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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.

Miscarriage


Text Only Home | Graphic-Rich Site | Overview | Risk and Causation | Diagnosis | Treatment | Prognosis | Differential Diagnosis | Specialists | Comorbid Conditions | Complications | Factors Influencing Duration | Length of Disability | Duration Trends | Ability to Work | Failure to Recover | Medical Codes | References

Medical Codes

ICD-9-CM:
634.10 - Spontaneous Abortion, Complicated by Delayed or Excessive Hemorrhage, Unspecified
634.11 - Spontaneous Abortion, Complicated by Delayed or Excessive Hemorrhage, Incomplete
634.12 - Spontaneous Abortion, Complicated by Delayed or Excessive Hemorrhage, Complete
634.70 - Spontaneous Abortion with Other Specified Complications, Unspecified
634.71 - Spontaneous Abortion with Other Specified Complications, Incomplete
634.72 - Spontaneous Abortion with Other Specified Complications, Complete
634.80 - Spontaneous Abortion with Unspecified Complication, Unspecified
634.81 - Spontaneous Abortion with Unspecified Complication, Incomplete
634.82 - Spontaneous Abortion with Unspecified Complication, Complete
634.90 - Spontaneous Abortion without Mention of Complication, Unspecified
634.91 - Spontaneous Abortion without Mention of Complication, Incomplete
634.92 - Spontaneous Abortion without Mention of Complication, Complete

Related Terms

  • Missed Abortion
  • Spontaneous Abortion

Overview

A miscarriage, or spontaneous abortion, is a pregnancy loss that occurs prior to 20 weeks gestation. Most miscarriages occur in the first 12 weeks of pregnancy (first trimester). A miscarriage is a naturally occurring and involuntary event in which the fetus and placenta are separated from the uterine wall. It should not be confused with an elective or induced abortion, which is a planned surgical or medical procedure.

Miscarriages, or spontaneous abortions, occur in a continuum of 4 stages: threatened, inevitable, incomplete, and complete abortion. A threatened abortion refers to vaginal bleeding during the first 20 weeks of pregnancy that may indicate that a miscarriage could occur, although no dilation of the cervix is present; this happens in about 20% to 30% of pregnancies, although only 50% of threatened abortions actually lead to miscarriage (Porter). An inevitable abortion has bleeding with dilation of the cervix and is more likely to lead to miscarriage than a threatened abortion. An incomplete abortion involves bleeding, cervical dilation, cramping, and passage of some of the contents of the uterus: only tissue may be passed, while the fetus or placenta remains in the uterus. An incomplete abortion is not to be confused with a missed abortion that occurs when the fetus has died but remains in the uterus, a specific condition that may lead to elective abortion. A complete abortion occurs when all the contents of the uterus are expelled through the vagina. All the symptoms of earlier stages of spontaneous abortion are typically present, but the miscarriage is complete and the uterus is empty. The status of the pregnancy in each case is evaluated by clinical symptoms and obstetric ultrasound imaging.

Spontaneous abortions within the first trimester account for 80% of all miscarriages (Puscheck). The most common cause of a spontaneous abortion is an embryo that is genetically abnormal due to chromosomal abnormalities or mutations, accounting for about 50% to 60% of miscarriages (Puscheck). Conception that occurs beyond the fertile period of the ovulatory cycle (conception is usually 8 to 10 days after ovulation) is also associated with miscarriage in some cases (Puscheck).

Three or more miscarriages in a row may be called "habitual abortion." This condition occurs in about 1% of women trying to conceive (Puscheck); genetic reasons (chromosomal translocation in parents) are found to be responsible in about 2% to 3% of cases (Puscheck), but often the reason for habitual abortion is unknown. It is possible for each miscarriage to have a different cause.

Incidence and Prevalence: Approximately 10% to 15% of all known pregnancies end in spontaneous abortion (Puscheck; Porter). Percentages are approximate since a miscarriage may occur before the woman realizes she is pregnant.

Source: Medical Disability Advisor



Causation and Known Risk Factors

Risk is equal in women of all races. Drug or alcohol abuse, exposure to environmental or industrial toxins, smoking, malnutrition, excessive caffeine consumption, and the use of nonsteroidal anti-inflammatory drugs have all been found to increase the risk of miscarriage. A history of uterine tumors, fibroids, uterine defects, cervical incompetence, uncontrolled thyroid disease or other hormonal imbalances, kidney disease, active infection, chronic disease (e.g., diabetes, polycystic ovary syndrome, lupus erythematosus, hypertension, and antiphospholipid syndrome), and maternal-fetal Rh incompatibility may also increase the risk of miscarriage.

