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PREGNANCYConditions in which pregnancy is of medicolegal importanceA. CIVIL CIRCUMSTANCES:1. Inheritance: a widow may feign pregnancy soon after her husband’s death so that the soon coming child would heir his estate.2. Divorce: a woman may allege pregnancy to get more alimony (??????).3. When a woman is accused of being pregnant while her husband is away and he is disputing paternity, then the estimation of the duration of pregnancy, here is very important.B. CRIMINAL CIRCUMSTANCESI. Rape: the accusation will be greater if pregnancy occurred as a resultand the girl may ask for more compensation.2. If a female is condemned to capital sentence of death she may allege pregnancy to delay the time of execution,3. in cases of suicidal attempts, pregnancy could be expected as the motive for suicide.signs of pregnancy I. Presumptive signs & symptoms of pregnancy:These signs and symptoms are not accepted medico legally to diagnose pregnancy as they may occur with other conditions.1. Amenorrhea (Cessation of Menstruation).2. Nausea and Vomiting (Morning Sickness).3. Frequent Urination.4. Breast Changes: (2nd — 3rd months)(a) Increased firmness and tenderness of the breasts.(b) More prominent and visible veins due to the increased blood supply.(c) Darkening of the areola: the brown part around the nipple.(d) Enlargement of Montgomery glands:, the tiny nodules or sebaceous glands within the areola.(e) Presence of colostrum (thin yellowish fluid that is expressed when the breast is squeezed).5. Skin Changes: ( 1” month,)(a) Striae gravidarum (stretch marks): These are marks noted on the abdomen and/or buttocks. They are caused by increased production or sensitivity to adrenocortical hormones during pregnancy.(b) Linea nigra (a black line in the midline of the abdomen that may run from the sternum or umbilicus to the symphysis pubis).(c) Chloasmam (mask of pregnancy): It is a bronze type of facial coloration.6. Abdominal enlargementThis gradually occurs as the uterus increases in size from below upwards- in the first three months the uterus is a pelvic organ.- After the third month it becomes abdominal.Enlargement of the body of the uterus:3rd month: the uterus is felt just above the symphysis pubis.- 41h month: the fundus is at the junction of the lower 1/3 with theupper 2/3 of the line joining the symphysis pubis to the umbilicus.5th month: it is at the junction of the lower 2/3 with the upper 1/3 of this line.-6th month it reaches the level of the umbilicus.7th month it reaches the junction of the lower 1/3 with the upper 2/3 of the line joining the umbilicus to the xiphi-sternum.8th month it reaches the junction of the lower 2/3 with the upper 1/3 of this line.9th month it is as high as the xiphoid.7. Palpable uterine contractions can be felt from 20 weeks.8. Genital changes:- The vulva becomes more pigmented.- The vaginal mucosa becomes violet (originally pink ) due toincreased vascularity (Chadwick’s sign) by the 2nd month.- The vagina shows also increased mucous secretion.The cervix is softened (Hagar's sign) by the 2’ month.9. Quickening: Feeling of fetal movement within the uterus by the. mother. It usually occurs toward the end of the fifth month.II- Sure signs of pregnancy1. Palpation of fetal parts especially the head and the back at 16 weeks.2. Palpation of fetal movements at 20 weeks.3. Auscultation of fetal heart sounds. This can be achieved using fetal stethoscope only at 22 weeks gestation and onwards. It is audible also with a Doppler at an earlier stage in pregnancy at 12 -14 weeks.The, rate of the fetal heart sounds is 120-140 beats/minute and is of regular rhythm. It should be differentiated from the maternal pulse and from the uterine soufflé (which is a soft blowing murmur heard over the uterus due to pulsation of blood through enlarged uterine artery). Sometimes, the fetal heart sounds are not heard e.g.- When the abdominal wall is very fatty.- When there is excess liquor amount.- When the fetus is dead in uterus.4. Pregnancy tests:These tests are based on the, presence of human chorionic gonadotropin (HCG) in the urine or blood of pregnant females.A. Urinary Immunological Tests:These tests detect HCG 2 weeks after the first missed period. The firsturine specimen of the morning is the best one to use.Agglutination test .It is an antigen-antibody reaction. Being a’ protein, HCG will ‘induce antibody formation in another animal. This, antiserum will detect the presence of the hormone in the urine. It is sensitive, rapid and simple.Procedure:A drop of urine is mixed with a drop of anti-serum against HCG on a slide. After few minutes, a drop of the antigen (latex particles coated with (HCG) is added.If the urine contains HCG (pregnant), it