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.

Pregnancy, Ectopic


Related Terms

  • Abdominal Pregnancy
  • Ovarian Pregnancy
  • Tubal Pregnancy

Differential Diagnosis

Specialists

  • General Surgeon
  • Gynecologist
  • Obstetrician/Gynecologist

Comorbid Conditions

Factors Influencing Duration

Expected length of disability depends on the type and extent of surgical treatment and the individual’s response. Complications from surgery, such as hemorrhage, infection, abdominal cramping, and the individual's job requirements, may influence the length of disability. The woman may also experience a normal grief reaction after the loss of the pregnancy. This may include an episode of depression that can lengthen disability.

Medical Codes

ICD-9-CM:
633.00 - Abdominal Pregnancy without Intrauterine Pregnancy
633.01 - Abdominal Pregnancy with Intrauterine Pregnancy
633.10 - Tubal Pregnancy without Intrauterine Pregnancy
633.11 - Tubal Pregnancy with Intrauterine Pregnancy
633.20 - Ovarian pregnancy without Intrauterine Pregnancy
633.21 - Ovarian pregnancy with Intrauterine Pregnancy
633.80 - Other Ectopic Pregnancy without intrauterine pregnancy
633.81 - Other Ectopic Pregnancy with Intrauterine Pregnancy
633.90 - Unspecified ectopic pregnancy without Intrauterine Pregnancy
633.91 - Unspecified Ectopic Pregnancy with Intrauterine Pregnancy; Endometritis; Salpingo-oophoritis; Afibrinogenemia; Defibrination Syndrome; Intravascular Hemolysis; Bladder; Uterus; Oliguria; Uremia; Circulatory Collapse; Shock (Postoperative) (Septic); Amniotic Fluid; Pulmonary; Cardiac Arrest or Failure; Urinary Tract Infection

Overview

© Reed Group
An ectopic pregnancy is the maturation of a fertilized egg implanted outside the uterus. It always results in loss of the fetus and can be life-threatening for the mother if not diagnosed and treated early. Ectopic pregnancy occurs in 2% of all pregnancies and is the most frequent cause of death in the first trimester of pregnancy (Sepillian).

Almost all ectopic pregnancies occur in a fallopian tube, which is how the term "tubal" pregnancy originated. In about 1.4% of cases, the egg may implant elsewhere, such as in the abdomen, ovary, or cervix (Sepillian). Because the narrow fallopian tubes are not designed to hold a growing embryo, the fertilized egg in a tubal pregnancy cannot develop normally. Eventually, the thin walls of the fallopian tube stretch to the point of bursting (rupture). If this happens, a woman is in danger of life-threatening blood loss (massive hemorrhage).

Most cases of ectopic pregnancy are caused by an inability of the fertilized egg to make its way through the fallopian tube into the uterus. This often is the result of blockage of the fallopian tube by the build-up of scar tissue from previous infection or chronic inflammation (pelvic inflammatory disease [PID]). Approximately 50% of women with ectopic pregnancies have a history of sexually transmitted chlamydia-associated salpingitis or gonorrhea-associated PID (Sepillian). Salpingitis isthmica nodosum, a condition similar to endometriosis of the uterus in which tubal epithelium forms pockets of tissue that protrude into the fallopian tube like small polyps, also can block a tube and predispose the individual to ectopic pregnancy. Other possible causes of ectopic pregnancy include a congenital abnormality in the shape of the fallopian tube or a T-shaped uterus. An estimated 35% to 50% of ectopic pregnancies develop after tubal surgery, including tubal ligation, surgery to open the fallopian tube (salpingostomy), removing the fibrous covering of the tube (fimbrioplasty), reversing tubal ligation (reanastomosis), and lysis of adhesions (Sepillian).

Incidence and Prevalence: The frequency of ectopic pregnancy is increasing; 2% of all pregnancies now occur outside the uterus. Annual incidence is 108,800 ectopic pregnancies, resulting in 58,200 hospitalizations (Sepillian).

