Medical Jurisprudence

Pregnancy
Roshni K T
620
VIII semester
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Contents
Introduction:
Pregnancy is the physiological condition of having a developing embryo or foetus in the body
from the time of fertilisation of the ovum (egg) by the spermatozoa until the birth of a child.
The Charaka Samhitha says !sukla sonitha "eeva samyogo tu khalu kukshigathe #arba
sam"na bhavathi$ (the %nion of male and female gametes and the life force together &ith the
influence of the eternal elements inside the uterus leads to pregnancy.) '(ack and (ill) a
popular nursery rhyme has been adapted by *( Chatton as '(ack told (ill to take her pill &ith
a glass of &ater+ (ill forgot and (ack begot , bouncing baby daughter-)
.t is not possible to determine the precise moment at &hich the spermatozoa fertilises the
ovum the e/act moment of the commencement of pregnanacy is usually uncertain. ,bout 0
days after the fertilisation the ovum reached the uterine cavity and implants itself in the
uterine &all. .n obstetric practice it is customary to estimate the e/pected date of delivery
using the 1aegele)s rule. This rule estimates the e/pected date of delivery (233) from the
first day of the &oman)s last menstrual period (4*P) by adding a year subtracting 5 months
and adding seven days to that date. This appro/imates to the average human pregnancy &hich
lasts 67 &eeks (897 days) from the 4*P or 59 &eeks ( 8:: days) from the date of
fertilisation. .t is also customary to divide the pregnancy into !trimesters$ to facilitate both
ease of diagnosis and a&areness of the problems particular to each stage of pregnancy.
Diagnosis of Pregnancy
.n medicolegal cases involving the issue of pregnancy the &oman in ;uestion may be sent to
a registered medical practitioner for e/amination and certification as to &hether she is really
pregnant or not (the e/pressed &ritten consent of the &oman duly &itnessed is mandatory).
To perform this duty one must be familiar &ith the symptoms and signs of pregnancy as &ell
as the laboratory and other e/aminations that are useful in the diagnosis of pregnancy. These
may be classified into: presumptive probable and positive signs.
Presumptive signs of Pregnancy:
This is based largely on the signs and symptoms e/perienced by the &oman:
1. Secondary ,menorrhoea< *enstruation ceases &ith the implantation of a fertilised
ovum in the uterus. Though strongly suggestive of pregnancy this is not reliable until
=7 or more days have passed after the e/pected date of the first day of menstruation. .t
must be noted that there are rare instances of pregnancy in &omen &ho have never
menstruated or &ho are supposedly menopausal. ,lso menstruation may continue
even after the conception. ,menorrhoea can also occur in anaemia hormonal
imbalance psychological conditions etc. on the contrary slight menstrual bleeding
can occur during the first 8 or 5 months of pregnancy. Pregnancy can develop during
lactational amenorrhoea.
2. *ammary Changes > ?rom the very commencement of pregnancy the breasts
become full and tender ad by 5<6 &eeks begin to actually increase in size. The
superficial veins appear more distinct and enlarged. The nipples are harder firmer
easily erectile and more prominent and deeply pigmented and the areolae surrounding
them become &ider and darker. There is also the presence of *ontgomery)s tubercles
(raised spots due to enlargement of the sebaceous glands). ?rom the fourth month
on&ards colostrum &hich consists of free fat globules and large phagocytic cells
filled &ith droplets of fat can be s;ueezed from the breasts. (,ll these changes can
also be seen in tumours of the ovary &hich secrete prolactin &omen &ho take
tran;uilisers &hich induce prolactinaemia &omen &ho suffer from psychic
pseudocyesis after taking certain tran;uilising drugs and after repeated stimulation of
the breasts). Colostrum &ill be present until a &eek after delivery and it is replaces by
milk. *ilk has ho&ever appeared in the breasts of &omen &ho have never been
pregnant or occassionaly in &omen taking contraceptive pills. @arely pregnancy may
occur &ithout any changes in the breasts or the breasts may even diminish in size
after the middle of pregnancy.
