DATE OF PROCEDURE: MM/DD/YYYY
PREOPERATIVE DIAGNOSIS:
Missed abortion at 9 weeks.
POSTOPERATIVE DIAGNOSIS:
Missed abortion at 9 weeks.
PROCEDURE PERFORMED:
Suction dilation and evacuation.
SURGEON: John Doe, MD
ASSISTANT: Jane Doe, MD
ANESTHESIA: General endotracheal anesthesia.
ANESTHESIOLOGIST: John Doe Jr., MD
IV FLUIDS: A liter of lactated Ringers.
URINE OUTPUT: 150 mL.
ESTIMATED BLOOD LOSS: Less than 50 mL.
COMPLICATIONS: None.
DISPOSITION: To the recovery room.
PROCEDURE FINDINGS: A 10-week size anteverted uterus, no adnexal masses, and os slightly dilated.
INDICATION FOR PROCEDURE: The patient was taken to the operating room through the emergency department. The patient presented to the emergency department at 9 weeks pregnant with bleeding. Ultrasound was performed, and no fetal heart tones were noted. The patient is O positive with a hemoglobin of 12.9. The patient was informed of the findings and the procedure to be performed, dilation and evacuation, was explained in detail. The patient subsequently signed the consent. Time-out was performed.
DESCRIPTION OF PROCEDURE: The patient was placed in the dorsal supine fashion in the operating room with legs elevated in Allen stirrups. The patient underwent general anesthesia without difficulty. The patient was prepped and draped in the normal sterile fashion. Exam under anesthesia revealed the above findings. Then, os was gently dilated with graduated metal dilators. Then, a curette was used to do the suction dilation and evacuation.
Following the suction dilation and evacuation, sharp curettage was performed until all 4 walls of the fundus had a gritty texture. All specimens were sent to pathology. All instruments were removed from the vagina and the uterus.
The anterior lip of the cervix had a small amount of bleeding, which was made hemostatic with Monsel’s. The patient tolerated the procedure well without any immediate complications observed. Specimens were sent to pathology. All instruments and sponge counts were correct x2. The patient was then taken to the recovery room in stable condition.
