAbdomen: abdominal wall is laxLinea albicantesLinea nigra
33Signs of Remote delivery in Living : External genitalia: labia are laxVaginal rugae are lostFourchette is lostHymen: carunculae myrtiformisOs in Nulliparous:- Internal os is well defined- External os is rounded and orifice closedOs in Multiparous:-Internal os is not well definedExternal os is transverse irregular and may admit a tip of finger
34Sign of Recent delivery in the Dead : Same as are found in livingAdditional findings are found in uterus and its appendagesUterus is firm and returns to a permanent reduced sizePlacental site can be identified by its dark colour andcoarse granular appearance and covered with blood clots,lymph and decidua.Ovaries and fallopian tubes are congestedHistopathological examination:- trophoblastic cells and chorionic villi are present in endometrium- one large corpus luteum is present in one ovary
35Signs of Remote delivery in Dead : Same as are found in remote delivery in livingAdditional findings are present in uterus and its appendagesUterus is concave inwards.Fundus is above the line of fallopian tubeLength 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 fingerInternal os is not well definedArbor vitae: lost in parous woman
36Different measuresimmediatelyAfter3daysAfter1 weekafter2weeksafter3weeksOuter length20cm17cm14cm12cm10cmOuter breadth13-14cm8cm7cm6cmThickness5cm4cm3cm2.5cmInner length15cmWeight1kg7oogm500gm300gm80-100gmDia of the site of placental attachment1.5cm
37Point of differencesnulliparousparoussize7cm x 5cm x 2 cm10cm x 6cm x 2.5cmweight40 gmgmRatio between Body/CervixEqual2:1Upper surface of fundusLess convexMore convexUterine cavityconvexconcaveScar for placental attachmentabsentpresentExternal osroundtransverseInternal osCircular , well definedIll defined , margin wrinkled
38AbortionDefinition:“Termination of pregnancy due to premature expulsion of product of conception at any time from the uterus.”
40Medical termination of pregnancy (MTP)act 1971 Came into force in 1972Amendments in 1975, 2002 and 2003Grounds for MTP:Therapeutic : risk to pregnant womanEugenic : risk to the child to be bornHumanitarian : pregnancy caused by rapeSocioeconomic : pregnancy due to failure of contraceptive, Unwanted pregnancy with low SE statusEnvironemental: no one to help from society
41Duration of pregnancy for MTP Below 12 weeks :only one medical officer alone can take decision for MTPBetween 12 to 20 weeks: decision is taken by two medical officers for MTPAfter 20 weeks: MTP can not be done, except in emergency conditions.(In emergency conditions decision can be taken by only a single doctor.)
42Places for MTPAny government or semi-government hospitalAny non-government hospital approved by government or CMO or district health officer
43Qualification 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 hospitalIn emergency cases: By any RMP , at any place , irrespective of duration of pregnancy.
44ConsentOnly consent of pregnant woman is necessaryNo need to obtain consent from her husbandIn case of minor (less than 18 year of age),and mentally ill woman, consent from guardian is required
45Common methods of MTP Medical : mifepristone and misoprostol Dilatation and curettage (D&C)Vacuum aspiration technique or surgical abortionIntra-embryonic instillation of PGExtra-embryonic instillation of hypertonic salineSurgical
46Immediate: Complications Haemorrhagic shock Perforation of uterus, perineum or intestineLaceration of cervix or vaginaIncomplete abortionEmbolismThrombophlebitis
48Criminal Abortion :Abortion done against the provision of MTP act.