will react with the antiserum, leaving no free antibodies to react with the antigen, therefore no agglutination of latex particles occurs; hence the result is positive.No agglutination--> PregnantIf there. is no HCG in urine (non-pregnant), the antiserum will be free toreact with the antigen, therefore agglutination occurs; then the test is negative. Agglutination --> Non-pregnant.B. Blood Radioimmunoassay:can detect HCG in the blood 2 days after implantation. Not only can this method detect HCG, but it can also measure its quantity.5. X ray: it will identify the entire fetal skeleton starting from the it week; It helps to identify the age of fetus, and to diagnose twin pregnancy, congenital anomalies and intrauterine fetal death. in uterus, the fetus receives total body radiation that may lead to genetic or gonadal alterations. An x-ray is not a recommended test for identifying pregnancy.6. Ultrasound scanning of the fetus: The gestational sac can be seen and photographed. An embryo as 5 week after conception can be identified. It helps to diagnose pregnancy, duration, diseases and age of fetus and can be used for the follow up during pregnancy.DURATION OF PREGNANCYThis is important in cases of pregnancy in absence of the husband and he is disputing the paternity.. The normal duration of pregnancy is 280 days, calculated from the st day of last menstrual period , or 40 weeks ± 2 weeks. It must be remembered that this duration includes 2 weeks prior to ovulation when the patient could never be pregnant. The actual duration of pregnancy, i.e. the fertilization -delivery period is most difficult to determine as one can never know the exact date of fertilization.A child born outside these limits can be disputed by the husband. With the advances of paternity tests nowadays by modern techniques, the importance of these theories has declined.DELIVERYThe medicoleagal conditions in which a female is examined for sign of delivery are:I. When a widow alleges that she delivered an infant to inherit,2. In cases of infanticide, when a woman is accused of killing her newly born infant. The suspected mother is examined for signs of delivery.3. In cases of disputed maternity when two women are alleging to be the mother of a certain child. The age of the fetus must coincide with the date of labor of the woman.4. In cases of kidnapping of a newly born infant.Signs of recent delivery in the living: (within 6 weeks)A. General sign:I. Pallor, exhaustion and rapid pulse.2. Breasts are enlarged and contain colostrum.3. The abdomen is lax and shows striae gravidara and linea nigra.Local signI. The vulva is congested and swollen, The perineum may show tears or bruising2. Presence of vaginal discharge “lochia”: It is bloody for the first 4 to 5 days, pinkish for another 5 days then gradually looses all color, becoming white and turbid until its final disappearance in 14 days.3. The cervix: The internal os closes within 24 hours. The external os is soft and patent and it may show recent tear. It admits 2 fingers for 3-4 days. one finger by the end of the . Ist week to close by 2 weeks and becomes button-bole shaped.4. The uterus starts to decrease in size (involution). Just after delivery it is 2-3 fingers above the umbilicus. After 1 week it becomes midway between the umbilicus and the symphysis pubis. In 2 weeks it becomes a pelvic organ to reach its normal size in 6 weeks. The involution occurs due to several factors including autolysis of the protein material of the cell cytoplasm which gradually decreases, shortening and thinning of the muscle fibers as well as blood loss.SIGNS OF RECENT DELIVERY IN THE DEAD:In addition to the above signs, autopsy shows:1. The involution of the uterus (observed from its length and weight).Soon after delivery, it weighs about 1kg. it contains large clots of blood.- At one week it weighs 500 g.- At 2 weeks it weighs 370 g.- At 6 weeks it weighs 100 g.2. The site of the placenta in the uterus appears as a bruised and lacerated area3. The ovary shows a large corpus luteum.4. The vagina is dilated, bruised and may be lacerated.5. There may be signs of episiotomy or perineal tear.SIGNS OF REMOTE DELIVERY IN THE LIVINGA parous female usually presents certain permanent body changes:1-Breast is lax, soft and pendulous with enlarged nipple and dark areola.2. The abdomen is ax and shows striae gravidara and linea nigra.3. The labia do not completely close the vaginal orifice and there may bescars of old tears in the perineum.4. The hymen is completely ruptured.5. The vaginal mucosa is smooth (loss of vaginal rugae “arbora vitae” that are present in nullipara).6. The external os in multipara is usually transverse (slit-like), fissured and may show old scar. In nullipara it is a small round