1. Virginity , Pregnancy & Delivery

2. Virginity Also known as Virgo Intacta.
Definition: Virgin is a female who has not experienced sexual intercourse.
Signs of virginity :
1. Extra genital signs (in breast)
2. Genital signs

3. GENITALS LABIA MAJORA LABIA MINORA VAGINAL WALL VESTIBULE
POSTERIOR COMMISURE
FORCHETTE
FOSSA NAVICULARIS
HYMEN

4. TYPES OF HYMEN SEMILUNAR ANNULAR INFANTILE CRIBRIFORM VERTICAL SEPTATE
IMPERFORATE
CARUNCULAE MYRTIFORMIS

5. features
virginity
Defloration
1.Basic difference
No experience of sexual intercourse
Have experience of sexual intercourse
2.hymen
Intact
Torn except in false virgin
3.introitus
Does 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 navicularis
Less conspicuous
More conspicuous after sexual intercourse
6.Fourchette
Healed tear
7.Labia minora
Smaller pinkish, covered with majora
enlarged, pigmented, not covered
8.Labia majora
Thick, fleshy, both majora are in close apposition
Less fleshy, not in full apposition
9.Breasts
Smaller, firm, pinkish smaller areola, and small nipple
Larger, flabby, pendulous, wider areola, large and raised nipple

6. Other conditions which may affect signs of virginity
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.

7. False Virgins
Hymen is intact but the woman has had sexual intercourse.

8. Point of difference True virgin False virgin 1.Basic difference
The woman has no experience of sexual intercourse
Has experience of sexual intercourse
2.Hymen
Not ruptured. It is thin flap of tissue of regular shape and appearance
Not ruptured. It is thick , fleshy or fibrous elastic with folds
3.Introitus
Does 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

9. 5.Fossa navicularis
Less conspicuous
More conspicuous after sexual intercourse
6.Fourchette
Intact
Healed tear
7.Labia minora
Smaller pinkish, covered with majora
enlarged, pigmented, not covered
8.Labia majora
Thick, fleshy, both majora are in close apposition
Less fleshy, not in full apposition
9.Breasts
Smaller, firm, pinkish smaller areola and small nipple
Larger, flabby, pendulous, wider areola, large and raised nipple

10. Medico legal importance of virginity
In Civil cases:
Nullity of marriage
Divorce
Defamation of character
Rape

11. Pregnancy 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 signs
Probable signs
Positive or conclusive signs

12. Presumptive signs of pregnancy
Amenorrhoea
Morning sickness
Changes in breasts
Changes in the Vagina
Urinary disturbances- increased frequency of micturition
Chloasma th week
Quickening – 20 weeks
Linea nigra th week
Striae gravidarum
Sympathetic change -increased salivation
-PICA (perverted appetite)
-irritable temper.

13. Changes in Breasts : Changes in Vagina :
Breasts enlarged & nodular(2nd month)
Surface veins prominent
Areola enlarged, pigmented with prominent Montgomery’s tubercles (2nd month).
Nipples enlarged
Colostrum (3rd month).
Changes in Vagina :
Jackquemier’s sign or Chadwick’s sign: violet or bluish discolouration of vaginal mucosa (after 4th week).

14. PROBABLE SIGNS OF PREGNANCY
Enlargement of abdomen
Height of uterus.
Palmer’s sign- regular rhythmic contractions of uterus at 4th to 8th week.

15. Fundal height

16. Hegar’s sign
-Bimanual examination
at 6th - 8th week

17. Goodell’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

18. PROBABLE SIGNS OF PREGNANCY
Braxton-hick’s sign -After weeks of pregnancy
Ballottement: internal and external (during 4th and 5th month)
Uterine soufflé at end of 4th month
Biological tests : Presence of gonadotropins in pregnant woman’s blood and their excretion in urine
External ballottement
Internal ballottement

19. Immunological tests : Inhibition (Indirect) Latex slide test
Haemagglutination inhibition test.
RIA and ELISA

20. 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.

21. Signs of pregnancy in Dead
Products of conception
Enlarged Uterus & other uterine change.
Corpus luteum

22. 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.

23. 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.

24. Pseudocyesis / False Pregnancy / Spurious Pregnancy / Phantom Pregnancy.
Superfoetation
Superfecundation
Foetus Papyraceous / Foetus Compressus

25. QUESTIONS

26. QUESTIONS
1. Uterine soufflé may be heard by auscultation at the end of-
10wks
12wks
14wks
16wks
2. Foetal parts can be detected by X ray usually by-
8wks

27. 3. A pregnant woman sentenced to death cannot be hanged till-
Delivery
Delivery and attainment of 6 months of age by new born
Delivery and one year after that
None of the above
4. Pseudocyesis is found in-
Young married woman
Aged unmarried girl
Menopausal ladies
Adolescent girl

28. 5. Impregnation of an ovum discharged from a previous ovulation has been developed is called-
Fecundation
Superfecundation
Super foetation
None of the above
6. Which of the following statements is true for virgo intacta-
Breasts are large and nodular
Labia majora not apposed with each other
Fossa navicularis is disappeared
Labia minora completely covered by labia majora

29. DELIVERY
Definition :
Expulsion of products of conception from within the uterus at term.

30. 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.