49Legal aspects of criminal abortion: Sec.312 IPC: Criminal abortion with the consent of patientPunishment to both for upto 3 year,and +/- fineIf the woman is quick with child then may extend upto 7yearsSec 313 IPC: if abortion done without her consentPunishment upto 10 years and fineSec 314 IPC:if woman dies by this act
50Sec 315 IPC : Any act with the intent to prevent the child being born alive or cause its death before birthPunishment : upto 10 years and/or fine.Sec 316 IPC : any act which cause death of quick unborn child amount to culpable homicideImprisionment upto 10 years and fine
51Methods adopted for criminal abortion I. Abortifacient drugsDrugs acting directly on the UterusIrritants of Genito-Urinary tractIrritants of GI tractDrugs having poisonous effect on BodyII. General violenceIII. Local violence
52I. Abortifacient drugs: 1. Drugs acting directly on the Uterus :ECBOLICS : (Increase Uterine Contraction)Eg. ErgotHydrastis canadensisQuinineLead ( lead oleate or lead plaster)Decoction of cotton root barkNitrobenzolPicrotoxin and strychnine
564.Drugs having poisonous effect on Body: Inorganic: Pb , Cu , Fe ,Hg , SbOrganic: cantharides , unripe fruits of papaya and pine apple, juice of calotropis , bark of plumbago rosea , methi ,saffron
57II. General violence: Intensional Severe pressure on abdomen: by blow, kick, jumping or kneelingViolent exercise: horse riding, cycling, jumping from height, severe jolting, carrying or lifting heavy weightsCupping4. Very hot and cold bath alternately
58III. Local violence : Syringing: by Higginson’s syringe Syringe aspirationVacuum aspirationRupture of membraneUse of laminaria tent /slippery elmAbortion sticksUtus paste (thymol, iodine, salt of mercury)Electric currentAir insufflations
59CAUSE OF DEATH AND DANGERS OF CRIMINAL ABORTION A. Cause of Rapid death:HaemorrhagePerforationVagal shockFat embolismAir embolism
60B. Cause of delayed death PeritonitisLocal infection getting complicatedTetanusSepticaemiaPyaemia
61C. Remote causes : D. Toxic effects of Abortifacient drugs: Renal failureMeningitisEndocarditisPneumonitisHepatitisD. Toxic effects of Abortifacient drugs:- causing early or delayed deaths
62Duties 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.
63Examination of Living individual Requisition from the concerned authorityIdentification of femaleWritten informed consentA female must be presentBrief historyClothing must be examinedClinical examination: sign of ill health, GIT disturbances, exhaustionLocal examinationLaboratory investigations
64Examination of Dead body Sudden death of a woman of child bearing age should give rise the suspicion of criminal abortion if:The deceased was pregnant and deeply cyanosedInstrument to procure the abortion or abortifacient drugs are found at scene of death.Underclothing appears to be disturbed after death.Fluid ,soapy material or blood coming out of vagina.
65Following points should be proved to convict the abortionist: The dead woman was pregnantThe accused was responsible for the act which resulted in the interruption of pregnancyThe accused acted for purpose of procuring illegal abortionDeath occurred as a result of attempt to interrupt the pregnancy
66Medical evidence of Abortion In a Living victim :Breasts-pigmentedColostrumLinea nigra and albicans may presentCongestion of labia majora and minoraTags of membrane may be present in uterusSwab taken from cervical canal may show chemical usedHCG in urine up to 7 daysAborted material, if available ,should be subjected to visual or histological examination.
67Medical 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. commissureSigns 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.
68Factor suggestive of Spontaneous / natural Abortion Blighted embryoDegenerative change of chorionic villiHydatidiform moleAttenuated trophoblastic layer and myxomatous avascular stromaMacerated foetus and placentaFoetal abnormalities
69Questions 1.In India MTP act was first introduced in a. 1947 B.1966 2.MTP act extends all over India ,except, the city/statea.Delhib.Mumbaic.Chennaid.Jammu and kashmir
70Questions(contd)3.under MTP act one doctor can terminate the pregnancy uptoA. six weeksB. twelve weeksC. Twenty weeksD. Twenty weeks4.if criminal abortion is performed with the consent of the woman ,the doctor will be charged under sectionA.310IPCB.312IPCC.313IPCD.320IPC
71Questions (contd)5. Age of pregnant woman to give consent in MTP act isA.12yearsB.16yearsC.18yearsD.21years6.Injection of soap water into vagina during criminal abortion can causeA.Air embolismB.fat embolismC.neurogenic shockD.peritonitis
72Questions (contd)7.Intra-amniotic injection of prostaglandins is successful in causing abortion in theA. First trimesterB. Second trimesterC. Third trimesterD. After viability of fetus8. If criminal abortion is performed without the consent of woman , the doctor will be charged under sectionA.310IPCB.312IPCC.313IPCD.320IPC
73Questions (contd)9. Under MTP act pregnancy can be terminated at any stage on the ground ofA. EugenicB. TherapeuticC. SocialD. Humanitarian10 Consent required for termination of pregnancy ,in an adult woman isA. Husband and herselfB. motherC. MotherD. Herself only