opening with smooth edges.SIGNS OF REMOTE DELIVERY IN THE DEADIn addition to the above signs:1. The shape of the uterus of a multipara is round or globular (In virgin itis triangular).2. The uterus is found enlarged with its body about double the length ofthe cervix (In virgin the body of the uterus equals that of the cervix).3. The placental site may show endarteritis obliterans.ABORTIONDefinition:“The expulsion of any contents of the gravid uterus at any time before full term”.Medicolegal circumstancesThere are certain circumstances of medicolegal importance in which aphysician is asked to examine a woman to prove that she has had anabortion:1. When abortion is alleged to have followed a blow or a quarrel.2. in road traffic accidents that result in abortion, the Woman may ask for compensation.3. In criminal abortion procured by anyone especially when fatal result issues.Type of abortion1- Spontaneous abortion NaturalH- Induced abortion:a- Therapeutic (Justifiable).b- Criminal.I. SPONTANEOUS ABORTIONThis type of abortion is not of medicolegal importance unless to disprove criminal abortion. it occurs due to pathological causes either in the mother or the fetus.A Maternal causesGeneral diseases eig. severe fevers, diabetes mellitus, nephritis.2. Local causes e.g. tumours, incompetent cervix, uterine displacement.B. Fetal causese.g. congenital anomalies, vesicular mole, polyhydramnios, placental infarctions.I INDUCED ABORTIONInduced abortion may be therapeutic or criminal.A. Therapeutic abortion (justifiable, legal):it is the expulsion of the contents of the gravid uterus at any time before full term in order to save the life of the mother, when the continuation of pregnancy endangers it.indications of therapeutic abortion1. Decompensate heart diseases.2. Uncontrolled hypertension.3. Uncontrolled diabetes mellitus.4. Chronic nephritis with renal failure.5. Apical bilateral TB of lungs.6. Diseases of pregnancy if medical treatment fails e.g. eclampsia, severehemorrhage, hyperemesis gravidarum.7, Cancer breast.8. Mental disease. in this condition the woman is incapable to take care of a child. Other conditions are given by some obstetricians as indications for therapeutic abortion when there is fear of having an abnormal child e.g. when a pregnant woman suffers from German measles or when pregnancy occurs on top of loop. However, these indications are not agreed by law.B. Criminal abortion (unjustifiable, illegal)It is interruption of pregnancy due to any cause other than saving the Life of the mother. It is done by the woman or anybody else.Methods of procuring criminal abortion.I. General violence It is a popular belief that abortion is easily precipitated by violence and the pregnant woman must not be exposed to any undue exercise. Therefore women try general violence to get rid of pregnancy e.g. by jumping, carrying heavy object, horse riding or cycling. however, violence of severe degree may fail to disturb any pregnancy; on the other hand serious body injuries may occur.2. DrugsA. Drugs acting directly on the uterus (Ecbolics):They cause contraction of the uterine muscle and expulsion of the fetus e.g. ergot, quinine, lead, pituitary extract.B. Drugs acting reflexlly on the uterus through their effect on the intestines Leading to pelvic congestion and reflex uterine contraction. e.g. purgatives as jalap, castor oil, croton oil.C. Protoplasmic poisons acting on the ovum or the fetus leading to its death and ultimately its expulsion e.g. metals as lead, antimony, arsenic, mercury.D. Prostaglandins: The mechanism of its action is through dilatation of the cervix producing uterine contraction.E. Hormones e.g. contraceptives.3. Local violence The objective is to dilate the cervix or to separate the membranes thus initiating uterine contractions, Every woman is using instruments or materials within reach of her hands according to her standard of living and her level of education.. Local violence may be applied to the vagina, to the cervix or to the uterusA. Violence to the Vagina Insertion of irritant substances in the form of vaginal plugs e.g. arsenic or mercury which may cause erosions in the mucous membrane resulting in rapid absorption of the poison and toxicity.B. Violence to the Cervix Alternating hot and cold douches. Insertion of foreign bodies e.g. cotton stick, pieces of wood, elm bark, knitting needle or the use of catheters, sounds, hegar dilators, laminaria tents.C. Violence to the Uterus Aiming at separation of the membranes:- Injection of soap and water or glycerin (syringing). Glycerin is hygroscopic and so will absorb water resulting in separation of the membranes- Mechanical separation of the membranes by foreign bodies e.g. cotton stick.., or by skilled abortionist according to the