Source: Medical Disability Advisor



Causation and Known Risk Factors

Damage to the fallopian tube from surgery, infection, or PID increases a woman's risk for ectopic pregnancy; however, most women do not present with an identifiable risk factor (Sepillian). Previous ectopic pregnancies pose the highest risk: the recurrence rate is 10% to 25% after the first ectopic pregnancy (Sepillian). The use of fertility drugs or other reproductive therapy has been shown in studies to increase risk of ectopic pregnancy by up to 4 times; researchers suggest that multiple eggs and excess hormone levels are responsible (Sepillian). Taking supplemental estrogen and progesterone can reduce the normal movement of the fertilized egg through the tubal epithelium and result in implantation in the fallopian tube. If a woman becomes pregnant while taking a progesterone-only contraceptive, she may be at increased risk of an ectopic pregnancy. Taking the morning after pill (progestin or progestin with estrogen) also may increase a woman's risk of ectopic pregnancy if it fails to prevent pregnancy. There is a slightly increased risk of ectopic pregnancy in the fallopian tube if a woman uses a progesterone-containing intrauterine device (IUD) for contraception, although no risk is associated with using standard copper IUDs. The incidence of ectopic pregnancy with an IUD in place is 3% to 4% (Sepillian). Other risk factors include having multiple abortions, exposure to sexually transmitted diseases (STD), prior tubal surgery, abdominal surgery (e.g., appendectomy), diethylstilbestrol (DES) exposure, smoking tobacco, and being between 35 and 44 years of age.

Source: Medical Disability Advisor



Diagnosis

History: Symptoms initially may include sharp, dull, or cramping lower abdominal pain. The pain may be constant or intermittent and is usually located on only one side of the abdomen. The individual may also experience vaginal bleeding, nausea, vomiting, and frequent urination. Breast tenderness and other symptoms of early pregnancy may be reported.

After the fallopian tube has ruptured, lower abdominal pain becomes sharp and may spread (radiate) to the shoulders, neck, and lower back. The individual may experience fainting as a sign of hemodynamic instability. Ectopic pregnancy usually is discovered in the first 2 months of pregnancy when the woman may not even realize that she is pregnant.

Physical exam: Physical findings suggestive of ectopic pregnancy include pelvic tenderness, an enlarged uterus (due to hormonal stimulation) but smaller than it would be if the pregnancy were normal, a mass in the area of the uterus (adnexal mass), or abdominal tenderness. Before rupture, a tender mass may be felt in the area of one fallopian tube. After rupture, pain that has spread to the neck and shoulder area becomes severe when pressure is applied to the affected area or to the cervical area. Symptoms of internal bleeding or shock may be present on initial examination, including a weak, rapid pulse (tachycardia) and low blood pressure (hypotension), suggesting that rupture has already occurred.

Tests: A pregnancy test (serum or urine beta human chorionic gonadotropin [beta-hCG] measurement) usually is done for any sexually active woman of childbearing age. Quantitative levels of beta-hCG also may be measured because lower than normal levels are associated with an abnormal pregnancy. Measuring serum progesterone also is useful in differentiating between an abnormal and normal pregnancy. Ultrasound imaging is important in diagnosing ectopic pregnancy or confirming intrauterine pregnancy because of the ability to view the intrauterine sac and fetal heart activity and possibly exclude ectopic pregnancy as a diagnosis. Transvaginal ultrasound performed in conjunction with color-flow Doppler also may be helpful, especially when the gestational sac is absent or in question.

A culdocentesis may also be performed. In this procedure, a thin needle is inserted through the vaginal wall just below the uterus. A sample is taken of any fluid found in the space, and the needle is then withdrawn. Finding free blood in the peritoneum (a positive culdocentesis) is consistent with a ruptured or leaking ectopic pregnancy. A laparoscopy may be performed subsequently to confirm the diagnosis. This minimally invasive procedure is able to assess all pelvic organs and determine the size and location of an ectopic pregnancy. In some cases, a surgical procedure that cleans out the uterus (dilatation and curettage [D&C]) is done to establish an intrauterine pregnancy when beta-hCG levels indicate pregnancy, and symptoms suggest ectopic pregnancy.

