Sedentary Work Exerting up to 10 pounds (4.5 kg) of force occasionally and/or a negligible amount of force frequently or constantly to lift, carry, push, pull, or otherwise move objects, including the human body. Sedentary work involves sitting most of the time, but may involve walking or standing for brief periods of time. Jobs are sedentary if walking and standing are required only occasionally and other sedentary criteria are met.

Light Work Exerting up to 20 pounds (9.1 kg) of force occasionally and/or up to 10 pounds (4.5 kg) of force frequently, and/or negligible amount of force constantly to move objects. Physical demand requirements are in excess of those for Sedentary Work. Light Work usually requires walking or standing to a significant degree. However, if the use of the arm and/or leg controls requires exertion of forces greater than that for Sedentary Work and the worker sits most the time, the job is rated Light Work.

Medium Work Exerting up to 50 (22.7 kg) pounds of force occasionally, and/or up to 25 pounds (11.3 kg) of force frequently, and/or up to 10 pounds (4.5 kg) of forces constantly to move objects.

Heavy Work Exerting up to 100 pounds (45.4 kg) of force occasionally, and/or up to 50 pounds (22.7 kg) of force frequently, and/or in excess of 20 pounds (9.1 kg) of force constantly to move objects.

Very Heavy Work Exerting in excess of 100 pounds (45.4 kg) of force occasionally, and/or in excess of 50 pounds (22.7 kg) of force frequently, and/or in excess of 20 pounds (9.1 kg) of force constantly to move objects.

Job Classification

In most duration tables, five job classifications are displayed. These job classifications are based on the amount of physical effort required to perform the work. The classifications correspond to the Strength Factor classifications described in the United States Department of Labor's Dictionary of Occupational Titles. The following definitions are quoted directly from that publication.

Sedentary Work Exerting up to 10 pounds (4.5 kg) of force occasionally and/or a negligible amount of force frequently or constantly to lift, carry, push, pull, or otherwise move objects, including the human body. Sedentary work involves sitting most of the time, but may involve walking or standing for brief periods of time. Jobs are sedentary if walking and standing are required only occasionally and other sedentary criteria are met.

Light Work Exerting up to 20 pounds (9.1 kg) of force occasionally and/or up to 10 pounds (4.5 kg) of force frequently, and/or negligible amount of force constantly to move objects. Physical demand requirements are in excess of those for Sedentary Work. Light Work usually requires walking or standing to a significant degree. However, if the use of the arm and/or leg controls requires exertion of forces greater than that for Sedentary Work and the worker sits most the time, the job is rated Light Work.

Medium Work Exerting up to 50 (22.7 kg) pounds of force occasionally, and/or up to 25 pounds (11.3 kg) of force frequently, and/or up to 10 pounds (4.5 kg) of forces constantly to move objects.

Heavy Work Exerting up to 100 pounds (45.4 kg) of force occasionally, and/or up to 50 pounds (22.7 kg) of force frequently, and/or in excess of 20 pounds (9.1 kg) of force constantly to move objects.

Very Heavy Work Exerting in excess of 100 pounds (45.4 kg) of force occasionally, and/or in excess of 50 pounds (22.7 kg) of force frequently, and/or in excess of 20 pounds (9.1 kg) of force constantly to move objects.

Hyperemesis Gravidarum


Related Terms

  • Hyperemesis Gravidarum with Metabolic Disturbance

Differential Diagnosis

Specialists

  • Gynecologist
  • Internal Medicine Physician
  • Obstetrician/Gynecologist

Comorbid Conditions

  • Helicobacter-pylori infection
  • Hyperthyroidism
  • Multiple gestation
  • Psychiatric disorders
  • Pyridoxine deficiency

Factors Influencing Duration

The severity of symptoms and response to treatment influence the length of disability.

