‫‪Abortion‬‬

‫عبدهللا ابوعاقوله‬
‫حسي السعدي‬‫ن‬
‫طارق الزعب‬
‫‪1‬‬
 Definitions
• Abortion is the ending of pregnancy due to
removing an embryo or fetus before it can
survive outside the uterus

• Spontaneous abortion (is also known as a

miscarriage): noninduced embryonic or fetal
death or passage of products of conception
before 20 wk gestation
• Induced abortion : When deliberate (intended)
steps are taken to end a pregnancy 2
 Spontaneous Abortion Etiologies
• Abnormal genes or chromosomes (the most common cause)
- Most miscarriages occur because the fetus did not develop
normally
- The most common syndromes associated with abortion are
Turner syndrome & Trisomy 16

• Maternal health conditions

- Uncontrolled diabetes
- Infections
- Hormonal problems
- Uterus or cervix problems
- Thyroid disease 3
 Induced Abortion

• Drugs & chemicals

• Instrumental interference
• Dilation of the cervix
• Iinsufflation of air
• Physical violence

4
 Legal termination of pregnancy

• legal abortion (therapeutic abortion): abortion induced following a

diagnosis of medical necessity
• Indications :
1- Medical illness in the mother (in which continuation of the pregnancy has the potential to
threaten the life or health of the mother is a factor) .

2- If there is a genetic condition in the embryo or fetus which is incompatible

with life ( sever case of certain genetic condition , sever case of profound mental impairment ,
cerebral hemispheres , anencephaly )

5
 Illegal abortion (criminal)
• llegal abortion: is any abortion which is contrary to the laws of the country
• When performed in a non-medical setting, they are sometimes referred to
as back-street abortions
• Whatever the cause, criminal abortion is associated with a considerable risk
of both morbidity and mortality, especially in countries with a lower level of
medical and social care

6
Deaths associated with pregnancy

• Although it is not usually forensic problem, it is intensively investigated in a

number of countries

• The pathologies has an important role in furthering the understanding of

the cause of death in pregnancy after childbirth

• A good autopsy is essential with full histological examination for

diagnosis

7
Deaths associated with pregnancy

A few deaths are reported from time to time, the causes including:
■ pulmonary embolism from leg vein thrombosis
■ disseminated intravascular coagulation (DIC) and cerebral damage
■ air embolism following vacuum aspiration
■ bleeding or infection, which failed to respond to treatment

8
9
 ‫قانون العقوبات األردني رقم ‪ 16‬لسنة‬
‫‪ 1960‬في االجهاض‬
‫المادة (‪(321‬‬ ‫•‬
‫كل امرأة اجهضت نفسها بما استعملته من الوسائل او رضيت بأن يستعمل لها غيرها هذه الوسائل ‪ ،‬تعاقب بالحبس من ستة أشهر الى ثالث‬
‫سنوات‪.‬‬
‫المادة (‪(322‬‬ ‫•‬
‫‪1-‬من أقدم بأية وسيلة كانت على إجهاض امرأة برضاها ‪ ،‬عوقب بالحبس من سنة الى ثالث سنوات‪.‬‬
‫‪ 2-‬وإذا أفضى االجهاض او الوسائل التي استعملت في سبيله الى موت المرأة عوقب الفاعل باألشغال الشاقة المؤقتة مدة ال تقل عن خمس‬
‫سنوات‪.‬‬
‫المادة (‪(323‬‬ ‫•‬
‫‪1-‬من تسبب عن قصد بأجهاض امرأة دون رضاها ‪ ،‬عوقب باألشغال الشاقة مدة ال تزيد على عشر سنوات‪.‬‬
‫‪ 2-‬وال تنقص العقوبة عن عشر سنوات إذا أفضى االجهاض او الوسائل المستعملة الى موت المرأة‪.‬‬
‫المادة (‪(324‬‬ ‫•‬
‫تستفيد من عذر مخفف ‪ ،‬المرأة التي تجهض نفسها محافظة على شرفها ويستفيد كذلك من العذر نفسه من ارتكب إحدى الجرائم المنصوص عليها‬
‫في المادتين (‪ 322‬و ‪ ( 323‬للمحافظة على شرف إحدى فروعه او قريباته حتى الدرجة الثالثة‪.‬‬
‫المادة ‪325‬‬ ‫•‬
‫‪10‬‬
‫إذا كان مرتكب الجرائم المنصوص عليها في هذا الفصل طبيبا او قابلة ‪ ً ،‬او صيدليااو جراحا العقوبة المعينة مقدار ثلثها‪.‬‬
 ‫قانون (‪ ) 47‬قانون الصحة العامة لعام‬
‫‪2008‬‬
‫المادة ‪: 12‬‬
‫أ_ يحظر على اي طبيب وصف اي شيء يقصد اجهاض امراة حامل او اجراء عملية اجهاض لها اال اذاكانت عملية االجهاض ضرورية لحمايتها من خطر‬
‫يهدد صحتها او يعرضها للموت وعلى ان يتم ذلك في مستشفى شريطة توافر ما يلي ‪_:‬‬
‫‪ _1‬موافقة خكية مسبقة من الحامل باجراء العملية وفي حال عدم مقدرتها على الكتابة او عجزها عن النطق تؤخذ موافقة من زوجها او ولي االمر ‪.‬‬
‫‪_2‬شهادة من طبيبين مرخصين من ذوياالختصاص والخبرة تؤكد وجوب اجراء العملية للمحافظة على حياة الحامل او صحتها ‪.‬‬
‫‪ _3‬تضمين قيود المستشفى اسم الحامل وتاريخ اجراء العملية ونوعها واالحتفاظ بالموافقة‬
‫الخطية وبشهادة الطبيبين لمدة عشر سنوات على ان تزود الحامل بشهادة مصدقة‬
‫من مدير المستشفى باجراء هذه العملية لها ‪.‬‬

