Dr. Leila Mousavi seresht GYNECO-ONCOLOGIST Abortion Dr. Leila Mousavi seresht GYNECO-ONCOLOGIST

213 million pregnancies occur worldwide each year and 42 million of these pregnancies end in abortion Approximately 22 million of these abortions are "safe" and the other 20 million are "unsafe"

4.7 to 13.2 percent of maternal deaths worldwide each year! Unsafe abortion is a major factor in maternal morbidity and mortality and accounts for about 4.7 to 13.2 percent of maternal deaths worldwide each year! .

one in eight pregnancy-related deaths are the result of unsafe abortion Unsafe abortion has large economic costs, as well, since the incomplete procedure creates a need for hospital care

The World Health Organization (WHO) "unsafe" abortion is : performed by people lacking the necessary skills or using hazardous technique, and/or in an environment that does not meet minimum medical standards. Spontaneous miscarriages in which sepsis or other complications occur are also classified as unsafe abortion. The World Health Organization (WHO)

It is estimated that 21 to 22 million unsafe abortions occur worldwide, and 98 percent of these abortions occur in the developing countries! performs abortion discreetly in his/her office by dilation and curettage or vacuum aspiration. Some physicians offer misoprostol or initiate an abortion surgically and then advise women to present to a hospital for completion of an incomplete abortion. These procedures can be unsafe even in the hands of medical providers due to the lack of adequate training, clean instruments, and sterile technique.

Abortion & Complication: associated with : the method, gestational age, patient characteristics, and clinician skill and experience.

Oral and injectable treatments include: metal salts, phosphorus, lead, kerosene, turpentine, detergent solutions, uterine stimulants (misoprostol or oxytocin), chloroquine, oral contraceptives, hormones (gynaecosid), and numerous teas and herbal remedies. Preparations placed in the cervix, vagina, or rectum include: potassium permanganate tablets, herbal preparations, misoprostol, enemas. Instrumentation of the uterus includes: catheter insertion followed by infusion of alcohol, saline, or other solution; insertion of foreign bodies such as coat hanger, knitting needle, stick crochet hook, or air blown through a syringe. Penetration with sharp objects with potential for uterine perforation and use of unclean instruments such as unsterilized catheters are methods that pose the highest risks for morbidity and mortality However, transcervical introduction of compounds such as mixtures of soap, cresol and phenol can cause renal toxicity, cardiac toxicity, and death. Trauma to the abdomen including: self-inflicted blows, abdominal massage, jumping from a height, lifting heavy weights. Traditional practitioners commonly use vigorous abdominal massage with the idea that this will result in disruption of the pregnancy, but this can result in uterine rupture or other morbidity Method…

COMPLICATIONS — In the developing world, it is estimated that five million women are admitted to hospitals for treatment of complications from induced abortions each year estimated rate of 6.9 per 1000 women,

Early complications hemorrhage, cervical laceration, stenosis and uterine perforation. incomplete abortion, sepsis, inability to complete the procedure, requiring re-suction or combined (intrauterine and tubal) pregnancy. convulsive seizure due to administration of local anesthetic Hematometra Hemorrhage —result from cervical or vaginal lacerations, uterine perforation, retained tissue, or uterine atony. infection, uterine arteriovenous malformation, placenta accreta, and coagulopathy (secondary to release of tissue thromboplastin into the maternal venous system). (also known as uterine distension syndrome or postabortal syndrome) usually presents with complaints of dull, aching lower abdominal pain, sometimes accompanied by tachycardia, diaphoresis, or nausea.