Medical Codes

ICD-9-CM:
643 - Excessive Vomiting in Pregnancy
643.0 - Hyperemesis Gravidarum, Mild or Unspecified
643.01 - Mild Hyperemesis Gravidarum, Delivered
643.03 - Mild Hyperemesis Gravidarum, Antepartum
643.1 - Hyperemesis Gravidarum with Metabolic Disturbance
643.10 - Hyperemesis Gravidarum with Metabolic Disturbance, Unspecified as to Episode of Care or Not Applicable
643.11 - Hyperemesis Gravidarum with Metabolic Disturbance, Delivered, with or without Mention of Antepartum Condition
643.13 - Hyperemesis Gravidarum with Metabolic Disturbance, Antepartum
643.2 - Vomiting of Pregnancy, Late
643.20 - Vomiting of Pregnancy, Late, Unspecified as to Episode of Care or Not Applicable
643.21 - Vomiting of Pregnancy, Late, Delivered, with or without Mention of Antepartum Condition
643.23 - Vomiting of Pregnancy, Late, Antepartum Condition or Complication
643.8 - Vomiting Complicating Pregnancy, Other; Vomiting as Reason for Obstetric Care During Pregnancy
643.80 - Vomiting Complicating Pregnancy, Other, Unspecified as to Episode of Care or Not Applicable
643.81 - Vomiting Complicating Pregnancy, Other, Delivered, with or without Mention of Antepartum Condition
643.83 - Vomiting Complicating Pregnancy, Other, Antepartum Condition or Complication
643.9 - Vomiting of Pregnancy, Unspecified
643.90 - Early or Threatened Labor, Antepartum Condition or Complication
643.91 - Vomiting of Pregnancy, Unspecified, Delivered, with or without Mention of Antepartum Condition
643.93 - Unspecified Vomiting in Pregnancy; Antepartum Condition or Complication

Overview

Hyperemesis gravidarum is a rare condition characterized by persistent and severe nausea and vomiting during pregnancy. It causes weight loss, dehydration, nutritional deficiencies, electrolyte imbalance, pH imbalance (metabolic acidosis), and possibly liver damage.

The exact cause of hyperemesis gravidarum is not known. Several theories have been advanced; one of the leading theories proposes that it may be related to the high levels of the hormones human chorionic gonadotropin (HCG) and estradiol in the blood from pregnancy.

During the first trimester of pregnancy, many women experience a mild form of self-limiting nausea and vomiting commonly called morning sickness. In considering the nausea and vomiting during pregnancy on a continuum from mild to severe, morning sickness tends to fall at the mild end of the continuum and hyperemesis is on the severe end of the spectrum. Although peak incidence of hyperemesis gravidarum occurs between the eighth and twelfth weeks of pregnancy, it may persist throughout the pregnancy with symptoms severe enough to require that the individual be hospitalized (Wilcox).

Incidence and Prevalence: Although morning sickness occurs in 50% to 90% of all pregnancies (Ogunyemi), only about 0.3% to 2% of pregnancies are complicated by hyperemesis gravidarum (Goodwin, Ogunyemi, Wilcox).

Source: Medical Disability Advisor



Causation and Known Risk Factors

The risk of hyperemesis gravidarum decreases with age, with women younger than age 30 more often affected than older women (Wilcox). Overall, women at highest risk for hyperemesis gravidarum are those with a family history of the condition, those carrying a female fetus, women with a low body mass index (BMI), those of nonwhite ethnicity, and those with a history of hyperemesis gravidarum with previous pregnancies, migraine headaches, hyperthyroidism, gastrointestinal disorders, motion sickness, and pregestational diabetes (Wilcox). Vitamin intake beginning early in pregnancy appears to be protective (Goodwin, Ogunyemi, Wilcox). Although cigarette smoking also appears to be protective, it is to be discouraged due to the potential harmful effects on the unborn child.

