Reference Determination Content
Suggested draft · fictitious patient
Miscarriage
Evidence
The evidence that I have considered in making this decision includes:
- Formal Claim with supporting statements;
- A Statement of your Service from the Department of Defence;
- Copies of your Service Medical Records.
- A Diagnostic Assessment by Dr Thomas Perkins, General Practitioner, Veterans Health Centre, dated 27 May 2025;
- A Diagnosis Form (D9287) by Dr Thomas Perkins, General Practitioner, Veterans Health Centre, dated 27 May 2025;
- A pre-deployment medical examination by the medical officer, dated 25 January 2010;
- A role 2 record (pathology and pelvic ultrasound) by the senior medical officer, Afghanistan, dated 5 March 2010;
- A role 2 record by the medical officer, Afghanistan, dated 16 March 2010;
- A role 2 record and pelvic ultrasound by the senior medical officer, Afghanistan, dated 19 March 2010;
- A role 2 record (pathology and pelvic ultrasound) by the medical officer, Afghanistan, dated 26 March 2010;
- An operation report and histology by Role 3 hospital, Afghanistan, dated 27 March 2010;
- A q fever serology by the pathology, dated 30 March 2010;
- A gynaecology consultation by the gynaecologist, dated 14 June 2010;
- A psychology assessment by the psychologist, dated 14 June 2010;
- Duty rosters and workload assessment by the february to march 2010, Unit records.
Your service
I have identified that you have the following service:
Australian Defence Force service between :
14 March 2005 and 21 January 2014
Miscarriage
You have stated that your condition was caused by:
- 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
- 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
- taking a tetracycline, macrolide, quinolone, sulfonamide or metronidazole antibiotic during the pregnancy before the clinical onset of miscarriage
- taking a non-steroidal anti-inflammatory drug on at least 7 days within the 4 weeks before the clinical onset of miscarriage
- consuming an average of at least 300 milligrams of caffeine per day during the pregnancy before the clinical onset of miscarriage
- undertaking night shift work on at least 2 nights per week during the 4 weeks before the clinical onset of miscarriage
- 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
- being exposed to organic solvents, including fuel vapours and degreasers, on more days than not during the pregnancy before the clinical onset of miscarriage
- smoking at least 10 cigarettes per day during the pregnancy before the clinical onset of miscarriage
- experiencing a severe psychological stressor involving a threat to life within the 4 weeks before the clinical onset of miscarriage
- having blunt trauma to the abdomen within the 7 days before the clinical onset of miscarriage
Diagnosis: Miscarriage
Basis of diagnosis: The diagnosis was made in the Diagnostic Assessment by Dr Thomas Perkins dated 27 May 2025, and is supported by a role 2 record and pelvic ultrasound by the senior medical officer, Afghanistan, dated 19 March 2010.
I am satisfied this is the appropriate diagnosis.
There is no Statement of Principles (SOP) for this condition. In determining your claim for this condition, I have therefore considered the available evidence, applying the standard of proof:
Reasonable Hypothesis - no Statement of Principles determined for this condition
which requires the evidence to connect the condition with service.
I am satisfied that the evidence establishes the following link to your service:
- 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
- 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
- taking a tetracycline, macrolide, quinolone, sulfonamide or metronidazole antibiotic during the pregnancy before the clinical onset of miscarriage
- taking a non-steroidal anti-inflammatory drug on at least 7 days within the 4 weeks before the clinical onset of miscarriage
- consuming an average of at least 300 milligrams of caffeine per day during the pregnancy before the clinical onset of miscarriage
- undertaking night shift work on at least 2 nights per week during the 4 weeks before the clinical onset of miscarriage
- 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
- being exposed to organic solvents, including fuel vapours and degreasers, on more days than not during the pregnancy before the clinical onset of miscarriage
- smoking at least 10 cigarettes per day during the pregnancy before the clinical onset of miscarriage
- experiencing a severe psychological stressor involving a threat to life within the 4 weeks before the clinical onset of miscarriage
- having blunt trauma to the abdomen within the 7 days before the clinical onset of miscarriage
I have noted your contention as to the cause of this condition. The available evidence indicates, I have noted your contention to the cause of your condition. Your service medical records indicate that you presented to the health facility with 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.You now report grief, anxiety about future pregnancy, intermittent pelvic pain and painful menstruation since the septic miscarriage, and you have been investigated for intrauterine adhesions on 19 March 2010.
