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Abortion

Abortion is premature expulsion of products of conception from womb, either

spontaneous or induced at any time before the period of gestation is completed.
The word abortion is derived from the Latin word ' Abortion ' that means, "to get
detached from the proper site. Legally there is no difference between Abortion,
miscarriage or premature delivery. However, medical jargon carries different
meaning. Medical terminology is given below. In medical terminology.
> Abortion means expulsion of products of conception in the first trimester of
pregnancy.
> Miscarriage means expulsion of product of conception in second trimester.
> Premature delivery refers to expulsion of fetus after 7 months of pregnancy but
before term.
CTASSIFICATION
Abortion is classified into following two major groups
1. Natural (spontaneous)
2. Artificial (Induced)
Induced abortion may be:
 Justifiable abortion (therapeutic)
 Criminal abortion
Natural abortion may be:
 Isolated abortion
 Recurrent Abortion

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Natural Abortion
Spontaneous or natural abortion occurs usually in first or Second trimester of
pregnancy .
Unsafe Abortion
. This term has been proposed by WHO
. It means abortion not provided through approved facilities and/or persons.
Fabricated Abortion
. This is false sort of abortion with malicious intention to accuse someone
. A female may allege a person that due to assault by that person, she has aborted.
In her support, she may produce false things such as menstrual pads or killed
animal fetus pertaining that it is abortus material.

LNDUCED ABORTION
. It is a type of Abortion which is deliberately induced. It may be justifiable
(therapeutic) or criminal.

CRIMINAL ABORTION.
Any abortion, which does not come under the rules of the Medical Termination of
pregnancy (MTp) , is considered as criminal abortion.
Thus, in other words, it is an unlawful expulsion of product of conception at any
stage of gestation by any unqualified person or a qualified doctor and is punishable
under the law.
MOTIVES FOR CRIMINAL ABORTION
1. Unmarried girls and widows may, at times, resort to criminal abortion when
child is product of illicit sexual intercourse. This is done to get rid of the
developing life or in some cases to save the honor and pride of the family.

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2. A poor family may procure criminal abortion to avoid the addition of a member
to family. These families seek the services of an unskilled person since he may
take fewer fees in comparison with a qualified one.
3. Female feticide i.e. killing of female fetus. In India, some societies are keen to
have male child. When female is pregnant, these people do sex determination test
(at present unlawful act) and if the sex of baby is found to be female, they persuade
the pregnant lady to abort the product of conception.
METHODS TO INDUCE CRIMINAL ABORTION ARE :
1. Use of abortifacient drugs
2. Application of mechanical violence .

1. Abortifacient Drugs
These drugs are classified as:
1. Ecbolics: These drugs initiate uterine contraction and causes abortion. Examples
are;
 Ergot preparations
 Synthetic estrogen
 Pituitary extract
 Quinine
2. Emmenagogues: These drugs promote uterine congestion and induce bleeding
thus expelling product of conception. Examples are:
 Borax
 Oil of savin
3. Irritants: These are of following types

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o Genitourinary tract irritants - these agents produce inflammation of

genitourinary tract and reflexly irritate the uterus and induce uterine
contraction example Cantharides, turpentine oil.
o Gastrointestinal tract irritants these agents cause reflex contraction of
uterine muscles - example; croton oil etc.
o Systemic poisons - For example: arsenic, mercury, fruit of papaya etc.
o Abortion pills etc.
VIOLENCE
l. General violence - may act directly or indirectly on uterus.
Following are examples of general violence
 Severe form of exercise like excessive cycling, riding, jumping etc.
 Application of blows or kicks over abdomen or pressure on abdomen
by kneading or firmly massaging the abdomen
 Cupping: a flame light is placed on abdomen and a metal mug is
placed over the flaming light.
2. Local method
A) By unskilled or semiskilled person.
Rupture of membrane by abortion stick, metal rod, knitting needle, hair Pin
etc.
 Application of abortion Paste
 Use of root of plant as Abortifacient agent
 Syringing: either for aspiration of fluid or forced filling of uterine
cavity with fluid and air.
B) By skilled Person
 Low rupture of membrane
 Vacuum aspiration

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 Dilatation and evacuation

 Use of Prostaglandins.