Source: Medical Disability Advisor



Diagnosis

History: Beginning early in pregnancy, a woman may complain of vomiting that becomes so persistent and severe that it leads to loss of more than 5% of original body weight and dehydration. Eventually, the woman may be unable to keep down any solids or liquids. In up to 60% of cases, the woman may complain of excessive salivation (ptyalism) (Goodwin). The woman may also report a rapid heartbeat (tachycardia), mood changes, insomnia, a decreased ability to concentrate, and feelings of anxiety and depression.

Physical exam: The woman may present with weight loss of 5 to 35 pounds (2 to 16 kg) or a failure to gain weight appropriately. There may be signs of dehydration (e.g., dry mucous membranes, poor skin turgor), yellow coloring to skin or whites of eyes (jaundice), tachycardia, and/or a low-grade fever. Changes in heart rate and blood pressure with position changes (orthostatic hypotension) may be evident. Ophthalmologic examination may reveal bleeding into the retina of the eye (hemorrhagic retinitis). Individuals may also have a distinct odor to their breath (ketonic odor).

Tests: Blood studies are done to assess electrolyte levels. Serum bicarbonate and urine ketones are checked to help detect acidosis. Liver function tests, white blood cell (WBC) count, and urinalysis are performed to help rule out other causes. Thyroid dysfunction can be associated with hyperemesis gravidarum; therefore, a thyroid stimulating hormone (TSH) and a free T4 test may be done to evaluate thyroid function. A fetal ultrasound evaluation may help rule out the possibility of a hydatidiform mole instead of a pregnancy.

Source: Medical Disability Advisor



Treatment

Affected individuals should be hospitalized immediately to restore fluids and replace electrolytes intravenously. No food should be given by mouth (orally) until vomiting ceases and dehydration is corrected. Nourishment may be supplied via the intestines (enteral feeding) or intravenously (parenteral feeding). Vitamin supplementation often is recommended, especially vitamins B6 (pyridoxine), C (ascorbic acid), and B1 (thiamine). Thiamine is recommended to prevent the development of a rare neurological disorder (Wernicke's encephalopathy). The individual's diet is gradually advanced as tolerated, with an emphasis on frequent small meals that include high-protein foods and an avoidance of fatty or spicy foods.

Drugs to stop vomiting (anti-emetics) may be required, but the risk of using them must be carefully weighed against the possibility of prolonged starvation and dehydration. Steroids may be used if no other treatment is effective (refractory hyperemesis gravidarum), but should be avoided during the first 10 weeks of pregnancy to reduce the risk of fetal cleft palate (Wilcox).

Regular prenatal visits to a physician or maternity clinic are essential for a healthy, safe pregnancy, delivery, and postpartum period.

Source: Medical Disability Advisor



Prognosis

The predicted outcome is excellent. The condition is generally self-limiting and usually resolves by week 20; however, serious complications and death are possible if condition is left untreated (Wilcox). Women with hyperemesis gravidarum who gain less than 15.4 pounds (7 kg) throughout the pregnancy are more likely to give birth to low birth weight infants and are thought to have an increased risk for preterm birth; those with a weight gain of greater than 15.4 pounds have fewer complications and a better prognosis (Wilcox).

The risk of experiencing hyperemesis gravidarum in subsequent pregnancies is 16% to 19%, a rate that is 29 times higher than for a woman who has never experienced the condition (Goodwin).

Source: Medical Disability Advisor



Complications

Complications from vomiting are rare, but may include a tear in the mucosa at the junction of the esophagus and stomach (Mallory-Weiss tear) or an esophageal perforation.

Without thiamine supplementation, a neurological disorder characterized by confusion, disorientation, involuntary rolling of the eyeballs (nystagmus), double vision (diplopia), and coma (Wernicke's encephalopathy) may occur.

When acid levels within the blood increase due to the loss of fluids, a serious condition called acidosis may occur. Acidosis suppresses the central nervous system by interfering with the ability of the nerves to communicate with each other (synaptic transmission). As the acid level in the blood rises, the malfunction of the nervous system worsens, and the individual may become disoriented or comatose or may even die.

