CHAPTER 19

Abortion and Medical Termination of

Pregnancy

The vilest abortionist is he who attempts to mould a child’s character.

- George Bernard Shaw

ABORTION ssifi tion

• bortion is premature expulsion o products o concep- Abortion is classified into following two major groups
tion rom womb, either spontaneous or induced at any (Fig. 19.2):
time be ore the period o gestation is completed. 1. Natural (spontaneous)
• The word abortion is derived from the Latin word arbor- 2. Artificial (Induced)
iri’ that means, “to get detached from the proper site”.1 Induced abortion may be:
• Legally there is no difference between abortion, miscar- Justifiable abortion (therapeutic)
riage or premature delivery.2 However, medical jargon Criminal abortion
carries different meaning. Medical terminology is given Natural abortion may be:
below. In medical terminology (Fig. 19.1): Isolated abortion
Abortion means expulsion of products of conception Recurrent abortion
in the first trimester of pregnancy.
Miscarriage means expulsion of product of concep- Natural Abortion
tion in second trimester. Spontaneous or natural abortion occurs usually in first or
Premature delivery refers to expulsion of fetus after second trimester of pregnancy and the causes3 are as men-
7 months of pregnancy but before term. tioned in Table 19.1.

Unsafe Abortion
• This term has been proposed by WHO
• It means abortion not provided through approved facili-
ties and/or persons.4

Fabricated Abortion
• This is false sort of abortion with malicious intention to
accuse someone
• A female may alleged a person that due to assault by that
person, she has aborted. In her support, she may produce
Fig. 19.1: Diagram representing difference between false things such as menstrual pads or killed animal fetus
legal and medical concept on abortion. pertaining that it is abortus material.
 346 rinciples o orensic edicine and oxicology

Table 19.1: Causes of spontaneous abortion Induced Abortion

Causes of abortion • It is a type of abortion which is deliberately induced
• It may be justifiable (therapeutic) or criminal.
1. Chromosomal abnormalities
- Trisomy
CRIMINAL ABORTION
- Triploidy
- Turner’s syndrome • Any abortion, which does not come under the rules of
- Blighted ova the Medical Termination of Pregnancy (MTP) Act 1971,
2. Abnormalities of placenta is considered as criminal abortion.5
- Acute hydramnios • Thus, in other words, it is an unlawful expulsion of
- Multiple pregnancy
product of conception at any stage of gestation by any
unqualified person or a qualified doctor and is punishable
- Hydatidiform mole
under the law.6, 7
- Placenta praevi
3. Infection of mother Motives for Criminal Abortion
- Acute infections like malaria
1. Unmarried girls and widows may, at times, resort to
- Toxoplasmosis
criminal abortion when child is product of illicit sexual
- Syphilis
intercourse. This is done to get rid of the developing life
- Listeria monocytogens
or in some cases to save the honor and pride of self or
4. Disease of mother family.
- Hypertension 2. A poor family may procure criminal abortion to avoid
- Chronic nephritis the addition of a member to family. These families seek
5. Drugs/radiation the services of an unskilled person since he may take
- Inhalation of nitrous oxide fewer fees in comparison with a qualified one.
- X-rays 3. Female feticide i.e. killing of female fetus. In India, some
6. Local abnormalities societies are keen to have male child. When female is
- Retroverted uterus pregnant, these people do sex determination test (at
- Fibromyoma
present unlawful act) and if the sex of baby is found to
be female, they persuade the pregnant lady to abort the
- Cervical incompetence
product of conception.
Forensic Medicine

