DATE OF OPERATION: MM/DD/YYYY
PREOPERATIVE DIAGNOSES:
1. Intrauterine embryonic demise.
2. Missed abortion.
POSTOPERATIVE DIAGNOSES:
1. Intrauterine embryonic demise.
2. Missed abortion.
OPERATION PERFORMED: Suction and dilatation and curettage.
SURGEON: John Doe, MD
ASSISTANT: None.
ANESTHESIA: General LMA.
ANESTHESIOLOGIST: Jane Doe, MD
INDICATIONS FOR OPERATION: This is a (XX)-year-old G3, P3 with a known intrauterine demise, who by last menstrual period is 13 weeks and 5 days’ gestational age by ultrasound. Crown-rump length is 10 weeks with no cardiac activity and the diagnosis of intrauterine fetal demise. The patient was counseled and consented and given the option for conservative management, but she has opted for surgical management with the D&C. Risks, benefits, indications, and alternatives to the procedure were reviewed with the patient, and informed consent was obtained.
DESCRIPTION OF OPERATION: The patient was taken to the operating room with an IV running. She underwent general anesthesia with LMA without complication and was placed in a supine position. In the low lithotomy position, the patient was prepped and draped in the usual sterile fashion. In-and-out catheterization of the bladder produced 150 mL of urine.
The cervix was exposed using a bivalve speculum. Single-toothed tenaculum was placed on the anterior lip of the cervix. The cervix was dilated with Hanks dilator and then #10 curved suction curette was advanced to the fundus of the uterus, and the machine was activated and commenced with the suction D&C.
Two passes were performed, and then after that, we proceeded with the sharp curette obtaining a gritty texture in all quadrants. Once again, suction curetted. Uterus was hemostatic. With this, we terminated the procedure. All the instruments were removed from the patient.
The procedure was well tolerated. Estimated blood loss was minimal, and the patient was taken down from the lithotomy position, awakened from anesthesia, and taken to the recovery room in stable condition. Sponge and laps were correct x2, and there were no complications.
