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ABORTION

Definition:
Legally,
Abortion is premature expulsion of products
of conception from womb, either
spontaneous or induced at any time before
period of gestation is completed.

(Abortion- derived from Latin word ‘arboriri’ that means


“to get detached from proper site”)
A]Legally, there is no difference between
abortion, miscarriage or premature delivery.

B] Medically,
1. Abortion- Expulsion of products of conception
in the first trimester .
2. Miscarriage - Expulsion of products of
conception in the second trimester.
3. Premature Delivery - Expulsion of fetus after 7
months of pregnancy but before term.
Classification:
A) Natural
1. Spontaneous
2. Accidental
B) Artificial
1. Justifiable
2. Criminal
•Natural Abortion:
- Occurs usually in first or second trimester of
pregnancy.
- Occurs in 10-15% cases.
- It is most common about 2nd / 3rd month of
pregnancy.
- Within first few weeks, ovum may be passed
off without being recognised.
- During first 2 months, ovum is covered by
decidua vera.
- In later months, fetus is expelled followed by
placenta & amniotic sac.
•Natural Abortion:
- Causes:
1. Defects in ova
2. Developmental defect in fetus
3. Low implantation
4. Diseases of deciduas/ placenta.
5. Uterus – malformations, fibroid, retroverted,
hypoplasia
6. General – syphilis, diabetes, hypertension,
hormonal deficiency, sudden shock, nephritis.
7. Drugs – Addictions, arsenic/lead toxicity.
•Justifiable / Therapeutic
abortion:
- When it is done in good faith to save the
life of the woman, if she is endangered by
continuation of pregnancy.

- WMA (World Medical Association)


adopted resolution on therapeutic
abortion, known as Declaration of Oslo
(1970).
Unsafe Abortion:
- This term proposed by WHO.

- It means abortion not provided through


approved facilities and/or persons.
Fabricated Abortion:
This is false abortion with malicious intention
to accuse someone.
Criminal Abortion:
- Any abortion, which does not come under the
rules of the Medical Termination of Pregnancy
(MTP) Act 1971, is considered as criminal abortion.

- It is an unlawful expulsion of product of


conception at any stage of gestation by any
qualified/unqualified person and is punishable
under the law.
Motives for Criminal Abortion:
1. Unmarried girls & widows
2. Socioeconomic conditions
3. Female feticide
•Abortionists:
1. Expert e.g. RMP

2. Semiskilled e.g. Nurses, Midwives etc

3. Unskilled
Section (IPC) Offence Punishment

312 1. Criminal Abortion with consent 3 years

2. Female feticide after sex determination 7 years

3. Quick with child 7 years

511 Unsuccessful attempt of criminal abortion 1.5 years

313 1. Criminal Abortion without consent 10 years

2. Female feticide after sex determination Life

314 1.Intention of abortion + Death of mother 10 years

2.Female feticide after sex determination Life

315 1. Any act with intention to prevent child from being born 10 years
alive or to cause to die after its birth

2. Female feticide after sex determination Life

316 1.Causing death of quick unborn child – Culpable homicide 10 years

2. Female feticide after sex determination life


The Medical Termination of
Pregnancy Act, 1971
•Indications:
A) Therapeutic
B) Eugenic
C) Humanitarian
D) Social
•Indications:
A) Therapeutic:
- When continuation of pregnancy may
cause risk to the life of the pregnant
woman or may cause grave injury to her
physical or mental health, it can be
terminated on therapeutic ground.
•Indications:
B) Eugenic:
- If there is possibility that child born would
be suffering from serious physical or mental
abnormalities that lead the child to be
handicapped, then such pregnancy can be
terminated.
•Indications:
C) Humanitarian:
- When the pregnancy is caused by rape,
then it can be terminated.
•Indications:
D) Social:
- When the pregnancy has resulted due to
failure of contraceptive method adopted by
married woman or her husband.
Rules for Doing MTP:
1) Qualification required:
- RMP
- An RMP, who has assisted in at least 25
cases of MTP in recognized hospital.
- A doctor with post graduate degree or
diploma in OBGY.
- An RMP with 6 months of experience in
house surgeon ship in obstetrics in a
recognized hospital.
Rules for Doing MTP:
2) Place:
- A hospital maintained or established by
government.
- Non government hospital approved by
government.
Rules for Doing MTP:
3) Consent:
- A female above 18 years of age with sound
mind
- In case of minor females or mentally ill,
consent of parents or guardians necessary.
Rules for Doing MTP:
4) Duration of Pregnancy:
- Period of Pregnancy < 12 weeks – Opinion
of one doctor.

