SN6 SHORT NOTE 5M ★ High-yield

Describe the signs of recent abortion in a living woman and the distinction between natural and induced abortion.

Forensic Medicine · 2nd Professional — Para-Clinical

Signs of Recent Abortion

System	Findings
General	Pallor and anaemia from blood loss; fever and features of sepsis; shock; and the general condition, which may be grave
Breasts	Enlarged with the pigmentation of pregnancy; colostrum may be expressible if the abortion occurred after about the 16th week, and is absent in an early abortion — so the breasts date the pregnancy rather than the abortion
Abdomen	The uterus enlarged and soft, and palpable above the pubis if the pregnancy was beyond about 12 weeks; tenderness and guarding where there is peritonitis
Vulva and vagina	Bleeding or blood-stained discharge; a foul discharge where there is sepsis; injury — lacerations, chemical ulcers (especially of potassium permanganate) and instrument tracks; and any foreign body still in place
Cervix	Soft and patulous; the OS admitting a finger in a recent abortion and closing over the following days; lacerations and instrument injury; and products of conception may be visible or protruding
Products of conception	Expelled material should be recovered and sent for histology — the demonstration of chorionic villi and decidua proves that the woman was pregnant, which may itself be denied

Timing of the physical signs — the uterus involutes over about 2 weeks after an early abortion and rather longer after a late one; the cervical os closes within a few days; bleeding continues for about a week to ten days; and the breast changes regress over weeks
Investigations — a pregnancy test, which remains positive for 2 to 3 weeks after the pregnancy ends and therefore confirms a recent pregnancy rather than a current one; ultrasound, which shows retained products, an empty uterus or a perforation; a blood count and coagulation screen; and cultures where there is sepsis

CLINICAL PEARL

Chorionic villi on histology are the one finding that proves the woman was pregnant. Every other sign — a soft uterus, a patulous os, bleeding, breast change — is compatible with other conditions and can be argued away. Villi and decidua cannot. Which is why the expelled material must be recovered rather than discarded, and why a curettage specimen in these cases is sent for histology rather than thrown away with the swabs.

Distinguishing Natural from Induced Abortion

Favouring natural (spontaneous) abortion	Favouring induced abortion
No injury to the genital tract	Injury — cervical or vaginal laceration, a chemical ulcer, uterine perforation, or an instrument track
A recognised cause — incompetent cervix, infection, chromosomal abnormality, antiphospholipid syndrome, uterine anomaly, trauma or systemic illness	A foreign body in the genital tract, or evidence of a substance introduced
A gradual onset with a history of threatened abortion	Abrupt onset in a previously normal pregnancy, often at a time of the woman’s choosing
Early gestation, when spontaneous loss is common	Evidence of a poison or abortifacient in the viscera or in the vagina
The woman sought care promptly and openly	Concealment, delayed presentation, an inconsistent or changing history, and evidence of an unqualified attendant
No motive	A motive — an unmarried or extramarital pregnancy, a sex-selective motive, or social pressure

The distinction cannot be made on the physical findings alone in most cases, since spontaneous abortion is very common — occurring in perhaps one in five recognised pregnancies — and produces the same uterine and cervical findings as an induced one. Injury and a foreign body are the findings that discriminate, and their absence proves nothing

Applied Aspects

Send every expelled specimen for histology; chorionic villi prove the pregnancy, and the material is routinely discarded in exactly the cases where it matters most
Look specifically for a chemical ulcer and a retained foreign body; both are strong evidence of interference and both are missed on a cursory examination
Do not infer interference from a spontaneous abortion; one in five pregnancies ends spontaneously, and an accusation founded on the uterine findings alone is unsustainable
Take consent, provide a chaperone and preserve dignity; the woman may be a victim, an accused or neither, and the examination is intrusive in every case
Record the history as alleged and treat her first; a woman who fears prosecution conceals the history, and concealment is what kills in septic abortion
Photograph and measure any genital injury, and preserve swabs, the foreign body and any tablets or plant material produced

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