duration of pregnancy: In the first trimester; D&C under anesthesia. . In the second trimester the membranes may be ruptured by a sound followed by packing of the cervical canal and vagina. In the third trimester one of the gum elastic bougies is introduced into the uterus between the membrane and the uterine wall.Dangers and complications of criminal abortionThe procedure of criminal abortion is usually done by incompetent people, in a hurry and in the dark i.e. hidden; therefore it is usually followed by complications. Dangers occur also due to ignorance of the woman of her anatomy or due to cleanliness of instruments or materials used.I. Neurogenic shock: may occur from vaginal douche or from vigorous dilatation of the cervix which is a trigger zone.2. Hemorrhage: this may be primary hemorrhage, rapid and fatal, due to injury of the placental area. It may occur over a long time due to retained parts of the ovum or placenta resulting in anemia. Or it may be secondary hemorrhage when infection occurs.3. Embolism: it may occur from:a- Air embolism: death is instantaneous due to passage of air throughthe opened placental sinuses. This is often observed, with vigorous manipulations.b- Thrombotic embolism: it is due to detached thrombus from either the uterine, ovarian, iliac or femoral veins.c- Amniotic fluid embolism.4. Infection: It is the most common complication where it usually starts after the 3Fd day due to the use of contaminated instruments. Sepsis may be delayed to the 7 — 10 day in case where other methods of induction of abortion have been used (non-instrumental).. It may be in any part of the genital tract e.g. cervicitis, endometritis, salpingitis oopheritis, par Infection may extend to the peritoneum i.e. peritonitis and may lead to septicaemia.5. ‘Acute poisoning when drugs are used.6, Uterine perforation leading to hemorrhage and shock.NB. If there is rupture of uterus it should be differentiated form pathologic, rupture or rupture due to obstructed labour.Pathologic rupture of uterus’ Rupture of uterus due to obstructed labor “Traumatic rupture of uterus (in criminal abortion)The site of rupture is anywhere. ‘ There are degenerative changes in uterine muscles,The site of rupture is in the lower segment It is transverseThe site of rupture is usually in the fundus. It is longitudinal and taking the shape of instrumentinvestigation of a case of abortion:1-In the living:The following steps should be followed:1. The patient’s consent for undertaking the examination should be taken.2. Careful history about all available facts and circumstances.3. General examination for signs of pregnancy as well as signs of general violence whether self-inflicted or in a quarrel. If bruises are present, changes seen will confirm the time passed.4. Examination of the perineum, vagina and os uteri.- Perineum is examined for bruises, lacerations and discharges.- The vagina is examined for:*any foreign body as parts of the ovum, fetus or placenta*any evidence of trauma as tears or bruises*signs of erosion of mucous membrane*any fluid- The condition of the os uteri is also recorded as regards dilatation ortears.5. Medical examination may reveal the presence of a predisposing disease,6. Laboratory investigations: e.g. urine analysis for pregnancy tests (they disappear after 2 weeks from abortion or delivery) as well as for chronic nephritis and any poison.7. If any products of abortion are present, they should be examined microscopically to detect fetal tissue. if an embryo is present we must be sure that it is human (precipitin test), it should also be examined for signs of maceration (death in utero) or for signs of vital injury. Also the estimation of its age is of utmost importance.In the dead:The signs will be the same as during life. In addition direct examination of the uterus as well as determination of the cause of death should be cared out:1. Peritoneum is examined for signs of peritonitis.2. Stomach and intestines are examined for evidence of poisoning. Samples are taken for analysis3. The uterus is measured, weighed and examined externally and internally for lacerations, sites of penetration, signs of inflammation, foreign body, fetal remnants and/or placental remnants. Uterine veins are examined for detection of air embolism or thrombosisINFANTICIDEIt is the intentional (willful) killing of live born infant. An infant is defined as a human child at the youngest stage of life, generally before the age of one. This infant may be a neonate (24 hours after birth) or a newborn (less than one month old). Infanticide differs from ordinary murder as it is necessary to prove that the child was born alive.infanticide is mostly committed by a young unmarried mother when she has an illegitimate infant.The