A Medico Legal Claim for

1
A Medico Legal Claim for Cervical Chlamydia
Infection  Pre-term Delivery Association or
Causation

• A R Markos FRCOG FRCP 
• Consultant in Genito Urinary Medicine and Sexual
  Health 
• Mid Staffordshire NHS Foundation Trust

2
Case Summary

• 17 years old
• Unplanned Pregnancy / O.C.P.
• Smoking 5-15 cigarettes / day
• Alcohol Occasional
• Shared Care
• Emergency Admission
• Vaginal Bleeding / RIF Pain

3

• Abd/E Suprapubic Tenderness
• V/E Inflammation of Cervix / Discharge
• U/S 15w
• Swabs HVS Gardenerella vaginalis
• Chlamydial Swab (EIA DFA ve)
•  
• Letter to GP ve Chlamydia
• Rx Erythromycin
• Letter to Patient

4
Follow up Events

• ANC had Rx from GP ??? swab N
• Recurrent admissions Abd. pain, bleeding after
  sex
• U/S 25w
• 999 call Pre-term Labour Ritodrine
• Chorio-amnionitis Rx Antibiotics
• HVS Gardenerella
• Chlamydia Test ve
•  
• N.B. 2nd pregnancy Pre-Term 29w ? Ritodrine ? 34w

5
Trial of the allegation of

• breach of duty
• Whether any such breach of duty was causative of
  the premature delivery 

6
Breach of Duty

• Failed to
• Inform patient of
• (a) Chlamydia is STI
• (b) not free from infection until repeat test
  Test of Cure
• Prescribe adequate treatment (Erythromycin
  250 QDS, 7d)
•  Contact tracing and treatment of partner
•  Refer patient to GUM Clinic
•  Treat Bacterial Vaginosis

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Breach of Duty

• Chlamydia STI letters to GPs
  confidentiality
• Referral to GUM OG referrals to GUM in early
  1990s
• Test of Cure whos responsibility -Hospital or
  GP
•   Validity of Test of cure
•  Efficacy of Rx BNF advice on dosage 1990s
•  Hospital in breach of duty to re-test for
  Chlamydia

8
Breach of Duty

• Gardenerella vaginalis Bacterial Vaginosis
• BV Prematurity
• Body of knowledge in 1990s
• Hospital not in breach of duty to treat
  Gardenerella

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• Causation
• Chlamydia trachomatis Prematurity
• Gardenerella vaginalis Prematurity
• Proof
• Balance of probabilities
• The negligence was the cause of the adverse
  consequences
• Breach of duty caused or materially contributed
  to the premature birth

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Level of Evidence

• Chochrane Review Meta analysis
• RCOG Antenatal Care Guidelines (2003)
• Chlamydia t. associated with higher rates of
  preterm birth
• Treatment did not alter the incidence of birth
  before 37 w
• Bcterial V. is associated with preterm
  birth (X1.85)
• Early pregnancy BV gtgtgt preterm birth
• Meta analysis (4249 pateints)
• Treatment No significant differences in
  rates of preterm birth or
  perinatal death
• 
  reduction in PROM
•   Screening for BV and
  CT
•  

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Royal College ofObstetricians andGynaecologists
Setting standards to improve womens health
Risk Management and Medico-Legal Issues In
Womens Health Joint RCOG/ENTER Meeting
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