Source: Medical Disability Advisor



Treatment

If rupture of the fallopian tube has occurred because of an ectopic pregnancy, internal bleeding and/or hemorrhage may lead to shock. Nearly 20% of ectopic pregnancies present in this manner (Sepillian). Shock is treated by keeping the woman warm, elevating her legs, and administering oxygen. Blood expanders, either red blood cells or plasma, may be transfused to restore blood volume, blood flow, and blood pressure. Emergency care begins as soon as possible.

If the fallopian tube has ruptured and there is significant hemorrhage, a laparotomy usually is performed. This procedure involves a large abdominal incision and can be performed faster in an emergency. If the tube has not ruptured, and it is not an emergency, minimally invasive laparoscopy or a minilaparotomy, which is even less invasive, is the preferred surgical approach. Most ectopic pregnancies are treated with one of these surgeries primarily because they result in fewer adhesions, less blood loss, and a reduced need for anesthesia. After performing either the laparotomy, minilaparotomy, or laparoscopy, the surgeon proceeds to perform either a salpingotomy, a procedure in which an incision is made on the fallopian tube and the pregnancy is removed (thus saving the fallopian tube), or a salpingectomy, a procedure in which the fallopian tube (or tubes) is removed. The most conservative surgical approach is to perform linear salpingostomy and ease the pregnancy out from the distal ampulla of the tube. A more radical approach is to cut (resect) the fallopian tube segment that contains the pregnancy and then perform reattachment (anastomosis) of the tube. Every attempt is made to save the fallopian tubes, but if the damage to them is too great or the salpingotomy fails, a salpingectomy is performed.

Nonsurgical (medical) management is implemented by some obstetricians for very early ectopic pregnancies that do not carry an immediate threat of rupture or for those known to be located in the cervix, ovary, or interstitial part of the tube, which is more apt to rupture and cause hemorrhage. The decision to use medical treatment is based on gestational age, beta-hCG level, ectopic pregnancy size and location, presence of a fetal heartbeat, patient compliance, and overall health status. If the woman is an appropriate candidate, a cytotoxic drug that stops cell division (methotrexate) is administered by injection. Blood chemistries to evaluate kidney and liver function are done before starting methotrexate therapy. A red blood cell count and hemoglobin are done periodically while the individual is taking methotrexate to assess for signs of anemia, and liver function tests may be repeated. When methotrexate is used, the woman's beta-hCG levels are closely monitored for up to 4 to 6 weeks by her physician or healthcare provider; a 15% drop in beta-hCG at day 7 of treatment is a sign that the methotrexate therapy is effective (Puscheck). If methotrexate fails to reduce beta-hCG levels significantly, surgery is still an option.

Source: Medical Disability Advisor



Prognosis

With prompt medical or surgical treatment, a complete recovery is expected. Chances of conception may be reduced, but a normal pregnancy is still possible, even if one fallopian tube has been removed. A repeat tubal pregnancy occurs in 10% to 20% of cases (Chen).

Ectopic pregnancy represents 9% of all pregnancy-related deaths and is the most frequent cause of first-trimester deaths (Sepillian). The maternal death rate decreased from 36.5 deaths in 10,000 cases in 1970 to 2.6 in 10,000 in 1992 (Sepillian); the current death rate in women with ectopic pregnancy is 0.1% (Chen).

Source: Medical Disability Advisor



Complications

If the site of the ectopic pregnancy ruptures, shock from severe loss of blood is a serious complication and may require a blood transfusion. Surrounding tissue structures may also be damaged by the developing pregnancy. Delayed or absent treatment may result in death, but this is very rare. After the fallopian tube is repaired, another tubal pregnancy may occur later. The tube may be damaged beyond repair and have to be removed (salpingectomy). About 10% to 15% of women who have had an ectopic pregnancy will become infertile (Chen).

