Miscarriage — DVA claim example

Diagnostic Assessment — Miscarriage

Example 1 of 1 · fictitious patient (Veteran CY)

Diagnostic Assessment

Miscarriage

No Statement of Principles applies to this condition (non-SOP claim).

ADF History

Veteran CY, date of birth 30 July 1986, Australian Army, Petroleum Operator, enlisted 14 March 2005, medically discharged 21 January 2014. Operational service: Afghanistan, 08 February 2010 to 28 March 2010 (warlike); Timor-Leste, 10 October 2007 to 15 April 2008.

Occupational History

Petroleum operators receive, store, test and dispense fuel in garrison and in the field, often on 12-hour day and night shifts. The work involves repeated lifting of jerry cans, hoses, couplings and drums, prolonged standing, exposure to fuel vapours and solvent degreasers, and work in extreme heat.

On operations, fuel installations are a priority target for indirect fire, and personnel work under the threat of rocket and mortar attack. Deployed personnel also face endemic infections, take antimalarial prophylaxis, and rely on energy drinks and tobacco to sustain long shifts.

History

Veteran CY, a petroleum operator in the Australian Army, became pregnant shortly before deploying to Afghanistan and miscarried on 19 March 2010 at 11 weeks of gestation, after acute Q fever, doxycycline prophylaxis, heavy lifting, night shifts, solvent exposure and blunt abdominal trauma in a rocket attack on warlike service. The miscarriage worsened to septic incomplete miscarriage with haemorrhage on 26 March 2010 because evacuation of the uterus could not be obtained for seven days.

Timeline

• 25 Jan 2010 — At her pre-deployment medical the veteran's urine pregnancy test was negative; her last menstrual period had begun on 01 January 2010. Haemoglobin was 118 g/L. She smoked about five cigarettes a day and was issued doxycycline 100 mg daily as malaria prophylaxis, starting 01 February 2010. "urine hCG negative, doxycycline issued"
• 05 Mar 2010 — On warlike service in Afghanistan she attended the role 2 facility with three days of fever to 39.4 degrees Celsius, rigors and myalgia. Urine hCG was positive, and ultrasound showed a single viable intrauterine pregnancy of 9 weeks with fetal heart activity. Q fever serology was positive, haemoglobin was 106 g/L and ferritin 6 micrograms per litre. Doxycycline and ibuprofen were stopped and she was placed on light duties awaiting return to Australia. "viable IUP 9 weeks, Q fever"
• 16 Mar 2010 — The day after a night rocket attack in which she was thrown against a blast wall and sheltered for three hours, she was reviewed with lower abdominal bruising and tenderness and acute distress. There was no vaginal bleeding. Her flight to Australia had been delayed by aircraft priorities. "abdominal bruising after rocket attack"
• 19 Mar 2010 — She presented with heavy vaginal bleeding, clots and cramping lower abdominal pain beginning that morning. Ultrasound showed no fetal heart activity, an open cervical os and retained products of conception. Incomplete miscarriage at 11 weeks was diagnosed by the senior medical officer. No gynaecological service, surgical evacuation or misoprostol was available at the base. "incomplete miscarriage, os open"
• 26 Mar 2010 — After seven days of continued bleeding, and ibuprofen on 24 and 25 March 2010, she developed fever of 39.0 degrees Celsius, offensive discharge and tachycardia. Haemoglobin was 78 g/L and ultrasound showed 32 mm of vascular retained tissue. Septic incomplete miscarriage with haemorrhage was diagnosed, and she was evacuated to a role 3 hospital. "septic incomplete miscarriage, Hb 78"
• 27 Mar 2010 — Suction curettage was performed under general anaesthesia, two units of red cells were transfused and intravenous antibiotics were given. Histology confirmed products of conception with acute inflammation and placental changes consistent with infection. She was aeromedically evacuated to Australia on 28 March 2010. "suction curettage, 2 units transfused"
• 14 Jun 2010 — At follow-up a gynaecologist recorded persisting pelvic pain and grief, with Q fever titres confirming recent infection. A psychologist diagnosed an adjustment disorder with depressed mood related to the pregnancy loss and the circumstances of her evacuation. "pelvic pain, grief, adjustment disorder"

Symptoms

At onset the veteran had heavy vaginal bleeding with clots and cramping lower abdominal pain, followed by persistent bleeding, fatigue and dizziness over the following week, and then fever, offensive discharge and severe pelvic pain when the miscarriage became septic.

She now reports grief, anxiety about future pregnancy, intermittent pelvic pain and painful menstruation since the septic miscarriage, and she has been investigated for intrauterine adhesions.

