Abortion.pptx

forensic Medicine

1. Dr Nikita Prabhakaran G Assistant Professor

2. Medically Expulsion or extraction From its mother of an embryo / fetus weighing 500g or less When it is not capable of independent survival Usually before 28 weeks /7 months

3. Definition Medically < period of viability  abortion > viability stillbirth Legally Premature expulsion of fetus from the uterus at any time of pregnancy (S.312, IPC).

4. Abortus  the non-viable product of abortion Abortifacient  any agent that induces abortion

5. Done under MTP ACT

6. Causes ( i ) Genetic (50%)- Autosomal trisomy (ii) Anatomic (10-15%)- cervical incompetence (iii) Endocrine (10-15%)- Luteal phase defect, DM (iv) Infections (15%) (v) Immunological (5-10%) Others

7. Criminal abortion Illegal induction of abortion is called criminal abortion Punishments  section 312 to 316 IPC

8. Section 312 IPC Whoever voluntarily causes a woman to miscarry with her consent Purpose – not for saving the life of the woman Punishment  3 years imprisonment /fine/both If the woman is quick with the child  7 years imprisonment + fine

9. Section 313 IPC Without woman’s consent 10 years imprisonment may extend to life + fine Whether quick or not

10. Section 314 IPC Death caused by an act to miscarry With consent  10 years imprisonment Without consent life imprisonment Quick child/ not – doesn’t matter

11. Criminal abortion Unlawfully induced destruction and expulsion of the fetus from the womb is called criminal abortion Methods: Abortifacient drugs General violence Local violence

12. Abortifacient drugs Ecbolics – increase uterine contractions Eg : Ergot, strychnine Emmenagogues- Increase menstrual flow Eg : estrogen , borax GIT/ Genitourinary disturbances Systemic toxicity drugs Abortion pill (lead + Diphenylethylene)

13. General Violence Severe pressure on abdomen Violent exercise Cupping

14. Local violence Syringing Syringe aspiration Vacuum Aspiration Rupturing of membranes Abortion stick Cervix dilation Utus Paste

15. Abortion stick Wooden /bamboo stick 12-18 cm long Wrapped at one end with cooton /wool/piece of cloth Soaked with juices of Marking nut Calotropis Paste made of Arsenous oxide/lead

16. UTUS paste Semi-solid soap mixed with potassium iodide Thymol mercury

17. S hould abortions be totally prevented??????

18. MTP ACT 1971 To liberalise and legalise abortions To reduce the mortality and morbidity rate in pregnant woman due to criminal abortions Ammended in 2002 Again in 2021

19. Basic principle Termination of pregnancy can be done only Under certain grounds By authorized people In authorized institutions

20. Indications : Medical grounds - risk to the life of the women/ her mental or physical health (2) Eugenic grounds - substantial risk to the physical/ mental health of the child if born and there is chance of handicap

21. (3) Humanitarian ground - pregnant woman to have been caused by rape/ or intercourse with a mentally ill person- grave injury to mental health (4) Social ground - failure of contraception  unwanted pregnancy may cause ill

22. Note: Only with the woman’s consent if she is > 18 years old A woman < 18 years  consent of guardian necessary

23. Qualification of the doctor A RMP – with MD/DGO A RMP with experience in doing MTP by assisting at least 25 cases / of which 5 independent cases – with a certificate from chief MO of the district A RMP – 6 month of House surgeoncy in OBG One year or more practice in OBG

24. Categories 3 and 4 can terminate onlu upto 12 weeks of pregnancy Legal punishment : Imprisonment 2 years to 7 years

25. < 12 weeks of gestation  termination can be done by one medical practitioner >12 weeks < 20 weeks  two paractitioners opinion is necessary Emergency to save the life of the woman even more than 20 weeks single RMP is sufficient

26. Authorized Places All state/ Central Govt Hospitals District Level committee certified hospitals Any NGOS only with special permission

27. Requirements Surgical theatre Operation table Resuscitation equipment Anesthetic equipment Keep a separate register for recording the details

