PREGNANCY

Learning Objectives:

Recognize medicolegal circumstances in which a woman is examined for pregnancy. List important signs to diagnose pregnancy Recognize medicolegal circumstances in which a woman is examined for delivery. Distinguish between recent and remote signs of delivery in the

Medicolegal Conditions
Divorce

more alimony Inheritance widow Disputed Paternity illegitimate preg Rape more compensation Capital sentence of death

Diagnosis of Pregnancy
Probable signs Skin changes Breast Abdomen
Pelvis Fetal heart sounds

Sure signs
Pregnancy tests Ultrasound Fetal movements

A- History

Amenorrhea

Morning

sickness Frequency of micturition Constipation Breast enlargement

signs 1Skin changes Pigmentation

B- Physical

1- Skin Stria Gravidarum Streching of skin Stria rubra : pink Stria albicans: white abd. Wall / thighs / buttocks 2- Face Cloasma Pregnancy mask 3- Abd. Wall

Linea nigra

Umb

Linea nigra

2- Breast changes

2- Breast changes
2nd month
(early)

Enlarged, dilated veins

2nd month

(late)

Pigment. Nipples+ 1ry aerola Enlarg. Montgomery Tubercle

3rd month

Colostrum

Breast changes

3- Abdomen
Uterine enlargement
First 3 months pelvic organ After 12 weeks abdominal

Uterine enlargement

4- Pelvis
Vaginal mucosa deep violet
(chadwik sign) vascularity Cervix

soft
(Hegars sign) 8th week

Palpation of fetal parts week

Sure signs of pregnancy

16th

Palpation of fetal movement 20th week Auscultation of fetal heart sound 22th week Detetion of fetal skeleton by X ray after 16th week

Fetal heart sounds

* Stethoscope Doppler flowmeter * * 120 140 / min, regular

To differentiate between Uterine soufle: is synchronous with maternal pulse Fetal heart sound:

Conditions in which

Fetal heart sounds are not heard

Fatty abdominal wall Excess liquor amni Death in utero Before 18th week duration

X ray
week

after 16th

Diagnose pregnancy Diagnose twin pregnancy Age of the fetus Congenital anomalies Intra uterine fetal death

Ultra sound
Diagnose *Pregnancy *Diseases

Estimate

*Duration *Age of fetus

Pregnancy tests

These depend on presence of Human Chorionic Gonadotrophin (HCG) in maternal serum and urine.

Human Chorionic Gonadotrophin

*Is a glycoprotein hormone secreted by the developping placenta (blastocyst) shortly after fertilization

Pregnancy tests
Urine Pregnancy test Latex test Serum Preg test ELISA
RIA

serum urine

Urine pregnancy tests

Rapid Simple based on antigen- antibody reaction Ex: Gravindex Latex Agglutination test

REGNANCY TESTS

Urine + Grav antiserum +Grav antigen

No agglutination (positive)

Agglutination (negative)

Pregnant

Not pregnant

Conditions in which a is examined for delivery

Inheritance

when a widow alleges that she gave birth to an infant. when a murdered new born is found & a woman is suspected of infants when babies are mixed in hospitals.

Infanticide

Interchange

DELIVERY
RECENT Within 6 weeks Living REMOTE Later Dead uterus

Signs of recent delivery in living

Signs of exhaustion: pallor, weak
pulse
Breasts:

enlarged

engorged : colostrum, milk + preg. signs

Abdominal

wall: lax
stria gravidarum linea nigra

Genital

signs:

Genital signs
PERINEUM swallen

UTERUS involution

VAGINA Lochia

CERVICAL OS dilated

Lochia Lochia Vaginal Vaginal discharge discharge

After After 2 2 weeks: weeks: disappears disappears Another Another 5 5 d d pink pink pale, pale, yellow yellow

st 1 1st 5 5 days days bloody bloody

Cervical(Ext)o Cervical(Ext)o s s dilated dilated

closed closed 2 2 weeks weeks after after 1 finger 1 finger 1 1 week week after after

2 2 fingers fingers Immediately Immediately after after

Involution of the uterus Immediately Immediately

2 2 fing fing above above umb umb PM PM Wt Wt = = 1kg 1kg

Normal Normal size size PM PM Wt Wt = = 100 100 g g 2 2 weeks weeks Pelvic Pelvic organ organ PM PM Wt Wt = = 370 370 g g

6 6 weeks weeks

Mid Mid way way bet bet Umb Umb & & SP SP

1 1 week week

PM PM Wt Wt = = 500 500 g g

 Breasts:

Signs of remote delivery in living

nipples soft, pendulous, dark areola, enlarged

Abdominal

wall: lax, linea albicans

Labia: gaping Vagina: dilated, patulous

scars of old tears loss of vaginal rugae

Cervix: Os uteri ext cerv

os
Nullipara
Small Round Smooth edges (non lacerated)

Multipara
More patent Transverse: slitlike Cicatriciallynotched

Cervix: Os uteri ext cerv

os
Nullipara
Small Round

Multipara
More patent Transverse: slit-like Cicatriciallynotched

Smooth edges (non lacerated)

Signs of remote delivery in dead

Nullipara
Shape uterus Cervix
Triangular

Multipara

Round, O large, heavy

Internal os External os

Body of uterus Body of uterus = cervix = double cervix Not well defined

Enlarged

Forensic Medicine & Toxicology Alexandria Faculty of Medicine