20.Virginity and pregnancy

Virginity, Pregnancy and Delivery, Legitimacy and Paternity

Virginity

• Definition of Virginity: A woman who has not experienced sexual intercourse.

• Loss of Virginity(Defloration) (UQ): Occurs when a woman engages in sexual intercourse, resulting in the tearing of the hymen.

• Types and Structure of Hymen (UQ):

  • Hymen is a fold of mucous membrane about 1mm thick at the vaginal outlet.

  • Variations:

    • Annular: Round or oval opening, common.

    • Semi-lunar/Crescentic: Crescent shape.

    • Infantile: Small linear opening.

    • Cribriform: Multiple small openings.

    • Vertical: Vertical opening.

    • Septate: Two lateral openings.

    • Imperforate: No opening.

    • Fimbriate: Fimbriated margin that may be misinterpreted as a rupture.

• After delivery, only remnants of hymen will be seen at the rim called carunculae hymenales or myrtiformes.

• Common site of rupture :both sides of midline on posterior aspect (5 o’clock - 7 o’ clock)

Signs of Virginity (UQ)

• Physical Characteristics:

  1. Breasts: Firm, elastic, small nipples, may reveal dark pigmentation in certain skin types.

  2. External Genitalia: Labia majora and minora in normal position, vagina tight and narrow, hymen intact.

• False Virgin (UQ): A woman who has experienced sexual intercourse but presents an intact hymen, often elastic and tough.

Differences Between True Virgin and False Virgin

Pregnancy

• Definition: A physiological condition where a female's ova is fertilized by spermatozoa, leading to embryo or fetus development.

• Legal Implications:

  • Pregnancy can affect court appearances, with women potentially excused in later stages.

  • Reduction of capital punishment ( CrPC 416)

  • May influence divorce settlements and claims for alimony.

  • Can be falsely feigned for property distribution.

  • Suicide/Homicide

  • Maternity leave

  • Relevant in cases related to infanticide, criminal abortion, and maternal negligence.

Signs and Symptoms of Pregnancy (UQ)

Presumptive signs

1. Amenorrhea: A missed period, often the first sign.

2. Morning Sickness: Nausea typically resolves by the third month.

3. Breast Changes: Enlargement and pigmentation of areola and Montgomery's tubercles by the second month.

4. Chadwick's Sign: Bluish discoloration of vaginal mucosa by the eighth week.

5. Quickening (UQ): First fluttering movements felt by 16-20 weeks.

6. Palmer’s Sign: Rhythmic contractions detectable during bimanual exam as early as 4-8 weeks.

Probable signs

1. Goodell’s Sign: Softening of the cervix noted in initial pregnancy stages.

2. Hegar's Sign: Softening of lower uterine segment observed between the second and fifth month.

3. Abdominal Enlargement: Progressive changes with the formation of linea nigra, striae gravidarum, striae albicans.

   

4. Braxton hick’s sign: intermittent painless uterine contractions

5. Ballottement

6. Fetal cells in mother’s blood

7. Uterine Soufflé: A heart-synchronous murmur by the sixteenth week.

8. Biological Tests: Detect levels of human chorionic gonadotropin (HCG) as a pregnancy indicator.

   • Tests include Ascheim-Zondek and other animal-based tests, though less common today due to modern methods.

9. Immunological tests: Detects HCG

   • Prognosticon tube test

   • Direct Latex Test

     • Procedure: A simple immunological test to detect HCG (Human Chorionic Gonadotropin) in urine.

       • Latex Reagent: Composed of particles coated with anti-HCG antibodies.

       • Agitation:

         • If HCG is present, it binds to the antibodies causing agglutination (Positive Test).

         • If no HCG is present, no agglutination occurs (Negative Test)

   • Rapid Chromatographic Immunoassay

     • Description: A more advanced method using a device with a membrane pre-coated with anti-HCG antibodies.

       • Procedure: Adding two drops of urine allows it to move by capillary action, producing a pink band (in addition to the control band) if positive.

     • Timing: Becomes positive approximately two weeks after a missed menstrual period; remains positive throughout pregnancy and becomes negative about a week after termination or abortion.

     • Interpretation:

       • A negative test during pregnancy may indicate fetal death.

       • False Positives: Can occur in ectopic gestation, hydatidiform mole, and pituitary tumors (about 2%).

       • False Negatives: Occurs in about 7% of normal pregnancies

Positive signs (UQ)

1. Palpable fetal parts

2. Fetal movements

3. Fetal Heart Sounds: Audible usually from the fifth month, indicating successful pregnancy.

4. Placental souffle: blowing sound by fetal circulation

5. X-ray

6. Ultrasound Confirmation: Gestational sac visible as early as five weeks; fetal developmental abnormalities assessed.

Pseudocyesis (Phantom Pregnancy)

• Description: A condition where a woman believes she is pregnant and exhibits symptoms.

  • Characteristics:

    • Typically affects women nearing menopause or those with a strong desire to be pregnant.

    • Symptoms may include abdominal enlargement and lactation.

  • Diagnosis: Ultrasound and pregnancy tests often reveal no actual pregnancy.

Corpus Luteum

• Roles: Present during both pregnancy and menstruation; not solely confirmatory of pregnancy.

  • Can be present in non-pregnant women or absent in some pregnant cases.

Period of Gestation

• Standard Duration: Recognized as 280 days (40 weeks) from the last menstrual period.

  • Variations: Can extend to 320-350 days in cases of post-maturity.

Period of Viability

• Definition: Refers to the ability of a fetus to survive outside the womb.

  • Viability Threshold: Generally accepted at 210 days of gestation for legal purposes, with some children born at 180 days possibly being viable.

Superfecundation (UQ)

• Definition: Fertilization of two separate ova from the same period by different acts of coitus.

