Suction D&C (Uterine Aspiration)
[Missed abortion / incomplete abortion / retained products of conception] at [X] weeks gestation
Same
Suction dilation and curettage using [manual / electric] vacuum aspiration
[***, MD/DO]
[Nurse/tech name]
[Paracervical block with IV sedation / MAC / general]
The patient is a [age]-year-old [gravida X, para Y] at [X] weeks gestation with [a missed abortion / an incomplete abortion / retained products of conception] confirmed by [ultrasound / clinical examination]. Expectant, medication, and procedural management were discussed, and the patient elected uterine aspiration. The risks, benefits, and alternatives were reviewed, and informed consent was obtained.
The cervix was [closed / dilated / open with tissue at the os]. The uterus was [anteverted / retroverted] and sized to approximately [X] weeks. A [X]-mm cannula was selected to match the gestational age. [Scant / moderate / abundant] products of conception were obtained, and villi were [identified / not identified] on gross inspection. The uterine cavity was empty and firm at the end of the procedure.
The patient was positioned in dorsal lithotomy with pressure points padded. The external genitalia and vagina were prepared and draped. Prophylactic [doxycycline / azithromycin] was administered before instrumentation. A speculum was placed, and the anterior cervical lip was grasped with a single-tooth tenaculum. A paracervical block was placed with [local anesthetic and volume].
Bimanual examination confirmed the uterine size and position. Routine sounding was deferred. The cervix was gently dilated as needed with [Hegar / Pratt] dilators to admit a [X]-mm cannula. The cannula was advanced in the established uterine direction and connected to [a manual vacuum aspirator / electric suction]. The cavity was evacuated with gentle rotational passes until no further tissue was obtained and a uniformly gritty tactile endpoint was appreciated. Suction was reapplied briefly to clear residual tissue.
The aspirated tissue was inspected, and the volume was consistent with the clinical scenario. The uterus was firm with minimal bleeding. The tenaculum was removed, and cervical hemostasis was confirmed.
None
Products of conception sent to pathology
[No additional testing / Cytogenetic testing requested]
Minimal
None
The patient tolerated the procedure well and was taken to PACU in stable condition. The patient was discharged with return precautions for heavy bleeding, fever, or worsening pain.
Epic SmartPhrase Version
PREOPERATIVE DIAGNOSIS: *** at *** weeks
POSTOPERATIVE DIAGNOSIS: Same
PROCEDURE PERFORMED: Suction D&C using [manual / electric] vacuum aspiration
ATTENDING: ***, MD/DO
ASSISTANT: ***
ANESTHESIA: Paracervical block/MAC
INDICATIONS: .PTAGE-year-old .PTSEX at *** weeks with ***. Expectant, medication, and procedural options were discussed; the patient elected uterine aspiration. Consent obtained.
FINDINGS: Cervix ***. Uterus *** sized to *** weeks. *** mm cannula. *** products of conception; villi ***. Cavity empty and firm.
PROCEDURE:
Dorsal lithotomy with pressure points padded. The patient was prepared and draped. Prophylactic [doxycycline / azithromycin] was administered before instrumentation. A speculum and anterior cervical tenaculum were placed, followed by a paracervical block. Bimanual examination confirmed uterine size and position, and routine sounding was deferred. The cervix was gently dilated to admit a ***-mm cannula. The cavity was evacuated by [manual / electric] vacuum aspiration using gentle rotational passes until no further tissue was obtained and a uniformly gritty tactile endpoint was appreciated. The tissue volume was consistent with the clinical scenario. The uterus was firm with minimal bleeding, and the cervix was hemostatic.
EBL: Minimal
SPECIMENS: Products of conception to pathology
COMPLICATIONS: None
DISPOSITION: Same-day discharge with return precautions.
Signed: .ME, .MYDEGREE
.TODAYVariants
Postpartum Retained Products (D&C After Delivery)
For retained products after a [vaginal / cesarean] delivery, curettage was performed for postpartum hemorrhage or retained placenta. Ultrasound guidance was used where available to limit the perforation risk in the soft postpartum uterus. A large blunt (banjo) curette or suction was used to clear retained tissue until the cavity was empty and the uterus contracted, and uterotonics were given to maintain tone.
Molar Pregnancy (Suction Evacuation)
For a suspected hydatidiform mole, suction evacuation was performed with an appropriately sized cannula. Hydropic tissue was evacuated and sent to pathology. Hemorrhage risk and uterine tone were monitored, and uterotonics were administered only as clinically indicated. A baseline quantitative hCG was obtained, Rh(D) management was documented, and serial hCG surveillance was arranged.
Charting Tips
- Document gestational age, uterine size and position, cannula size, manual or electric aspiration, tissue yield, and the endpoint used to confirm evacuation.
- Record antibiotic prophylaxis before instrumentation. Routine sharp curettage should not be implied when aspiration alone completed the evacuation.
- Document Rh(D) status and the actual prophylaxis decision. Current US recommendations differ below 12 weeks; at 12 weeks or later, Rh immune globulin is recommended for an unsensitized Rh-negative patient.
- If the expected tissue is not identified, document the follow-up plan using pathology, quantitative hCG, and ultrasound as appropriate rather than claiming an ectopic pregnancy was excluded immediately.
- If perforation, cervical laceration, hemorrhage, or incomplete evacuation was suspected, replace the default complication field and document the evaluation and treatment.
- Use the nonpregnancy D&C template for abnormal uterine bleeding or endometrial sampling and the hysteroscopy template for directly visualized intrauterine pathology.
Documentation & Reimbursement Considerations
- Report Suction D&C (Uterine Aspiration) as the primary service when it is the definitive operation performed.
- Use the routine note for first-trimester miscarriage or retained products of conception managed by vacuum aspiration.
- The reporting category follows the clinical scenario and gestational timing rather than whether manual or electric suction was used.
- Pregnancy-loss, postpartum, and molar evacuations have different reporting and global-period rules; document the actual scenario and completed procedure.
- For suspected molar pregnancy, document the diagnosis, pathology submission, baseline quantitative hCG, and surveillance plan.
- Dilation and curettage are components of the pregnancy-specific evacuation rather than unrelated additional procedures.