Obstetrics / Gynecology
Sample Name: Intrauterine Clots Removal
Description: Exam under anesthesia. Removal of intrauterine clots. Postpartum hemorrhage
(Medical Transcription Sample Report)
PREOPERATIVE DIAGNOSIS: Postpartum hemorrhage.
POSTOPERATIVE DIAGNOSIS: Postpartum hemorrhage.
PROCEDURE: Exam under anesthesia. Removal of intrauterine clots.
ANESTHESIA: Conscious sedation.
ESTIMATED BLOOD LOSS: Approximately 200 mL during the procedure, but at least 500 mL prior to that and probably more like 1500 mL prior to that.
INDICATIONS AND CONCERNS: This is a 19-year-old G1, P1 female, status post vaginal delivery, who was being evaluated by the nurse on labor and delivery approximately four hours after her delivery. I was called for persistent bleeding and passing large clots. I examined the patient and found her to have at least 500 mL of clots in her uterus. She was unable to tolerate exam any further than that because of concerns of the amount of bleeding that she had already had and inability to adequately evaluate her. I did advise her that I would recommend they came under anesthesia and dilation and curettage. Risks and benefits of this procedure were discussed with Misty, all of her questions were adequately answered and informed consent was obtained.
PROCEDURE: The patient was taken to the operating room where satisfactory conscious sedation was performed. She was placed in the dorsal lithotomy position, prepped and draped in the usual fashion. Bimanual exam revealed moderate amount of clot in the uterus. I was able to remove most of the clots with my hands and an attempt at short curettage was performed, but because of contraction of the uterus this was unable to be adequately performed. I was able to thoroughly examine the uterine cavity with my hand and no remaining clots or placental tissue or membranes were found. At this point, the procedure was terminated. Bleeding at this time was minimal. Preop H&H were 8.3 and 24.2. The patient tolerated the procedure well and was taken to the recovery room in good condition.
Keywords: obstetrics / gynecology, uterus, intrauterine clots, postpartum hemorrhage, intrauterine, curettage, hemorrhage, bleeding, postpartum, clots,