  • Example: Can result in non-identical twins with different fathers.

  • Notable Case: Hybrid twins born to a black woman married to a black man.

• Medicolegal Aspects of Superfecundation: Variations in appearance of twins can raise questions of infidelity.

Superfoetation (UQ)

• Definition: Fertilization of a second ovum while already pregnant, leading to two fetuses of different developmental stages.

  • Nutritional Disparity: One fetus may receive more blood supply than another.

• Outcome: May result in different sizes at birth.

Twin Pregnancy Complications

• States: In twin pregnancies, one fetus may be aborted or retained, leading to conditions known as 'fetus compressus' or 'fetus papyraceus'.

• Faternal vs Identical Twins:

  • Fraternal twins (dizygotic) result from two eggs fertilized.

  • Identical twins (monozygotic) arise from a split fertilized egg.

Vanishing Twin Syndrome

• Description: Multifetal gestation with one or more fetuses disappearing, increasingly identified due to sonography.

Fecundation ab Extra

• Concept: Pregnancy can occur without coitus; sperm deposited near the vagina can migrate and cause conception.

Pre-Conception and Prenatal Diagnostic Techniques (PC & PNDT) Act 1994 (Amended 2012)

• Regulation: Prohibits sex determination of the fetus.

  • Prenatal Diagnostic Tests: Include amniotic fluid analysis, ultrasound, etc.

  • Permitted Cases:

    • Clause 2

      • (1) Chromosomal abnormalities

      • (2) Genetic metabolic disorders

      • (3) Hemoglobinopathies

      • (4) Sex- linked genetic diseases

      • (5) Congenital anomalies

      • (6) Any other abnormalities specified by the Central Supervisory Board

    • Clause 3

      • (1) Spontaneous abortions or fetal loss

      • (2) History of exposure to radiation, chemicals or teratogenic drugs

      • (3) Pregnant woman aged more than 35 years

      • (4) Pregnant woman or her spouse has a family history of mental retardation or physical deformity

      • (5) Any other condition specified by the Central Supervisory Board

• Punishment

  • Doctor punished with 3 years rigorous imprisonment and fine up to Rs. 10,000/- and suspension of his name for a period of 5 years for the first offence

  • For the subsequent offence permanent removal, imprisonment for 5 years and fine Rs. 50,000.

  • Any person, who seeks the aid of genetic counselling laboratory/clinic or doctor for this purpose punished with imprisonment up to 3 years and fine up to 50,000 rupees

  • For subsequent offence, imprisonment up to 5 years and fine up to one lakh rupees.

Delivery

• Definition: Expulsion of the fetus from the uterus.

• M/L significance:

  • Infanticide

  • Concealment of birth

  • Feigned delivery

  • Abortion

  • Legitimacy

  • Nullity of marriage

  • Divorce

  • Blackmail

Signs of Recent Delivery in Living (UQ)

1. General Physical State: Fatigue, paleness, increased pulse.

2. Breast Changes: Enlarged breasts with colostrum post-delivery.

3. Abdomen Changes: Lax, pendulous with pink striae gravidarum(striae rubra) and linea nigra.

4. Genitalia Changes: Swollen labia, soft and dilated cervix.

5. Uterus Size: Initially contracted, progressively involution occurs.

6. Lochia Discharge (UQ):

   • Discharge from uterus after delivery

   • Disagreeable puerperial odour

   • If the discharge is offensive it indicates infection

   • For 1 — 4 days the discharge will be bright red with blood clots (lochia rubra).

   • From 5—9 day it will be pale and serous (lochia serosa).

   • From 10—15 days it will become yellowish-white and turbid (lochia Alba) and then disappears

   • Discharge will stop by about 15 days.

Signs of Recent Delivery in Dead (UQ)

• Characteristics: Uterine size reduction and changes similar to living signs post-delivery.

Signs of Remote Delivery in Living

• Breasts: pendulous and enlarged with Montgomery’s tubercles.

• Abdomen : Abdominal wall lax with silvery striae albicans.

• External Genitalia and Cervix

  • Labia majora will not be apposing and labia minora will be seen exposed

  • Hymen will be absent or caranculae hymenales

  • Cervix will show healed lacerations

  • External os will be dilated and slit like.

Differentiation Between Nulliparous and Parous Uterus

Legitimacy and disputed paternity

• Legal Definitions:

  • Legitimate child: Conceived during valid marriage or within 280 days of dissolution of marriage by death of the husband or divorce-as per Sec 112 IEA.

  • Illegitimate child: Born out of wedlock or not fitting within legal timeframes.

• Medicolegal Significance

  • Inheritance: Legitimacy affects inheritance rights.

  • Nullity of Marriage: Affects the validity of the marriage contract.

  • Divorce: Illegitimacy can be grounds for divorce.

  • Affiliation Cases: Legal claims for paternity support.

  • Posthumous Child: Addressing legitimacy after the father’s death.

  • Supposititious Child: Claims of false pregnancy.

  • Atavism: Resemblance to grandparents as proof of legitimacy.

• Paternity Tests: Blood group and DNA testing to establish paternity.

Marriage

• Contract between a man and a woman which implies physical union by coitus

• Nullity of Marriage and Divorce

  • Divorce is the legal dissolution already existing marriage contract.

  • According to Sec. 11, 12 and 13 of the Hindy marriage Act - Grounds for Divorce:

    • Adultery

    • Cruelty

    • Desertion

    • Apostasy: Change in religion

    • Unsoundness of mind

    • Sexually transmitted diseases including HIV/ AIDS

    • Renouncing the world

    • Bigamy

    • Impotence

    • Additional grounds for women: Husband convicted of rape, sodomy or bestiality