Abortion and miscarriage

Dr Sagal Omar
Anatomical pathologist
 MISCARRIAGE OR ABORTION

• Legal Definition: It is meant to expulsion of the products of

conception at any period of gestation before full-term. No offence
is committed if it is done in good faith for saving the life of the
woman.
• Medical Definition: Abortion – it is expulsion of fertilized ovum
within 3 months of pregnancy. Miscarriage at 3 to 7 months of
gestation. Premature Labor after 7 months when fetus is viable.
 Classification of Abortion

1. Natural, spontaneous or accidental abortion.

2. Artificial abortion or induced abortion may be:
(i) Justifiable or therapeutic or legal.
(ii) Criminal
 NATURAL ABORTION

• The general consensus appears to be that something like 20% of all

pregnancies end in abortion, and that perhaps 50-60% of these are
natural, the remainder are criminal and most frequently occur in
about second or third month.
• Causes of Natural Abortion:
i. Maternal or Gynecological issues
ii. Fetal problems
iii. Paternal issues
 i. Maternal or Gynecological causes:
1. Uterine and ovarian tumors, uterine poly, retroversion of uterus,
inflammation of cervix
2. Systemic poisons and micro-organisms circulating in blood e.g.
smallpox, syphilis, malaria, influenza, pneumonia, typhoid, lead,
copper, mercury and phosphorus, excessive use of alcohol, high
fever, CO, CO2 poisoning.
3. Diseases affecting circulation e.g. Rhesus factor, anemia,
hypertension.
4. Nervous causes e.g. sudden fright, grief, violent anger or shock.
5. Trauma separating Ovum from blow on abdomen or fall.
6. Placental diseases and abnormalities
7. Hormonal imbalance.
 ii. Fetal causes
• Any cause which brings death of the fetus in utero e.g. faulty
development of the fetus like hydrocephalus, anencephalies,
syphilis, diseases of decidua and degeneration of placenta, fetal
anoxia, diseases of the cord as torsion and stenosis, big
placental infarcts.
iii. Paternal Causes:
1. Defective Spermatozoa from lead or phosphorus poisoning.
2. Excessive use of alcohol
3. Syphilis
• The occurrence of natural abortion is not the subject of Forensic
Medicine and it need to be excluded from criminal abortion.
 ARTIFICIAL ABORTION OR THERAPEUTIC
ABORTION
• It is done in good faith to save the life of the mother, if there is
danger for continuance of pregnancy, but not to save the family
honor or other ethical reasons.
Indications of justifiable abortion are:
1. Maternal
2. Fetal
3. Eugenic grounds
4. Humanitarian grounds
 1.Maternal Indications
a. Gynecological
1. Contracted and deformed pelvis
2. A very large uterine fibroid or ovarian tumor
3. Repeated caesarians
4. Malignant tumors of ovaries or cervix or breast
5. Uterine hemorrhage – severe and persistent and threatened
abortion
6. Irreducible prolapse of gravid uterus
7. Infected uterus after attempt at criminal abortion
b. Systemic diseases:
1. Toxemia of pregnancy e.g. eclampsia.
2. Serious cardiac disease e.g. heart failure.
3. Active pulmonary tuberculosis or pulmonary hypertension
4. Renal disease e.g. nephritis or nephrotic syndrome
5. Hyperthyroidism – if causing cardiac irregularities.
6. Active cancer of breast, lung or other place or leukemia.
7. Uncontrolled severe diabetes mellitus
 2.Foetal Causes
1. Ectopic gestations or dead pregnancies
2. Hydatidiform mole
3. Placental detachment or disease
4. Diseases as in Rh. Incompatibility

3.Eugenic Grounds: (Production of fine offspring).

• These include conditions where there is substantial risk that the
child if born is likely to suffer from such physical or mental
abnormalities as to be seriously handicapped. Termination should
be done before 20th week of pregnancy.
 4.Humanitarian Grounds
• These include those cases where pregnancy has been caused by
rape. According to W.H.O health is not merely absence of disease,
but a positive state of over all physical, mental and social well
being.
• Thus, where any pregnancy is alleged by the pregnant woman to
have been caused by rape, the anguish caused by such pregnancy
is presumed to constitute a grave injury to her mental health.
There is every likely-hood that she may commit suicide and the
psychiatrist certifies.
 Criminal abortion
• The main focus is on this type of abortion. It is practiced on
unmarried women, widows and those who do not want more
children’
• Criminal abortion mostly take place at about second or third
month, when the woman has become certain of the cessation of
her periods and morning sickness has confirmed the pregnancy.
This period is specially suitable because the fact of her being
pregnant is unknown to others.
• Cases come for investigation to the police only when the death of
the woman occurs as a result of criminal abortion or due to family
enmity or due to infanticide to punish the woman.
 METHODS TO PROCURE ABORTION

