Diagnostic Assessment — Pelvic Inflammatory Disease
Example 1 of 1 · fictitious patient (Veteran CW)
Diagnostic Assessment
Pelvic Inflammatory Disease
No Statement of Principles applies to this condition (non-SOP claim).
ADF History
Veteran CW, date of birth 19 November 1985, Royal Australian Navy, Electronics Technician, enlisted 06 February 2004, medically discharged 28 April 2017. Operational service: Middle East Area of Operations aboard a frigate, 10 January 2011 to 25 July 2011 (warlike); Middle East Area of Operations aboard a frigate, 01 June 2013 to 16 June 2013 (warlike, ended by aeromedical evacuation).
Occupational History
As an electronics technician aboard a frigate the veteran maintained radar, communications and weapons electronics in confined, hot compartments, wearing synthetic coveralls and fire-retardant clothing for long watches. At sea, fresh water for showering was rationed, laundry facilities were limited, and privacy for personal and menstrual hygiene was poor, conditions recognised to promote vaginal infections.
Ships deployed in the Middle East carried a medical officer or medical sailor but no gynaecologist, no pelvic ultrasound and limited laboratory testing, so lower genital tract infections could not be screened for, investigated or fully treated at sea, and partner notification and test-of-cure were often not completed. Smoking was common among ship's companies during the period.
History
Veteran CW, an electronics technician in the Royal Australian Navy, developed acute pelvic inflammatory disease with purulent salpingitis on 02 July 2012, 30 days after childbirth and 9 days after a uterine curettage with insertion of an intrauterine device, with chlamydial, gonococcal and Mycoplasma genitalium infection first acquired on warlike service in the Middle East in 2011. The condition worsened with a left tubo-ovarian abscess on warlike service at sea in the Middle East on 10 June 2013.
Timeline
- 18 May 2011 — On warlike service in the Middle East the veteran presented to the ship's medical officer with an offensive grey vaginal discharge, recurring since early in the deployment when shower water was rationed. Bacterial vaginosis was diagnosed clinically and treated with oral metronidazole. No testing for sexually transmitted infections was available on board, and the medical officer recorded a plan for screening on return that was not carried out. "bacterial vaginosis, STI screen deferred"
- 12 Oct 2011 — At her first antenatal visit with a Defence-funded general practitioner the veteran was eight weeks pregnant. Chlamydia and gonorrhoea testing was not performed, and her history of possible exposure during the 2011 deployment was not followed up. She was smoking 12 cigarettes a day, a habit started in recruit training in 2004 and increased at sea. "antenatal booking, no STI screen"
- 02 Jun 2012 — The veteran gave birth vaginally at term after a prolonged labour. On 23 June 2012, for heavy bleeding from retained products of conception, a gynaecologist performed a suction curettage and inserted a copper intrauterine device at the same procedure. No pre-procedure screening for sexually transmitted infection was performed. She had been taking prednisolone 30 mg daily since 10 June 2012 for an exacerbation of asthma. "suction curettage, copper IUD inserted"
- 03 Jul 2012 — The veteran presented to a hospital emergency department with 24 hours of lower abdominal pain, fever of 38.9 degrees and a purulent vaginal discharge. Examination showed cervical motion tenderness and bilateral adnexal tenderness. White cell count 18.2 and CRP 164 mg/L. Cervical swabs on nucleic acid testing were positive for Chlamydia trachomatis, Neisseria gonorrhoeae and Mycoplasma genitalium, and a Gram stain showed bacterial vaginosis with a Nugent score of 9. "cervical motion tenderness, fever 38.9"
- 05 Jul 2012 — After failure to improve on intravenous antibiotics, a gynaecologist performed a diagnostic laparoscopy, which showed bilateral purulent salpingitis with pus in the pouch of Douglas and early peritubal adhesions. Acute pelvic inflammatory disease was confirmed. The intrauterine device was removed and she completed 14 days of antibiotics covering all three organisms. "laparoscopy, bilateral purulent salpingitis"