3. Aaginal changes >
a. (ac;uemir)sB Chad&ick)s signs: Cluish discolouration instead of the normal
pinkish colour of the mucous membrane of the vagina and violet colouration
of the vulva due to venous obstruction o&ing to pressure of the gravid)s
uterus after the fourth &eek of pregnancy. This is not reliable as such
discolouration may be caused by anything that obstruct proper venous return.
b. Carne)s sign: flattening of the anterior vaginal &all because of the up&ards
tilting of the cervi/.
4. Pigmentation of the skin > Aulva abdomen and armpits become darker and a dark line
e/tends from the pubis to the umbilicus (linea nigra). ,fter : months silver coloured
lines called 'striae gravidrum) appear on the abdomen due to the stretching of skin and
rupture of its deeper layers.
5. *orning sickness > Symptoms such as e/cessive salivation nausea vomiting soon
after &aking up dizziness perverted appetite etc appear during the first month of
pregnancy. These symptoms usually disaapear by 8<5 months. .n sme &omen these
symptoms &ill be absent+ but in some these &ill be severe. The symptoms are due to
increased levels of hormones (DC# and oestrogen) and sympathetic disturbance.
These may also be observed in cases of severe gastrointestinal disorder. .t may usually
persist as hyperemesis gravidrum.
6. Euickening > The pregnant &oman starts feeling the movement of the foetus from the
beginning of the =9
th
&eek. ,s pregnancy advances the movements &ill increase in
intensity. The sensation of ;uickening may be stimulated by flatulence and peristaltic
movements of the intestines especially in a nervous or hysterical &oman &ho is
an/ious to have children although she is not pregnant. This is kno&n as phantom
pregnancy &hich &ill be discussed later in this pro"ect.
7. Sympathetic disturbances > Salivation perverted appetite in the form of craving for
unusual and even disgusting food and irritable temper and easy fatigability are
observed.
8. ?re;uency of micturition < .n the early and late stages of pregnancy due to the
pressure of the enlarging uterus on the bladder the &oman passes urine very
fre;uently.
1one of the above signs are reliable and the medical "urist should never venture an opinion
on these signs alone.
Probable Signs:
1. ,bdominal changes< ,s the uterus enlarges in size the abdomen gradually enlarges
after the =8
th
&eek so the the umblilicus becomes flush &ith the skin. %pto the first =8
&eeks the gravid uterus remains in the cavity of the pelvis and about the =:
th
&eek it
rises "ust above the symphysis pubis and comes into contact &ith the abdominal &all.
,t the end of the 86
th
&eek it reaches the level of the umbilicus and at the end of the
89
th
&eek it is mid&ay bet&een the umbilicus and the /iphisternum. ,t the 5:
th
&eek
it reaches the /iphesternum or epigasternum. ,t the 67
th
&eek the uterus &idens and
receds in its height from the /iphisternum to 58&eek level i.e. it reaches Fcm belo&
/iphisternum. The enlargement of the abdomen is considered a prima facie evidence
of pregnancy during the child bearing but may also occur in ascites ovarian cysts
ovarian and uterine tumours and phantom tumours. There is also an increased
pigmentation linea albicantes striae gravidarum and linea nigra can be observed.
