Virginity , Pregnancy

1

• Virginity , Pregnancy
• Delivery

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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

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GENITALS

• LABIA MAJORA
• LABIA MINORA
• VAGINAL WALL
• VESTIBULE
• POSTERIOR COMMISURE
• FORCHETTE
• FOSSA NAVICULARIS
• HYMEN

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TYPES OF HYMEN

1. SEMILUNAR
2. ANNULAR
3. INFANTILE
4. CRIBRIFORM
5. VERTICAL
6. SEPTATE
7. IMPERFORATE
8. CARUNCULAE MYRTIFORMIS

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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
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• 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.

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False Virgins

• Hymen is intact but the woman has had sexual
  intercourse.

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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 regular shape and appearance Not ruptured. It is thick , fleshy or fibrous 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
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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
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Medico legal importance of virginity

• In Civil cases
• Nullity of marriage
• Divorce
• Defamation of character
• Rape

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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
• Presumptive signs
• Probable signs
• Positive or conclusive signs

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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.

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• Changes in Breasts
• Breasts enlarged nodular(2nd month)
• Surface veins prominent
• Areola enlarged, pigmented with prominent
  Montgomerys tubercles (2nd month).
• Nipples enlarged
• Colostrum (3rd month).
• Changes in Vagina
• Jackquemiers sign or Chadwicks sign violet
  or bluish discolouration of vaginal mucosa
  (after 4th week).

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PROBABLE SIGNS OF PREGNANCY

• Enlargement of abdomen
• Height of uterus.
• Palmers sign- regular rhythmic
  contractions of uterus at 4th to 8th week.

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Fundal height
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• Hegars sign
• -Bimanual examination
• at 6th - 8th week

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• Goodells sign -softening of cervix at 4th month
• Osianders sign increase pulsation felt
  through lateral fornices at 8th week
• Piskaceks sign asymmetrical enlargement of
  uterus if there is lateral implantation.

Goodells sign
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PROBABLE SIGNS OF PREGNANCY

• Braxton-hicks sign -After 15-16 weeks of
  pregnancy
• Ballottement internal and external (during 4th
  and 5th month)
• Uterine soufflé at end of 4th month
• Biological tests Presence of gonadotropins in
  pregnant womans blood and their excretion in
  urine

External ballottement
Internal ballottement
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• Immunological tests
• Inhibition (Indirect) Latex slide test
• Direct Latex slide test
• Haemagglutination inhibition test.
• RIA and ELISA

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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 mothers blood.

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Signs of pregnancy in Dead

• Products of conception
• Enlarged Uterus other uterine change.
• Corpus luteum

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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.

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• 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.

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• Pseudocyesis / False Pregnancy / Spurious
  Pregnancy / Phantom Pregnancy.
• Superfoetation
• Superfecundation
• Foetus Papyraceous / Foetus Compressus

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• QUESTIONS

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QUESTIONS

• 1. Uterine soufflé may be heard by auscultation
  at the end of-
• 10wks
• 12wks
• 14wks
• 16wks
• 2. Foetal parts can be detected by X ray usually
  by-
• 8wks
• 12wks
• 14wks
• 16wks

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• 3. A pregnant woman sentenced to death cannot be
  hanged till-
• Delivery
• Delivery and attainment of 6 months of age by new
  born
• Delivery and one year after that
• None of the above
• 4. Pseudocyesis is found in-
• Young married woman
• Aged unmarried girl
• Menopausal ladies
• Adolescent girl

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• 5. Impregnation of an ovum discharged from a
  previous ovulation has been developed is called-
• Fecundation
• Superfecundation
• Super foetation
• None of the above
• 6. Which of the following statements is true for
  virgo intacta-
• Breasts are large and nodular
• Labia majora not apposed with each other
• Fossa navicularis is disappeared
• Labia minora completely covered by labia majora

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DELIVERY

• Definition
• Expulsion of products of conception from within
  the uterus at term.