age, marital status, level of education, biological factors, cultural traditions, and the economic standard of living of the female may play arole in the problem of infanticide. Also, the puerperium, pregnancy and lactation are known to affect occasionally the mental state of the mother.In a ease of infanticide the following medicologal questions should be answered:1. What points of identity are shown as regards the infant?2. Was the infant viable or not? Was it mature or not?3. Was it a stillborn, live born or a case of intrauterine fetal death?4, If born alive, how long did it survive?5. What was the cause of death?6. What was the time passed since death?7. Has the suspected woman been recently delivered? was she really the mother of the deceased infant?In most cases the evidences collected to answer these questions are achieved by examination of the infant.1-Points of identification:-Date and place where it was found- Clothes and wrapping-Features, color of skin and of hair— Birth marks, congenital anomalies-Ligature- Any paper or article found with the infanH. Was the fetus viable or not? Was it mature or not?Viability:It is the ability to acquire a separate existence. The law considers a fetus viable if it had reached the end of the 28th week of gestation i.e. before this period it is unable to maintain a separate existence. Hence, if it is found dead, this is due to immaturityThe intrauterine age of fetus can be determined by its length, weight, appearance of ossification centers and external and internal changes.At 7 months: (Viable fetus) As previously described in the chapter of abortionAt 9 months: (Full term = mature) As previously described in the chapter of abortionWas the infant live born or stillborn?Nonmedical evidence: When a witness states that he heard the infant crying, sneezing or ‘ 4c. saw it moving. This is subjective, and one cannot rely upon.Medical evidence of living:L Signs denoting intake of food:- Presence of well formed stools in the wrappings.- Presence of well formed stools in the rectum..- Presence of milk or colostrum in the stomach.ii. Vital signs:External signs:Presence of antemortem wound e.g. birth trauma or homicidalinjuries.2-Desquamation of the epithelium: Starts on the trunk 2 days after birth and is completed in about 2 weeks.3-Umbilical cord changes:? During the first 12 to 24 hour: the cord becomes dry, shriveled.? After 36 hours: a zone of reddening of skin appears around the attachment of the cord.? From 5 days: shrinkage of the cord and complete separation.? 10 to 12 days: healing of the scar at the site of the cord.? Within 2 weeks: complete cicatrisation.4- Caput succedaneum Internal sign I Signs of respiration:1. The chest: It is flattened in the non respired ad after respiration it become arched or barrel-shaped.2, The diaphragm: in the non- respired, the diaphragm rises in the chest to the level of the third, fourth or fifth rib. After respiration it is pushed downwards to the sixth or seventh rib.3. The lungs:On starting respiration changes start to occur in the lung due to:- Expansion of the lung alveoli.- Transformation of venous blood from the placenta to the pulmonary circulation4. The hydrostatic test:The principle of this test is based on the lowered specific gravity of the respired lungs due to presence of air.The respiratory organs from the tongue to lung are taken in one mass and put in a water. Floating denotes respiration. Then each lung is tested alone, then each lobe, then pieces of the lungs.Fallacies of the test:A. A respired lung may sink when there is a disease of consolidation e.g. pneumonia, atelectasis or acuteB. Non respired lung may float due to putrefaction or artificial inflation..5. Stomach-bowel float titian test:On starting breathing, the child usually swallows some air which gradually passes from the stomach to the intestine. The cardiac and pyloric ends of stomach, the two ends of the duodenum, the upper and lower ends of intestines are legated and put in water basin. Floatation of the stomach indicates living for 2 hours, the duodenum four hours, the ilium 8 hours and the large intestine 12 hours.Cardiovascular changes:I. Changes in the umbilical vessels:They are contracted and filled with red clot within 2 day after birth. Organization of the clot begins after one week and is corn leted within 2 weeks. The lumen completely disappears and the vessels are changed in a fibrous cord within 4 weeks.2. Ductus arteriosus:It is completely obliterated within one week to 10 days, and is changed into ligamentum arteriosum.3. Ductus venosus:It is becomes converted into ligament venosus within 4to5 days.4. Foramen ovale:It becomes gradually closed after respiration by 6to8 days.IV. How long did the infant survive?This could be achieved from different signs mentioned before. In addition caput succedaneum disappears within one to 7 days.V. The Cause of death:A. Natural causes of death:1- Due to maternal causes:- Toxemia of pregnancy.