Abortion Stick
. This is a thin wooden or bamboo stick about 15 to 20 cm in length and 0.5
to 1 cm in diameter' One end of stick is wrapped with cloth or cotton wool
and is soaked in or smeared with irritant abortifacient substances
. The substances consist of juice of marking nut, or paste made up of arsenic
or lead etc'
. The stick is then passed into the uterus per vaginally resulting in rupture of
membrane and expulsion of product of conception.
Complications of abortion sticks are:
l. Local injury
2. Hemorrhage and shock
3. Perforation of uterus
4. Perforation peritonitis
5. Incomplete abortion
6. Embolism
7. Septicemia

COMPLICATION OF CRIMINAL ABORTION

Immediate
l. Hemorrhage
2. Perforation of uterus
3. Shock due to vagal inhibition resulting from instrumentation
4. Fat embolism
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5. Air embolism
6. Amniotic fluid embolism
7. Incomplete abortion
8. Local injury
Delayed
l. Septicemia
2. Tetanus
3. Endometritis
4. Renal failure
5. Peritonitis
6. Sterility
7. Recurrent abortion
Causes of Death in Criminal Abortion
l. Vaso-vagal shock
2. Hemorrhagic shock
3. Perforation of uterus
4. Septicemia
5. Embolism
6. Disseminated intravascular coagulation

DUTIES OF REGISTERED MEDICAL PRACTITIONER IN

CRIMINAL ABORTION
Unsafe abortion today, constitutes the single largest cause of pregnancy-
related deaths.
When a female comes to RMP with history of criminal abortion or
attempted criminal abortion, then:
1. Doctor should record history of the incident, the method
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adopted to procure abortion.

2. If death is imminent, doctor must arrange for dying declaration.
3. If female dies, he should report matter to the police.
Medical Evidence of Abortion
It consists of
1. Examination of female.
2. Examination of aborted material.

EXAMINATION OF FEMALE (DURING LIFE)

1. General: Female will have exhaust look, increase temperature, increase

pulse.
2. Breasts; Are heavy, enlarged, areola and nipples are pigmented,
colostrum/milk may ooze on squeezing the breasts .
3. Abdomen: Is lax and wrinkled. Striae may be present along with linea
nigra. Involuting uterus may be palpable.
4. Perineum: Laceration or bruises may be noted, inflammation is evident
5. Labia: majora and minora will be inflamed and bruised
6. Vagina: Tags of membrane, partial aborted material, blood, foreign body,
abortion stick etc. may be found. The vaginal wall is contused, abraded or
lacerated. The wall is lax, dilated.
7. Cervix: The external os would be patulous, ulceration or erosions may be
present. Cervical canal may be dilated with abrasions or lacerations.
8. Uterus: May be enlarged on bimanual examination or may be showing
signs of involution.

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9. Swab from cervical canal will reveal chemical used for procuring
abortion and can be used for bacteriological examination.
10. Urine examination: hCG may be detected up to 7 days.

EXAMINATION OF FEMALE (AFTER DEATH)

In addition to above, following findings may be noted at autopsy

. Clothes: Undergarments may show blood, clots, pieces of product of
conception, stains of chemicals used etc.
. Uterus: Enlarged, cavity may show presence of partially separated product
of conception, foreign body, blood clots, presence of any paste or chemical,
evidence of injury or perforation etc.
. Evidence of infection .
Ovaries: Presence of corpus luteum
EXAMINATION OF ABORTED MATERIAL
. ''Police may request medical examiner to examine a substance alleged to
have been expelled from uterus as product of conception.
Doctor should examine the substance carefully.
. The alleged product of conception should be washed.
If it happens to be product of conception, it may be suggestive of criminal
abortion.
. Difficulty arises in early months of pregnancy when embryo is small or not
found.
In such cases presence of chorionic villi on microscopic examination
will confirm that it is product of conception.
. During first three months of pregnancy, the fetus is expelled with its
membrane en mass but after this period, the fetus is born first and then after
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that placenta is detached and expelled. If only placenta is sent for medical
examination then it should also be examined to ascertain injuries or tears
and any degenerative changes in its surface.
. The fetus should be examined to determine its:
l. Probable intrauterine age.
2. Presence or absence of injuries on body.
3. Viability of child.