One in eight pregnancy-related deaths worldwide is the result of unsafe abortion and an estimated 47,000 women die every year from unsafe abortion Death —

Deaths from unsafe illegal abortion account for a significant percentage of all maternal deaths worldwide. In some developing countries where abortion is illegal, ≥25 percent of all maternal deaths are abortion-related Maternal mortality is lowest before 8 weeks of gestation, and increases rapidly after 18 weeks of gestation (<0.3 per 100,000 induced abortions at ≤8 weeks versus 7 per 100,000 at 16 to 20 weeks and 11 per 100,000 at ≥21 weeks)

— Hemorrhage is the most common complication of unsafe abortion, and may result in: hypovolemic shock, coagulopathy, and death. Hemorrhage may be related to: lacerations of the vagina, cervix, uterus, or adnexal vasculature; uterine infection; and/or atony. Retained products of conception are a common cause of uterine infection and atony. Hemorrhage

Women may present with one or more of the following signs and symptoms anytime from minutes to days after the procedure: abdominal and/or pelvic pain, malodorous discharge, fever and chills, bleeding or spotting, and uterine or adnexal tenderness. Infection related to unsafe abortion is caused by ; retained products of conception, trauma, and non-sterile techniques. If untreated or inappropriately treated, infection can lead to: sepsis, septic shock, organ failure, disseminated intravascular coagulation, and future sterility. Infection —

Patients generally present with bleeding or infection Incomplete abortion is more common in: self-induced abortion or abortion by an untrained provider, at later gestational ages, in the presence of uterine anomalies, or with distorting uterine pathology (eg, uterine leiomyomas). Patients generally present with bleeding or infection Incomplete abortion

Trauma Presenting signs and symptoms include vaginal bleeding, — Insertion of a foreign body is a common cause of abortion-related trauma. injuries to the genital tract: overt vaginal bleeding perforation can result in trauma to the bowel and other internal organs. Ingestion of chemical agents can also cause trauma: internal bleeding can mask the total estimated blood loss. Lacerations to the cervix and lateral uterus are particularly dangerous due to the risk of lacerating one of the vessels in the parametrial space. Trauma Presenting signs and symptoms include vaginal bleeding, hemodynamic instability, and sepsis

Late complications Signs and symptoms are similar for isolated endometritis and endometritis with retained products of conception (placental tissue, fetal fragments, fetal membranes), and include fever, an enlarged tender uterus, lower abdominal pain, and uterine bleeding greater than expected postabortion. occurring more than 72 hours after the procedure; Fever, infection, hemorrhage, and retained products of conception Ongoing pregnanacy Postabortal endometritis occurs in 5 to 20 percent of women not given prophylactic antibiotics; this rate may be reduced by about one-half if prophylactic antibiotics are given

Ultrasonography can help distinguish these two groups if retained products are visualized in the uterine cavity .

Any physical or sonographic evidence of retained products of conception should prompt consideration of suction curettage to complete evacuation of the uterus. In the absence of detectable retained material, a presumptive diagnosis of endometritis may be made and treated with a trial of broad spectrum antibiotic therapy, with coverage of anaerobes (eg, cefotetan [2 g intravenously] plus doxycycline [100 mg intravenously or orally] every 12 hours). This regimen can be completed as an outpatient oral regimen for a 14-day course.

Generalized abdominal tenderness, guarding, tachycardia, high fever, and prostration suggest advanced sepsis. An alternative outpatient regimen is ceftriaxone 250 mg intramuscularly in a single dose plus doxycycline 100 mg orally twice a day for 14 days with or without metronidazole 500 mg orally twice a day for 14 days. >>> These patients require aggressive therapy with broad spectrum intravenous antibiotics, uterine re-evacuation, assessment for uterine perforation, and monitoring and support in an intensive care unit.

Ongoing pregnancy — is more likely to be a complication of early rather than late abortion. Return of the serum hCG concentration to undetectable following pregnancy termination varies widely from 7 to 60 days The hCG concentration peaks at 8 to 11 weeks at approximately 90,000 mIU. The decline in serum hCG is rapid for the first several days (half-life 9 to 31 hours) and then proceeds more slowly (half-life 55 to 64 hours) An ongoing intrauterine pregnancy may occur after an attempted pregnancy termination if the products of conception are not closely examined by an experienced clinician at the time of the procedure (and by a pathologist) to verify successful completion. Alternatively, ongoing pregnancy may rarely result from a multiple gestation in which only one of the sacs was aborted. reported an ongoing pregnancy rate of 1.3 per 1000 procedures for pregnancies less than 6 weeks of gestation Direct or indirect injury to the developing embryo could occur. increased risk of Moebius sequence with autism in children exposed to misoprostol in the first trimester Moebius sequence is a clinical condition characterized by ophthalmic-facial palsy and muscle or bone malformations in the limbs. It represents a cascade of events resulting from embryo trauma from varied etiologies (eg, genetic factors, environmental injuries, prolonged membrane ruptures and chorion villus sampling).