- 25 May 2013 — Before her second deployment a levonorgestrel intrauterine device was inserted by a Defence-funded general practitioner. Test-of-cure after the 2012 infection had not been arranged and her partner had not been notified or treated. She had been taking prednisolone 25 mg daily since 20 May 2013 for a further asthma exacerbation, continuing for four weeks. "levonorgestrel IUD inserted"
- 10 Jun 2013 — On warlike service at sea in the Middle East the veteran developed severe left lower abdominal pain, fever of 39.4 degrees and vomiting. The ship's medical officer recorded marked left adnexal tenderness. Only oral antibiotics were available on board, and no ultrasound or gynaecological care could be obtained until her aeromedical evacuation on 16 June 2013. "severe left pelvic pain, febrile"
- 17 Jun 2013 — Pelvic ultrasound and CT at a hospital ashore showed a 5.5 cm left tubo-ovarian abscess. Cervical swabs were positive for Chlamydia trachomatis, a reinfection. A gynaecologist recorded worsening of her pelvic inflammatory disease and performed image-guided drainage of the abscess, with removal of the intrauterine device and intravenous antibiotics. "left tubo-ovarian abscess 5.5 cm"
Symptoms
At onset the veteran had constant lower abdominal and pelvic pain, fever, rigors, purulent vaginal discharge, pain on intercourse and pain on movement, and she could not care for her newborn without help. The worsening in 2013 caused severe left-sided pelvic pain, high fever and vomiting.
She now reports chronic pelvic pain, deep dyspareunia and painful periods. Hysterosalpingography in 2015 showed a blocked left fallopian tube and she has been unable to conceive again despite trying for three years.
Imaging
- 03 Jul 2012 — Transvaginal pelvic ultrasound: "Bilaterally thickened, fluid-filled fallopian tubes with hyperaemia. Small volume of complex free fluid in the pouch of Douglas. Copper intrauterine device correctly sited. No retained products."
- 17 Jun 2013 — Pelvic ultrasound and CT abdomen and pelvis: "5.5 cm thick-walled multiloculated left tubo-ovarian abscess with surrounding inflammatory change. Left hydrosalpinx. Levonorgestrel intrauterine device in situ."
- 14 Sep 2015 — Hysterosalpingography: "Occlusion of the left fallopian tube at the ampulla with hydrosalpinx. Right tube patent with delayed peritoneal spill and peritubal loculation, consistent with adhesions."
Onset Date
The most likely date of onset of this condition is 02 Jul 2012.
At that date the veteran was serving full time in the Royal Australian Navy, on maternity leave 30 days after childbirth and 9 days after a suction curettage at which a copper intrauterine device was inserted. That day she developed lower abdominal pain, fever and a purulent discharge, and presented to hospital the next morning.
This date is appropriate because the gynaecologist's record of the curettage on 23 June 2012 documented no fever, no pelvic tenderness and a normal discharge, and she presented with acute pelvic inflammatory disease on 03 July 2012, 24 hours after the symptoms began. The diagnosis was confirmed at laparoscopy on 05 July 2012.
For the procedure and intrauterine device causes, the 21 days before onset run from 11 Jun 2012 to 02 Jul 2012, and the curettage with device insertion on 23 June 2012 falls within it. For the childbirth cause, the 6 weeks before onset run from 21 May 2012 to 02 Jul 2012, and the birth on 02 June 2012 falls within it. For the smoking cause, the 12 months before onset run from 02 Jul 2011 to 02 Jul 2012, during which she smoked 12 cigarettes a day. For the immunosuppression cause, the 4 weeks before onset run from 04 Jun 2012 to 02 Jul 2012, and she took prednisolone 30 mg daily from 10 June 2012, 22 days of it before onset. The chlamydial, gonococcal, Mycoplasma genitalium and bacterial vaginosis infections were present at onset, confirmed on swabs on 03 July 2012.