Source: Medical Disability Advisor



Ability to Work (Return to Work Considerations)

Work responsibilities may need to be largely sedentary at first. Heavy work, especially any work involving heavy lifting, may temporarily be restricted. Lifting and climbing may have to be limited initially after salpingectomy. Long periods of standing may need to be avoided. Work restrictions also may apply during medical management of ectopic pregnancy with methotrexate and for several weeks afterwards.

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:

  • Does individual have a history of STDs?
  • Has individual had previous surgery on her fallopian tubes?
  • Does individual have a history of PID or salpingitis isthmica nodosum?
  • Has individual experienced an infection or inflammation of the fallopian tubes?
  • Does individual have a history of ectopic pregnancy or of repeated, induced abortions?
  • Does individual use a progesterone IUD for contraception?
  • Does individual take hormone medication to stimulate ovulation?
  • Does individual have lower abdominal pain on one side only?
  • Is there vaginal bleeding? Abnormal blood pressure and hemodynamic instability?
  • Is nausea, vomiting, or frequent urination present?
  • Is a tender mass palpable in the area of one fallopian tube?
  • Has pregnancy test been done?
  • Were ultrasound and laparoscopy done to examine the pelvic cavity?
  • Were blood tests done to measure beta-hCG or progesterone levels?
  • Was a D&C or culdocentesis performed?
  • Were the gestational age and size and location of the pregnancy determined?
  • Had the fallopian tube ruptured on presentation?

Regarding treatment:

  • Was emergency surgery necessary to treat a ruptured fallopian tube and stop hemorrhage? Was laparotomy performed without complications?
  • Was shock treated? Did individual receive transfusions of blood or plasma?
  • Was early ectopic pregnancy, without immediate threat of rupture, treated with a cytotoxic drug (methotrexate)? Were kidney and liver function evaluated before giving methotrexate? Were RBC and hemoglobin measured periodically?
  • Were beta-hCG levels monitored at 7 days and for 4 to 6 weeks of medical management?
  • Was medical management successful and without complications?
  • Was surgery such as minilaparotomy or laparoscopy required?
  • Was linear salpingotomy performed? Anastomosis of a resected tube?
  • Was the surgical procedure successful and without complications?
  • Were the fallopian tubes preserved?

Regarding prognosis:

  • Is this a recurrent ectopic pregnancy?
  • Did individual obtain prompt medical and/or surgical treatment?
  • If methotrexate therapy is being used, have any side effects been noted?
  • Did individual experience a complete recovery after treatment?
  • Did individual require removal of the fallopian tube (salpingectomy)?
  • Did individual experience significant blood loss and shock? Was hemodynamic stability promptly restored? Was blood volume restored?
  • Would individual benefit from psychotherapy or counseling for grief or depression?
  • Would individual benefit from consultation with an infertility specialist?

Source: Medical Disability Advisor



References

Cited

Chen, Peter. "Ectopic Pregnancy." MedlinePlus. 27 Aug. 2009. National Library of Medicine. 23 Sep. 2009 <http://www.nlm.nih.gov/medlineplus/ency/article/000895.htm>.

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>.

Sepillian, Vicken P., and Ellen Wood. "Ectopic Pregnancy." eMedicine. Eds. Robert K. Zurawin, et al. 2 Aug. 2009. Medscape. 23 Sep. 2009 <http://emedicine.medscape.com/article/258768-overview>.

General

Katz, V. L., et al., eds. "Ectopic Pregnancy." Comprehensive Gynecology. 5th ed. Mosby Elsevier, 2007. MD Consult. Elsevier, Inc. 17 Sep. 2009 <http://mdconsult.com>.

Source: Medical Disability Advisor






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