Transcript BY, Dr Pradeep Kumar Yadav JR 1 Department of Forensic

Virginity ,
Pregnancy
&
Delivery
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
GENITALS
• LABIA MAJORA
• LABIA MINORA
• VAGINAL WALL
• VESTIBULE
• POSTERIOR COMMISURE
• FORCHETTE
• FOSSA NAVICULARIS
• HYMEN
TYPES OF HYMEN
1)
2)
3)
4)
5)
6)
7)
8)
SEMILUNAR
ANNULAR
INFANTILE
CRIBRIFORM
VERTICAL
SEPTATE
IMPERFORATE
CARUNCULAE MYRTIFORMIS
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
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
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.
False Virgins
•Hymen is intact but the woman has had
sexual intercourse.
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 Not ruptured. It is thick , fleshy or fibrous
regular shape and appearance
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
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
Medico legal importance of virginity
In Civil cases:
1.
2.
3.
4.
Nullity of marriage
Divorce
Defamation of character
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 - 24th week
• Quickening - 16 – 20 weeks
• Linea nigra - 20th week
• Striae gravidarum
• Sympathetic change -increased salivation
-PICA (perverted appetite)
-irritable temper.
•Changes in Breasts
:
• 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).
PROBABLE SIGNS OF
PREGNANCY
• Enlargement of abdomen
• Height of uterus.
• Palmer’s sign- regular rhythmic
contractions of uterus at 4th to 8th
week.
Fundal height
•Hegar’s sign
-Bimanual examination
at 6th - 8th week
• 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
PROBABLE SIGNS OF PREGNANCY
• Braxton-hick’s sign -After 15-16 weeks
of pregnancy
• Ballottement: internal and external
(during 4th and 5th month)
• Uterine soufflé at end of 4th month
External ballottement
• Biological tests : Presence of
gonadotropins in pregnant woman’s
blood and their excretion in urine
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 18-20 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.
• Pseudocyesis / False Pregnancy / Spurious Pregnancy
/ Phantom Pregnancy.
• Superfoetation
• Superfecundation
• Foetus Papyraceous / Foetus Compressus
•QUESTIONS
1. Uterine soufflé may be heard by auscultation at the end ofa) 10wks
b) 12wks
c) 14wks
d) 16wks
2. Foetal parts can be detected by X ray usually bya) 8wks
b) 12wks
c) 14wks
d) 16wks
3. A pregnant woman sentenced to death cannot be hanged tilla) 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 ina) 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 calleda) Fecundation
b) Superfecundation
c) Super foetation
d) None of the above
6. Which of the following statements is true for virgo intactaa) 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
immediately
After3days
After1 week
after2weeks
after3weeks
Outer length
20cm
17cm
14cm
12cm
10cm
Outer breadth
13-14cm
10cm
8cm
7cm
6cm
Thickness
5cm
5cm
4cm
3cm
2.5cm
Inner length
15cm
12cm
10cm
8cm
7cm
Weight
1kg
7oogm
500gm
300gm
80-100gm
Dia of the site of
placental
attachment
10cm
7cm
4cm
2.5cm
1.5cm
Point of differences
nulliparous
parous
size
7cm x 5cm x 2 cm
10cm x 6cm x 2.5cm
weight
40 gm
80-100 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
Abortion
•Definition:
“Termination of pregnancy due to premature
expulsion of product of conception at any time from
the uterus.”
TYPES OF ABORTION
1.SPONTANEOUS
A)NATURAL
B)ACCIDENTAL
2. INDUCED
A)LEGAL
B)CRIMINAL
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
Delayed:
•
•
•
•
•
•
PID
Menstrual irregularities
Sterility
Endometritis
Cervicitis
Vaginitis
Criminal Abortion :
•Abortion done against the provision of
MTP act.
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
• Punishment upto 10 years and fine
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 : (Increase 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
•KMnO4
3. Irritants of GI tract :
•Saline cathartics eg. - MgSO4
•Purgatives
eg. - aloes
- calomel
- castor oil
- croton oil
•Emetic eg. tartar
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. 1947
 B.1966
 C.1971
 D.1975
2.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