For the worsening factors, the documented worsening was on 10 Jun 2013. The 60 days before it run from 11 Apr 2013 to 10 Jun 2013, within which she was reinfected with Chlamydia trachomatis by her untreated partner. The 21 days before it run from 20 May 2013 to 10 Jun 2013, within which the levonorgestrel device was inserted on 25 May 2013, and she took prednisolone 25 mg daily from 20 May 2013 to the worsening.
1. What is the formal diagnosis of the condition claimed above?
The formal diagnosis is Pelvic Inflammatory Disease, acute bilateral salpingitis (ICD-10-AM N70.0), complicated in 2013 by a left tubo-ovarian abscess.
Pelvic inflammatory disease is infection and inflammation of the upper female genital tract, including the endometrium, fallopian tubes, ovaries and pelvic peritoneum. It usually results from organisms ascending from the cervix and vagina, most often Chlamydia trachomatis, Neisseria gonorrhoeae and Mycoplasma genitalium, together with the mixed organisms of bacterial vaginosis. Ascent is promoted by procedures that breach the cervical barrier, such as insertion of an intrauterine device or uterine curettage, and by the open cervix after childbirth. It presents with pelvic pain, fever, abnormal discharge and cervical motion tenderness, and can lead to tubo-ovarian abscess, chronic pelvic pain, ectopic pregnancy and tubal infertility.
The condition began on 02 July 2012 after childbirth and a uterine procedure, in the presence of infections acquired on warlike service in 2011 that were never screened for, was confirmed at laparoscopy on 05 July 2012, and worsened with a tubo-ovarian abscess on warlike service at sea on 10 June 2013.
2. For each diagnosis identified, please also provide the following dates:
When did the veteran first experience symptoms attributable to this condition?
02 July 2012.
When did the veteran first present to a health / medical provider for this condition?
03 July 2012.
When was the condition confirmed / formally diagnosed?
05 July 2012.
When did the veteran first present to you (or your practice) for this condition?
25 June 2025.
3. How was this diagnosis confirmed? i.e. what were the key symptoms and signs, investigation results, specialist opinions?
The diagnosis was confirmed at diagnostic laparoscopy on 05 July 2012, which showed bilateral purulent salpingitis with pus in the pouch of Douglas. This is the reference standard for the diagnosis of pelvic inflammatory disease. The clinical criteria were also met: lower abdominal pain, cervical motion tenderness and adnexal tenderness, with fever of 38.9 degrees, a purulent discharge, a raised white cell count and CRP, and positive cervical nucleic acid tests for Chlamydia trachomatis, Neisseria gonorrhoeae and Mycoplasma genitalium.
Transvaginal ultrasound on 03 July 2012 showed thickened, fluid-filled tubes and excluded retained products of conception and other causes of pelvic pain. The worsening was confirmed on ultrasound and CT on 17 June 2013, which showed a 5.5 cm left tubo-ovarian abscess, and by a gynaecologist who drained it.
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 pelvic inflammatory disease. The claim is therefore decided on the sound medical-scientific evidence of what causes the condition and on the facts of the veteran's service, without the limits that a Statement of Principles would impose. The recognised causes below are drawn from the medical literature and phrased in the style of a Statement of Principles.
Legislation: the clinical onset of this condition was on 02 July 2012, after 1 July 2004, during continuous full-time service. This is a Military Rehabilitation and Compensation Act 2004 (MRCA) claim. The infections that led to it were first acquired on warlike service in the Middle East in 2011 and were not screened for or treated, and the condition worsened on warlike service in the Middle East in 2013. Each cause 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: being infected with Chlamydia trachomatis in the lower genital tract at the time of the clinical onset of pelvic inflammatory disease; — MET
- A cervical nucleic acid test on 03 July 2012 was positive for Chlamydia trachomatis. The infection was acquired during her warlike service in the Middle East in 2011, when the ship's medical officer recorded possible exposure and planned screening that was never carried out, and it was not tested for at her Defence-funded antenatal care in October 2011. It persisted untreated and was present at onset.
