pregnancy - medical jurisprudence

7/25/2019 Pregnancy - Medical Jurisprudence

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Medical Jurisprudence

Pregnancy

Roshni K T620

VIII semester

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Contents


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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 1aegeles rule. This rule estimates the e/pected date of delivery (233) from the

first day of the &omans 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:


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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

a. ac;uemirsB Chad&icks signs: luish 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 gravids

uterus after the fourth &eek of pregnancy. This is not reliable as such

discolouration may be caused by anything that obstruct proper venous return.


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b. arnes 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 The pregnant &oman starts feeling the movement of the foetus from the

beginning of the =9th&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 isan/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 =8th&eek so the the umblilicus becomes flush &ith the skin. %pto the first =8


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&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

89th&eek it is mid&ay bet&een the umbilicus and the /iphisternum. ,t the 5th&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. #oodells 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 &ithease 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. Degars 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. ra/ton Dicks 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. allottement (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


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&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 HI. iological 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 ,


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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


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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


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thora/ made out by the =6th&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


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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 females 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 ovulatingrather than in one &ho is pregnant. n addition space is also an issue in the cro&ded already

pregnancy - medical jurisprudence

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