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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.

Pregnancy, Multiple Gestation


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:
651.00 - Twin Pregnancy, Unspecified as to Episode of Care or Not Applicable
651.01 - Twin Pregnancy, Delivered, with or without Mention of Antepartum Condition
651.03 - Twin Pregnancy, Antepartum Condition or Complication
651.10 - Triplet Pregnancy, Unspecified as to Episode of Care or Not Applicable
651.11 - Triplet Pregnancy, Delivered, with or without Mention of Antepartum Condition
651.13 - Triplet Pregnancy, Antepartum Condition or Complication
651.20 - Quadruplet Pregnancy, Unspecified as to Episode of Care or Not Applicable
651.21 - Quadtriplet Pregnancy, Delivered, with or without Mention of Antepartum Condition
651.23 - Quadtriplet Pregnancy, Antepartum Condition or Complication
651.80 - Other Specified Multiple Gestation, Unspecified as to Episode of Care or Not Applicable
651.81 - Other Specified Multiple Gestation, Delivered, with or without Mention of Antepartum Condition
651.83 - Other Specified Multiple Gestation, Antepartum Condition or Complication
651.90 - Unspecified Multiple Gestation, Unspecified as to Episode of Care or Not Applicable
651.91 - Unspecified Multiple Gestation, Delivered, with or without Mention of Antepartum Condition
651.93 - Unspecified Multiple Gestation, Antepartum Condition or Complication

Related Terms

  • Multiple Pregnancy
  • Quadruplets
  • Triplets
  • Twins

Overview

Multiple gestation refers to a pregnancy in which two or more fetuses are present in the womb. Multiple pregnancy can occur when two or more eggs (ova) are released from the ovary and fertilized at the same time, or if a single fertilized egg divides at an early stage of development. Multiple pregnancies usually produce twins. Twin pregnancies produce dizygotic twins when two eggs are fertilized and monozygotic twins when a single fertilized egg splits after conception. Dizygotic twins have separate placentas; monozygotic twins each have a placenta, but the placentas fuse together in about 30% of twin gestations, and about 1% will have a common placenta with a vascular connection between the 2 fetal circulations (Fletcher).

Multiple gestations are viewed as high-risk pregnancies with a greater likelihood of maternal complications, including high blood pressure, anemia, premature rupture of membranes, higher incidence of nausea and vomiting, placenta previa, and delivery complications. It is important to diagnose a multiple pregnancy early in the pregnancy to ensure proper care of the mother and fetuses. Multiple pregnancies frequently involve premature labor and delivery. The average length of a single gestation pregnancy is 39 weeks. The average length of multiple gestation pregnancies is 37 weeks for twins, 33 weeks for triplets, and 28 weeks for quadruplets (Fletcher). The use of fertility drugs and advanced procedures (e.g., in vitro fertilization) is making multiple gestations more common.

Prior to the development of ultrasound to view the contents of the uterus in pregnancy, multiple gestations were not always diagnosed, and in some cases, a twin or fetus in a multiple pregnancy essentially disappeared early in the pregnancy. Since the advent of ultrasound and the ability to scan effectively prior to 14 weeks gestation, this "vanishing fetus" phenomenon has been studied and is reported to occur in about 13% to 78% of multiple pregnancies; the greater percentages were shown in scans taken prior to 10 weeks' gestation (Cleary-Goldman).

Incidence and Prevalence: Monozygotic twins account for 3 to 5 out of every 1,000 births, and dizygotic twins account for 4 to 50 out of every 1,000 births, showing wide variability depending on the population being studied (Gomella). The incidence of dizygotic twins varies by race, with 10 to 40 twins in 1,000 births among blacks, 7 to 10 twins in 1,000 births among whites, and about 3 in 1,000 births among Asians (Fletcher).

Triplets account for 1 out of 7,000–10,000 births, and quadruplets for 1 out of 600,000.

Source: Medical Disability Advisor



Causation and Known Risk Factors

Blacks have a greater chance of giving birth to dizygotic twins than whites or Asians, whereas the birth rate of monozygotic twins is constant among races. Dizygotic twins are also more commonly born to older mothers (Fletcher).

Source: Medical Disability Advisor



Diagnosis

History: General symptoms of pregnancy may include absence of menstrual periods (amenorrhea), nausea and vomiting, breast tenderness and tingling, increased frequency of urination, breast enlargement, abdominal enlargement, increased pressure on the pelvic bone, backache, constipation, painful hemorrhoids, or varicose veins. Symptoms of a multiple gestation are not necessarily exaggerated, but certain maternal symptoms may be present or more pronounced in multiple gestations, including high blood pressure, anemia, and nausea and vomiting. Medical history may include a family history of twins, a history of fertility drugs use, or in vitro fertilization. A history of prior illness, pregnancy, and surgery is taken to reveal any condition that could affect the pregnancy, such as hypertension, diabetes mellitus, deep vein thrombosis, prior high-risk pregnancies, prior cesarean section, or a history of pre-eclampsia, eclampsia, hypotonic uterine contractions, or miscarriage.