Additionally, as women age, their risk of miscarriage increases. The rate of miscarriage is 15% in women younger than age 35, 20% to 25% in women age 35 to 39, 35% in women age 40 to 42, and 50% in women over age 42 (Puscheck).

Source: Medical Disability Advisor



Diagnosis

History: Women may report vaginal bleeding, cramping, and the passing of large blood clots or tissue. These symptoms may be accompanied by low abdominal pain that radiates to the back, buttocks, and vaginal area. There may also be a gush of fluid from the rupture of the amniotic sac. Additionally, there may no longer be signs of pregnancy such as breast tenderness or nausea. It is important to keep in mind that the woman may not know that she is pregnant. A history of prior pregnancies, spontaneous abortion, infection, chronic illnesses, and surgeries is usually obtained.

Physical exam: Pelvic examination must assess the source and intensity of bleeding, open or patent cervix, tenderness on cervical motion, uterine size and tenderness, and presence of any mass on or near the uterus. A miscarriage is confirmed if the pelvic exam reveals a dilated cervix and tissue protruding through the cervix, indicating imminent expulsion of tissue. An abdominal exam is performed to assess for any signs that may indicate other abdominal pathology such as distension, enlarged liver or spleen, and areas of tenderness. The examination must address possible ectopic pregnancy or rupture of an ovarian cyst, which may be detected by tenderness on only one side of the abdomen. The characteristics of bowel sounds help rule out acute abdomen not associated with pregnancy. Measuring vital signs can be important if excess bleeding is present, which can alter blood pressure and fluid balance (hemodynamic instability).

A missed abortion can be suspected if pregnancy symptoms (tender breasts and nausea) have disappeared and no symptoms of spontaneous abortion are present. The most common sign of a missed abortion is a uterus that is smaller than expected.

Tests: A pregnancy test is usually done. Blood tests that measure quantitative levels of human chorionic gonadotropin (hCG) may be done and then repeated in several days to see if the level is increasing or decreasing; besides confirming pregnancy, this test is important in distinguishing whether bleeding is related to pregnancy or another cause. If the passed tissue is recovered, laboratory analysis (histopathologic examination) can determine if it is of fetal origin. A complete blood count (CBC) will be done to evaluate degree of blood loss. A white blood cell (WBC) count with differential can rule out potential infection. Coagulation tests (platelet count, fibrinogen level, prothrombin time and partial thromboplastin time) may be done if significant bleeding or CBC suggest hematologic disease or possible disseminated intravascular coagulation (DIC). Blood chemistries may be done to evaluate fluid imbalances due to bleeding, and kidney and liver function. Blood typing, antibody screening, and crossmatching may be done to prepare for possible transfusion, if needed, and to determine if an Rh negative mother should receive Rho (D) immune globulin (RhoGAM) to avoid sensitization for future pregnancies. Urinalysis may be done to rule out urinary tract infection.

Abdominal or vaginal ultrasound imaging may be used to evaluate and confirm any of the stages of miscarriage and rule out ectopic pregnancy or gynecologic problems.

If the individual has experienced habitual abortion, evaluation may include genetic studies and other special tests to determine the reason, tests to rule out chronic infections or hormonal dysfunction, and x-rays of the uterus and fallopian tubes (hysterosalpingography).

Source: Medical Disability Advisor



Treatment

With an uncomplicated, complete abortion, in which all fetal tissue is passed out of the uterus, no unusual surgical or medical treatment is required. Follow-up care is necessary to check for infection or excessive blood loss.

A threatened abortion is a watch and wait situation, and no medical therapy is given other than bed rest, an increase in fluid consumption, and possibly progesterone supplements, although there is no evidence that hormone therapy is useful.

An incomplete, inevitable, or missed abortion, in which some of the products of conception remain in the uterus, may require removal of uterine contents by D&C (dilation and curettage or suction curettage). If this is not done, the tissue remaining inside the uterus can cause an infection or delayed bleeding. The D&C may be done under general anesthesia at the outpatient department of a hospital or clinic. A medical alternative to surgical intervention is administration of misoprostol, a drug that induces complete abortion with few complications in most women (87% to 96.3%) (Puscheck).

Women who develop infection after any stage of miscarriage require treatment with antibiotics. Severe bleeding may require treatment with iron supplementation or a blood transfusion and hospitalization. Women who have habitual abortions may benefit from consulting a fertility specialist.

If bleeding continues after D&C, due either to perforation of the uterus or blood vessels, electrocauterization of the bleeding site may be done using laparoscopy or laparotomy to access the uterine cavity.

Rh-negative women are given Rho(D) immune globulin to prevent antibody development and future Rh complications. Psychological treatment such as counseling or psychotherapy may be indicated for help in coping with the loss of the pregnancy. Some women may also benefit from attending support groups with other women who have experienced a miscarriage.

