Pregnancy, Abortion & Delivery DR: Asmaa Fady Assistant professor of forensic medicine and Clinical Toxicology اسم ورقم المقرر – Course Name and No. 6/5/2019

Learning Objectives By the end of the lecture, the student should: understand Medico-legal aspects of pregnancy Recognize Signs of pregnancy Estimate Period of gestation and Estimate intrauterine age of new born. Diagnose therapeutic & criminal abortions and method used to induce them. Determine cause (s) of death: (complications) in criminal abortion. Medicolegal importance and diagnosis of delivery. اسم ورقم المقرر – Course Name and No. 6/5/2019

Medicolegal importance of pregnancy 1- In cases of rape. 2- When a woman is committed to death, she may allege pregnancy to delay execution. 3- In cases of divorce, the woman may allege pregnancy to obtain more alimony. 4- Inheritance, a widow may allege to be pregnant to inherit her husband 5- Married women living apart from their husbands when they are accused of having illegitimate pregnancy. اسم ورقم المقرر – Course Name and No. 6/5/2019

Diagnosis of pregnancy: Probable signs Breast Abdomen Vulva- vagina- uterus Immunological tests Sure signs ultrasonography اسم ورقم المقرر – Course Name and No. 6/5/2019

Probable signs of pregnancy 1- Breast signs: Enlarged breasts, dark areolas, Montgomery’s follicles, colostrum secretion. 2- Abdominal wall signs: Enlargement of the abdomen with linea nigra in the middle line and striae gravidarum on the sides due to abdominal distension and tearing of the subcutaneous tissues. 3- Vulva signs: becomes darker in color. 4- Vaginal signs: the vagina becomes warm; its pink color turns dark violet with pulsation and excess of mucus. These changes are due to increased vascularity and venous stasis. اسم ورقم المقرر – Course Name and No. 6/5/2019

Probable signs of pregnancy 5- Uterine signs: Amenorrhea. Size of the uterus: The uterus enlarges gradually. Hegar’s sign: Softening of the lower uterine segment at about the 6th week of the pregnancy. Goodell’s sign: Softening of the os from below upwards at the 2nd month due to increased vascularity Braxton-Hicks sign: Intermittent uterine contractions and relaxation after the 4th month, they are palpable painless contractions that increase by uterine massage اسم ورقم المقرر – Course Name and No. 6/5/2019

Probable signs of pregnancy: Immunological test: It gives positive result 2 weeks after the first missed period. Advantages of this test are: The test is simple and rapid. No special equipment is required. The test is sensitive. A false positive result may be (2 weeks after abortion or delivery). positive result may be obtained in cases other than pregnancy e.g chorionic epithelioma. اسم ورقم المقرر – Course Name and No. 6/5/2019

Sure signs of pregnancy Ultra-sonography: can detect fetal heart beat as early as the twelfth week. It can also indicate the size of the baby’s head, follow the baby’s growth and detect physical abnormalities اسم ورقم المقرر – Course Name and No. 6/5/2019

Period of gestation Average normal period is usually about 280 days or 40 weeks or 10 lunar months. The law considers 6 months as the shortest period of pregnancy, and the 12 months as the longest maximal period. اسم ورقم المقرر – Course Name and No. 6/5/2019

Abortion means Expulsion of uterine contents of the gravid uterus before full term Diagnosis of abortion mother clinical lab Fetus Fetal Age

Types of abortion induced Therapeutic Criminal spontaneous To save the mother’s life: Dilatation and curettage. Suction aspiration. Hystereotomy reasons other than saving the mother’s life: General violence. Local violence. Introduction of foreign bodies into vagina. Introduction of plug containing irritant substance (arsenic) into vagina. douche nozzle containing glycerin or iodine. Abortifacient drugs.