- Period of Pregnancy 12 weeks – 20 weeks –


Opinion of two doctors.

-Period of Pregnancy > 20 weeks – No MTP.


Rules for Doing MTP:
5) Documentation & Record
- Maintain records till 5 years
- Professional Secrecy
Rules for Doing MTP:
6) Other important points:
1. Proof of age not required
2. No necessity of complaint in cases of
rape.
3. Emergency – Any RMP, Any Hospital, Any
period of pregnancy.
4. Various sections of IPC not applicable.
5. Husband’s consent not required
6. Punishment – 2-7 years.
Methods of MTP:
A] Up to 12 weeks:
1. Manual vacuum aspiration
2. Suction evacuation &/or curettage
3. Dilatation & Curettage
4. Mifepristone & misopristol
5. Methotrexate & misopristol
Methods of MTP:
A] 13-20weeks:
1. Dilatation & evacuation
2. Oxytocin
3. Prostaglandins
Complications of MTP:
A] Immediate:
1. Hemorrhage & shock
2. Perforation of uterus
3. Injuries to cervix & vagina
4. Incomplete abortion
5. Endometritis
6. Embolism
Complications of MTP:
A] Delayed:
1. Menstrual Disturbances
2. Sterility
3. PID
4. Recurrent abortions
5. Rh isoimmunisation
•Methods of Criminal Abortion:
A) Up to end of one month –
Violent exercises, hot bath, purgatives.
B) Up to end of second month –
Abortifacient drugs
C) Third / fourth month –
Mechanical interference.
I) Abortifacient Drugs
(a)Drugs acting directly on the uterus
1. Ecbolics
Initiate uterine contractions
e.g. Ergots, synthetic estrogen, pituitary
extract, quinine, Gossypium
2. Emmenogogues
Promote uterine congestion & bleeding
e.g. Borax, Sanguinarine, Oil of Savin
I) Abortifacient Drugs
(b) Irritants of GUT
- Produce inflammation of GUT, irritate uterus
& produce uterine contractions.
E.g. Cantharides, turpentine oil.

(c) Irritants of GIT


- Produce inflammation of GIT,
& produce uterine contractions.
E.g. Croton oil, colosynth.
I) Abortifacient Drugs
(d) Drugs having pisonous effect on body
1. Inorganic Irritants
e.g., Arsenic, Mercury, Lead etc.
2. Organic Irritants
e.g. Papaya, Calatropis etc.
II) General Violence
a) Intentional
1. Severe pressure over abdomen
2. Violent exercises
3. Cupping
4. Alternate hot & cold baths
b) Accidental
III) Local Violence:
1. Syringing
2. R.O.M.
3. Syringe aspiration
4. Dilation of cervix
5. Abortion stick
6. Air insufflation
7. Electricity
8. Curretage
9. Pastes
Abortion Stick:
- This is thin wooden or bamboo stick about
15-20 cm in length & 0.5-1cm in diameter.
-One end is wrapped wit cotton wool or cloth
& is soaked in irritant abortifacient
substance
e.g. juice of marking nut, calatropis,
oleander, abrus, lead, arsenic
compound paste etc.
Abortion Stick:
Complications:
1. Local injury
2. Hemorrhage & shock
3. Perforation of uterus
4. Perforation peritonitis
5. Embolism
6. Septicemia.
IV) Therapeutic Methods:
1. L.R.O.M.
2. Utus paste injection
3. Dilation of cervix & oxytocic infusion
4. Dilation & curretage
5. Prostaglandins
6. Amniotic fluid replacement therapy
7. Electrical vacuum aspiration
8. Manual vacuum aspiration
9. Abdominal hysterotomy
Causes of death associated with
Criminal abortion:
A) Immediate:
1. Vagal Inhibition
2. Air embolism
3. Haemorrhage
4. Fat embolism
5. Amniotic fluid embolism
6. Poisoning.
Causes of death associated with
Criminal abortion:
B) Delayed: 48-72 hours
1. Septicaemia
2. Pyaemia
3. Local infection & toxaemia
4. General peritonitis
5. Tetanus.
Causes of death associated with
Criminal abortion:
C) Remote deaths:
1. Jaundice & renal failure
2. Bacterial endocarditis
3. Pulmonary embolism
Doctor's duties in cases of criminal
abortion:
1. Professional secrecy.
2. Ask patient to make a statement.
3. Consultation
4. Treatment.
5. Dying declaration.
6. If death, inform police.
Medical Evidence of Abortion:
It consists of
1. Examination of female
a) Living
b) Dead
2. Examination of Aborted Material
Examination of Female (During Life):
a) General:
- Exhausted, increased temperature & pulse rate.
b) Breasts: S/o pregnancy & delivery e.g.
colostrum etc.
c) Abdomen: Lax, wrinkled, Linea nigra, striae
gravidarum. Involuting uterus may be
palpable.
d) Perineum: Laceration/bruises.
e) Labia: Inflamed, bruised
Examination of Female (During Life):
f) Vagina: Tags of membrane, partial aborted
material, blood, foreign body, abortion
stick etc.
The vaginal wall is contused, abraded or
lacerated.
g) Cervix: The external os would be patulous,
ulcerations & erosions present.
h) Uterus: May be enlarged or in a stage of involution.
i) Swab from cervical canal – Chemical used & also for
bacteriological examination.
J) Urine: hCG may be detected up to 7 days.
Examination of Female (After
Death):
Four important points to prove:
1. Dead woman was pregnant
2. Accused person caused abortion
3. Accused person acted with purpose of producing
illegal abortion.
4. Woman died due to abortion.