Imaging

• 05 Mar 2010 — Pelvic ultrasound: "Single intrauterine pregnancy, crown-rump length 23 mm, consistent with 9 weeks of gestation. Fetal heart activity present."
• 19 Mar 2010 — Pelvic ultrasound: "No fetal heart activity. Irregular gestational sac low in the uterus with open internal os and retained products of conception."
• 26 Mar 2010 — Pelvic ultrasound: "32 mm of heterogeneous vascular retained tissue in the endometrial cavity with free fluid in the pouch of Douglas."

Onset Date

The most likely date of onset of this condition is 19 Mar 2010.

At that date the veteran was on warlike service in Afghanistan, on light duties awaiting return to Australia after her pregnancy was discovered. She had recovered from acute Q fever, had taken doxycycline and ibuprofen in the preceding weeks, and four days earlier had been thrown against a blast wall in a rocket attack. On the morning of 19 March 2010 she began to bleed heavily with cramping pain, and the miscarriage was confirmed that day.

This date is appropriate because ultrasound on 05 March 2010 showed a viable pregnancy with fetal heart activity and the review of 16 March 2010 recorded no bleeding, and she presented on 19 March 2010 with an incomplete miscarriage confirmed on ultrasound. It falls within warlike service.

For the night shift, anti-inflammatory and psychological stress factors, the 4 weeks before onset run from 19 Feb 2010 to 19 Mar 2010; night shifts continued to 05 Mar 2010, ibuprofen was taken from 20 Feb 2010 to 05 Mar 2010, and the rocket attack occurred on 15 Mar 2010. For the abdominal trauma factor, the 7 days before onset run from 12 Mar 2010 to 19 Mar 2010 and include the injury of 15 Mar 2010. For the fever, lifting and first trimester factors, the first trimester ran from conception in mid-January 2010 to onset, and included the febrile illness from 02 Mar 2010 and the heavy lifting from 08 Feb 2010. Doxycycline, caffeine, solvent exposure, smoking and the Q fever infection were all present during the pregnancy before onset.

For the worsening factors, the period after onset runs from 19 Mar 2010 to the documented worsening on 26 Mar 2010. The retained products remained for seven days, more than 72 hours; the 48 hours before the worsening run from 24 Mar 2010 to 26 Mar 2010 and contain the ibuprofen doses; and the iron-deficiency anaemia was present at the worsening.

1. What is the formal diagnosis of the condition claimed above?

The formal diagnosis is Miscarriage, an incomplete spontaneous abortion at 11 weeks of gestation (ICD-10-AM O03.4), later complicated by genital tract infection and haemorrhage (O03.0). No Statement of Principles has been determined for this condition.

Miscarriage is the spontaneous loss of a pregnancy before 20 weeks of gestation. Most first-trimester losses result from failure of the embryo or placenta, which can be triggered by maternal infection and fever, certain medications, toxic exposures, physical strain, trauma and severe stress. An incomplete miscarriage, in which tissue remains in the uterus, needs prompt medical or surgical evacuation; untreated retained tissue causes continued bleeding and can become infected, causing septic miscarriage, which can lead to haemorrhage, sepsis and later intrauterine adhesions and infertility.

The miscarriage occurred on warlike service in Afghanistan on 19 March 2010 after multiple deployment exposures in early pregnancy, was confirmed on ultrasound that day, and worsened to septic incomplete miscarriage with haemorrhage on 26 March 2010.

2. For each diagnosis identified, please also provide the following dates:

When did the veteran first experience symptoms attributable to this condition?

19 March 2010.

When did the veteran first present to a health / medical provider for this condition?

19 March 2010.

When was the condition confirmed / formally diagnosed?

19 March 2010.

When did the veteran first present to you (or your practice) for this condition?

27 May 2025.

3. How was this diagnosis confirmed? i.e. what were the key symptoms and signs, investigation results, specialist opinions?

The diagnosis was confirmed on 19 March 2010 by the history of heavy bleeding and cramping in a known intrauterine pregnancy, examination showing an open cervical os, and ultrasound showing no fetal heart activity with retained products of conception, after a viable pregnancy had been documented on 05 March 2010.

Histology of the tissue removed at suction curettage on 27 March 2010 confirmed products of conception with acute inflammation. The ultrasound and laboratory findings of 26 March 2010 confirmed the worsening to septic incomplete miscarriage with haemorrhage.

4. What do you consider to be the cause(s) of the condition in this veteran? Give consideration to constitutional and common risk factors, pre-existing injuries or diseases, and occupational or lifestyle risks, as well as direct causative mechanisms.

No Statement of Principles has been determined for miscarriage, so the claim is decided on the sound medical-scientific evidence of what causes it, without the limits that a Statement of Principles would impose. The recognised causes below are drawn from the medical literature and are each addressed against the veteran's service.

