Sick leave after a stroke: how many days are they kept on sick leave, what can be the extension periods, who and where issues a certificate of incapacity for work? YurExpert Online

The reasons for issuing a sick leave can be very different: ARVI, pregnancy, surgery, etc. In each case, the sheet is provided for different periods.

Why are deadlines so important for employers?

The Labor Code has a provision according to which the employer does not have the right to dismiss an employee while he is on sick leave.

However, forced rest can last indefinitely. If the employer formalizes dismissal, the employee can easily challenge this decision.

Grounds for extradition

Stroke in medical terminology refers to a group of clinical syndromes that develop as a result of a decrease or cessation of blood supply to the brain.

How many days do they stay on paid b/l?

The approximate deadlines for issuing a certificate of incapacity for various types of stroke are enshrined in the Recommendations of the Ministry of Health of Russia No. 2510/9362-34 dated August 20, 2000 and are:

Type of stroke	Name according to ICD-10	Number of sick days depending on the severity of treatment
Hemorrhagic	Subarachnoid hemorrhage	60-70 (moderate); 80-100 (severe).
	Intracerebral hemorrhage	85-100 (moderate); 90-100 (severe).
	Subdural hemorrhage	40-50 (mild); 60-70 (moderate); 80-100 (severe).
Ischemic	Brain infarction	60-75 (mild); 75-90 (moderate); 90-105 (severe).

The indicated periods of sick leave are approximate : the attending physician in each specific case takes an individual approach to determining the duration of the patient’s incapacity for work, guided by the time restrictions of Part 4 of Art. 59 of the Federal Law “On the Fundamentals of Protecting the Health of Citizens in the Russian Federation” (hereinafter referred to as the Federal Law of November 21, 2011 No. 323-FZ), according to which, in the event of an obvious unfavorable prognosis of the disease, no later than 4 months from the date of opening the bulletin, the patient is sent for passing the ITU, and if he refuses the prescribed assessment of disability, the certificate of incapacity for work must be closed.

Results and discussion

All women included in the study were aged between 17 and 41 years. The average age was 30.53±6.14 years. There were no significant differences in age between the study groups. The general characteristics of the examined women are presented in Table. 1.

Table 1. General characteristics of patients in the examined groups

In the 1st group there were 3 primigravidas, 11 patients were expected to give birth again. The obstetric history in more than 7% of cases was complicated by: recurrent miscarriage (3), premature abruption of a normally located placenta (1), perinatal losses (1). In the 2nd group there were 15 (41.7%) primiparas and 21 (58.3%) multiparas. The obstetric history was complicated only in 2 (5.5%) pregnant women (recurrent miscarriage, premature abruption of a normally located placenta).

According to a retrospective analysis, in 2 multiparous women of the 1st group, previous births were completed by cesarean section for obstetric indications - placental abruption and severe preeclampsia. In the 2nd group of subjects, the main indication for abdominal delivery during a previous pregnancy was the presence of a previous stroke - in 5 (13.9%) cases, of which in one case IS occurred during pregnancy, in the remaining 4 - the duration was from 5 months to 3 years, which may have been the reason for choosing cesarean section as a method of delivery. However, currently the approach to this problem has changed somewhat. Another patient of group 2 was operated on as an emergency for premature abruption of a normally located placenta.

When assessing the somatic status of patients in the study groups, it was found that the majority of them had concomitant extragenital diseases. Arterial hypertension was most often observed - in 16 (32%) pregnant women. According to our data, 3 pregnant women of the 1st group and 5 pregnant women of the 2nd group had a burdened family history - strokes in close relatives and other thromboembolic complications. In table Table 2 presents risk factors for the development of IS in the groups of patients studied.

Table 2. Risk factors for the development of IS in patients of the examined groups

Established risk factors for the development of IS in group 1 were: arterial hypertension (in 6), malformations of the heart valve apparatus (in 3), lipid metabolism disorders (in 3), combined thrombophilia (in 6), abnormalities in the structure of cerebral vessels ( in 2), migraine (in 2), diabetes mellitus (in 1). Pregnancy occurred with symptoms of vomiting during pregnancy in 7; threatened miscarriage - in 7 pregnant women, fetoplacental insufficiency (FPI) - in 3; preeclampsia - in 4 pregnant women. IS developed in the first trimester in 2 pregnant women, in the second trimester in 3, in the third trimester and early postpartum period in 9, i.e., in 2/3 of the patients.