Future pregnancies risk of bearing low birth weight babies, delivering prematurely, or suffering spontaneous abortions in subsequent pregnancies in women who carried their first pregnancy to term versus whose first pregnancy ended in induced abortion is controversy in different studies. All of these retrospective studies are flawed because they are subject to recall bias and inadequate adjustment of other risk factors for adverse pregnancy outcome (eg, sexually transmitted disease, smoking).

ongoing intrauterine or ectopic pregnancy or incomplete abortion CONTRACEPTION — Contraception should be discussed prior to and reviewed immediately after the termination. Ovulation can occur two weeks after a first trimester abortion, thus immediate contraception is important (if desired) and can be initiated the day of the procedure. A routine follow-up visit two to four weeks after the procedure is intended to confirm that the abortion is complete and to diagnose and treat complications. Pregnancy symptoms generally should have dissipated within one week of the pregnancy termination and normal menses should return within six weeks. suggest : ongoing intrauterine or ectopic pregnancy or incomplete abortion

require further evaluation. Fever, pelvic pain, uterine enlargement, heavy bleeding, passage of tissue, and on-going pregnancy symptoms require further evaluation.

Any sexually active female is at risk for sexually transmitted infection (STI) associated (PID)

Clinical symptom

Pelvic inflammatory disease (PID) acute and subclinical infection of the upper genital tract: uterus, fallopian tubes, and ovaries; (endometritis, salpingitis, oophoritis, peritonitis, peri-hepatitis, and/or tubo-ovarian abscess)

Clinical diagnosis remains the most important practical approach.

Rare case: PID can occur in the first 12 weeks of gestation of pregnancy before mucus plug formation. instrumentation of the cervix (eg, termination of pregnancy) are at higher risk Older women less commonly present with PID, but the cause is more likely to be non-STI related. Salpingitis in premenarcheal girls and adolescents who are not sexually active, is very rare. respiratory and enteric bacteria should be also considered.

Acute symptomatic PID Acute onset of lower abdominal or pelvic pain, pelvic organ tenderness, and evidence of inflammation of the genital tract. The findings can be subtle and nonspecific.

Lower abdominal pain is the (cardinal presenting symptom) usually bilateral pain and rarely of more than two weeks' duration May be quite subtle. May worsens during coitus or with jarring movement May start during or shortly after menses (particularly suggestive ) May with Abnormal uterine bleeding (post-coital bleeding, inter- menstrual bleeding, menorrhagia) May with urinary frequency and abnormal vaginal discharge.

physical examination, abdominal tenderness in the lower quadrants, which may or may not be symmetrical. Acute cervical motion, uterine, and adnexal tenderness on bimanual pelvic (characteristic of acute PID) Purulent endocervical discharge and/or vaginal discharge is also common.

Rebound tenderness, fever, decreased bowel sounds Showed more severe PID. significant lateralization of adnexal tenderness is uncommon in PID.

Laboratory — are nonspecific. peripheral blood leukocytosis In more severe disease elevated erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP) have poor sensitivity and specificity.

PID should be suspected in The index of suspicion for PID should be high any young or sexually active female presents with lower abdominal pain and pelvic discomfort.