A
Section

Fig. 19.2: lassification of abortion

 bortion and edical ermination o regnancy 347

Legal Aspects of Criminal Abortion Methods to Induce Criminal Abortion are

The IPC 312, 313, 314, 315 and 316 deals with offenses of Grouped as (Fig. 19.3):
criminal abortion or attempted criminal abortion and punish- 1. Use of abortifacient drugs
ments for these offenses. 2. Application of mechanical violence (Table 19.2)
1. 312 IPC – causing miscarriage – whoever voluntarily
causes a woman with child to miscarry, shall, if such Abortifacient Drugs
miscarriage be not caused in good faith for the pur-
pose of saving the life of the woman, be punished with These drugs are classified as:
imprisonment of either description for a term which may 1. Ecbolics: These drugs initiate uterine contraction and
extend to three years, or with fine, or with both; and, if causes abortion. Examples are:
the woman be quick with child, shall be punished with – Ergot preparations
imprisonment of either description for a term which may – Synthetic estrogen
extend to seven years, and shall also be liable to fine. – Pituitary extract
xplanation: A woman, who causes herself to miscarry, – uinine
is within the meaning of this section. – Gossypium (cotton root bark)
2. 313 IPC – causing miscarriage without woman’s con- 2. Emmenagogues: These drugs promote uterine congestion
sent – whoever commits an offense defined in the section and induce bleeding thus expelling product of concep-
312 of IPC without the consent of the woman, whether tion. Examples are:
the woman is quick with child or not, shall be pun- – Borax
ished with imprisonment for life, or with imprisonment – Sanguinarine
of either description for a term which may extend to ten – Oil of savin
years, and shall also be liable to fine. 3. Irritants: These are of following types
3. 314 IPC – death caused by act done with intent to cause – Genitourinary tract irritants – these agents produce
miscarriage, if act done without woman’s consent – inflammation of genitorurinary tract and reflexly
whoever, with intent to cause miscarriage of a woman with irritate the uterus and induce uterine contraction –
child, does any act which causes the death of such woman, example Cantharides, turpentine oil.
shall be punished with imprisonment of either descrip- – Gastrointestinal tract irritants – these agents cause
tion for a term which may extend to ten years, and shall reflex contraction of uterine muscles – example: cro-
also be liable to fine. If the act is done without woman’s ton oil, colocynth etc.
consent – shall be punished either with imprisonment for – Systemic poisons – For example: arsenic, mercury, cal-
life or with the punishment above mentioned. atropis, copper, unripe fruit of papaya, Plumbago etc.
xplanation: It is not essential to this offense that the – Abortion pills – these pills are made up of lead diphe-
offender should know that the act is likely to cause death. nylephylene etc.
4. 315 IPC – act done with intent to prevent child being born
alive or to cause it to die after birth – whoever, before
the birth of any child, does any act with the intention of Table 19.2: Means used to induce criminal
thereby preventing that child from being born alive or caus- abortion
ing it to die after its birth, and does by such act prevent
Methods used
that child from being born alive, or causes it to die after
Forensic Medicine

its birth, shall, if such act be not caused in good faith for A. Abortifacient drugs
the purpose of saving the life of the mother, be punished 1. Ecbolics
with imprisonment of either description for a term which 2. Emmenogogues
may extend to ten years, or with fine, or with both. 3. Irritant poisons
5. 316 IPC – causing death of quick unborn child by act 4. Systemic poisons
amounting to culpable homicide – whoever, does any act 5. Abortion pills
under such circumstances that if he thereby caused death 6. Abortion stick
he would be guilty of culpable homicide, and does by such
A
B. Mechanical violence
Section

act cause the death of quick unborn child, shall be punished 1. General violence
with imprisonment of either description for a term which 2. Local violence
may extend to ten years, and shall also be liable to fine.
 348 rinciples o orensic
Fig. 19.3: Various means used to induce criminal
abortion
Violence
1. 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 mas-
saging the abdomen
– Cupping: a flame light (diya) is placed on abdo-
men and a metal mug (lota) is placed over the
flaming light (diya) (Fig. 19.4).
2. Local method
A) By unskilled or semiskilled person (Fig. 19.5)
– Rupture of membrane by abortion stick, metal
rod, knitting needle, hair pin etc.
Forensic Medicine
A
Section
Fig. 19.4: Diagram showing the procedure of
cupping
edicine and oxicology
– 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
– Dilatation and evacuation
– Use of laminaria tent
– 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 (Fig. 19.6).
• The substances consist of juice of marking nut, calat-
ropis, oleander, abrus, plumbago or paste made up of
arsenic oxide, arsenic sulphide, lead etc.
• The stick is then passed into the uterus per vaginally
resulting in rupture of membrane and expulsion of prod-
uct of conception.
• Complications of abortion sticks are:
1. Local injury
2. Hemorrhage and shock
3. Perforation of uterus
4. Perforation peritonitis
5. Incomplete abortion
Fig. 19.5: Different material used to procure
criminal abortion
 bortion and edical ermination o regnancy 349