Additional instrumental examination methods revealed lesions of the carotid area involving the middle cerebral artery (MCA) in 77% of patients, and vessels of the vertebrobasilar area of the brain in 33%. Residual neurological deficit was noted in 7 cases (Table 3): mild hemiparesis (in 3); cognitive impairment (1 case), pyramidal insufficiency (1 case), encephalopathy (2 cases). The remaining 7 pregnant women showed complete regression of neurological symptoms after treatment.

Table 3. Residual neurological symptoms in patients of the examined groups

In group 2, risk factors for the development of IS were: arterial hypertension (in 10), malformations of the heart valve apparatus (in 6), lipid metabolism disorders (in 5), combined thrombophilia (in 9), Ehlers-Danlos syndrome (1) , smoking (1) (see Table 2). Residual effects of a history of stroke were observed in 28 (77.8%) women: hemiparesis (in 9), hyposthesia (in 2), pyramidal insufficiency (in 3), hemianopsia (in 2), optic nerve atrophy (in 3), post-ischemic encephalopathy (in 7), brain cyst (in 2) (see Table 3).

Gestational complications in patients of the 2nd group were vomiting of pregnancy (in 8), threatened miscarriage (in 16), FPN (in 12), moderate preeclampsia (in 9), anemia (in 7), gestational diabetes mellitus (in 2) .

Thrombophilias were detected in the majority of cases in the second trimester of pregnancy - about 86.7%, which was associated with the late presentation of patients to the outpatient department of the State Budgetary Institution of Healthcare of the Moscow Region Moniiag and the examination. The majority of patients with a history of acute stroke were not examined at all for congenital thrombophilias before their first visit to MONIIAG, despite a burdened somatic history. It should be noted that combined forms of thrombophilia were detected more often - 70% of observations in group 1 and 78% in group 2. In the 1st group, thrombophilia was detected in 6 patients (in the 1st and 2nd groups, different forms of thrombophilia were observed in the same patient), in the 2nd group - in 9 (Table 4). Analyzing the results obtained in group 1 with IS, during pregnancy, homozygous carriage of the PAI-1 gene was observed in 2 patients, heterozygous carriage of the PAI-1 gene - also in 2 patients, homozygous mutations of the MTHFR gene - in 1 pregnant woman, heterozygous mutations of the MTHFR gene - in 2, heterozygous ACE mutations in 1 patient. In the 2nd group of examined pregnant women with a history of IS, heterozygous carriage of factor V Leiden was noted in 2 pregnant women, homozygous carriage of the PAI-1 gene in 4, heterozygous carriage of this gene in 4, heterozygous mutations of the MTHFR gene in 6 patients, protein deficiency S - in 2, FII G20210A - in 1 pregnant woman. In order to prevent thromboembolic complications, 43 patients of groups 1 and 2 received anticoagulant therapy. The main thromboelastogram parameters in pregnant study groups before therapy and at the peak concentration of the drug in the prophylactic dose did not differ and corresponded to the reference normal ranges. Dynamic indicators of the TD test - initial (Vi) and stationary (Vst) velocities, as well as clot size (CS) at the 30th minute of the study recorded pronounced hypercoagulation, the data are presented in table. 5 and 6. In some patients, more often in group 1 (56.7%), according to TD data, there were foci of pathological spontaneous thrombus formation. In the presence of a peak concentration of the drug in a prophylactic dose, a significant decrease in the initial and steady-state rates of clot growth was recorded in the 1st group; in the 2nd group, a decrease in the steady-state rate of the clot was noted. Evaluation of the effectiveness of anticoagulant treatment was based on determining the anti-Xa factor of the blood coagulation system.

Table 4. Structure of thrombophilia in patients of the examined groups Note. homo- - homozygous carriage; hetero- - heterozygous carriage.