2. Changes in the %terus > The mucus becomes like a thick and viscid plug blocking
the cervical canal. #oodell)s sign (softening of cervi/ because of increased
vascularity. The cervi/ &hich normally feels like the tip of the nose feel like lips) can
first be appreciated at : > 9 &eeks. The cervi/ becomes more and more patulous as
pregnancy advances but this change may also occur in acute cervicitis
haematometra and in &omen &ho are long< term regular users of combined
contraceptives. To&ards term there is an apparent shortening of the cervi/ the
cervical canal becomes circular and the e/ternal os admits the tip of the finger &ith
ease and to a greater depth. %terine souffle (a soft blo&ing murmur synchronous
&ith the maternal pulse &hich can be heard &ith a stethoscope applied "ust above the
midline of the inguinal ligament) produced by the passage of blood rushing through
the dilated arteries is usually audible from the =:
th
&eek on&ards. Degar)s sign
(softening and easy compressibility of the lo&er uterine segment) first appears at :< 9
&eeks. This sign is elicited by introducing t&o fingers of one hand into the posterior
forni/ &hile the other hand rests on the pelvis "ust above the pubic symphysis. Gn
pressing up&ards &ith the first hand it appears as if there is no intervening uterus in
bet&een the t&o hands. Cra/ton Dick)s sign< the appreciation of intermittent painless
contractions of the uterus from the =:
th
&eek on&ards by palpation of the abdomen
occurring at intervals of F< 87 mins each lasting for about = > F minutes.
3. Callottement (tossing of a ball) i.e. the method of eliciting the presence of the foetus
floating in the li;uor aminii. This can be determined either e/ternally or internally.
2/ternal ballottement is elicited by placing the palms of both hands over the abdomen
on either side of the midline and pushing firmly of one hand to&ards the other
&hereupon the impetus thus given to the foetal head can be felt against the other.
.nternal ballottement is done by inserting t&o fingers of one hand into the posterior
forni/ and pushing sharply up&ards. The foetal head &ill first move up&ards in the
li;uor then settle do&n onto the fingers.
4. 2ndocrine Tests< The presence of human chorionic gonadotriphin(DC#) in the
maternal plasma and urine forms the basis of the endocrine tests. They give a fair
degree of accuracy of more than H:I. Ciological or immunological tests are used to
determine pregnancy. The morning midstream urine of the &oman suspected to be
pregnant is used for these tests. The follo&ing are the biological tests:
a. ,scheim Jondek Test: , suitable mouse for use in an ,<J test needs to be
three to five &eeks in age and &eigh bet&een si/ and ten grams. ?or each
pregnancy test three to five of these infant mice are necessary as some of
them &ill die before the end of the test. ,fter a urine specimen is collected
from the female it is tested for acidity and made basic. ,fter&ard one or t&o
drops of tricresol are often added in order to preserve the sample and the
urine is filtered if cloudy in appearance. Subse;uently 5 m4 of the urine
sample is in"ected subcutaneously into each mouse three times per day for
three days. T&o days after the last in"ection all of the mice are sacrificed and
the ovaries are e/amined macroscopically. The presence of the human
gonadotropin hormone in the urine sample is indicated by several
characteristic changes in the mice. The ,<J test is said to be positive if the
ovaries are enlarged (t&o to three times normal size) &ith red dots visible
(due to hemorrhage into the follicles) or if luteinization occurs and several
corpora lutea are visible. , corpus luteum can be identified macroscopically
as a small yello& dot on the ovaries. .f the uterus appears enlarged &ith no
changes in the ovaries the test is negative. The uterus becomes enlarged
because of other hormones present in the urine not because of hC#.
Do&ever if the first reaction is observed but the organism displays other
features of heat such as cornification of the vagina the test is repeated &ith a
second urine sample. This test gives a positive reaction in about H0I of cases
of pregnancy. 1ot used no& because of the time factor.
b. The ?riedman *odification: The rabbit test consisted of in"ecting the tested
&omanKs urine into a virgin female rabbit then e/amining the rabbitKs ovaries
a fe& days later &hich &ould change in response to a hormone only secreted
by pregnant &omen. 86<5: hours later a positive reaction &ill be indicated by
the presence of corpora lutea and corpora harmorrhagica in the hypertrophied
ovaries of the rabbit. There &ill also be a marked in"ection of the uterus and
oviduct.
c. The Lenopus Test or Dogben Test: .n"ect some urine into its dorsal lymph sac
in the morning and check back at the end of the day. , dose of a pregnant
&omanKs pee &ill cause a female South ,frican cla&ed frog to lay eggs &ithin
eight to =8 hours. The test also &orks on male frogs &hich produce sperm in
response to the in"ection.