Physical exam: Besides the usual signs of pregnancy (breast enlargement, bluish color and softening of the cervix), physical exam may reveal more than one fetal heartbeat. In addition, the weight gain may be greater and uterine size greater than what is expected for the stage of pregnancy.

Tests: A urine or blood (serum) pregnancy test confirms the pregnancy, and ultrasound scans confirm multiple pregnancy. As recently as the late 1970s, half of all twin pregnancies were undiagnosed until labor began. Today, the diagnosis is made safely and accurately by using a combination of ultrasound examination and an alpha-fetoprotein blood test. Routine pregnancy monitoring is similar to that of a singleton pregnancy and may include the following tests: complete blood count (CBC), serum iron, quantitative beta-human chorionic gonadotropin (beta-hCG), alpha-fetoprotein, glucose tolerance, serology tests for syphilis and rubella, blood group and Rh determination, atypical antibody screening, hepatitis B surface antigen (HBsAg), and HIV. Ultrasound scanning can reveal multiple fetal parts and the presence of more than one fetus and is also performed to monitor fetal growth.

Source: Medical Disability Advisor



Treatment

As with a single gestation pregnancy, regular prenatal visits to a physician or maternity clinic are essential for a healthy, safe pregnancy, delivery, and postpartum period. Prenatal visits may be scheduled more often than for women carrying a single fetus. Frequent ultrasound monitoring allows early detection and treatment of complications.

The individual should be instructed in diet and nutrition. Vitamin and iron supplements are usually prescribed. Instruction also includes avoidance of harmful substances (tobacco, alcohol, recreational drugs), avoidance of certain prescription and over-the-counter medications, abstinence from strenuous activities (especially heavy lifting), and weight control. The individual is instructed to take frequent rest periods after the twenty-fourth week of pregnancy. If complications occur, bed rest may be advised.

An ablation procedure may be done if twin-to-twin transfusion syndrome (TTTS) is diagnosed, and surgery is performed in some cases of conjoined twins. Neonatal care varies according to the neonates' condition and presence of complications. Routine newborn care is given in most cases; exceptions that require intensive care include complications due to prematurity or low birth weight.

Source: Medical Disability Advisor



Prognosis

Premature labor occurs in about 61% of twin pregnancies, compared to 11% in singletons (Fletcher). About 90% of triplet pregnancies result in preterm labor, and the rate may be even greater (up to 97%) in quadruplet pregnancies (Cleary-Goldman, 734). Mothers may be at greater risk for pregnancy-associated morbidities such as hypertensive disorders, fetal growth restriction, and placental insufficiency and often have longer hospital stays; nevertheless, studies have not shown statistically significant differences between singleton and multiple pregnancies (Fletcher).

Multiple pregnancies have a higher rate of cesarean delivery, especially for breech presentation, congenital anomalies of a fetus, conjoined twins, or higher order multiple births (e.g., triplets, quadruplets).

Babies who are delivered early may not be fully developed, and about 59% are of low birth weight, putting them at risk for developing other medical complications (Fletcher).

Although outcomes are variable, multiple fetal pregnancies have a fetal mortality rate approximating that of singleton pregnancies; however, the rate is influenced by decreasing gestational age (Fletcher). Neonates born of multiple pregnancies have an increased risk of developing respiratory distress syndrome. With adequate prenatal care and constantly improving neonatal care, delivery can still result in healthy infants.

Source: Medical Disability Advisor



Differential Diagnosis

Source: Medical Disability Advisor



Specialists

  • Gynecologist
  • Obstetrician/Gynecologist

Source: Medical Disability Advisor



Comorbid Conditions

Source: Medical Disability Advisor



Complications

Complications of multiple pregnancy include abnormal placental implantation, spontaneous abortion (miscarriage), premature labor and delivery, low-birth-weight infants, birth defects, and increased risk of fetal death. Complications affecting the mother's health include severe nausea and vomiting (hyperemesis gravidarum), severe anemia, gestational diabetes, pregnancy-induced hypertension or pre-eclampsia (toxemia), an increase in urinary tract infections, ineffective (hypotonic) uterine contractions, a longer latent stage of labor, and vaginal and/or uterine hemorrhage.