number of abortions being performed every year by untrained

persons in totally unhygienic conditions.8 Unsafe abortion
today, constitutes the single largest cause of pregnancy-
related deaths.9 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
adopted to procure abortion.
2. If death is imminent, doctor must arrange for dying dec-
Fig. 19.6: Abortion stick laration.
3. If female dies, he should report matter to the police.
6. Embolism
7. Septicemia Medical Evidence of Abortion
It consists of
Complication of Criminal Abortion
1. Examination of female.
2. Examination of aborted material.
Immediate
1. Hemorrhage Examination of Female (During life)
2. Perforation of uterus 1. General: Female will have exhaust look, increase tem-
3. Shock due to vagal inhibition resulting from instrumenta- perature, increase pulse.
tion 2. Breasts: Are heavy, enlarged, areola and nipples are
4. Fat embolism pigmented, clostrum/milk may ooze on squeezing the
5. Air embolism breasts (Fig. 19.7).
6. Amniotic fluid embolism 3. Abdomen: Is lax and wrinkled. Striae may be present
7. Incomplete abortion along with linea nigra (Fig. 19.8). Involuting uterus may
8. Local injury be palpable.
4. Perineum: Laceration or bruises may be noted, inflam-
Delayed mation is evident
1. Septicemia 5. Labia: majora and minora will be inflamed and bruised
2. Tetanus (Fig. 19.9)
3. Endometritis 6. Vagina: Tags of membrane, partial aborted material,
4. Renal failure blood, foreign body, abortion stick etc. may be found.
5. Peritonitis The vaginal wall is contused, abraded or lacerated. The
6. Sterility wall is lax, dilated.
7. Recurrent abortion 7. Cervix: The external os would be patulous, ulceration or
erosions may be present. Cervical canal may be dilated
Causes of Death in Criminal Abortion with abrasions or lacerations.
8. Uterus: May be enlarged on bimanual examination or
1. Vaso-vagal shock may be showing signs of involution.
Forensic Medicine
2. Hemorrhagic shock 9. Swab from cervical canal will reveal chemical used for
3. Perforation of uterus procuring abortion and can be used for bacteriological
4. Septicemia examination.
5. Embolism 10. Urine examination: hCG may be detected up to 7 days.
6. Disseminated intravascular coagulation
Examination of Female (After Death)
Duties of Registered Medical Practitioner in
Criminal Abortion
In addition to above, following findings may be noted at A
autopsy
Section

Despite the enactment of MTP Act, the number of illegal and • Clothes: Undergarments may show blood, clots, pieces
unsafe abortion in India continues to be very high with large of product of conception, stains of chemicals used etc.
 350 rinciples o orensic edicine and oxicology

• 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
• Differences between criminal abortion and natural abor-
tion are given in Table 19.3.

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
Fig. 19.7: Changes in breast it happens to be product of conception, it may be sug-
gestive 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 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.5
• The fetus should be examined to determine its:
1. Probable intrauterine age.
2. Presence or absence of injuries on body.
3. Viability of child.

Fig. 19.8: Abdomen with striae marks Table 19.3: Showing difference between natural
and criminal abortion
Features Natural Criminal abortion
abortion
Reason Predisposing History of
disease pregnancy in
unmarried girl or
Forensic Medicine

widow
Infection Rare Frequent
Injuries to Absent Frequently present
genitals
Signs of Absent Present
violence
A Application of Absent Present
chemical or
Section

drugs
Foreign body Absent Present
Fig. 19.9: External genitals in abortion
 bortion and edical ermination o
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 across
placenta (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
• In 1970, the World Medical Association (WMA)
adopted a resolution on therapeutic abortion, known as
“Declaration of Oslo”.
• It is performed either in accordance with the legal pro-
visions 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 woman.10
Medical Termination of Pregnancy11
With enactment of Medical Termination of Pregnancy (MTP)
Act 1971, abortion is liberalized in India, under the provi-
sions of Act, but it is not legalized.
Indications
As per MTP Act 1971, pregnancy can be terminated on the
following grounds (mnemonic “SETH” - S social, E
eugenic, T therapeutic, H humanitarian).
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 termi-
nated on humanitarian ground.
regnancy 351
4. Social
When pregnancy has resulted due to failure of contracep-
tive 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, irrespec-
tive 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.12
Rules for Doing MTP
ua ification Re uire
• 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-surgeonship 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
(license to be obtained from the Chief Medical Officer/
Civil surgeon of the district).
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 (lunatic), consent of parents or guardian is necessary.
4. Duration of Pregnancy
• When duration of pregnancy is below 12 weeks of ges-
Forensic Medicine
tation, one Registered Medical Practitioner (RMP) can
terminate the pregnancy.
• When duration of pregnancy is above 12 weeks but less
than 20 weeks (i.e. 12–20 weeks), then two RMP are
required to terminate the pregnancy.
13
Documentation an Recor A
• According to regulation 5 of MTP Regulations, all
Section
approved centers are required to maintain an admission
register in the format prescribed in form III.
 352 rinciples o orensic edicine and oxicology