‫ب_ على الرغم مما ورد في قانون العقوبات ال تالحق الحاملوالشخص او االشخاص الذين اجروا او اشتركوا في اجراءعملية االجهاض لها وفقا الحكام‬
‫الفقرة (أ) من هذه المادة بتهمة اقتراف جريمة االجهاض‪.‬‬

‫‪11‬‬
Methods of Abortion

12
 SAFE vs. UNSAFE abortion:
According to WHO:
- Safe abortion: abortion in countries where abortion law is not restrictive
(abortion is legally permitted) or countries in which, despite formal law, safe
abortion is broadly available.

- Unsafe abortion: abortion that is performed by people lacking the necessary

skills or using hazardous technique, and/or in an environment that does not
meet minimum medical standards

Legalization, socioeconomic determinants, provider’s skills, method

used … etc. 13
Methods of abortion:
• Drugs & chemicals
• Instrumental interference
• Dilation of the cervix
• Insufflation of air
• Physical violence

14
15
Drugs & chemicals
• Oral and injectable treatments include: metal salts, phosphorus, lead, kerosene,
turpentine, detergent solutions, uterine stimulants (misoprostol or oxytocin?),
chloroquine and Mifepristone (progesterone receptor antagonist)
Their efficacy is either nil or the dose needed to produce abortion is near the fatal
level.
Also Quinine can be dangerous, as the dosage required for any effect on the uterus is
likely to cause cinchonism

• Preparations placed in the cervix, vagina, or rectum include:

- Potassium permanganate  vaginal necrosis & bleeding, renal failure
- Interruptin: paste, contains elemental iodine  Fat or Air embolism.
- Herbal preparations, misoprostol, enemas.
16
 Instrumental interference
Disturbing the pregnancy sac so that, once damaged, it will be expelled by
uterine contraction.
• Several technique have been used:
 Vacuum Aspiration

Dilation and Curettage

Dilation and Evacuation

17
Vacuum/Syringe Aspiration

- Manual vacuum aspiration

(< 9 weeks)

- Electrical vacuum aspiration

(> 9 weeks)

18
• A large syringe attached to a catheter or length of plastic tubing
can produce suction within the uterus sufficient to rupture the
chorionic sac and precipitate abortion.

• The method is safe as long as aseptic methods are used, though,

if evacuation is incomplete, some fragments of placenta or any
other products of conception may be left behind that can form a
nidus for infection.

19
20
Dilation and Curettage (D&C) (<14 weeks)

21
Complication of D&C:
• Deep scraping can damage the stem cell layer 
decrease proliferation of the endometrium,
leading to amenorrhea. (Asherman syndrome)
• May cause infertility

22
Dilation and Evacuation (14-24 weeks)

23
Complications:

• Perforation, laypersons don’t know anatomy!

• Hemorrhage
• Cervical Shock: dilating the cervix with an instrument in an non
anaesthetized patient may trigger a vagal reflex  cardiac arrest. It
occurs especially if the woman is not anesthetized.
• Sepsis, to the pelvis and peritoneum

24
Dilation of the cervix

• A strip of substance that absorb water and become greatly

enlarged, such as Laminaria digitale or slippery elm:
Hard when dehydrated  absorb water from the surrounding
tissues
 the cervical canal became widely dilated and abortion might
take place

 Might be followed by other procedure such as D&E.

25
Digoxin Injection

26
Inserting Laminaria

27
Laminaria inflates and
kept there for 2-3 days

28
 Complications:
• Perforation of the cervix
• Infection, especially if the strip tore into the tissues.
The substances used, often crude vegetable material, could
be the source of infecting micro-organisms including anaerobes
• Future pregnancy complications, such as:
Cervical incompetence: Loss or premature delivery due to abortion-
related trauma and injury to the cervix (the fetus can easily slip down!)

29
Syringing (Air Insufflation)
A rubber pump, usually a Higginson enema syringe, is used to introduce FLUID
under pressure into the cavity of the uterus.
This strips the chorionic sac from the wall of the uterus, exposing the placental bed. If
sufficient detachment is achieved, then abortion will occur.