Severe dehydration can result in an abnormally low volume of blood circulating in the body (hypovolemia). Untreated, hypovolemia can lead to shock and be potentially fatal. Another serious complication of hyperemesis gravidarum is bleeding within the retina (hemorrhagic retinitis). Hyperemesis gravidarum sometimes affects the liver; liver tissue may show deterioration signs similar to that found in starvation. Maternal failure to gain weight can cause intrauterine growth retardation.

Source: Medical Disability Advisor



Ability to Work (Return to Work Considerations)

Hospitalization may be required until dehydration and electrolyte imbalances are successfully treated; in severe cases, hospitalization may be necessary for an average of 2 to 4 days (Wilcox). Individuals may require many breaks during the workday to consume frequent small, bland meals. Nausea and vomiting can be triggered by odors. Individuals who work in an environment subject to odors may need to be assigned different duties on a temporary basis. Once women begin to gain weight, they usually can resume normal duties for the duration of the pregnancy.

Source: Medical Disability Advisor



Failure to Recover

If an individual fails to recover within the expected maximum duration period, the reader may wish to consider the following questions to better understand the specifics of an individual's medical case.

Regarding diagnosis:

  • Did individual report severe nausea and vomiting and excessive salivation?
  • Has individual experienced weight loss of 5 to 35 pounds? Failure to gain weight?
  • Did individual have a distinct ketonic odor to the breath?
  • Was diagnosis of hyperemesis gravidarum confirmed?
  • Have other conditions with similar symptoms been ruled out?
  • Does individual have a coexisting condition such as hyperthyroidism, pyridoxine deficiency, Helicobacter pylori infection, or psychological factors that may complicate treatment or affect recovery?

Regarding treatment:

  • Was individual promptly hospitalized for replacement of fluids and nutritional support?
  • If symptoms persisted despite treatment, was nourishment supplied via enteral or parenteral feeding?
  • Did treatment include vitamin supplementation?
  • Was individual able to advance intake to consumption of small, frequent high-protein meals? Is individual avoiding fatty or spicy foods?
  • Were steroids appropriate for treatment?

Regarding prognosis:

  • Was condition so severe and persistent that it caused weight loss, dehydration, nutritional deficiencies, electrolyte imbalance, pH imbalance (metabolic acidosis), or liver damage? Have these complications responded to treatment?
  • With increasing sophistication of home care, can individual continue to receive treatment at home rather than through long-term hospitalization?
  • If psychological factors are present, would individual benefit from psychological counseling?

Source: Medical Disability Advisor



References

Cited

Goodwin, T. Murphy. "Hyperemesis Gravidarum." Obstetrics and Gynecology Clinics 5 3 (2008): 401-417. PubMed. 2 Nov. 2009 <PMID: 18760227>.

Ogunyemi, Dotun A., and Alex Fong. "Hyperemesis Gravidarum." eMedicine. Eds. Suzanne R. Trupin, et al. 19 Jun. 2009. Medscape. 2 Nov. 2009 <http://emedicine.medscape.com/article/254751-overview>.

Wilcox, Susan Renee, Alison Edelman, and Judith R. Logan. "Pregnancy, Hyperemesis Gravidarum." eMedicine. Eds. Assaad J. Sayah, et al. 10 Dec. 2008. Medscape. 2 Nov. 2009 <http://emedicine.medscape.com/article/796564-overview>.

General

Porter, Robert S., et al., eds. "Hyperemesis Gravidarum." The Merck Manual of Diagnosis and Therapy. 18th ed. Whitehouse Station, NJ: Merck and Company, Inc., 2008. Merck. Nov. 2005. Merck & Co., Inc. 30 Nov. 2009 <http://www.merck.com/mmpe/sec18/ch263/ch263h.html>.

Source: Medical Disability Advisor






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