• A fresh register should be started in each calendar year 2. When Doctor violates the provisions of MTP Act, he is
with new serial number generated by mentioning the year liable to be punished by the law and similarly his act
against the serial number amount to misconduct in professional sense.
• The admission register is a secret document. It should 3. To bring a false charge of assault against any person, a
be maintained for at least 5 years from the last entry. female may plead that she has been assaulted and due
to assault, abortion was induced.
Methods of Inducing MTP14 4. A female may be falsely charged or implicated for induc-
ing criminal abortion.
Up to 12 Weeks
1. Manual vacuum aspiration REFERENCES
2. Suction evacuation and/or curettage
3. Dilatation and curettage 1. Pillay VV. Abortion. In: Textbook of Forensic Medicine and
Toxicology, 14th edn. Paras Publishing, Hyderabad. 2004;273–8.
4. Mifepristone
2. Ramchandran A, Chandran MR. Human sexual function –
5. Mifepristone and misoprostol (PgE1) medicolegal considerations. In A Short Textbook of Forensic
6. Methotrexate and misoprostol medicine and Toxicology, 1st reprint edn. All India Publishers
7. Tamoxifen and misoprostol and Distributors, Regd., New Delhi. 2006;63–99.
3. Padubidri V, Daftary SN. Abortion. In: Howkins and Bourne
Between 13 to 20 Weeks Shaw’s Textbook of Gynaecology, 10th edn. B I Churchill
Livingstone, New Delhi. 1989;244–55.
1. Dilatation and evacuation 4. Vij K. Abortion and delivery. In: Textbook of Forensic
2. Oxytocin infusion Medicine and Toxicology, 3rd edn. Reed Elsevier India Pvt.
3. Induction by prostaglandins E1 (misoprostol) 15 methyl Limited, New Delhi. 2005;545–62.
PGF2 (carboprost), PGE2 (dinprostone) and their ana- 5. Mathiharan K, Patnaik AK. Abortion, medical termination of
logues. (Used as intravaginally, intramuscularly or intra- pregnancy and female feticide. In: Modi’s Medical Jurisprudence
amniotically) and Toxicology, 23rd edn. LexisNexis Butterworths, New
4. Hysterotomy – less common method Delhi. 2005;1013–46.
6. Sharma RK. Abortion and medical termination of pregnancy. In:
Concise Textbook of Forensic medicine and Toxicology, 1st edn.
Complications of MTP
Reed Elsevier India Pvt. Limited, New Delhi. 2005;126–31.
7. Rao NG. Sexual jurisprudence. In: Textbook of Forensic
Immediate Medicine and Toxicology, 1st edn. Jaypee Brothers Medical
Publishers (P) Ltd., New Delhi. 2006;281–320.
1. Hemorrhage and shock
8. Kumar S. Medical abortion in purview of MTP Act,
2. Perforation of uterus, intestine India (1971). Consortium on national consensus for medical
3. Laceration of cervix or vagina abortion in India. Available from http:/www.aiims.edu/aims/
4. Incomplete abortion events/gynaewebsite.
5. Endometritis 9. Kabra SG. Reproductive health care for women: a saga of
6. Embolism excess, exploitation and violation. Indian J Med Ethics 1997;
5: available from www.ijme.in/052mi047.html.
Delayed 10. Subrahmanyam BV. Abortion and medical termination of preg-
nancy. In: Modi’s Medical Jurisprudence and Toxicology, 22nd
Forensic Medicine

1. Menstrual disturbances edn. Butterworths India, New Delhi. 2001;581–603.

2. Sterility 11. The Medical Termination of Pregnancy Act 1971 (Act No. 34
3. Pelvic inflammatory disease of 1971).
12. Reddy KSN. Abortion. In: The Essentials of Forensic
4. Recurrent abortion or premature labor
Medicine and Toxicology, 22nd edn. K. Suguna Devi,
5. Rh isoimmunization Hyderabad. 2003;345–54.
6. Psychological sequelae 13. Sherier N. Medicolegal aspects – medical methods for early
abortion. Consortium on national consensus for medical abor-
A Medicolegal Importance of Abortion tion in India. Available from http:/www.aiims.edu/aims/events/
gynaewebsite.
Section

1. When abortion is induced without proper indication or 14. Konar H, Dutta DC. Hemorrhage in early pregnancy. In:
in contravention to the provisions of MTP Act, it is con- Textbook of Obstetrics, 6th edn. New Central Book Agency
sidered as criminal abortion and is punishable by law. (P) Ltd., Calcutta. 2004;174.