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Virginity , Pregnancy

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Title: Virginity , Pregnancy


1
  • Virginity , Pregnancy
  • Delivery

2
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

3
GENITALS
  • LABIA MAJORA
  • LABIA MINORA
  • VAGINAL WALL
  • VESTIBULE
  • POSTERIOR COMMISURE
  • FORCHETTE
  • FOSSA NAVICULARIS
  • HYMEN

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

5
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
6
  • 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.

7
False Virgins
  • Hymen is intact but the woman has had sexual
    intercourse.

8
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
9
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
10
Medico legal importance of virginity
  • In Civil cases
  • Nullity of marriage
  • Divorce
  • Defamation of character
  • Rape

11
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

12
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.

13
  • 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).

14
PROBABLE SIGNS OF PREGNANCY
  • Enlargement of abdomen
  • Height of uterus.
  • Palmers sign- regular rhythmic
    contractions of uterus at 4th to 8th week.

15
Fundal height
16
  • Hegars sign
  • -Bimanual examination
  • at 6th - 8th week

17
  • 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
18
PROBABLE SIGNS OF PREGNANCY
  • Braxton-hicks sign -After 15-16 weeks of
    pregnancy
  • Ballottement internal and external (during 4th
    and 5th month)
  • Uterine soufflĂ© at end of 4th month
  • Biological tests Presence of gonadotropins in
    pregnant womans blood and their excretion in
    urine

External ballottement
Internal ballottement
19
  • Immunological tests
  • Inhibition (Indirect) Latex slide test
  • Direct Latex slide test
  • Haemagglutination inhibition test.
  • RIA and ELISA

20
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.

21
Signs of pregnancy in Dead
  • Products of conception
  • Enlarged Uterus other uterine change.
  • Corpus luteum

22
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.

23
  • 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.

24
  • Pseudocyesis / False Pregnancy / Spurious
    Pregnancy / Phantom Pregnancy.
  • Superfoetation
  • Superfecundation
  • Foetus Papyraceous / Foetus Compressus

25
  • QUESTIONS

26
QUESTIONS
  • 1. Uterine soufflĂ© 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

27
  • 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

28
  • 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

29
DELIVERY
  • Definition
  • Expulsion of products of conception from within
    the uterus at term.

30
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.

31
  • 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)

32
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

33
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

34
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

35
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

36
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
37
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








38
Abortion
  • Definition
  • Termination of pregnancy due to premature
    expulsion of product of conception at any time
    from the uterus.

39
TYPES OF ABORTION
  • SPONTANEOUS
  • NATURAL
  • ACCIDENTAL
  • 2. INDUCED
  • LEGAL
  • CRIMINAL

40
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

41
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.)

42
Places for MTP
  • Any government or semi-government hospital
  • Any non-government hospital approved by
    government or CMO or district health officer

43
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.

44
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

45
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

46
Complications
  • Immediate
  • Haemorrhagic shock
  • Perforation of uterus, perineum or intestine
  • Laceration of cervix or vagina
  • Incomplete abortion
  • Embolism
  • Thrombophlebitis

47
  • Delayed
  • PID
  • Menstrual irregularities
  • Sterility
  • Endometritis
  • Cervicitis
  • Vaginitis

48
Criminal Abortion
  • Abortion done against the provision of MTP act.

49
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

50
  • 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

51
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

52
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

53
  • B. EMMENAGOGUES (Increase Menstrual Flow)
  • Eg. - savin
  • borex
  • apiol
  • rue
  • laburum
  • oestrogen
  • sanguinarin
  • caulophyllin
  • hallebore

54
2. Irritants of Genito-urinary tract
  • Oil of pennyroyal
  • Oil of tansy
  • Oil of turpentine
  • Cantharides
  • KMnO4

55
3. Irritants of GI tract
  • Saline cathartics eg. - MgSO4
  • Purgatives eg. - aloes
  • - calomel
  • -
    castor oil
  • -
    croton oil
  • Emetic eg. tartar

56
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

57
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

58
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

59
CAUSE OF DEATH AND DANGERS OF CRIMINAL ABORTION
  • A. Cause of Rapid death
  • Haemorrhage
  • Perforation
  • Vagal shock
  • Fat embolism
  • Air embolism

60
B. Cause of delayed death
  • Peritonitis
  • Local infection getting complicated
  • Tetanus
  • Septicaemia
  • Pyaemia

61
C. Remote causes
  • Renal failure
  • Meningitis
  • Endocarditis
  • Pneumonitis
  • Hepatitis
  • D. Toxic effects of Abortifacient drugs
  • - causing early or delayed deaths

62
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.

63
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

64
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.

65
  • 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

66
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.

67
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.

68
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

69
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

70
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

71
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

72
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
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