The main danger: Air embolism??

30
Mechanism of Air Embolization in this technique:
The intention was to introduce a fluid such as water-soap solution or
disinfectant through the cervix by means of the syringe, the other end, which
carried a one-way valve, being dipped in a receptacle (container)of the fluid.
As the level in the receptacle dropped, the inlet tube rose above the surface and
the syringe began to inject air instead of fluid, often as soapy foam.
In addition to this danger, unless the bulb of the pump was primed with fluid
before use; the first ejection would be the appreciable volume of air contained
in the empty syringe, which in itself was enough to cause a fatal embolism.
Under the considerable pressure available from the instrument, this air was
forced into he exposed vascular channels of the placental bed and from there
into venous sinuses and pelvic veins to cause cardiac embolism.

31
The addition of various sub- stances, such as phenol,
formalin, alcohol and turpentine, to the fluid introduced a
toxic element, and in some cases these fluids were extruded
into the peritoneal cavity through the uterine tubes, causing
a chemical peritonitis!

32
This woman insufflated her uterus with a
Higginson syringe and had time to clean up the
equipment before collapsing with air embolism
33
 Physical Violence
Women anxious to lose their pregnancy have resorted to
extremes of physical activity and even violence in efforts to
dislodge the fetus.

Some unfortunate women went on to seek violent

treatment from husbands or consorts. Punching and
kicking of the abdomen were most common, and death
from visceral rupture, such as liver, spleen or intestine, has
been reported. Ironically, the uterine contents were usually
undisturbed.
34
Complications of abortion:
1. Hemorrhage; internal or external

2. Infection; either from dirty instrument or bacterial transfer from skin, vagina or bowel
(Non haemolytic strep, clostridium perfringens, coliforms, staph)

3. Perforation: any surrounding structure could be damaged ;

Vagina
Cervix; tear & excessive cervical dilation – which may lead to cervical incompetence
Uterus; when the fundus is perforated, the instrument may enter a small bowel or reach as far as
the liver.
Bladder
35
4. Neurogenic shock (cervical shock); a more potent mechanism in states of fear, apprehension
and nervous tension, which obviously in female during criminal abortion. Avoided by anesthetizing the
mother.

5. Embolism (Air / Amniotic fluid ); Rupture of the uterus and Instrumental interference late in
pregnancy may allow opening of the sinuses in the placental bed with consequent escape of amniotic
fluid.

6. Poisoning ( by toxic doses of abortifacient drugs )

7. Anesthesia complication

8. DIC

36
The Autopsy In Abortion Deaths:
 If death in pregnancy or criminal abortion is suspected, usual full autopsy with fullest
possible history is required .
 A careful EXTERNAL examination must be carried out, noting especially:
1- Abnormal coloration of the skin, such as in the bronzing of clostridial septicaemia and
the jaundice of liver damage.
2- Signs and duration of pregnancy, such as abdominal swelling and breast changes.
3- Signs of injury, including bruising or abrasion of the vulva from instrumentation, and
vaginal bleeding or burns on the abdomen .
4- The vagina should be examined for signs of recent or current pregnancy, and
attempted or successful recent abortion.
5- Where any possibility of air embolism is considered, pre-autopsy radiology of the
chest and abdomen must be performed [air in thoracic veins, heart, IVC37 ,pelvic veins or
peritoneal cavity]
Postmortem chest radiograph shows air in the right ventricle
38
INTERNAL exam The uterus becomes:
1- Swollen, spongy and discolored.
2-The serosal surface seen at autopsy may be brownish – especially in clostridial
infections.
3-The endometrium may be foul-smelling, ragged or purulent.

Signs of septicaemia may develop :

Enlarged, soft spleen.
Prominent lymph nodes.
The kidneys may show bilateral cortical necrosis in extreme cases. 39
40
DEFINITION FACTS POST-MORTEM
EXAMINATION

41
 Is the intentional killing or any act
Aka Infant
homicide goes directly against the right to
life of infants or children.

42
•
•

43
THE MOTHER STILL/DEAD BORN PERIOD OF CAUSE OF DEATH VIABILITY OF THE
OR LIVE BORN SURVIVAL FETUS

44
•
•
•
•
•

45
 Still/dead born Live born

Shape of chest Flat Barrel shape

Position of diaphragm 4th , 5th ribs 6th , 7th ribs

Milk or air in stomach or Not present Present (not always for the milk)
intestine
Meconium Present in large intestine Absent after 24h of life

Middle ear Gelatinous material Air

46
a)
b)
c)
d)

47
Presence of clothing and absence of vernix caseosa suggestive of live birth.
48
49
 (completely excreted by 24 – 48h)

Age Fetal hemoglobin

At birth 80%

3 months 10%

6 months Disappears
50
•
•
•
•
•

51
It is the deciding factor regarding prosecution.

52