An indolent presentation of PID with low-grade fever, weight loss, and abdominal pain has been reported with actinomycosis (IUD) and tuberculosis.

clinical diagnosis of PID can be made : on the basis of history and physical exam findings alone. laboratory testing** is also done at the initial evaluation of all patients with suspected PID, empiric treatment should not be delayed

The following tests should be performed for all women suspected of having PID: Pregnancy test Microscopy of vaginal discharge Nucleic acid amplification tests (NAATs) for C. trachomatis and Neisseria gonorrhoeae , Mycoplasma genitalium HIV screening Serologic testing for syphilis Urinalysis is also checked in women with urinary symptoms. Hepatitis B virus testing ( depending on the patient's risk history )

A complete blood count, erythrocyte sedimentation rate, and C-reactive protein are often obtained in who have more severe clinical presentations, including fever.

Ultrasound is generally the preferred imaging modality if an abscess or adnexal pathology is suspected clinically for women who are acutely ill (eg, with fever, peritonitis, or a pelvic mass), whose symptoms are atypical (eg, with an abnormal site or duration of symptoms) or do not improve significantly within 72 hours after starting empiric antibiotic therapy, or who have persisting pain after completing therapy.

Absence of radiographic findings consistent with PID does not rule out the possibility of PID and should not be a reason to forgo or delay therapy for presumptive PID.

sonographic findings operator-dependent, and often minimal changes seen in women with uncomplicated PID. Thickened, fluid-filled fallopian tubes, the cogwheel sign (on a cross- section of the tube) may be present. fluid or gas within the endometrial canal, heterogeneous thickening, or indistinctness of the endometrial stripe, Among women who have endometritis, a complex thick-walled, multilocular cystic collection in the adnexa, typically with internal echoes or multiple fluid levels, When a tubo- ovarian abscess is present,

Laparoscopy can be a useful part of the diagnostic workup for PID when imaging studies have not been definitively informative • In a patient who has failed outpatient treatment for PID, In a patient wo not clearly improving or worsening after approximately 72 hours of inpatient treatment for PID, • some surgeons may proceed directly to laparoscopy in an acutely ill patient with a high suspicion of a competing diagnosis that would be diagnosed and intervened on through laparoscopy (eg, appendicitis).

DIAGNOSIS clinical diagnosis of PID is made in sexually active young women, who present with pelvic or lower abdominal pain and have evidence of cervical motion, uterine, or adnexal tenderness on exam.

The sensitivity of this clinical diagnosis is only 65 to 90% but because of the potential for serious reproductive sequelae if PID treatment is delayed or not given, this presumptive diagnosis is sufficient to warrant empiric antimicrobial therapy for PID. Even patients with minimal or subtle findings should be treated since the potential consequences of withholding therapy are great!

additional findings used to support the clinical diagnosis of PID Oral temperature >101°F (>38.3°C) ● Abnormal cervical or vaginal mucopurulent discharge or cervical friability ● Presence of (WBCs) on saline microscopy of vaginal secretions (eg, >15 to 20 WBCs per high power field or more WBCs than epithelial cells) The CDC also lists an elevated C-reactive protein (CRP) or erythrocyte sedimentation rate (ESR) ● Documentation of cervical infection with N. gonorrhoeae or C. trachomatis

Certain findings can suggest against PID, such as : the combination of normal cervical discharge and absence of WBCs on microscopy of vaginal secretions. prominent gastrointestinal and urinary symptoms can suggest other etiologies of pelvic pain.

Doppler studies (tubal hyperemia) certain findings can help to confirm the diagnosis of PID, although their absence does not rule out the possibility of PID: Pelvic imaging (thickened, fluid-filled tubes/oviducts with or without free pelvic fluid, or tuboovarian complex) Doppler studies (tubal hyperemia) Laparoscopic abnormalities(tubal erythema, edema, and adhesions; purulent exudate or cul-de-sac fluid; and abnormal fimbriae.) Histologic evidence of endometritis in a biopsy.

Standards for the diagnosis of subclinical PID remain to be established.

It is typically diagnosed retroactively in women who are ultimately found to have tubal factor infertility. Subclinical PID can also be identified incidentally in women undergoing laparoscopy for other reasons.