There are two methods in common use. They are:-

I. Administration of drugs – Abortifacients
II. Application of violence or Mechanical Interference – General or
Local
 MEDICOLEGAL ASPECTS OF ABORTION
1. When abortion is alleged to have followed a blow or quarrel.
2. A woman may have been charged with abortion and she may wish to
conceal it. This occurs in cases of infanticide or enmity.
3. When death occurs as a result of abortion and thus crime generally
comes to light.
4. Abortion following vehicular accident or fright which could have
precipitated abortion and medical opinion is sought for compensation
purpose.
• Before any opinion of abortion is formed, full and careful examination
should be given to:-
A. History of the woman
B. Examination of woman (her body)
C. Examination of aborted material if available.
EXAMINATION: (1) Living (2) Dead
• In the living: History may or may not be available. History of use
of drugs or instruments, or any previous abortions. The medical
officer should be guarded against fabricated abortions.
• These are cases when assaulted woman tries to exaggerate the
offence by simulating in abortion. She may produce menstrual
blood clot, human or even an animal fetus.
In a genuine case of abortion the following are the findings:-
1. Uterus enlarged
2. OS opening
3. Tags of membrane are coming out
4. Discharge per vagina (Lochial discharge)
5. Other signs of pregnancy and recent delivery in the breast and
abdomen.
6. Note signs of any disease which may cause abortion.
7. If drugs are used or suspected, send – urine, faeces and vomit for
chemical analysis.
8. Breast – Milk can be squeezed out
9. Hormone – increase gonadotrophic hormone in the urine is
detected up to 9 days after delivery or abortion.
• In the dead woman: Possibility of post-mortem delivery due
to putrefactive gases must be kept in mind.
1. Presence of signs of pregnancy which may be visible upon the
exterior of the body, and in primipara, the expression of
colostrum or milk from the breast may be of indirect value in
the diagnosis of recent abortion.
2. The genital tract should be carefully examined for injuries
such as punctures or laceration indicating the introduction of
an instrument. Note any hemorrhage in the pelvic floor. The
primary incision should be a small one above the pubis to
inspect the uterus and the adnexal tissues, assessing any
crepitation and possible evidence of necrosis, and whether
perforation of wall has occurred.
3. The mucous membrane of the vagina may show signs of
lacerations bruising or erosion from abusive substances.
4. Examine for the presence of uterine or extra uterine infection. The
extent and spread of infection should also be noted to get an ideal
of time since abortion. Time can also be assessed by the character
of discharge and by microscopic examination.
5. The uterus and its appendages with the vagina attached should be
carefully dissected out to get a better view of the parts. See, if any
foreign bodies are present. It is advisable to note the size of the
uterus and weight it. The non pregnant uterus weighs 45 grams
and is 7.5cm long, 5cm broad and 2.5cm thick.
EXAMINATION OF ABORTED MATERIAL OR PROOF OF ABORTION BY
ABORTED MATERIAL
• When thoroughly and find out, if it is fetus or only blood clot
or polyp or hydatidiform mole. Also examine
microscopically for chorionic villi.
• If fetus, determine its intra-uterine age. Also remove a
piece of tissue from what is thought to have been the
placental site, so that presence of chorionic villi may be
identified microscopically.
 COMPLICATIONS OF CRIMINAL
ABORTION
1. Death from :
1. Shock
2. Hemorrhage
3. Air or fat embolism (in 1 to 20 minutes to 2 hours)
4. Perforation of uterus
5. Sepsis with or without Pyrexia
6. Poisoning by drugs – acute or chronic
II. Subinvolution of uterus may result along with symptoms of:
Displacement
Menorrhagia
Leucorrhoea & Chronic discharge
Retained products
 DISTINCTION BETWEEN NATURAL AND CRIMINAL ABORTION

• Natural abortion being common, criminal interference should not

be alleged without clear proof and such proof is often most difficult
to find. In natural abortion in early stages, the ovum is usually
expelled entire and any laceration in genital tract suggest
mechanical interference (criminal abortion).
• In later stages, the site, extent and appearance of the injuries
together with the physical development of the fetus help to
distinguish natural from criminal abortion. Marks of violence on the
abdomen or wounds on the membranes and or fetus provide
positive evidence of criminal interference.
 features of distinguishing between natural and
criminal abortion includes:
Natural abortion Criminal abortion

Cause Natural Criminal

Genital tract injuries Nil Usually present

Foreign body in genital tract Nil May be present

Sepsis Not usual Frequent

Signs of violence on abdomen Nil May be present

Toxic drug effects Nil May be present

Fetal injuries Nil May be present

•The end