DATE OF OPERATION: MM/DD/YYYY
PREOPERATIVE DIAGNOSIS: Incomplete spontaneous abortion with vaginal bleeding.
POSTOPERATIVE DIAGNOSIS: Incomplete spontaneous abortion with vaginal bleeding.
OPERATION PERFORMED: Dilation and curettage.
SURGEON: John Doe, MD
ASSISTANTS: None.
ANESTHESIA: General endotracheal anesthesia.
ANESTHESIOLOGIST: Jane Doe, MD
INDICATIONS FOR OPERATION: The patient is a (XX)-year-old gravida 3, para 2 at 6 weeks pregnancy who presented today with heavy vaginal bleeding and cramping. The patient was seen in the emergency room where she was found to have dilated cervix and passing clots. There was no evidence of products of conception or passage of products of conception from the vagina. Transvaginal ultrasound performed in the emergency room showed no gestational sac in the uterus and a large amount of blood and tissue within the uterus near the internal os. The ultrasound in the emergency room also showed no fluid in the cul-de-sac and both adnexa were well visualized and within normal limits. The patient was counseled at that time for expectant management and dilation and curettage to evacuate the uterus and the patient choose to have the D&C.
OPERATIVE FINDINGS: Pertinent findings at the time of procedure are products of conception at the internal os. Specimens removed were contents of uterus. Estimated blood loss 50 mL. No complications.
DESCRIPTION OF PROCEDURE: The patient was taken from the preoperative holding area to the operating room. Prior to the procedure, the patient was fully counseled as to the risks, benefits, indications, and options for the procedure, to which the patient agreed. The patient was placed supine on the operating room table. General endotracheal anesthesia was administered, and once adequate anesthesia was demonstrated, the patient’s legs were then placed in candy cane stirrups. The patient was then prepped and draped in the standard surgical fashion for D&C.
The patient was placed in 10 degrees of Trendelenburg. The patient was given 100 mg of doxycycline prior to the start of the case. The bladder was then decompressed and approximately 50 mL of urine was produced. A weighted speculum was placed in the posterior vagina and cervix was grasped with single tooth tenaculum. Uterus sounded to 8 cm. The cervix was then serially dilated with Hanks dilator. An 8 cm straight suction curette was then introduced and a suction curettage was performed. Once all products of conception were evacuated, a sharp curettage was performed until a gritty surface was appreciated on all four quadrants of the uterus. No further bleeding was noted. Products of conception were then examined on the back table, which was grossly consistent with products of conception.
The patient tolerated the procedure and anesthesia well, was awakened from anesthesia without complications and was transported to the recovery room in stable condition.