Pathogenesis, risk factors

The vaginal flora of most normal, healthy women includes; a variety of potentially pathogenic bacteria : streptococci, staphylococci, Enterobacteriaceae (most commonly Klebsiella spp, Escherichia coli, and Proteus), anaerobes. Which flow under the influence of : hormonal changes (eg, pregnancy, menstrual cycle), contraceptive method, sexual activity, and other as yet unknown forces. Endocervical infection with sexually transmitted pathogens can disrupt the endcervical canal barrier.

The reasons why lower genital tract bacteria cause PID in some women but not others is not fully understood but may relate to : genetic variations in immune response, estrogen levels affecting the viscosity of cervical mucus, bacterial load of potential pathogens

(PID) among sexually active pre-menopausal females: Neisseria gonorrhoeae Chlamydia trachomatis Mycoplasma genitalium

rare cases of PID seen in post-menopausal women: E. coli colonic anaerobes, Mycobacterium tuberculosis actinomycosis. it is important to consider ovarian cancer, fibroids, diverticulitis, and colorectal cancer.

the initiating pathogen, PID is clinically considered Regardless of the initiating pathogen, PID is clinically considered a mixed polymicrobial infection.

so!! Annual screening of sexually active adolescent girls and young women and older women at increased risk for chlamydia is recommended in the United States and other countries

Risk factor: Having four or more sexual partners within the prior six months increased the risk of PID 3.4 times, and having sex with a single partner six or more times per week increased it 3.2 times 1. Sex is the primary risk factor for pelvic inflammatory disease (PID); Celibate women are not at risk for PID, women with longstanding monogamous relationships rarely develop PID. Reinfection with genital C. trachomatis is also a function of age. whose first infection occurred at <15 years and 15 to 19 years was eightfold (at 54 percent) and fivefold (at 30 percent) greater, respectively, compared to those whose first infection occurred older than age 30 2. women with Multiple sexual 3. Younger age*, 4. past infection with chlamydia or PID** 5. a partner with a STI Approximately one in four women with PID will suffer recurrence a third of men with gonococcal or chlamydial urethritis are asymptomatic. Having a symptomatic (dysuria, urethral discharge) male partner can increase a woman's risk of PID

Risk factor; The choice of contraceptive method does not clearly affect the risk of pelvic infection:

Condom although consistent use of condoms offers a significant reduction of risk. The frequency of PID is also affected by the method of contraceptive used; barrier contraception is protective.

OCP Thus, women using OCs appear to develop Oral contraceptives (OCs) have a complex interaction with PID. doubles the prevalence of both cervical chlamydia and gonococcal infection & fourfold asymptomatic endometritis But associated with a 50 percent reduction in PID risk & gross salpingitis Thus, women using OCs appear to develop PID about as frequently as other women, but the severity of the infection is substantially diminished.

IUD The risk of PID is primarily limited to the first three weeks after IUD insertion close follow-up with leaving the IUD in place while treating acute PID with antibiotics is acceptable The IUD should be removed if clinical improvement is delayed beyond a few days.

the presence or absence of clinical symptoms, Long-term indwelling IUDs have been associated with pelvic actinomycosis: a rare disease that can present as a pelvic mass with weight loss and constitutional symptoms The decision to treat a patient for possible pelvic actinomycosis is influenced by the presence or absence of clinical symptoms, since actinomyces are part of normal vaginal flora

TL Tubal ligation may protect the distal oviducts from involvement, but the clinical syndrome of PID is otherwise unaffected.

درمان

Microorganism? Even if endocervical testing is not positive for either of C. trachomatis and N. gonorrhoeae, these pathogens should still be covered, as upper tract infection cannot be ruled out !

Microorganism? So: we do not routinely include it, only recommend it when: severe or complicated infection (eg, a tubo-ovarian or other pelvic abscess) recent gynecologic instrumentation when bacterial vaginosis or Trichomonas infection is identified whether antibiotic therapy for PID should routinely include anaerobic coverage is controversial ?! Although many women with PID have demonstrated the presence of anaerobes at initial presentation, but there is the gastrointestinal side effects of metronidazole that can result in nonadherence and inadequately treated PID.