Medicolegal importance of placenta

1. At term placenta is about 500 gm in weight.
2. Period of gestation can be estimated.
3. Some poisons may be detected in placenta.
4. Retained placenta or pieces of placenta may be found in criminal abortion
and may be the cause of death due to hemorrhage.
5. Disease can be ascertained.
6. Transfer of poisons, drugs, bacteria or antibodies acrossplacenta
(placental barrier) may result in fetal death, fetal
infections or fetal malformations.
JUSTIFIABLE ABORTION THERAPEUTIC
. It is also called as therapeutic abortion or legal abortion .
. It is performed either in accordance with the legal provisions under the
Medical Termination of Pregnancy (MTP) Act 1971 (i.e. legal abortion) or
caused in good faith to save the life of the pregnant .

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Medical Termination of Pregnancy

INDICATIONS
1. 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.
2. Eugenic
If there is possibility that child born would be suffering from physical or
mental abnormalities that lead the child to be handicapped, then such
pregnancy can be terminated on Eugenic grounds.
3. Humanitarian
When the pregnancy is caused by rape then it can be terminated on
humanitarian ground.
4. Social
When pregnancy has resulted due to failure of contraceptive method adopted
by married woman or her husband for the purpose of limiting the number of
children, then such pregnancy can be terminated on social grounds.
Important:
In an emergency, a Registered Medical Practitioner can terminate
pregnancy at any place, irrespective of duration of pregnancy.
Abortion done in good faith to save the life of a woman, if it appears that
continuance of pregnancy would endanger maternal health is not considered
as criminal abortion.

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Rules for Doing MTP

1. Qualification Required
 Only qualified Registered Medical Practitioner, having
following required experience can terminate the pregnancy.
 A RMP who has assisted in at least 25 cases of MTP in a recognized
hospital
 A Doctor with MD in Gynecology and Obstetrics or DGO
qualification or has 6 months of experience in house-surgeon ship in
obstetrics in a recognized hospital.
2. Place - MTP can be Carried Out at A hospital maintained or established
by government . Non-government hospital approved by government
3. Consent
 A female above 18 years of age with sound mind can give consent for
MTP
 In minor females (i.e. age less than 18 years) or mentally ill ,
consent of parents or guardian is necessary.
4. Duration of Pregnancy
. When duration of pregnancy is below 12 weeks of gestation, one
Registered Medical Practitioner (RMP) can terminate the pregnancy.
. When duration of pregnancy is above 12 weeks but less
that 20 weeks (i.e. 12-20 weeks), then two RMP are required to terminate
the pregnancy.
5. Documentation and Record
Date generated by mentioning the year against the serial number
. The admission register is a secret document.
It should be maintained for at least 5 years from the last entry.

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Methods of Inducing MTP

Up to 12 Weeks
l. Manual vacuum aspiration
2. Suction evacuation and/or curettage
3. Dilatation and curettage
4. Mifepristone
5. Methotrexate and misoprostol

Between 13 to 20 Weeks
1. Dilatation and evacuation
2. Oxytocin infusion
3. Induction by prostaglandins E, (misoprostol) (Used as intravaginally,
intramuscularly or intra amniotically)
4. Hysterotomy - less common method
Complications of MTP
Immediate
1. Hemorhage and shock
2. Perforation of uterus, intestine
3. Laceration of cervix or vagina
4. Incomplete abortion
5. Endometritis
6. Embolism
Delayed
l. Menstrual disturbances
2. Sterility
3. Pelvic inflammatory disease
4. Recurrent abortion or premature labor
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5. Rh isoimmunization
6. Psychological sequelae

MEDICOLEGAL LMPORTANCE OF ABORTION

1. When abortion is induced without proper indication or in contravention

to the provisions of MTP Act, it is considered as criminal abortion and is
punishable by law.
When Doctor violates the provisions of MTP Act, he is liable to be punished
by the law and similarly his act amount to misconduct in professional sense.
To bring a false charge of assault against any person, a female may plead
that she has been assaulted and due to assault, abortion was induced.
A female may be falsely charged or implicated for inducing criminal
abortion.

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