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

Mid Staffordshire NHS Foundation Trust NHS  17 years old  Unplanned Pregnancy / O.C.P.  Smoking: 5-15 cigarettes / day  Alcohol: Occasional  Shared Care  Emergency Admission  Vaginal Bleeding / RIF Pain

Mid Staffordshire NHS Foundation Trust NHS Abd/ESuprapubic Tenderness V/EInflammation of Cervix / Discharge U/S:15w Swabs :HVS : Gardenerella vaginalis Chlamydial Swab (EIA & DFA + ve) Letter to GP : +ve Chlamydia Rx Erythromycin Rx Erythromycin Letter to Patient

Mid Staffordshire NHS Foundation Trust NHS  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. 2 nd pregnancy Pre-Term: 29w → Ritodrine → 34w

Mid Staffordshire NHS Foundation Trust NHS  breach of duty  Whether any such breach of duty was causative of the premature delivery  Whether any such breach of duty was causative of the premature delivery

Mid Staffordshire NHS Foundation Trust NHS Failed to: 1. Inform patient of (a) Chlamydia is STI (b) not free from infection until repeat test “Test of Cure” 2. Prescribe adequate treatment (Erythromycin 250 QDS, 7d) 3. Contact tracing and treatment of partner 4. Refer patient to GUM Clinic 5. Treat “Bacterial Vaginosis”

Mid Staffordshire NHS Foundation Trust NHS Chlamydia & STI : letters to GPs # confidentiality Referral to GUM: O&G referrals to GUM in early 1990s “Test of Cure”:who’s responsibility -Hospital or GP Validity of Test of cure Validity of Test of cure Efficacy of Rx : BNF advice on dosage 1990s Efficacy of Rx : BNF advice on dosage 1990s Hospital in breach of duty to re-test for Chlamydia Hospital in breach of duty to re-test for Chlamydia

Mid Staffordshire NHS Foundation Trust NHS Gardenerella vaginalis # Bacterial Vaginosis BV # Prematurity Body of knowledge in 1990s Hospital not in breach of duty to treat Gardenerella

Mid Staffordshire NHS Foundation Trust NHSCausation  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

Mid Staffordshire NHS Foundation Trust NHS Chochrane Review : Meta analysis RCOG Antenatal Care Guidelines (2003): Chlamydia t. associated with higher rates of preterm birth 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) Bcterial V. is associated with preterm birth (X1.85) Early pregnancy BV >>> preterm birth Meta analysis (4249 pateints) Treatment: No significant differences in rates of preterm birth or perinatal death reduction in PROM reduction in PROM Screening for BV and CT Screening for BV and CT

Royal College of Obstetricians and Gynaecologists Setting standards to improve women’s health Risk Management and Medico-Legal Issues In Women’s Health Joint RCOG/ENTER Meeting Please turn off all mobile phones and pagers