Cause 2: being infected with Neisseria gonorrhoeae in the lower genital tract at the time of the clinical onset of pelvic inflammatory disease; — MET
- The same swab on 03 July 2012 was positive for Neisseria gonorrhoeae, confirmed on culture. Like the chlamydial infection, it dated from her warlike service in 2011, was asymptomatic and went undetected because screening was not available at sea and was not performed afterwards. It was present at onset.
Cause 3: being infected with Mycoplasma genitalium in the lower genital tract at the time of the clinical onset of pelvic inflammatory disease; — MET
- Mycoplasma genitalium was detected on nucleic acid testing on 03 July 2012, with macrolide resistance on genotyping. It was acquired at the same time as the other infections during her 2011 deployment and was present at onset.
Cause 4: having bacterial vaginosis at the time of the clinical onset of pelvic inflammatory disease; — MET
- Bacterial vaginosis was first diagnosed on warlike service on 18 May 2011, when rationed shower water, long watches in synthetic coveralls and poor facilities for personal hygiene at sea caused recurrent episodes. It recurred after her return and was present at onset, with a Nugent score of 9 on 03 July 2012.
Cause 5: having an intrauterine device inserted within the 21 days before the clinical onset of pelvic inflammatory disease; — MET
- A copper intrauterine device was inserted by a gynaecologist on 23 June 2012, 9 days before onset, within the 21 days from 11 June 2012 to 02 July 2012. The procedure was provided and paid for by Defence health services, and no screening for sexually transmitted infection was done beforehand.
Cause 6: undergoing a procedure involving instrumentation of the uterine cavity through the cervix within the 21 days before the clinical onset of pelvic inflammatory disease; — MET
- A suction curettage for retained products of conception was performed through the cervix on 23 June 2012, 9 days before onset, within the 21 days before onset, by a Defence-funded gynaecologist.
Cause 7: giving birth, or having a miscarriage or termination of pregnancy, within the 6 weeks before the clinical onset of pelvic inflammatory disease; — MET
- The veteran gave birth vaginally on 02 June 2012, 30 days before onset, within the 6 weeks from 21 May 2012 to 02 July 2012, while serving full time. The open postpartum cervix and the retained products allowed the organisms already present to ascend.
Cause 8: smoking at least 10 cigarettes per day for at least the 12 months before the clinical onset of pelvic inflammatory disease; — MET
- The veteran began smoking in recruit training in 2004 and smoked 12 cigarettes a day throughout the 12 months before onset, from 02 July 2011 to 02 July 2012, having increased her intake during long watches on her 2011 deployment, as recorded at her antenatal booking on 12 October 2011.
Cause 9: taking a systemic corticosteroid at a dose of at least 20 milligrams of prednisolone or equivalent per day for at least 14 days within the 4 weeks before the clinical onset of pelvic inflammatory disease; — MET
- Prednisolone 30 mg daily was prescribed by a Defence-funded general practitioner from 10 June 2012 for an exacerbation of asthma, and she took it for 22 days within the 4 weeks before onset, from 04 June 2012 to 02 July 2012. The immunosuppression reduced local defence against ascending infection.
Worsening factors
Worsening 1: being infected or reinfected with Chlamydia trachomatis or Neisseria gonorrhoeae within the 60 days before the clinical worsening of pelvic inflammatory disease; — MET
- Cervical swabs on 17 June 2013 were again positive for Chlamydia trachomatis, a reinfection acquired within the 60 days before the worsening, from 11 April 2013 to 10 June 2013, from her partner, who had not been notified or treated because partner notification was not completed by the treating Defence clinic in 2012.
