DATE OF PROCEDURE: MM/DD/YYYY
PREOPERATIVE DIAGNOSIS: Routine products of conception.
POSTOPERATIVE DIAGNOSES:
1. Routine products of conception.
2. Presumed placenta accreta.
PROCEDURES PERFORMED:
1. Postpartum curettage.
2. Uterine packing.
SURGEON: John Doe, MD
SEDATION: Mask, general, converted to a general endotracheal tube.
PROCEDURE FINDINGS: A 14-week size uterus with heavy vaginal bleeding. Cervix open, 2 cm, small amounts of adhered placental fragments and ruddy, rough texture in the body of the uterus consistent with placenta accreta.
SPECIMENS: Endometrial curetting.
ESTIMATED BLOOD LOSS: 1000 mL.
COMPLICATIONS: Presumed placenta accreta.
FLUIDS: Two liters of crystalloids, one unit of Hespan and two units of packed red cells.
INDICATIONS AND DESCRIPTION OF PROCEDURE: The patient is a (XX)-year-old G3, P3-0-0-3 female status post vaginal delivery, who has had postpartum bleeding since the delivery. The patient was seen in the emergency room approximately 2 days prior to admission this time, with heavy vaginal bleeding. Her hemoglobin at that time was approximately 11.8.
She was seen by the ER physician without a great deal of bleeding and the ultrasound did not show significant amount of placental tissue left in the uterus and so the decision was made to discharge her home on Methergine. She was given Methergine and antibiotics and had continued vaginal bleeding. She called today with passage of large amounts of clots and was sent back to the emergency room. In the emergency room, she was seen and had an open cervical os with a great deal of bleeding. She was, therefore, consented for D and C for removal of placental fragments as the presumed cause of her postpartum bleeding.
She was consented for D and C and brought to the operating room. General anesthesia was initiated with mask general. She was prepped and draped sterilely. Straight catheterization of the bladder was obtained. A weighted speculum was placed in the vagina and a great deal of bleeding was noted, heavy brisk vaginal bleeding. The anterior lip of the cervix was grasped with ring forceps and the cervix was opened 2 cm wide.
A banjo curette was used to curette via the uterus and a small amount of placental fragments were obtained. There was still active bleeding and clots expelled from the uterus. Because of this, a suction curettage with a 12 mm curette was used to evacuate the uterus, but the bleeding persisted. This was attempted once as the curettage was re-performed using the banjo curette to attempt to remove the products of conception. Intravenous Pitocin and intramuscular Methergine were used to cause uterine contractions. The uterus appeared firm at approximately 12-14 week size; however, the bleeding continued briskly.
After feeling digitally into the uterus because of the continued bleeding, a fine ruddy texture was noted throughout the body of the uterus and the majority of the area, except for the anterior surface of the uterus, which felt rough, but the roughness was at the same level as the uterus and not protruding out signifying a possible placenta accreta. Given that the patient is (XX) years of age and the active bleeding, she was given volume expanders, crossed for 4 units of blood and uterine packing was performed as a stop-gap measure prior to possible need for hysterectomy, uterine artery ligation or hypogastric artery ligation to prevent any further hemorrhage and bleeding.
While we were waiting for the blood products to be obtained to the operating room for transfusion prior to laparotomy, it was noted that her bleeding from the uterus with the packing had almost completely stopped. The decision was made to leave the pack in place, pack the vagina, leave a Foley in place and observe for bleeding. She was observed in the operating room for approximately another 30 minutes with no further bleeding noted to the pack.
Her vital signs remained stable after volume expanders and decision was made to transfer the patient to the recovery room for further observation in case of possible need for laparotomy. The decision by the anesthesiologist was to leave the patient intubated so as to prevent the need for further intubation if need be. Sponge, lap, needle and instrument counts were correct x2. Following the procedure, the patient was taken intubated to the recovery room.