Source: Medical Disability Advisor



Prognosis

Complete physical recovery is expected. The majority of women who miscarry can eventually carry a baby to full term.

Source: Medical Disability Advisor



Differential Diagnosis

Source: Medical Disability Advisor



Specialists

  • Emergency Medicine Physician
  • Family Physician
  • Gynecologist
  • Obstetrician/Gynecologist

Source: Medical Disability Advisor



Comorbid Conditions

  • Blood or coagulation disorders
  • Pre-existing psychological problems (depression)

Source: Medical Disability Advisor



Complications

Complications may include infection, severe bleeding, or complications from a D&C and/or blood transfusion. The timeliness of the D&C is critical in preventing morbidity and mortality. Anemia may occur due to severe blood loss or hemorrhage. Disseminated intravascular coagulation (DIC) is a serious coagulation disorder that can develop with prolonged heavy bleeding. Shock may also accompany DIC. Women who have had a D&C are at risk for developing adhesions in the uterine cavity (Asherman syndrome), which can interfere with future fertility. Psychological depression may slow overall physical recovery.

Source: Medical Disability Advisor



Factors Influencing Duration

Abortions that are incomplete or missed or those resulting in infection or hemorrhage will require a longer period of disability than an uncomplicated abortion. Severe depression or grief reaction due to pregnancy loss may increase the length of disability.

Source: Medical Disability Advisor



Ability to Work (Return to Work Considerations)

At first, work responsibilities may need to be largely sedentary, and long periods of standing may need to be avoided. Until healing is complete, heavy work, especially involving heavy lifting, may be restricted.

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:

  • Has the woman had a threatened, inevitable, incomplete, complete, or missed spontaneous abortion or miscarriage?
  • Has the woman had previous miscarriages? What is her age?
  • Does the woman have risk factors such as acute infection, uterine tumors, uterine defects, fibroids, cervical incompetence, hormonal imbalances, or maternal-fetal Rh incompatibility?
  • Does the woman have diabetes, uncontrolled thyroid disease, renal disease, lupus erythematosus, polycystic ovary syndrome, hypertension, antiphospholipid syndrome, or malnutrition?
  • Does the woman smoke, use recreational drugs, or consume alcohol or caffeine?
  • Does the woman report vaginal bleeding, cramping, or passing large clots or tissue?
  • Did the woman report a gush of fluid?
  • Does the woman complain of a foul-smelling or cloudy vaginal discharge?
  • On pelvic exam, did the physician find tissue protruding through an open cervix or an open and dilated cervix?
  • Has the woman had a blood or urine pregnancy test?
  • Was laboratory analysis of any passed tissue done?
  • Did the woman have a CBC and WBC with differential, coagulation tests, and blood chemistries? Was typing and crossmatching done to reserve blood for possible transfusion?
  • Was abdominal or vaginal ultrasound performed?
  • Were genetic studies, tests to rule out chronic infections or hormonal dysfunction, or hysterosalpingography indicated?
  • Have conditions with similar symptoms been ruled out?

Regarding treatment:

  • Did the woman have an uncomplicated complete miscarriage? Did she follow up with her physician as scheduled?
  • Did the woman require hospitalization or a blood transfusion? Antibiotics?
  • Did the woman have an inevitable or incomplete abortion? Has a D&C completely removed the uterine contents?
  • Was misoprostol used instead of D&C? Was complete abortion achieved?
  • Was it necessary to induce labor for a missed abortion?
  • Is the woman Rh negative? Was she given Rho(D) immune globulin?
  • If necessary, did the woman seek psychiatric counseling? Attend a support group?

Regarding prognosis:

  • Is the woman's employer able to accommodate any necessary restrictions?
  • Does the woman have any conditions that may affect her ability to recover?
  • Does the woman have any complications such as infection, severe bleeding, or complications from a D&C and/or blood transfusion? Does she have anemia? Does she experience depression?

Source: Medical Disability Advisor



References

Cited

Porter, Robert S., et al., eds. "Spontaneous Abortion." Merck Manual of Diagnosis and Therapy. Eds. Robert S. Porter, et al. Nov. 2005. Merck & Co., Inc. 16 Sep. 2009 <http://www.merck.com/mmpe/sec18/ch263/ch263l.html>.

Puscheck, Elizabeth E., and Archana Pradhan. "First-Trimester Pregnancy Loss." eMedicine. Eds. Suzanne R. Trupin, et al. 25 Jun. 2006. Medscape. 16 Sep. 2009 <http://emedicine.medscape.com/article/266317-overview>.

Source: Medical Disability Advisor