DATE OF PROCEDURE: MM/DD/YYYY
PREOPERATIVE DIAGNOSIS: Eight-week missed abortion.
POSTOPERATIVE DIAGNOSIS: Eight-week missed abortion.
PROCEDURE PERFORMED: Suction dilation and curettage.
SURGEON: John Doe, MD
SEDATION: General with endotracheal tube.
COMPLICATIONS: None.
ESTIMATED BLOOD LOSS: Minimal.
FINDINGS: Small amount of products of conception.
DESCRIPTION OF PROCEDURE: The patient was taken to the operating room where general anesthesia was performed without difficulty. She was prepped and draped in normal sterile fashion in dorsal lithotomy position. Bivalve speculum was placed in the patient’s vagina. The anterior lip of the cervix was grasped with uterine forceps. Uterus was dilated to 7 Hegar dilator, sounded to 10 cm, and then #7 curved suction curette was placed gently into the fundus. The suction machine was turned on and two passes of the suction curette were used to clear the uterus. Sharp curettage was used to confirm that the uterus was empty, and the edges were gritty in all four quadrants. The suction curette was placed one more time to suction any products that were scraped off with the sharp curette. Once this was accomplished, the procedure was terminated. All instruments were removed from the patient’s vagina. The patient was allowed to wake up and went to the recovery room awake, alert, and oriented x4, in stable condition. There was minimal blood loss.
Sample #2
DATE OF PROCEDURE: MM/DD/YYYY
PREOPERATIVE DIAGNOSES:
1. Approximately 8 weeks’ blighted ovum.
2. Incomplete abortion.
POSTOPERATIVE DIAGNOSES:
1. Approximately 8 weeks’ blighted ovum.
2. Incomplete abortion.
PROCEDURE PERFORMED: Suction dilation and curettage.
SURGEON: John Doe, MD
ANESTHESIA: General.
ESTIMATED BLOOD LOSS: 600 mL preoperatively, 200 mL intraoperatively.
COMPLICATIONS: None.
SPECIMENS: POCs to pathology for evaluation.
DESCRIPTION OF PROCEDURE: The patient was taken to the operating room where she was prepped and draped in the normal sterile fashion in the dorsal lithotomy position. A weighted speculum was placed vaginally. A Foley catheter was removed.
A single-tooth tenaculum was placed on the cervix. Cervix was noted to be approximately a little over 1 cm dilated. The uterus, on bimanual examination, felt to be about 8 weeks; this was unable to be determined preoperatively secondary to patient’s pain and discomfort with the exam and patient’s habitus. A #10 suction curette was then passed for removal of POCs. Once POCs were removed, a sharp curettage was gently performed circumferentially, and the uterine cry was palpated. One more time a suction curettage was then performed and again no POCs were discernible. The uterus was palpated at approximately six weeks at this point; however, there was still some bleeding from the cervix. Methergine 0.2 was given as well as 800 mcg of Cytotec. The bleeding was then noted to be very scant and the procedure was finished.
Sponge, lap, needle, and instrument counts were correct x2. The patient was taken to PACU awake, extubated, and in good condition.