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 5 March 2010.
This has then led to further investigations and the diagnosis of your condition of Miscarriage. I have accepted your condition of Miscarriage.
Having considered your service records and the available medical evidence, I am satisfied the evidence establishes that this condition is related to your wartime service.
I have therefore accepted that this condition is related to your service with effect from 19 March 2010.
Miscarriage (Worsening)
Evidence
The evidence that I have considered in making this decision includes:
- Formal Claim with supporting statements;
- A Statement of your Service from the Department of Defence;
- Copies of your Service Medical Records.
- A Diagnostic Assessment by Dr Thomas Perkins, General Practitioner, Veterans Health Centre, dated 27 May 2025;
- A Diagnosis Form (D9287) by Dr Thomas Perkins, General Practitioner, Veterans Health Centre, dated 27 May 2025;
- A pre-deployment medical examination by the medical officer, dated 25 January 2010;
- A role 2 record (pathology and pelvic ultrasound) by the senior medical officer, Afghanistan, dated 5 March 2010;
- A role 2 record by the medical officer, Afghanistan, dated 16 March 2010;
- A role 2 record and pelvic ultrasound by the senior medical officer, Afghanistan, dated 19 March 2010;
- A role 2 record (pathology and pelvic ultrasound) by the medical officer, Afghanistan, dated 26 March 2010;
- An operation report and histology by Role 3 hospital, Afghanistan, dated 27 March 2010;
- A q fever serology by the pathology, dated 30 March 2010;
- A gynaecology consultation by the gynaecologist, dated 14 June 2010;
- A psychology assessment by the psychologist, dated 14 June 2010;
- Duty rosters and workload assessment by the february to march 2010, Unit records.
Your service
I have identified that you have the following service:
Australian Defence Force service between :
14 March 2005 and 21 January 2014
Miscarriage (Worsening)
You have stated that the worsening of your condition was caused by:
- 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
- taking a non-steroidal anti-inflammatory drug within the 48 hours before the clinical worsening of miscarriage
- having iron-deficiency anaemia, with a haemoglobin level below 110 grams per litre, at the time of the clinical worsening of miscarriage
- inability to obtain appropriate clinical management for miscarriage
Diagnosis: Miscarriage (Worsening)
Basis of diagnosis: The diagnosis was made in the Diagnostic Assessment by Dr Thomas Perkins dated 27 May 2025, and is supported by a role 2 record and pelvic ultrasound by the senior medical officer, Afghanistan, dated 19 March 2010.
I am satisfied this is the appropriate diagnosis.
There is no Statement of Principles (SOP) for this condition. In determining your claim for this condition, I have therefore considered the available evidence, applying the standard of proof:
Reasonable Hypothesis - no Statement of Principles determined for this condition
which requires the evidence to connect the condition with service.
I am satisfied that the evidence establishes the following link to your service:
- 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
- taking a non-steroidal anti-inflammatory drug within the 48 hours before the clinical worsening of miscarriage
- having iron-deficiency anaemia, with a haemoglobin level below 110 grams per litre, at the time of the clinical worsening of miscarriage
- inability to obtain appropriate clinical management for miscarriage
I have noted your contention as to the cause of this condition. The available evidence indicates, I have noted your contention to the cause of your condition. Your service medical records indicate that you presented to the health facility with 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.You now report grief, anxiety about future pregnancy, intermittent pelvic pain and painful menstruation since the septic miscarriage, and you have been investigated for intrauterine adhesions on 19 March 2010.
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 5 March 2010.
After the condition arose, it was worsened during your service. 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. For cramping pain you were 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. Haemoglobin was 106 g/L with a ferritin of 6 micrograms per litre on 5 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. From the onset on 19 March 2010 you 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 your evacuation for seven days.
This has then led to further investigations and the diagnosis of your condition of Miscarriage (Worsening). I have accepted your condition of Miscarriage (Worsening).
Having considered your service records and the available medical evidence, I am satisfied the evidence establishes that the worsening of this condition is related to your wartime service.
I have therefore accepted that the worsening of this condition is related to your service with effect from 26 March 2010.