Complications (cause of death) of abortion Neurogenic shock. Hemorrhage. Thromboembolism. Acute poisoning. Sepsis Precautions before performing therapeutic abortion: 1. The decision after consultation of two specialists and a written opinion about the necessity of induction of abortion should be taken. 2. A written consent must be taken from the woman and her husband. 3. It should be done in general or maternal hospital. 4. It must be done by a specialist. 5. The cases must be recorded in the hospital files. 6/5/2019

Intrauterine fetal age assessment Length, weight & placenta Sex and skin Limbs, eyes, nail & hair Ossific centers

1st month 1 cm Chorionic villi appears Flat limb buds

2nd month 4 cm Chorionic villi aggregated to one side Distinguished limbs Mouth & nose are separate Ossific center, clavicle, lower jaw & vertebral bodies

3rd month Ossific center: shafts of long bones 9 cm, 30 gm. Well formed placenta Fingers are well developed Undifferentiated sex Ossific center: shafts of long bones

4th month 16 cm, 100 gm weight. 100 gm. Placenta Distinguishable sex Hair and nails begin to appear

5th month Ossific center: calcaneum, pubis & ischium 25 cm. 350- 450 gm. Weight. 200 gm. placenta. Lanugo hair Ossific center: calcaneum, pubis & ischium

6th month 30 cm, 650 gm. Weight., 300 gm. placenta age of viability with medical assistance 30 cm, 650 gm. Weight., 300 gm. placenta Eye lashes and eye brows appear Pupillary membrane disappeared Red wrinkled skin Testes at kidney level 3 Ossific center at manubrium sterni

7th month Ossific center: Talus 35 cm, 1.50- 1.75 kg, 400 gm. placenta (age of viability with separate existence) 35 cm, 1.50- 1.75 kg, 400 gm. placenta Still wrinkled Testes reach internal inguinal ring Ossific center: Talus

8th month Ossific center: lower femur 40 cm, 2-2.5 kg, 500 gm placenta Deposition of subcutaneous fat Finger nails reach tips of fingers Testes reach external inguinal ring Ossific center: lower femur

Full term 45- 50 cm, 3- 3.5 kg weight and 600 gm. placenta Umbilical cord length 50 cm Testes in scrotum Nails beyond tips of fingers Head circumference 13 inches 3 cm scalp hair Closed posterior fontanelle Dark meconium Ossific center: lower femur becomes 0.5 cm in diameter, ossific centers appear at cubiod, upper tibia, head of humorous

Ossific Centers??? 2: (clavicle, lower jaw, vertebrae (العظام الصغيرة 3: shaft of long bones العظام الطويلة 5: CIP 6: 3OC in manubrium sterni. 7: talus 8: LF 9: LF—0.5 cm, UT, HH, cuboid

Medico-legal importance of delivery: 1-Inheritance: when a widow alleges that she gave birth to an infant to inherit her husband. 2-Infanticide: when a murdered newly born infant is found, a woman suspected to be its mother is examined for signs of recent delivery. 3-Interchange of infants: when babies mixed in maternity hospitals, the different mothers are examined to determine the time passed since delivery and compare this with the infant’s age. 4-Disputed maternity. اسم ورقم المقرر – Course Name and No. 6/5/2019

Signs of recent delivery 1-General signs of exhaustion: pallor, rapid weak pulse, etc. 2-Breasts: firm, full and contains colostrum. 3-Abdominal wall: lax, wrinkled and flabby with lineae nigra and stria gravidarum. 4-External genitals: perineal bruises, swelling or tears. 5-Lochia: Bloody for the first 5 days after delivery; Its color becomes pale yellow for another 5 days. It starts to disappear after 10 – 12 days in the normal puerperium. 6-External cervical os: It admits 2 fingers immediately after delivery, one finger a weeks after delivery and it closes two weeks after delivery 7-Uterus: estimation of the time passed since delivery depends on the fundal level of the uterus. اسم ورقم المقرر – Course Name and No. 6/5/2019

Signs of remote delivery Breasts: Soft, lax, pendulous with enlarged nipples and dark areolae. Abdominal wall: Lax with lineae albicans. Perineum: Scars of old perineal tears. Vagina: Smooth mucosa, dilated and patulous. It has a partially open orifice (the vaginal mucosa is wrinkled in nullipara). Cervix: External cervical os is transverse (slit-shaped) and may show old lacerations (the os is small, round, and non-lacerated in nullipara). اسم ورقم المقرر – Course Name and No. 6/5/2019

اسم ورقم المقرر – Course Name and No. 6/5/2019