28. Changes in MTP Act 2021 Upto 20 weeks - opinion of one RMP is enough > 20 weeks < 24 weeks - 2 RMPs opinion is necessary Anytime  fetal abnormalities by a medical board

29. Methods of MTP 1 st trimester ( upto 12 weeks) Drugs- Misoprostol(prostaglandin analogues) Mifepristone (anti- progesterones ) Manual vacuum aspiration Dilatation and evacuation

30. 2 nd trimester(12-20 weeks) Dilatation and evacuation Intra-uterine installation of hyperosmotic solutions Hypertonic saline Ethacrydine lactate Prostaglandins Oxytocin infusion

31. Complications of criminal abortion Immediate: Vasovagal syncope Genital injuries  Perforation of vaginal wall and hemorrhage Laceration of cervix Perforation of uterus and bowel Placental hemorrhage Air/ fat embolism Amniotic fluid embolism

32. Delayed complications Infections and necrosis vaginal infections cervical necrosis Ascending infections- Metritis Salpingitis Oopheritis Peritonitis Septicemia Pneumonia Tetanus

33. Late complications Pulmonary thrombophlebitis and embolism Hepatic failure and jaundice Renal failure Pneumonitis endocarditis Endotoxic shock

34. Remote complications Chronic debility Chronic pelvic pain Dyspareunia Ectopic pregnancy Secondary infertility depression

35. Septic abortion Type of abortion associated with sepsis of the products of conception and the uterus Starts from endometrium  myometrium perimetrium Perimetritis  peritoneum

36. Causes of sepsis : Proper antiseptic and asepsis is not maintained Incomplete evacuation Inadvertent injury to genital organs /adjacent structures

37. Micro-organisms: Anaerobic: Bacteroides group, anaerobic streptococci, Clostridium welchii and tetanus bacilli Aerobic E-coli, klebsiella, Staphylococcus aureus, Pseudomonas, Hemolytic streptococci

38. AMNIOTIC FLUID EMBOLISM Causes: first and 2 nd trimester abortion active labour amniocentesis abdominal trauma Rare, unforeseeable and dreadful complication

39. Occurs when massive amount of amniotic fluid enters the maternal venous system. DIC  fibrin deposition in many organs CF : breathlessness, tonic clonic seizures Loss of consciousness

40. Diagnosis: Demonstration of mucin, lanugo hair Vernix caseosa, fat globules, meconium And fetal squamous cells in cut sections of lung

41. Duties of a medical practitioner in case of criminal abortion 1. Doctor has to record the history of the case Regarding induction 2.Professional secrecy to be maintained 3. Consult a professional colleague 4. If woman is serious, dying declaration should be taken 5. Dies, arrange for postmortem after sending police intimation

42. Examination of an individual with alleged history of abortion

43. Living individual General ill health, exhaustion, GIT disturbances in sepsis  pyrexia, tachycardia Local 1. Perineum, vulva and vagina abrasion, contusion and laceration

44. 2. Os - remains dilated for few days shows injuries due to instrumentation 3. Uterus – tender and soft 4. Presence of tears and injuries 5. Discharge- character and amount Ix  serum hCG – upto 7 to 10 days

45. Dead person – Postmortem examination Points to be proven Dead women was pregnant Accused was responsible for the interference Illegal abortion Death occurred due to this abortion

46. FETUS as well as MATERNAL findings are important

47. Clothing preserved  traces of foreign solutions External features - of pregnancy or other diseases - Injection marks  abortifacient

48. Local findings Injuries Abdomen – blood if perforation is there Uterus- cavity enlarged, soft and tender Uterine cavity – products++ placental attachment site corpus luteum ++

49. Skull vault  evidence of air embolism Lungs  evidence of amniotic fluid embolism

50. Samples to be collected Pubic hair Vaginal contents Blood, urine and stomach contents Blood from inferior vena cava Swabs of the uterine wall and fluids from uterine cavity Histopathology from all organs

51. Medico-legal importance of placenta Gives an idea about the length of gestation Transfer of poisons, bacteria and antibodies across the placenta In criminal abortion, pieces are often retained in the uterus