1ame Test ,nimal 2nd Point Time of Test
,<J Test ?emale
*ice(immature)
Corpus 4uteum F days
?riedman test ?emale @abbit Corpus 4uteum 8 days
?rog Test ?emale 2/trusion of 2ggs 86 hours
Toad Test *ale 2/trusion of sperm 8<F days
.mmunological Tests are more faster more specific less cumbersome more sensitive and do
not re;uire lab animals e;uipment or special skills. ,ll these take advantage of the antigenic
property of DC#. They include:
a. Demagglutination<.nhibition Test (Prognosticon): .t is based on antigen
anti body reaction bet&een DC# and anti serum obtained from rabbits
immunised against the antigen. Tanned red cells agglutinate &hen mi/ed &ith
specific antiserum. ,bsence of agglutination is positive for pregnancy and the
presence is negative.
b. 4ate/ ,gglugination (#ravinde/): This test involves the use of late/
particles coated &ith DC#. ,ddition of an antiserum containing specific
antibodies causes particles to agglutinate. The late/ particles take the place of
tanned red cells as in Prognosticon test. .t can deliver a result in t&o hours and
its improvement the preg colour test &hich can be read in t&o minutes.
c. @adio<.mmuno ,ssay: This is highly sensitive and H9I accurate.
Do&ever all these DC# based tests &ill also be positive in those conditions in
&hich abnormal or pathological products of conception are formed namely
hydaitidiform mole and chorionepithelioma. ?urther ?alse positives could also
occur because of the biological and immunological similarities bet&een DC#
and 4D.
Conclusive Signs
1. ?oetal Deart Sounds<This is an absolute positive sign of pregnancy usually heard for
the first time generally from the =9
th
<87
th
&eek and is comparable to the muffled ticks
of a &atch under a pillo&. They vary in rate from =87<=:7bpm and are not
synchronized &ith the mothers pulse. They are not heard &hen the foetus is dead
&hen there is an e/tensive ;uantity of li;uor amnii or &hen the abdominal &all is
very fat.
2. ?oetal *ovements< They are felt and seen through the abdomen after the =:
th
<87
th
&eeks. They may be felt on bi manual e/amination through the vagina at the
commencement of the 86
th
&eek. The foetal parts may also be palpated through the
abdominal &all. This is a certain sign of pregnancy. These vary from a faint flutter to
a brisk motion.
3. L<@ay 2/amination< This makes the diagnosis of pregnancy certain after the =:
th
&eek. Mhen the centres of ossification have become &ell developed. L<@ay
e/amination &ill reveal the foetal skeleton inside the lo&er abdomen in the form of a
circular or crescentic outline of the skull ladder like shado& of the ribs beaded
shado& of the spine and shado&s of other bones. Cecause of the radiation hazards L<
@ay e/amination should not be carried out routinely to diagnose pregnancy.
4. Sonography< .t can make out the gestational ring b the :
th
&eek and distinct echoes
from the embryo &ithin the gestational ring by 9&eeks.Sonography can make out the
blighted ovum by loss of gestational ring and the absence of foetal echoes after 9
&eeks of gestation. ?oetal heart can be made out by the =8
th
&eek and foetal head and
thora/ made out by the =6
th
&eek. The latter half of the pregnancy sonography can
identify t&ins foetal anomalies and the rate of foetal gro&th by measuring serially
biparietal diameter.
Pseudocyesis:
, phantom or false pregnancy is a condition in &hich a non<pregnant &oman e/hibits all the
classic symptoms of pregnancy and is firmly convinced that she is pregnant even &hen clear
medical evidence sho&s that she is not. The medical term for this condition is pseudocyesis.
