DATE OF OPERATION: MM/DD/YYYY
PREOPERATIVE DIAGNOSIS: Incomplete abortion at 8 weeks.
POSTOPERATIVE DIAGNOSIS: Incomplete abortion at 8 weeks with likely gestation further than 8 weeks.
OPERATION PERFORMED: Sharp and suction dilation and curettage.
SURGEON: John Doe, MD
ASSISTANT: None.
ANESTHESIA: LMA anesthesia.
ANESTHESIOLOGIST: Jane Doe, CRNA
COMPLICATIONS: None.
ESTIMATED BLOOD LOSS: Approximately 300 mL in the vaginal vault, minimal during the procedure.
IV FLUIDS: Approximately 1200 mL of crystalloid.
URINE OUTPUT: Minimal.
OPERATIVE FINDINGS: Products of conception, open cervical os with approximately 300 mL of blood clots in the vaginal vault at the time of surgery. Cervical os was closed at the time of end of procedure with adequate hemostasis.
DESCRIPTION OF OPERATION: The patient was taken to the operating room where she was placed in the dorsal supine position and placed under LMA anesthesia. Legs were placed in candy-cane stirrups. The patient was then prepped and draped in the usual sterile fashion. Bladder was emptied with a red rubber catheter.
A weighted speculum was placed in the posterior aspect of the vagina. Deaver was placed in the anterior aspect of the vagina, and all the remaining blood clots were evacuated using the suction curette. The cervix was then grasped with a single-tooth tenaculum, and then using a #10 curved suction curette, the products of conception were then removed with several passes. Sharp curetting was then performed in all four quadrants of the uterus until a gritty texture was felt and then suction curette was then readvanced. The patient did have some bleeding, so the uterus was then massaged and 0.2 mg of Methergine was given IM.
Once the uterus had contracted down and adequate hemostasis was noted, all instruments were removed from the vagina, and adequate hemostasis was noted. The patient was then awakened and taken to the recovery room in stable condition.
Sample #2
DATE OF OPERATION: MM/DD/YYYY
PREOPERATIVE DIAGNOSIS: Missed abortion at approximately 8 to 10 weeks.
POSTOPERATIVE DIAGNOSIS: Missed abortion at approximately 8 to 10 weeks.
OPERATION PERFORMED: Suction dilation and curettage.
SURGEON: John Doe, MD
ANESTHESIA: General LMA.
COMPLICATIONS: None.
ESTIMATED BLOOD LOSS: Minimal.
DISPOSITION: The patient was taken to recovery in stable condition.
DESCRIPTION OF OPERATION: The patient was taken to the OR and satisfactory general anesthesia obtained, draped and prepped in the usual sterile fashion, placed in the dorsal lithotomy position. Bladder was drained of approximately 50 mL of clear amber urine via straight catheter. At this time, a bivalve speculum was placed in the vaginal vault and the cervix visualized. The cervix was grasped across the anterior lip with a single-tooth tenaculum and gently and gradually dilated to 10 mm. A #9 mm suction curette was introduced in the patient’s uterine cavity and a thorough suction and curettage accomplished. After a thorough curettage was completed, bleeding was minimal. The uterus contracted down well and the procedure was terminated. Instruments were removed from the patient’s vaginal vault. The patient tolerated the procedure well and was taken to the recovery room in stable condition. Sponge and needle counts were correct x3.
