Criminal Abortion: Methods of Procurement and Complications

Types of Abortionists

1. Expert / medically qualified professionals
2. Semi-skilled - midwives, nurses, chemists
3. Unskilled - persons with no training

Methods Used to Procure Criminal Abortion

A. Mechanical Violence

1. General Mechanical Violence

• Severe pressure over the abdomen: blows, kicks, tight lacing, jumping
• Violent exercise: riding, cycling, jumping from height, jolting, driving on rough roads, lifting heavy weights
• Cupping: A coin is placed on the hypogastrium, a piece of camphor lighted on it, and a cup/mug placed over it mouth-downward. The partial vacuum created pulls the abdominal wall, causing partial separation of the placenta. Used mainly in advanced pregnancy
• Application of leeches to the pudenda, perineum, and inner thighs
• Very hot and cold baths alternately
• Massaging the uterus through the abdominal wall

General violence generally fails except in women already predisposed to abort.

2. Local Mechanical Violence

• Unskilled interference: Self-instrumentation using whatever is at hand - pencil, knitting needle, hairpin, nail, etc. No attempt at asepsis; major risk of sepsis.
• Semi-skilled interference: Use of syringes to inject fluids (soap solution, potassium permanganate, Lysol, mercuric perchloride, glycerine) into the uterine cavity under pressure; insertion of a laminaria (sea tangle) tent into the cervix to cause swelling and dilatation, followed by passage of a soft rubber catheter as an irritating foreign body
• Skilled interference: Vacuum aspiration or D&C under anaesthesia (first trimester); prostaglandins F2α via amniocentesis or cervical route (second trimester); amniotic fluid replacement with 20% saline or 50% glucose (third trimester)

B. Instruments

1. Rupture of membranes using a uterine sound, catheter, pencil, knitting needle, hairpin, or fingers
2. Abortion stick: A thin wooden or bamboo stick, 12-18 cm long, with one end wrapped in cotton wool soaked in juice of Marking nut (Semecarpus anacardium), Calotropis, or a paste of arsenic oxide, arsenic sulphide, or red lead. Instead of a stick, a twig of an irritant plant may be used - Calotropis gigantea (madar), Plumbago rosea (lal chitra), or Nerium odorum (kaner). It is introduced into the os uteri, causing local excoriation, bruising, perforation, and often sepsis
3. Dilatation of the cervix: Using slippery elm bark (a flat piece about 3 mm thick inserted into the cervical canal), which absorbs vaginal secretions, swells, and dilates the canal. Compressed sponge is used similarly
4. Air insufflation: Air instilled into the vagina via syringe or pump
5. Electricity: Negative electrode applied to the cervix, positive electrode over the sacrum or lumbar vessels; current causes uterine contractions
6. Paste (Utus paste): Contains iodine (or a salt such as potassium iodide), thymol, or mercury, injected from a collapsible tube with a uterine applicator. The main active component is iodine
7. Syringing: An enema syringe (Higginson's syringe) with a hard nozzle inserted into the cervix. Fluids used include soapy water, inorganic and organic acids, lead solutions, arsenic, Lysol, cresol, formalin, potassium permanganate. The fluid detaches the amniotic sac and placenta from the uterine walls, causing uterine contractions and haemorrhage

C. Abortifacient Drugs

i. Drugs acting directly on the uterus

• Ergot (Ergometrine) - the most commonly used
• Quinine
• Cotton root bark
• Posterior pituitary extract (oxytocin)
• Potassium permanganate tablets (placed locally in vagina - cause ulceration and bleeding)
• Lead oleate pills (cause tonic uterine contraction)
• Nitrobenzol
• Strychnine

• Savin (oil of Juniperus sabina)
• Borax
• Apiol (toxic effects due to tricresyl phosphate)
• Synthetic oestrogens
• Prostaglandins

ii. Drugs acting indirectly on the uterus

• Oil of tansy
• Oil of turpentine
• Cantharides (in large doses: renal inflammation, albuminuria)
• Potassium permanganate (120-300 ml via vaginal route: erosion of vessels, haemorrhage)

• Emetics (tartaric acid)
• Purgatives (Colocynth, Castor oil, Croton oil)
• Magnesium sulphate

• Inorganic irritants: Lead, copper, antimony, mercury, arsenic. Lead (as diachylon pills) was extensively used - it causes tonic uterine contraction and has a direct toxic effect on trophoblastic epithelium, resulting in abortion or fetal death. Symptoms of lead poisoning often appear
• Organic irritants used in India: Unripe fruits of papaya (Carica papaya) and pineapple, seeds of Gajar (Daucus carota), milky juice of Madar (Calotropis gigantea), bark of Lal chitra (Plumbago rosea), Karela (bitter gourd), Sanguinaria

Complications of Procuring Abortion

Immediate Complications

Delayed Complications

• Septicaemia and pyaemia: due to dirty surroundings, dirty instruments, or uterine injury - organisms commonly involved are Clostridium welchii and Clostridium tetani
• General peritonitis
• Toxaemia (absorption of toxic substances through uterine/vaginal mucosa)
• Tetanus
• Necrosis of cervix
• Fatal haemorrhage from retained products of conception, perforation of cervix, vaginal vault, or fundus of uterus
• Delayed air embolism: air held in the uterus until placental separation opens vessels; mucus plug may prevent escape via cervix. Minimum lethal dose is ~100 ml

Remote Complications

• Jaundice and renal suppression
• Bacterial endocarditis
• Pulmonary embolism
• Pneumonia
• Empyema and meningitis
• Poisonous effects of the drug itself (especially lead, arsenic)
• Salpingitis leading to tubal factor infertility

Causes of Death (Forensic Classification)

Postmortem Evidence of Criminal Abortion

• The deceased is pregnant and deeply cyanosed
• Instruments or drugs are found at the scene
• Underclothing is apparently disturbed
• Fluid, soapy water, or blood-stained discharge is coming from the vagina