Most complications in neonates of multiple pregnancies are secondary to premature birth, low birth weight, or intrauterine growth retardation (Fletcher). Group B streptococcal infection and hyaline membrane disease are common illnesses that affect such infants. An increased incidence of congenital anomalies occurs with multiple pregnancies compared to singletons, such as central nervous system, cardiovascular, and gastrointestinal defects. Deformation is found in twins due to intrauterine space restriction during development. Another neonatal complication, twin-to-twin transfusion syndrome (TTTS), in which blood is shunted from one monozygotic twin to the other in a common placenta, results in a 60% to 100% chance of death for the infants (Fletcher). Early ultrasound examination has shown that up to 50% of twin gestations result in delivery of a single fetus (“vanishing twin” syndrome) (Fletcher).

Source: Medical Disability Advisor



Factors Influencing Duration

Duration may be influenced by the mother's age, overall health status, preexisting medical conditions, type of delivery (vaginal or cesarean section), or the presence of complications (vaginal and/or uterine hemorrhage, infection). Bed rest is sometimes required for the duration of the pregnancy.

Source: Medical Disability Advisor



Ability to Work (Return to Work Considerations)

Obstetricians recommend that individuals with multiple gestation pregnancies rest more, especially during weeks twenty through thirty of gestation. Individuals may require a 2-hour rest period in the afternoon and 8 full hours of sleep every night. Individuals carrying triplets or more may need to reduce their physical activity and stop working by the twentieth week of gestation. In many cases, shortened work hours or earlier preterm leave may be required. As with any pregnancy, strenuous work, heavy lifting, and prolonged periods of standing should be avoided.

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:

  • Was multiple gestation confirmed? By what method (ultrasound examination and an alpha-fetoprotein blood test)?
  • How many fetuses are there?
  • How was individual's general health prior to pregnancy?
  • Is the individual anemic? Does she have high blood pressure? Pronounced nausea and vomiting?
  • Was individual recently pregnant (that is, have there been 2 pregnancies that followed each other closely)?
  • Does individual have an underlying condition, such as hypertension, diabetes mellitus, deep vein thrombosis, prior high-risk pregnancies, prior cesarean section, or a history of pre-eclampsia, eclampsia, hypotonic uterine contractions, or miscarriage, that may affect pregnancy and recovery?
  • Have there been pregnancy-related complications, such as hyperemesis gravidarum, severe anemia, gestational diabetes, or pregnancy-induced hypertension or pre-eclampsia (toxemia); an increase in urinary tract infections; ineffective uterine contractions; a longer latent stage of labor; and vaginal/uterine hemorrhage?

Regarding treatment:

  • Is individual scheduled for (and attending) frequent prenatal appointments?
  • Is individual regularly monitored (lab, blood pressure, fetal distress test) for potential problems? Are ultrasound exams monitoring fetal growth?
  • Have complications been caught early? Treated appropriately?
  • Was individual adequately instructed in nutrition guidelines and supplements?
  • Is individual able to obtain adequate nutrition? If not, has she been directed to a community resource that can assist?
  • Does individual understand the reason for and importance of avoiding harmful substances (tobacco, alcohol, certain prescription and over-the-counter medication)?
  • Is individual compliant with treatment regimen? If not, what can be done to increase compliance?
  • Is this pregnancy at risk?
  • Is multifetal pregnancy reduction being considered?

Regarding prognosis:

  • Is individual keeping scheduled prenatal appointments? If not, why not?
  • What can be done to enable attendance or improve compliance?
  • Have complications been caught early and treated appropriately?
  • Did individual have vaginal delivery or cesarean section?
  • Have complications of delivery compromised the mother’s health in any way?
  • Is a full and timely recovery anticipated?

Source: Medical Disability Advisor



References

Cited

Cleary-Goldman, Jane, Usha Chitkara, and Richard L. Berkowitz. "Multiple Gestations." Obstetrics - Normal and Problem Pregnancies. Eds. Steven G. Gabbe, et al. 5th ed. New York: Churchill Livingstone, Inc., 2007. 733-763.

Fletcher, Garth, et al. "Multiple Births." eMedicine. Eds. David N. Sheftel, et al. 8 Jul. 2009. Medscape. 21 Sep. 2009 <http://emedicine.medscape.com/article/977234-overview>.

Gomella, Tricia L., et al. "Multiple Gestations." Neonatology: Management, Procedures, On-Call Problems, Diseases, and Drugs. Eds. Janet Foltin, et al. 5th ed. McGraw-Hill, 2004. 476.

Source: Medical Disability Advisor