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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.

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• 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)

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Signs ofRecent 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

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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

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Sign ofRecent 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

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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

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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
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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 21
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








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Abortion

• Definition
• Termination of pregnancy due to premature
  expulsion of product of conception at any time
  from the uterus.

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TYPES OF ABORTION

• SPONTANEOUS
• NATURAL
• ACCIDENTAL
• 2. INDUCED
• LEGAL
• CRIMINAL

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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

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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.)

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Places for MTP

• Any government or semi-government hospital
• Any non-government hospital approved by
  government or CMO or district health officer

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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.

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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

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Common methods of MTP

• Medical mifepristone and misoprostol
• Dilatation and curettage (DC)
• Vacuum aspiration technique or surgical abortion
• Intra-embryonic instillation of PG
• Extra-embryonic instillation of hypertonic saline
• Surgical

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Complications

• Immediate
• Haemorrhagic shock
• Perforation of uterus, perineum or intestine
• Laceration of cervix or vagina
• Incomplete abortion
• Embolism
• Thrombophlebitis

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• Delayed
• PID
• Menstrual irregularities
• Sterility
• Endometritis
• Cervicitis
• Vaginitis

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Criminal Abortion

• Abortion done against the provision of MTP act.

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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 IPCif woman dies by this act
• Punishment upto 10 years and fine

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• 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

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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

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I. Abortifacient drugs

• 1. Drugs acting directly on the Uterus
• ECBOLICS (Increase Uterine Contraction)
• Eg. Ergot
• Hydrastis canadensis
• Quinine
• Lead ( lead oleate or lead plaster)
• Decoction of cotton root bark
• Nitrobenzol
• Picrotoxin and strychnine

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• B. EMMENAGOGUES (Increase Menstrual Flow)
• Eg. - savin
• borex
• apiol
• rue
• laburum
• oestrogen
• sanguinarin
• caulophyllin
• hallebore

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2. Irritants of Genito-urinary tract

• Oil of pennyroyal
• Oil of tansy
• Oil of turpentine
• Cantharides
• KMnO4

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3. Irritants of GI tract

• Saline cathartics eg. - MgSO4
• Purgatives eg. - aloes
• - calomel
• -
  castor oil
• -
  croton oil
• Emetic eg. tartar

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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

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II. General violence

• Intensional
• Severe pressure on abdomen by blow, kick,
  jumping or kneeling
• Violent exercise horse riding, cycling, jumping
  from height, severe jolting, carrying or lifting
  heavy weights
• Cupping
• 4. Very hot and cold bath alternately

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III. Local violence

• Syringing by Higginsons 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

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CAUSE OF DEATH AND DANGERS OF CRIMINAL ABORTION

• A. Cause of Rapid death
• Haemorrhage
• Perforation
• Vagal shock
• Fat embolism
• Air embolism

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B. Cause of delayed death

• Peritonitis
• Local infection getting complicated
• Tetanus
• Septicaemia
• Pyaemia

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C. Remote causes

• Renal failure
• Meningitis
• Endocarditis
• Pneumonitis
• Hepatitis
• D. Toxic effects of Abortifacient drugs
• - causing early or delayed deaths

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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 womans 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.

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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

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Examination of Dead body

• Sudden death of a woman of child bearing age
  should give rise the suspicion of criminal
  abortion if
• The deceased was pregnant and deeply cyanosed
• Instrument to procure the abortion or
  abortifacient drugs are found at scene of death.
• Underclothing appears to be disturbed after
  death.
• Fluid ,soapy material or blood coming out of
  vagina.

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• Following points should be proved to convict the
  abortionist
• The dead woman was pregnant
• The accused was responsible for the act which
  resulted in the interruption of pregnancy
• The accused acted for purpose of procuring
  illegal abortion
• Death occurred as a result of attempt to
  interrupt the pregnancy

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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.

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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.

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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

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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

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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

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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

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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

73
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