Table 5. Parameters of global tests and anti-Xa factor in the 1st group of examined patients

Table 6. Parameters of global tests and anti-Xa factor in the 2nd group of examined patients

According to the results of the examination conducted in 40 patients of the study groups, in the 1st group hypercoagulation during heparin therapy was detected in 11 observations, in the 2nd group - in 7 observations. The therapy required adjustment with an increase in the dose of the anticoagulant during pregnancy. In 78.9% of cases, UFH was used in a prophylactic dose depending on body weight, in the rest (21.1%) - LMWH.

The duration of use of the drug was specified depending on the clinical picture and concomitant extragenital diseases under the control of the blood coagulation system. In order to prevent the undesirable effect of anticoagulant therapy, the drug was discontinued 24 hours before the expected birth, and its use was resumed after 4-6 hours of the postpartum period.

In 49 (98%) cases, pregnancy was prolonged to full term during treatment; in one case, premature birth occurred at 34 weeks of gestation.

All pregnant women were given birth in the conditions of MONIIAH, the data are presented in table. 7. There were no differences in the approach to the method of delivery in groups 1 and 2: cesarean section was performed in 17 (34%) pregnant women, the main indications for surgical delivery were thinning of the uterine scar after cesarean section (8), clinically narrow pelvis (1); breech presentation of the fetus (1); multiple pregnancy (1), increasing severity of preeclampsia (3), including one premature birth; progressive fetoplacental insufficiency (1), concomitant extragenital pathology (1). In only one case, the indication for abdominal delivery was the conclusion of a neurosurgeon due to an unspecified diagnosis and suspicion of the presence of arteriovenous malformation of the brain. Birth through the birth canal occurred in 33 (66%) pregnant women: spontaneous - in 26; in 6, vacuum extraction of the fetus was used to limit pushing; in one, obstetric forceps were used to stop pushing (patient of group 1 with AI in III trimester). After examination and consultation with specialists, 11 pregnant women underwent programmed labor; spontaneous development of regular labor was noted in 22 patients, of which 5 had prenatal rupture of amniotic fluid. The duration of labor ranged from 3 hours 20 minutes to 10 hours 30 minutes (average 7 hours 30 minutes). The duration of the anhydrous interval is 7 hours 30 minutes ± 56.3 minutes. Pathological blood loss was not noted in any observation.

Table 7. Delivery of pregnant women in the surveyed groups

When assessing the condition of newborns, it was found that 40 (80%) children were born in satisfactory condition with an Apgar score of 8-9 points, 10 children were born with mild asphyxia, 1 child was born with moderate asphyxia. In 8 children who were born with an Apgar score of 7 and 8 points, the condition on the 3rd day was assessed as satisfactory. Three children after cesarean section (2 children from twins and 1 child after premature surgical birth at 34 weeks of gestation) were transferred to the 2nd stage of nursing (Table 8).

Table 8. Perinatal outcomes in patients of the examined groups

During spontaneous labor, 80% of women in labor used long-term epidural analgesia in combination with drug pain relief. During caesarean section, the method of anesthesia was selected individually (in 10 cases - regional anesthesia, in 4 - general anesthesia with endotracheal anesthesia). There was no deterioration in the neurological status of all patients under our supervision before childbirth and in the early postpartum period.

Follow-up observation was carried out for 5 years for all women who gave birth in the obstetric clinic of the State Budgetary Healthcare Institution MO MONIIAG. In only one observation, 2 months after surgical delivery (caesarean section), an IS occurred against the background of discontinuation of anticoagulant therapy. Therefore, it is important to note that the assessment of thrombotic risk factors and postpartum management of patients with IS is the prerogative of neurologists.

According to E. Kuklina et al. [4], in the USA from 1994 to 2007 there was an increase in the frequency of strokes in pregnant women from 4085 to 6293, i.e. by 47% (from 0.15 to 0.22 per 1000 births), and within 12 weeks after births, this indicator increased by 83% (from 0.12 to 0.22 per 1000 births). If for every 100 thousand non-pregnant women of childbearing age in the United States there are 11 cases of stroke, then for every 100 thousand births there are 34 cases; in developing countries, there are 208 cases of stroke per 100 thousand pregnant women. This confirms that pregnancy increases the risk of developing stroke. L. Carbillon in his work [7] accurately calls pregnancy “a spontaneous screening test for the risk of early stroke.”