The first thing a &oman &ith a phantom pregnancy &ill probably do is visit her #P or
antenatal clinic complaining of all the usual symptoms and minor discomforts of early
pregnancy such as absence of periods+ breast enlargement+ nausea and vomiting+ &eight gain
and abdominal distension. .f a urine sample is tested at this stage it &ill confirm the
e/istence or other&ise of a pregnancy but a &oman suffering from a true pseudocyesis &ill
continue to insist that she is pregnant regardless of medical opinion
Superfetation:
Superfetation is the onset of a subse;uent pregnancy during an ongoing pregnancy+ a ne&
pregnancy during an initial pregnancy. .t happens &hen there is fertilization of an ovule by a
sperm cell &hile a conceptus is already present in the &omb. The phenomenon of
superfetation in animals has long been speculated as far back as fourth century C.C by
,ristotle. ,ristotle came to this thought &hen he observed that hares often gave birth to litters
&hich comprised sets of healthy and imperfect offsprings. De deduced that the imperfect
offsprings &ere younger ones &ho had spent less time in their mother)s &ombNa direct
conse;uence of superfetation. .n effect ,ristotle &as supposing that the younger offsprings
&ere from a litter &hich &as the result of the second pregnancy. Mhile there is evidence that
superfetation may indeed be part of the reproductive processes of certain animals in humans
it is in all likelihood a rare reproductive abnormality. .n other &ords it probably occurs by
accident. Cecause for superfetation to occur a number of things must happenNthings that a
&oman)s reproductive cycle is intrinsically programmed to prevent.
?irst for any pregnancy to occur an ovule must be present. ,nd for an ovule to be present
ovulation must have taken place. Therefore for superfetation to be possible ovulation must
be triggered during an ongoing pregnancy. ,nd this is a ma"or stumbling block right there.
Mhile ovulation happens every month in a fertile &oman it is normally impeded during
pregnancy. 3uring the early stages of pregnancy this is due to the corpus luteum the
surrounding tissue from &hich the ovule is shed during ovulation. .t remains for a couple of
days and releases hormones &hich ultimately prevent further ovulation. .f implantation of a
conceptus then occurs the corpus luteum stays for longer still actively secreting more
hormones. 2ventually this endocrine role is taken over by the placenta. Therefore strictly
speaking ovulation can only occur &hen neither the corpus luteum nor the placenta is
present.
Pregnancy also re;uires the fertilization of the ovule &ith a sperm cell. This means that
semen from the male must be able to attain the ovule in the female)s oviduct. Mhen a &oman
is pregnant ho&ever a mucus plug is formed in the cervi/ blocking the passage of sperm.
This mechanism prevents semen from passing through the pregnant uterus let alone allo&ing
it to reach the oviduct. The mechanism is an important measure against microbes contained in
semen &hich can cause venereal diseases to the fetus. .t also prevents the possibility of
superfetation.
?inally a viable pregnancy also re;uires proper implantation to occur. ,nd for superfetation
to occur the conceptus needs to implant in a pregnant uterus. .mplantation is only possible in
a delicate and specific environment controlled by different hormones though. %nder normal
conditions the appropriate uterine environment is catered for in a &oman &ho is ovulating
rather than in one &ho is pregnant. .n addition space is also an issue in the cro&ded already<
occupied uterus-
.n order for superfetation to occur in humans therefore it &ould appear that three seemingly
impossible things need to happen: ovulation must take place during an ongoing pregnancy
semen must someho& find its &ay through the blocked cervi/ to the oviduct via the occupied
uterus and finally the conceptus has to successfully implant itself in an unsuspecting already<
occupied uterus. The odds of all three of them happening are &ithout doubt e/tremely small
as reflected by the very occasional reports of superfetation in humans in the medical
literature. .t should be noted that reports of superfetation in humans are more commonly
associated &ith &omen &ho have undergone fertility treatments.
Superfecundation:
Superfecundation is the &ord for t&ins &ith separate fathers. ?or this to happen t&o things
have to happen:
1. The &oman &ould have to ovulate t&ice (dizyogtic).
2. The &oman &ould have to have se/ual intercourse &ith different men &ithin a couple
of days of ovulation.
