Q5 LONG ANSWER 10M ★ High-yield

Describe criminal abortion with its methods, complications and the medicolegal examination.

Forensic Medicine · 2nd Professional — Para-Clinical

Definition and Methods

Criminal abortion is the intentional termination of a pregnancy for a purpose other than that permitted by the MTP Act, or by a person or at a place not authorised under it. It is an offence under BNS 88 to 90, and the woman herself is liable if she procures her own miscarriage.

Method	Description and dangers
General violence	Blows or kicks to the abdomen, jolting, violent exercise, lifting weights, and jumping from a height. Ineffective in a healthy pregnancy and dangerous to the woman — producing abruptio placentae, uterine and visceral rupture
Local violence — instruments	The commonest and most dangerous group in India. A knitting needle, hairpin, stick, twig, catheter, wire or the stem of a plant is passed through the cervix to rupture the membranes. Causes perforation of the uterus, injury to the bowel and bladder, haemorrhage and sepsis. Sticks of plant origin carry Clostridium and are notorious for gas gangrene
Syringing and injection of fluid	Soap solution, disinfectant, potassium permanganate or plain fluid injected into the uterine cavity by a syringe or enema nozzle. Causes air embolism and chemical injury; and a soap-solution death may be very rapid
Abortifacient drugs and poisons	See below — largely ineffective in the doses that are survivable, so the woman is poisoned before she aborts
Intravaginal and intracervical applications	Potassium permanganate tablets or crystals inserted into the vagina — which do not cause abortion but produce a deep chemical ulcer of the vaginal wall with torrential haemorrhage, and are a recognised cause of death in India
Unsafe surgical evacuation	Dilatation and curettage or suction by an untrained person, or in unsterile conditions
Self-administered medical abortion	Misoprostol and mifepristone obtained without prescription and used without supervision or gestational assessment — increasingly the commonest route, and dangerous chiefly because an ectopic pregnancy is missed and because incomplete abortion goes untreated

CLINICAL PEARL

Potassium permanganate in the vagina does not cause abortion — it causes exsanguination. The tablet burns a deep chemical ulcer into the vaginal wall, which may erode a vessel and bleed torrentially, while the pregnancy continues undisturbed. It is a recurring cause of death in Indian practice, and the appearance — a punched-out ulcer with brown-black staining and an intact pregnancy — is nearly diagnostic of an attempted criminal abortion.

Complications and Causes of Death

Immediate — haemorrhage, external or concealed; vagal inhibition from sudden dilatation of the cervix, causing instantaneous death with a negative autopsy; air embolism, characteristically from syringing, in which air is driven into the open uterine sinuses; amniotic fluid embolism; injury to the uterus, bowel or bladder; and the effects of an anaesthetic or of the poison used
Delayed — sepsis, which is the commonest cause of death overall: pelvic and generalised peritonitis, septicaemia, tetanus, and Clostridium welchii infection with gas gangrene, haemolysis and the characteristic bronze discolouration; acute renal failure; disseminated intravascular coagulation; and retained products with continued bleeding
Late — chronic pelvic infection, infertility, cervical incompetence and Asherman syndrome
The characteristic Indian picture is a young woman presenting late, in septic shock, with a history of amenorrhoea denied or concealed, having been treated by an untrained person; and the mortality is high because presentation is delayed by fear

The Medicolegal Examination

In the living woman	In the dead woman
Consent is essential; a female doctor or chaperone; and privacy	A complete autopsy, with all three cavities opened
General condition, anaemia, sepsis and shock	Signs of recent delivery or abortion — a large soft uterus, lochia, engorged breasts
Signs of recent pregnancy and of its termination — a large soft uterus, an open cervical os, lochia, breast changes	The uterus opened in situ and examined for perforation, retained products, instrument tracks and injury
Local examination for injury — cervical and vaginal tears, chemical ulcers, and foreign bodies	The genital tract examined throughout, and any foreign body or instrument recovered and preserved
Investigations — pregnancy test, ultrasound, blood count, culture	Search for air embolism by opening the heart under water before anything else is disturbed
Preserve — vaginal and cervical swabs, blood, urine, any expelled products, and any drug or instrument produced	Preserve viscera for toxicology in every case, including the uterus and its contents
Record the history as alleged, and treat the woman as a patient first	Take material for histology to confirm pregnancy — chorionic villi and decidua

The questions to be answered — was the woman pregnant; was the pregnancy terminated; by what means; was it lawful; what was the cause of death; and was there any injury indicating interference
Open the heart under water first where syringing is suspected; air embolism is a specific and rapidly fatal complication and the evidence is destroyed by ordinary dissection

Applied Aspects

Treat the woman first and without judgement; she is a patient, and delay caused by moralising or by insisting on police formalities has killed women
The case is medicolegal and the police must be informed, but this does not precede resuscitation, and the woman’s account should be recorded as alleged
Record a dying declaration where she is deteriorating, with certification of mental fitness before and after; it is frequently the only evidence identifying the abortionist
Look for a vaginal chemical ulcer in any woman bleeding heavily with a continuing pregnancy; potassium permanganate is still used and the appearance is characteristic
Suspect Clostridium where a plant stick was used, and look for gas gangrene, haemolysis and bronze lividity; the mortality is very high and treatment must be immediate
Exclude ectopic pregnancy in a woman who has taken abortifacient drugs and continues to bleed or has pain; unsupervised medical abortion misses it, and rupture is the consequence
Preserve everything, including the expelled products; histology showing chorionic villi establishes that the woman was pregnant, which may itself be denied
Sepsis is the commonest cause of death in criminal abortion, and the delay in presentation caused by fear is what makes it lethal
Air embolism follows syringing; open the heart under water before anything else is disturbed, or the evidence is destroyed
Clostridium welchii gives bronze discolouration and haemolysis, and follows the use of plant sticks carrying soil organisms
Vagal inhibition may kill instantly on cervical dilatation, leaving a wholly negative autopsy in a woman who was otherwise well
Self-administered medical abortion is now the commonest route, and its danger is the missed ectopic rather than the drug itself
The woman herself is liable under BNS 88 if she procures her own miscarriage, which is why she conceals the history
Potassium permanganate does not abort; it burns a vaginal ulcer that may bleed torrentially while the pregnancy continues
Perforation of the uterus is the classical instrumental injury, with bowel and bladder damage and peritonitis following
General violence rarely aborts a healthy pregnancy but readily injures the woman, causing abruption and visceral rupture
Take viscera and the uterus for examination, and histology to confirm pregnancy where it is denied
Record a dying declaration where she is deteriorating; it is often the only evidence identifying the abortionist
Treat first, report afterwards; delay caused by insisting on police formalities has killed women in septic abortion
Exclude ectopic pregnancy in every case of bleeding after an abortifacient; the drug history is exactly what delays the diagnosis
Recover any instrument or plant root still in the genital tract intact, and preserve it sealed
Look for tetanus and gas gangrene after the use of an unsterile stick; both are recognised and both are rapidly fatal
The distinction from spontaneous abortion rests on injury, a foreign body or a poison; the uterine findings alone prove nothing
Preserve the expelled products for histology; chorionic villi are the one finding that proves pregnancy, and are routinely discarded
Soap solution injected into the uterus kills rapidly by air embolism and chemical injury, and death may occur within minutes
Spontaneous abortion is very common — about one in five recognised pregnancies — so interference must be positively demonstrated
Photograph and measure every genital injury, and record whether a foreign body was recovered and from where
The examination needs consent and a chaperone, and the woman may be a victim, an accused, or neither

All questions in Infanticide & Abortion

Every Forensic Medicine chapter →