forensic Medicine

1. Abortion
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. Abortion
Induced/Artificial
Legal/justifiable Illegal/ criminal
Natural/spontaneous
1.Threatened
2.Inevitable
3.Complete
4.Incomplete
5.Missed
6.septic
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

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

9. 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

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

11. 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

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

13. 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)

14. General Violence
• Severe pressure on abdomen
• Violent exercise
• Cupping

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

16. 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

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

19. • Should abortions be totally prevented??????

21. 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

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

23. Indications :
(1) 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

24. (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

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

26. Qualification of the doctor
1. A RMP – with MD/DGO
2. 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
3. A RMP – 6 month of House surgeoncy in OBG
4. One year or more practice in OBG

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

28. • < 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

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

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

31. 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

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

33. • 2nd trimester(12-20 weeks)
• Dilatation and evacuation
• Intra-uterine installation of hyperosmotic
solutions
a. Hypertonic saline
b. Ethacrydine lactate
c. Prostaglandins
d. Oxytocin infusion

34. 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

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

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

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

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

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

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

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

42. • 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

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

44. 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

45. Examination of an individual
with alleged history of abortion

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

47. • 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

48. 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

49. • FETUS as well as MATERNAL findings
• are important

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

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

52. • Skull vault  evidence of air embolism
• Lungs  evidence of amniotic fluid embolism

53. • Samples to be collected
1. Pubic hair
2. Vaginal contents
3. Blood, urine and stomach contents
4. Blood from inferior vena cava
5. Swabs of the uterine wall and fluids from uterine
cavity
6. Histopathology from all organs

54. 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

55. THANK YOU