- Chronic hypertension- Nephritis- Diabetes.2- Due to fetal causes:- Immaturity- Congenital anomalies- Infections- Congenital syphilis- Anoxic syndromes.B-Accidental causes:1. Prolonged difficult labour.2. Precipitate labour3. Prolapse, strangulation or hemorrhage from the cord..4. Early placental separation.5. Cranial birth trauma.C. Criminal causes: .1. Infanticide by omission;“Intentional negligence of the mother to make the necessary preparations of the infant’ e.g. to tie the cord, to protect the infant or to supply it with food.2. Infanticide by commission: -Due to:- Violent asphyxia e.g. Smothering, suffocation, strangulation (usually bythe cord), throttling. - Head injury- Drowning - Burning- Poisoning - Wounding.VI. Time passed since death:Rigor mortis and the rate of cooling are rapid, while putrefaction is delayedVII. The time since delivery:This equals the time the infant had survived added to the postmortem interval. This should be compared to the date of delivery of the suspected mother,Differences between accidental and criminal strangulation by the umbilical cordAccidental strangulation by the umbilical cord Criminal strangulation by th umbilical cord The cord is long The length is normal There are no abrasions There may be abrasions There is no displacement of Wharton’s jellyThere may be compressions of Wharton’s jelly There may be pseudo knotsThere are usually true knots.Cause of death due to stoppage of circulationCause of death may be due asphyxia Non-respired lung . Respired lung CHILD ABUSEThe child abuse syndrome is also known as “the battered baby” or “non-accidental injury in childhood” (NAI) or syndrome of child abuse and neglect (SCAN). It is defined as non-accidental repetitive physical injuries including minimal as well as fatal injuries inflicting upon infants or children by persons caring for them e.g. parents, teachers at schools and baby sitters, in circumstances that exclude accidents.This definition is extended to include willful neglect in providing food and warmth, sexual abuse, emotional neglect or rejection and psychological deprivation.Risk factors include(1) Parental factors:? Young parents (15-20 years).? The abusive parents usually have severe emotional problems as being sadistic, depressed or impulsive.(2) childhood factors:a. The abnormal child with:? Congenital anomalies.? Cerebral patsy.? Emotional handicaps.? Chronic illness.b. The difficult child:Babies with feeding difficulties fit into this category.c. The rejected child:This child may be of unwanted sex or pregnancy.(3) External factors:Child abuse occurs in all social classes but poverty; overcrowded living arrangements, limited money for food and clothing increase the risk of abuse. When the effect of drugs and alcohol are added, the risk of both physical and sexual abuse escalates dramatically.Classification:Nine district syndromes are recognized:(1) Neonaticide:It is killing of a premature or full term baby within 24 hours after birth. Jt is done usually by young single uneducated mother by act of commission or omission.(2) Infanticide:it is killing of thc live born infant within the first year of life. The mother with maternal psychosis (especially puerperal depression) is almost always the perpetrator.(3) Euthanasia:It is killing of a handicapped (physical, mental or both) child usually under 3 years by a parent. The mother is almost always the perpetrator.(4) Syndrome of repetitive physical child abuse: It occurs more frequently in families of lower socioeconomic standard. High risk factors include young parents, isolated parents, and history of psychosis. The child is Usually in the age group 6 weeks - 5 years and, experiencing pleomorphic assaults often with increase in severity and frequency;(5) Child neglect:It may take many forms:a. Physical neglect (food, hygiene, clothes).b. Safety neglectc. Medical neglect.d. Educational neglect.e. Emotional neglect.(6) Murder-suicide: Parents are always depressed. Often whole family is killed usually in one accident.(7)Murder-homicide: The great majority of victims are girls after sexual assaults,(8) Sexual abuse Is defined as any sexual activity between an adult and child for the gratification of adult sexual needs and desires.