31. Abdomen: 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 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)

32. 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

33. 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

34. 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

35. 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

36. Different measures
immediately
After3days
After1 week
after2weeks
after3weeks
Outer length
20cm
17cm
14cm
12cm
10cm
Outer breadth
13-14cm
8cm
7cm
6cm
Thickness
5cm
4cm
3cm
2.5cm
Inner length
15cm
Weight
1kg
7oogm
500gm
300gm
80-100gm
Dia of the site of placental attachment
1.5cm

37. Point of differences
nulliparous
parous
size
7cm x 5cm x 2 cm
10cm x 6cm x 2.5cm
weight
40 gm gm
Ratio between Body/Cervix
Equal
2:1
Upper surface of fundus
Less convex
More convex
Uterine cavity
convex
concave
Scar for placental attachment
absent
present
External os
round
transverse
Internal os
Circular , well defined
Ill defined , margin wrinkled

38. Abortion
Definition:
“Termination of pregnancy due to premature expulsion of product of conception at any time from the uterus.”

39. SPONTANEOUS NATURAL ACCIDENTAL 2. INDUCED LEGAL CRIMINAL
TYPES OF ABORTION
SPONTANEOUS
NATURAL
ACCIDENTAL
2. INDUCED
LEGAL
CRIMINAL

40. 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

41. 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.)

42. Places for MTP
Any government or semi-government hospital
Any non-government hospital approved by government or CMO or district health officer

43. 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.

44. 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

45. 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

46. Immediate: Complications Haemorrhagic shock
Perforation of uterus, perineum or intestine
Laceration of cervix or vagina
Incomplete abortion
Embolism
Thrombophlebitis

47. Delayed: PID Menstrual irregularities Sterility Endometritis
Cervicitis
Vaginitis

48. Criminal Abortion :
Abortion done against the provision of MTP act.

49. Legal aspects of criminal abortion:
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

50. 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

51. 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

52. I. Abortifacient drugs:
1. Drugs acting directly on the Uterus :
ECBOLICS : (Increase Uterine Contraction)
Eg. Ergot
Hydrastis canadensis
Quinine
Lead ( lead oleate or lead plaster)
Decoction of cotton root bark
Nitrobenzol
Picrotoxin and strychnine

53. B. EMMENAGOGUES : (Increase Menstrual Flow)
Eg. :- savin
borex
apiol
rue
laburum
oestrogen
sanguinarin
caulophyllin
hallebore

54. 2. Irritants of Genito-urinary tract:
Oil of pennyroyal
Oil of tansy
Oil of turpentine
Cantharides
KMnO4

55. 3. Irritants of GI tract : Saline cathartics eg. - MgSO4
Purgatives eg aloes
- calomel
- castor oil
- croton oil
Emetic eg. tartar

56. 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

57. II. General violence: Intensional
Severe pressure on abdomen: by blow, kick, jumping or kneeling
Violent exercise: horse riding, cycling, jumping from height, severe jolting, carrying or lifting heavy weights
Cupping
4. Very hot and cold bath alternately

58. 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

59. CAUSE OF DEATH AND DANGERS OF CRIMINAL ABORTION
A. Cause of Rapid death:
Haemorrhage
Perforation
Vagal shock
Fat embolism
Air embolism

60. B. Cause of delayed death
Peritonitis
Local infection getting complicated
Tetanus
Septicaemia
Pyaemia

61. C. Remote causes : D. Toxic effects of Abortifacient drugs:
Renal failure
Meningitis
Endocarditis
Pneumonitis
Hepatitis
D. Toxic effects of Abortifacient drugs:
- causing early or delayed deaths

62. 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.

63. 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

64. Examination 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 cyanosed
Instrument 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.

65. Following points should be proved to convict the abortionist:
The dead woman was pregnant
The accused was responsible for the act which resulted in the interruption of pregnancy
The accused acted for purpose of procuring illegal abortion
Death occurred as a result of attempt to interrupt the pregnancy

66. 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.

67. 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.

68. 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

69. Questions 1.In India MTP act was first introduced in a. 1947 B.1966
2.MTP act extends all over India ,except, the city/state
a.Delhi
b.Mumbai
c.Chennai
d.Jammu and kashmir

70. 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

71. 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

72. 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

73. 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