In most cases, IS develops in the third trimester of pregnancy and in the postpartum period [2, 8]. Studies have shown that 60-80% of cerebral infarctions in pregnant women are caused by acute thrombosis of cerebral vessels in the second and third trimesters of pregnancy. In this case, arterial occlusions develop more often, and during the 1st month of the postpartum period - venous ones. In the postpartum period, endocrine, electrolyte and other changes occur in the woman’s homeostasis system. Significant changes are observed in the coagulant and anticoagulant blood systems. It should be noted that the risk of stroke remains elevated for quite a long period of time after childbirth. In a study conducted by C. Tang et al. [9] in Taiwan, analyzed 139 hemorrhagic and 107 ischemic strokes associated with pregnancy, and found that the risk of these complications in patients with preeclampsia was 10.7 and 40.9%, respectively, during the third trimester of pregnancy, 6.5 and 34.7% within 3 days postpartum, 5.6 and 11.2% from 3 days to 6 weeks postpartum, 11.8 and 11.6% from 6 weeks to 6 months postpartum and 19 .9 and 4.3% from 6 to 12 months after birth [9]. The results obtained from our observations correspond to the data of the world literature - in 64.3% of patients in group 1, IS occurred in the third trimester and early postpartum period.

C. Davie, R. Brien [2], J. Tate, C. Bushnell [10], C. Tang et al. [9] consider arterial hypertension (both pre-pregnancy and gestational) as a significant risk factor for the development of IS in pregnant women. It has been shown that women with pregnancy complicated by hypertension have a 6-9 times higher risk of stroke compared to patients whose blood pressure is within normal limits. According to our data, significantly higher hypertension ( p

<0.05) was observed in patients of group 1 - 42.9% compared to that in patients of group 2 - 27.8%. Antihypertensive therapy should be carried out under careful monitoring of blood pressure levels, it is important to avoid its sharp decrease.

Recently, there has been an increase in the risk of stroke in multiparous women with cesarean section compared with spontaneous birth; in addition, the risk of stroke increases significantly with the age of a pregnant woman (from 30 cases per 100 thousand for people under 20 years of age to 90.5 per 100 thousand for people over 40 years of age). Caesarean section, according to A. James et al. [11], is associated with an increase in the risk of stroke by 3–12 times, which cannot be ignored in connection with the progressive trend towards expanding indications for abdominal delivery.

Testing for thrombophilia is necessary in patients from the younger age group with IS, which may affect the tactics of further management and the development of methods for the prevention of recurrent arterial and venous thrombotic complications. In addition, there are suggestions that thrombophilia may influence the severity of ischemic lesions, leading to more extensive thrombosis in the acute phase, and causing an increased risk of relapses [12, 13].

In modern hematology, thrombophilia is officially considered to be a deficiency of antithrombin III, protein S and protein C, as well as gene polymorphism (homo- and heterozygous forms) of factor V Leiden and FII G20210A [14]. However, according to our data, a large percentage of the prevalence of MTHFR

,
PAI-1
in the examined patients, which suggests the possible influence of these conditions on the development of IS and requires further study.

According to a number of authors [3, 15], the probability of stroke recurrence during repeated pregnancy is very low - only about 1%. S. Lamy [16], when examining 187 pregnancies in 125 patients who had undergone IS, recorded 13 relapses of IS, of which only 2 were associated with pregnancy. Due to the low frequency of recurrent stroke cases, the author concludes that stroke is not a contraindication for future pregnancy. The risk of stroke recurrence was respectively 0.5% in patients who had no subsequent pregnancies and 1.8% in women who carried a pregnancy to term. This study also reported the absence of recurrent strokes in 5 patients with thrombophilia during subsequent pregnancies during which the pregnant women received anticoagulant therapy.

The question of pregnancy management in women with a history of stroke and the possibilities of preventing recurrent thrombotic complications still remains open. A unified protocol, according to world literature, has not been developed. According to some authors, in patients who have undergone IS, the use of low doses of aspirin during pregnancy and the postpartum period is recommended [15].