Legislation: the clinical onset of this condition was on 19 March 2010, after 1 July 2004, during warlike service in Afghanistan. This is a Military Rehabilitation and Compensation Act 2004 (MRCA) claim. Because the condition arose on warlike service, the reasonable hypothesis standard applies; for peacetime service the condition must be connected to service on the balance of probabilities. Each factor must be related to the person's service. Under the beneficial approach required by the legislation, the absence of documentation does not mean that an event or exposure did not occur: lack of evidence is not evidence of lack.

Recognised causes on the medical-scientific evidence (no Statement of Principles)

Causative factors

Cause 1: having a febrile illness with a body temperature of at least 38.5 degrees Celsius during the first trimester of the pregnancy before the clinical onset of miscarriage; — MET

- From 02 March 2010, on warlike service in Afghanistan, the veteran had fever to 39.4 degrees Celsius, rigors, headache and myalgia for five days, recorded at the role 2 facility. This was at 8 to 9 weeks of gestation, in the first trimester and 17 days before onset on 19 March 2010. Maternal fever in early pregnancy is associated with fetal loss.

Cause 2: having an infection with Coxiella burnetii (Q fever), Listeria monocytogenes, Plasmodium species or another recognised fetotoxic pathogen during the pregnancy before the clinical onset of miscarriage; — MET

- The febrile illness of March 2010 was acute Q fever: Coxiella burnetii phase II IgM and IgG were positive on 05 March 2010, with a fourfold rise in titre on 30 March 2010. Q fever is endemic around the forward operating base in Afghanistan, where livestock grazed against the perimeter, and placental infection is a recognised cause of miscarriage. The infection was acquired on warlike service before onset.

Cause 3: taking a tetracycline, macrolide, quinolone, sulfonamide or metronidazole antibiotic during the pregnancy before the clinical onset of miscarriage; — MET

- The veteran took doxycycline 100 mg daily as malaria prophylaxis, issued for her deployment, from 01 February 2010 until the pregnancy was discovered on 05 March 2010, covering the first nine weeks of gestation before onset. Exposure to tetracyclines in early pregnancy is associated with an increased risk of spontaneous abortion.

Cause 4: taking a non-steroidal anti-inflammatory drug on at least 7 days within the 4 weeks before the clinical onset of miscarriage; — MET

- She took ibuprofen 400 mg three times a day from 20 February 2010 to 05 March 2010, issued by the unit medic for back pain from carrying fuel equipment and body armour and later for the febrile illness. This was 14 days within the 4 weeks before onset, which run from 19 February 2010 to 19 March 2010. Prostaglandin inhibition around implantation is associated with miscarriage.

Cause 5: consuming an average of at least 300 milligrams of caffeine per day during the pregnancy before the clinical onset of miscarriage; — MET

- To stay alert on night refuelling shifts the veteran drank two to three 500 mL energy drinks and two cups of instant coffee a day, about 450 milligrams of caffeine, from January 2010 throughout the pregnancy to onset. The energy drinks were freely available from the coalition exchange store on the base.

Cause 6: undertaking night shift work on at least 2 nights per week during the 4 weeks before the clinical onset of miscarriage; — MET

- Duty rosters show that the veteran worked three to four 12-hour night refuelling shifts a week from her arrival on 08 February 2010 to 05 March 2010, including the period from 19 February 2010 to 05 March 2010 within the 4 weeks before onset. Night work disrupts circadian and hormonal regulation of early pregnancy.

Cause 7: lifting loads totalling at least 1,000 kilograms per day, or lifting objects of at least 20 kilograms more than 10 times per day, on most working days during the first trimester before the clinical onset of miscarriage; — MET

- As a petroleum operator she lifted 20 kilogram jerry cans, fuel hoses, couplings and drums dozens of times a shift, recorded in a later workload assessment at about 1,400 kilograms a day, on most working days from 08 February 2010 to 05 March 2010. This was in the first trimester, before onset.

Cause 8: being exposed to organic solvents, including fuel vapours and degreasers, on more days than not during the pregnancy before the clinical onset of miscarriage; — MET

- Throughout her deployment from 08 February 2010 the veteran handled aviation turbine fuel and diesel and cleaned equipment with solvent degreasers on more days than not, often without a respirator in the heat, and fuel vapour was noted on her clothing and skin at the end of shifts. Occupational exposure to organic solvents in early pregnancy is associated with miscarriage.

Cause 9: smoking at least 10 cigarettes per day during the pregnancy before the clinical onset of miscarriage; — MET

- The veteran smoked about 15 cigarettes a day throughout the pregnancy to onset, increased from 5 a day before deployment. Smoking on deployment was used to cope with long shifts and rocket attacks, and cigarettes were cheap and widely available.