(9) Emotional abuse: It is the persistent rejection and coldness of a parent or guardian towards a child which affects the child’s behavior and development.Medicolegal investigations of a case of child abuse:Characteristic history:1. Unexplained delay in reporting injuries or seeking treatment.2. Presenting symptoms and history are changed after initial presentation.3. Discrepancy in the stories given by each parent or caregiver separately.4. Discrepancy between the history and the physical findings.5. Injuries blamed upon a sibling or another child.II. Characteristic signs:A General signs highly suggestive of child abuse:1. The child may be alert or apathic or in an undue fear..2, injuries appear. older than the alleged history.3. Presence of different types of injuries e.g. fractures together with burns of different kinds.4. Presence of multiple lesions of different ages (recent and old).5. . Multiple lesions from a single cause (e.g. 2 separate cigarette burns).6. Unusual soft issue injuries e.g. avulsion of frenulum of the lips.7. The suspected lesions are covered by sticking plasters, clothes.B. Examination of the child:(A) Clothing: examination for cleanliness, quality, suspected stains.(13,1 Photography: colored photographs of all injuries.(C) Regional examination:1. Head:a. Scalp bruises are easily felt.b. Skull fractures (common): The most common fractures lie in the occipito-parietal area. The parietal bone may dimple inward &without fracture leading to brain damage in the absence of fracture. Suture diastases may occur with or without fractures. Skull fractures are often associated with subdural hemorrhage.c. Bruises inside the lips, lacerations and torn frenulum are pathognomonic sign of deliberate child abuse.d. Eyes: black eyes, conjunctival and sclera hemorrhages, vitreous hemorrhage, lens dislocation and retinal hemorrhage.e, Ear: external ear injuries e.g. pinnae bruises and lacerations. Inner ear impacts may cause deafness.f. Finger tips bruises on the sides of the cheek across the mouth to stop the child crying.g. Teeth: Loosening, breakage even total avulsion of teeth from the sockets.Nit: The shaken baby syndrome (Caffeys’ syndrome): It is characterized by retinal, subdural and/or subarachnoid hemorrhages. It is caused by severe shaking.2. Neck: Neck bruises from fingers pressure in asphyxia! trials.3. Chest: at Different levels of bruises over the costal margin and scapulae when gripping the child from behind with both hands.6. Multiple rib fractures and callus formation that gives string beaded appearance in X-ray.c. Single rib fracture.d. Pulmonary contusion and rupture heart are rare,4. Abdomen: Liver and pancreas hemorrhage and laceration. Stomach—>traumatic rupture.Small intestine---bowel ruptures especially duodenum.These are produced by compression or kneeling on the child:5. Limbs:a. Bruises around the joints (especially wrist, forearm, upper arm, thighs and ankles) from gripping in order to swing or shake the infant.b. Fractures at any site in diaphysis, may be multiple.c. Spiral fractures indicate twisting injury.d. Avulsion of parts of metaphysis and slipped epiphysis are caused by traction.e, Joint effusions may be present.6. Bites: We must differentiate between abuser bites, other children bites and self- inflicted bites that are within the reach of the child to restrain his own screams.sites: are arms, back of hands, cheeks, shoulders and buttocks. Shape: consists of two opposing semicircles with abrasion, or both.Size: size of the dental arch determines whether it is done by an adult, child or animal,7. Burns: These may be:a. Dry burns: Burns in unlikely sites e.g. buttocks and perineum. Children may be sat on hot plates, branded with irons or hot metals. Cigarette burns on areas normally covered by clothing, usually multiple and of different ages. If fresh, cigarette burns are red with a rim of deep red. After healing —> pink —+slivery.b. Scalds from: Over hot bath water. Deliberate polling of hot water. Dipping in hot liquid.It shows clear cut line of immersion. The child reacts by flexion resulting in relative protection or body creases, which results in stripped pattern that will be more important than the extent and location.c. Poisoning: It occurs more with baby sitters. The drugs used more are antihistamines, cough mixtures and laxatives.Re-examination; It is done after one or two days to assess bruises and to do another X-ray or CT scan or MRI for better visibility of hair line fractures by elevation of the periosteum or to see intracranial hemorrhage of subacute hemorrhagic contusion.IV. Radiological examination:1. X-ray skull, chest, abdomen and tlrn whole skeleton to discover the extent of acute injuries as well as to disclose the presence of healed lesions.2. Computed tomography scan (CT): to assess brain injury’ and intracranial hemorrhage.3. Magnetic resonance imaging (MRI): It is more sensitive to small subdural and subarachnoid hemorrhages, contusions of cortex and deep white matter lesions ................
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