UFH and LMWH do not cross the placenta, do not produce teratogenic effects, and are not associated with the risk of hemorrhagic complications in fetuses. Complications that may occur in pregnant women while receiving antithrombotic therapy are similar to those reported in the general population and include bleeding (a risk associated with the use of any antithrombotic drugs), as well as heparin-induced thrombocytopenia, osteoporosis and local reactions at the injection sites for UFH and LMWH. The incidence of severe bleeding when using UFH during pregnancy is about 2% [17]. According to our data, the use of anticoagulants in prophylactic doses did not lead to bleeding or any thrombotic complications during childbirth and the early postpartum period.

What affects the duration?

How long the period of disability after a stroke will last depends on many factors:

type of stroke;
severity of stroke;
speed of restoration of impaired functions;
general state of human health (primarily the cardiovascular system);
the patient's response to treatment;
the presence or absence of recurrent hemorrhage (in the case of hemorrhagic stroke) while on sick leave;
the presence or absence of repeated incoming cerebrovascular accidents;
the nature of the patient’s work activity.

It should be noted that in most cases, the patient’s condition after a stroke (except for all types of mild stroke and moderate subdural hemorrhage) indicates an unfavorable prognosis in terms of performance and the doctor, guided by Part 4 of Art. 59 of the Federal Law of November 21, 2011 No. 323-FZ, has the right to immediately refer the patient to receive disability.

How long can you stay on sick leave in 2019?

It is clear that then the health of the insured employee comes first, especially since he has every right to sick leave. Sick leave can be issued for temporary disability, but many are interested in the question: how long is it legal to remain on sick leave continuously in 2021? Legislation changes almost every year and is supplemented by a host of important rules and regulations; only an experienced lawyer can keep up with the process.

Back in 2012, a term was established that a regular therapist can indicate on sick leave - 15 days. After 15 days, the patient is obliged to come to the doctor for an appointment at the clinic and confirm the closure of the sheet (if the patient has recovered) or extend the sick leave for another 15 days, i.e. up to 1 month. If after a month the patient is still in unsatisfactory physical condition, a medical commission meets to decide what to do next. If before this the therapist whom the patient visited was seen in a private hospital, he is sent to a state institution for a commission.

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Grounds for extension and possible deadlines

The basis for extending sick leave is the patient’s slow recovery of lost functions and insufficient response to treatment. The specifics of the work of an employee on sick leave are of no small importance.

Attention! The advisability of extending the certificate of incapacity for work within the 4 months established by law is decided by a medical commission, taking into account the specified circumstances.

For patients with ongoing restoration of functions and stable positive dynamics, the decision is predominantly made to continue treatment simultaneously with being on sick leave; otherwise, the most likely decision is to refer them to medical examination to establish the disability group.

Where and who issues a bill of lading?

All types of stroke are the result of severe brain damage , so the person who has suffered it undergoes treatment in a hospital setting, where he receives a certificate of incapacity for work.

Of course, opening a sick leave at a clinic is also possible, but in practice this is not so common.

In accordance with Order of the Ministry of Health and Social Development of Russia dated June 29, 2011 No. 624n, licensed medical institutions have the right to issue certificates of incapacity for work . In addition to general information about the patient, the sick leave must include a two-digit code – “01”, indicating the disease as a general cause of disability.

The procedure for paying for time spent on sick leave is regulated by Federal Law No. 255-FZ of December 29, 2006. Three days of incapacity for work are paid by the employer, and all subsequent days by the Social Insurance Fund.

The amount that an employee will receive directly depends on his total insurance period - the period of employment during which the employer transferred insurance contributions to extra-budgetary funds for him. The longer the total insurance period, the larger the payments.

Note! An employee with less than 1 year of experience will receive the least - 30% of average earnings. An employee for whom contributions to insurance funds have been received for 8 or more years has the right to receive a payment in the amount of 100% of the average salary.

Duration of sick leave after a stroke

The document in question guarantees not only the preservation of a job, but the receipt of cash payments. Therefore, the paper should be handed over to the employer, who in turn sends it to the accounting department to assign benefits.

A sick leave certificate is an important official document that confirms that a person was legally absent from work due to a short-term disability. Only those medical institutions that have passed state accreditation have the right to issue it.