1. Evidence at the scene


2. Post mortem examination
I) Evidence at the Scene:
1. Condition of the bed, linen.
2. Condition of the clothes
3. Evidence of discarded swabs, dressings, bowl
etc.
4. Presence of abortifacient drug
5. Presence of instrument.
Examination of Female (After
Death):
In addition to above, following findings may be
noted at the time of autopsy,
Clothes: Undergarments show blood clots,
pieces of products of conception, stains
of chemicals used.
II) Post mortem examination:
(a) Abortion by drugs:
- GIT- Traces of drug.
- Urinary tract – signs of inflammation.
- Vagina & cervix – Drugs, signs of
irritation, erosion.
II) Post mortem examination:
(b) Instrumental Abortion:
1. Injury to genitals-
- More injuries – less skill
- Kind of instrument.
- Infection
Natural abortion – infection rare.
II) Post mortem examination:
(b) Instrumental Abortion:
2. Injury to abdomen/ body:
- First open abdomen.
- Ruptures, punctures, bleeding, inflammation.
- Embolism – Air in large veins & heart
- Remove genitals en masse.
- Uterus – Caesarean incision ( long axis).
- Examine all genitals for injuries.
- Cervix – 50% cases injured.
- Perforation of fundus.
- Foreign bodies in genital tract.
II) Post mortem examination:
(c) Abortion by syringing:
- Fluid in vagina.
- Mucus plug in cervix displaced.
- Foamy red fluid in uterus.
- Detachment of the placenta.
- Foamy fluid may be present on right side
of the heart, large veins.
- Air embolism
- Perforation
Examination of Aborted Material:
1. First we have to decide whether its
product of conception or not:
- Late stages – Easy.
- Early stages – Difficult. Chorionic villi on
microscopic examination will confirm.

2. The fetus should be examined to determine-


a) Probable intrauterine age
b) Viability of Foetus
c) Presence or absence of injuries on body.
STERILIZATION
Definition:
Sterilization is a process to make a
male or female sterile without
affecting potency of that person.
Types of Sterilization:
a] Voluntary
b] Compulsory
A} Voluntary Sterilization:
- With consent of both parteners
- Purpose:
1. Contraceptive
2. Therapeutic
3. Eugenic
B} Compulsory:
- Not done in India.
Methods:
a) Permanent
b) Temporary
a) Permanent:
1. In male – Vasectomy
2. In female - Tubectomy
B] Temporary:
1. Barrier methods
a. Physical
b. Chemical
c. Combined
2. Intrauterine devices
3. Harmonal methods
4. Miscellaneous methods
a. Coitus interruptus
b. Rhythm method.
Guiding Principles:
1. For permanent method, informed written
consent of both partners i.e. husband & wife
should be obtained.
2. Inform about failure rate of permanent
contraception methods.
3. After vasectomy, advise to use other
contraceptive method for three months.
4. Before prescribing contraceptive pills, medical
examination of the female should be done & she
should be informed regarding adverse effects of
these medicines.
Medico-legal Implications:
1. Failure of sterilization operation
2. Adultery
3. Disputed paternity
4. Legitimacy of child
5. Divorce