Coth of these events can happen on the same day or different days as sperm can survive for
up to F days. *ultiple ovulations happen in about =I (or more) of all ovulations and more
often &hen you take ovulation<inducing medications.
Death of Foetus (In Utero)
.n the early months the diagnosis of the foetal death is difficult. @epeated e/aminations over
a number of &eeks sho& that the uterus is not gro&ing but regresses in size. .n the later half
of the pregnancy the foetal movements disappear. ?oetal heart cannot be heard by
conventional foetoscope or by 3oppler. The uterus does not correspond in size to the
estimated duration of pregnancy. .t is smaller than its size in previous observations. The
radiological signs of foetal death are:
#ross overlap of the skull bones(Spalding)s Sign)caused by li;uefaction of the brain
Collapse of the spinal column due to absence of muscle tone+
3emonstration of gas in the heart and great vessels.
?oetal death can confirmed sonographically. The amniotic fluid is turbid and bro&n. The
immunological tests for pregnancy become negative.
Signs of Pregnancy in the 3ead: .n addition to some of the ob"ective signs mentioned above
the diagnostic signs of pregnancy at the post<mortem e/amination are:
I) The presence an ovum or foetus
II) %terine changes
III) The Corpus 4uteum
edico !egal "spects of Pregnancy:
1. Civil Cases:
a. Mhen a &oman feigns pregnancy soon after her husband)s death so as to
defraud the rightful heir by producing a suppositious heir to an estate the heir
at la& may apply to the Court to order an en;uiry into the allegation.
b. Mhen a &oman &ho had filed a suit in Court for breach of promise of
marriage or for seduction claims to be pregnant.
c. Mhen a &oman blackmails a person and accuses him that she is pregnant by
him or a divorced &oman claims greater alimony as she is pregnant by the
husband.
d. Mhen a &ido& or an unmarried &oman or a separated married &oman has
been defamed or libelled to be pregnant.
e. Mhen a &oman alleges that she is pregnant in order to secure greater
compensation from some person or persons through &hose culpable neglect
her husband has died.
f. .t is possible that a surgeon may terminate a pregnancy by carrying out surgery
on the uterus for a fictitious tumour.
2. Criminal Cases
a. Mhen pregnancy is alleged to have been a motive for suicide or murder
b. .n case of infanticide or alleged concealment of pregnancy child birth or
criminal abortion
3. *iscellaneous
a. Mhen a &oman advances pregnancy as a plea to avoid attendance in court as a
&itness in an important trial. , pregnant &oman is entitled to be e/cused from
attendance in Court only if a physician certifies to the fact that delivery is
imminent or that there is a fear of the occurrence of a serious complication if
she &ere forced to attend court.
b. Mhen a condemned &oman pleads pregnancy as a bar to hard labour or
e/ecution. %nder s. 6=: of CrPC The Digh Court is the only "udicial court
&hich can postpone the e/ecution of a sentence of death confirmed by it or
commute it to life imprisonment after it is satisfied from the medical officer)s
certificate that the &oman is pregnant.
,ccording to the Preconception and Prenatal diagnostic techni;ues (Prohibition of Se/
Selection ,ct) =HH6 se/ selection is prohibited before or after conception and prenatal
diagnostic techni;ues for the purposes of detecting genetic abnormalities or metabolic
disorders or chromosomal abnormalities or certain congenital malformations or se/ linked
disorders are regulated. This is to prevent misuse of se/ determination leading to female
foeticide.
#ibliography
AA Pillay Te/tbook of ?orensic *edicine and To/icology Paras *edical Publishers
=:
th
ed. (87==)
*odi)s *edical (urisprudence and To/icology edited by C A Subrahmanyam 4e/is
1e/is Cutter&orths 88
nd
ed. (8776)
3r %madethan Principles and Practice of ?orensic *edicine S&amy 4a& Douse =
st
ed. (8779)