Worsening 2: having an intrauterine device inserted within the 21 days before the clinical worsening of pelvic inflammatory disease; — MET
- A levonorgestrel intrauterine device was inserted by a Defence-funded general practitioner on 25 May 2013, 16 days before the worsening, within the 21 days from 20 May 2013 to 10 June 2013, as contraception for her deployment and without test-of-cure or screening beforehand.
Worsening 3: taking a systemic corticosteroid at a dose of at least 20 milligrams of prednisolone or equivalent per day for at least 14 days within the 4 weeks before the clinical worsening of pelvic inflammatory disease; — MET
- Prednisolone 25 mg daily was taken from 20 May 2013 to the worsening on 10 June 2013, 21 days within the 4 weeks before the worsening, for an asthma exacerbation, and continued on board.
Worsening 4: having pelvic inflammatory disease that has not been treated to cure, including failure of test-of-cure or partner treatment, before the clinical worsening of pelvic inflammatory disease; — MET
- After the 2012 episode no test-of-cure was arranged for the macrolide-resistant Mycoplasma genitalium or the chlamydial infection, and her partner was not treated. Residual hydrosalpinx and adhesions were seen on ultrasound before her deployment, and the infection was not cured before the worsening on 10 June 2013.
Worsening 5: inability to obtain appropriate clinical management for pelvic inflammatory disease. — MET
- On warlike service at sea from 10 June to 16 June 2013 the veteran had only oral antibiotics, with no pelvic ultrasound, intravenous therapy or gynaecological care, until her aeromedical evacuation. A tubo-ovarian abscess of 5.5 cm had formed by the time she was imaged on 17 June 2013. 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 pelvic inflammatory disease is a sequela of infections acquired on warlike service and left unscreened and untreated, and of a uterine procedure and device insertion provided by Defence health services. In turn it has caused chronic pelvic pain, deep dyspareunia, left tubal occlusion with hydrosalpinx and tubal-factor infertility, and an increased risk of ectopic pregnancy.
Unintended Consequence
Met. The suction curettage and copper intrauterine device insertion of 23 June 2012, and the levonorgestrel device insertion of 25 May 2013, were provided and paid for by Defence health services without prior screening for sexually transmitted infection, and ascending pelvic infection is a recognised complication of both. The onset and the worsening are in part unintended consequences of that treatment (section 6A of the DRCA and the equivalent provisions of the MRCA).
Inability to Attain Appropriate Medical Management
MET. On warlike service in the Middle East in 2011 the veteran could not be screened for sexually transmitted infections at sea, and the planned screening on return was not done, so infections that cause pelvic inflammatory disease went undetected for more than a year. After the 2012 episode no test-of-cure or partner treatment was arranged. On warlike service at sea from 10 to 16 June 2013 she had only oral antibiotics and no imaging or gynaecological care, and a tubo-ovarian abscess formed before she could be evacuated. Applying the objective and subjective tests in Brew v Repatriation Commission (Full Federal Court, 10 September 1999, Merkel J), the unavailability of screening, investigation and treatment because of her service circumstances amounts to an inability to obtain appropriate clinical management.
5. Please provide a Health Summary and a medication / prescribing history.
See attached report.
References
- 18 May 2011, Ship's health record, Medical Officer, frigate, Middle East
- 12 Oct 2011, Antenatal booking record, General practitioner
- 02 Jun 2012, Birth record, Obstetric unit
- 23 Jun 2012, Operation report, Gynaecologist
- 03 Jul 2012, Emergency department record, microbiology and pelvic ultrasound reports, Emergency physician and Radiologist
- 05 Jul 2012, Laparoscopy operation report, Gynaecologist
- 25 May 2013, Outpatient health record, General practitioner, Naval health centre
- 10 Jun 2013, Ship's health record, Medical Officer, frigate, Middle East
- 17 Jun 2013, Ultrasound, CT and microbiology reports and gynaecology consultation, Radiologist and Gynaecologist
- 14 Sep 2015, Hysterosalpingography report, Radiologist