Cause 10: experiencing a severe psychological stressor involving a threat to life within the 4 weeks before the clinical onset of miscarriage; — MET

- On 15 March 2010, four days before onset, a rocket struck within 40 metres of the veteran's accommodation during a night attack on the base. She was thrown against a blast wall, sheltered in a bunker for three hours believing she would be killed, and a soldier nearby was wounded. Acute severe stress raises cortisol and catecholamines and is associated with miscarriage.

Cause 11: having blunt trauma to the abdomen within the 7 days before the clinical onset of miscarriage; — MET

- In the rocket attack of 15 March 2010 the veteran was thrown against the edge of a concrete blast wall, striking her lower abdomen. The role 2 record of 16 March 2010 notes bruising and tenderness of the lower abdomen. This blunt abdominal trauma occurred on warlike service, four days before onset.

Worsening factors

Worsening 1: having retained products of conception in the uterus for at least 72 hours after the clinical onset of miscarriage, before the clinical worsening of miscarriage; — MET

- Ultrasound on 19 March 2010 showed an incomplete miscarriage with retained products, and they remained in the uterus untreated for seven days because neither surgical evacuation nor misoprostol was available at the base and evacuation was delayed. Ultrasound on 26 March 2010 showed 32 mm of vascular retained tissue, the source of the haemorrhage and sepsis.

Worsening 2: taking a non-steroidal anti-inflammatory drug within the 48 hours before the clinical worsening of miscarriage; — MET

- For cramping pain the veteran was given ibuprofen 400 mg three times a day on 24 and 25 March 2010, within the 48 hours before the worsening on 26 March 2010. Ibuprofen impairs platelet function and increased the bleeding.

Worsening 3: having iron-deficiency anaemia, with a haemoglobin level below 110 grams per litre, at the time of the clinical worsening of miscarriage; — MET

- Haemoglobin was 106 g/L with a ferritin of 6 micrograms per litre on 05 March 2010, iron deficiency attributed to the restricted deployed diet and heavy menstrual loss, and it fell to 78 g/L on 26 March 2010. The pre-existing anaemia reduced her reserve and contributed to haemodynamic compromise.

Worsening 4: inability to obtain appropriate clinical management for miscarriage. — MET

- From the onset on 19 March 2010 the veteran needed surgical or medical evacuation of the uterus within 24 to 48 hours, but the base role 2 facility had no gynaecological capability or misoprostol, and dust storms and aircraft priorities delayed her evacuation for seven days. On 26 March 2010 she developed septic incomplete miscarriage with haemorrhage requiring transfusion. Under Brew v Repatriation Commission (1999) this is an inability to obtain appropriate clinical management.

The % contribution of the causes is 100% and significant.

Sequelae

The miscarriage is a sequela of the veteran's warlike service in Afghanistan, including acute Q fever, deployment-issued doxycycline, heavy lifting, night shifts, solvent exposure and the blunt trauma and stress of the rocket attack. Its own sequelae include iron-deficiency anaemia, chronic pelvic pain and an adjustment disorder with depressed mood.

Unintended Consequence

Met. The doxycycline prophylaxis and ibuprofen that contributed to the miscarriage, and the ibuprofen given after onset that increased the bleeding, were prescribed and issued by Defence health services. These are unintended consequences of treatment provided by the Commonwealth (section 6A of the DRCA and the equivalent provisions of the MRCA).

Inability to Attain Appropriate Medical Management

MET. After the incomplete miscarriage was diagnosed on 19 March 2010 the veteran needed evacuation of the uterus within one to two days, but the base facility had no gynaecological capability or misoprostol, and dust storms and aircraft priorities delayed her evacuation for seven days. She developed septic incomplete miscarriage with haemorrhage requiring transfusion. Applying the objective and subjective tests in Brew v Repatriation Commission (Full Federal Court, 10 September 1999, Merkel J), the unavailability of standard treatment because of the circumstances of warlike service is an inability to obtain appropriate clinical management.

5. Please provide a Health Summary and a medication / prescribing history.

See attached report.

References

1. 25 Jan 2010, Pre-deployment medical examination, Medical Officer
2. 05 Mar 2010, Role 2 record, pathology and pelvic ultrasound, Senior Medical Officer, Afghanistan
3. 16 Mar 2010, Role 2 record, Medical Officer, Afghanistan
4. 19 Mar 2010, Role 2 record and pelvic ultrasound, Senior Medical Officer, Afghanistan
5. 26 Mar 2010, Role 2 record, pathology and pelvic ultrasound, Medical Officer, Afghanistan
6. 27 Mar 2010, Operation report and histology, Role 3 hospital, Afghanistan
7. 30 Mar 2010, Q fever serology, Pathology
8. 14 Jun 2010, Gynaecology consultation, Gynaecologist
9. 14 Jun 2010, Psychology assessment, Psychologist
10. Duty rosters and workload assessment, February to March 2010, Unit records