Microorganism there is no consensus on whether women PID treatment regimens should include coverage M. genitalium, Sensitive to: azithromycin, doxycycline, FQ & clindamycin. Azithromycin, 5 day course of 250 mgr. or single dose of 1gr, oral.

Microorganism Drug resistance is an ongoing challenge in the therapy of gonococcal infections: As an example, the prevalence of fluoroquinolone resistance reaches nearly 100 percent

THRESHOLD FOR TREATMENT Clinicians should maintain a low threshold of suspicion for the diagnosis and treatment of PID The typical case is: a sexually active young women or women at risk for sexually transmitted infections (STIs) who present with pelvic or lower abdominal pain(even minimal) and have evidence of cervical motion, uterine, or adnexal tenderness on exam Occasionally, acute PID can occur in women without recent sexual activity.

HOSPITALIZATION ?? ● Severe clinical illness ● Complicated PID with pelvic abscess ● Possible need for invasive diagnostic evaluation for alternate etiology ● Inability to take oral medications ● Pregnancy (high fever, nausea, vomiting, severe abdominal pain) (including tubo-ovarian abscess) (eg, appendicitis or ovarian torsion or surgical intervention for suspected ruptured tubo-ovarian abscess ) due to nausea and vomiting or Concern for nonadherence to therapy

cefoxitin (2 g.IM) with probenecid (1 g orally), cefotaxime (1 g .IM), A single intramuscular dose of a long-acting cephalosporin* plus doxycycline(100 mg orally twice daily for 14 days); An alternative to doxycycline is azithromycin (1 gram once per week for two weeks, given with the single cephalosporin dose) * ceftriaxone (250 -500 mg)IM. cefoxitin (2 g.IM) with probenecid (1 g orally), cefotaxime (1 g .IM), ceftizoxime (1 g.IM).

Alternative, similar cure rate Azithromycin (500 mg intravenously daily for one to two days followed by 250 mg orally daily to complete a seven-day course), with or without 12 days of metronidazole, cure rates (>95 percent) for mild to moderate PID Ampicillin-sulbactam (3 g intravenously every six hours) plus doxycycline (100 mg twice daily) resulted in a similar clinical cure rate for hospitalized with PID (86 versus 89 percent)

Transition to oral therapy after 24 hours of sustained clinical improvement*, Oral therapy : doxycycline 100 mg twice daily to complete a 14-day course.(azithromycin (500 mg once followed by 250 mg once daily to complete a seven-day course) is alternative). add metronidazole 500 mg orally twice daily for the 14-day course for women with a pelvic abscess or women with a documented Trichomonas vaginalis infection or bacterial vaginosis or who had recent (2-3weeks) gynecologic instrumentation.(Clindamycin 450 mg orally every six hours is an alternative). reflected by resolution of fever, nausea, vomiting, and severe abdominal pain

Surgical interventions are usually reserved for patients with tubo- ovarian abscesses that are associated with sepsis, are large, or do not improve with medical therapy

Work up: Hepatitis B vaccination for those who have no evidence of immunity to hepatitis B virus (eg, through vaccination history or serologic testing). Human papillomavirus vaccination for those within the appropriate age range if they have not previously been vaccinated. All patients diagnosed with acute PID should be screened for other important STIs, including HIV and syphilis

Partner? to decrease the risk of reinfection. Male sex partners of women with PID should be examined and treated if they had sexual contact with the patient during the 60 days prior to the patient's onset of symptoms, regardless of the woman's STI test results. Cover the N. gonorrhoeae and C. trachomatis, such as : ceftriaxone (250 mg) intramuscularly plus either azithromycin (1 gram) orally as a single dose or doxycycline (100 mg) orally twice daily for seven days.

Close follow-up is essential In outpatient therapy: see the patient within 48 to 72 hours to be certain that clinical improvement has occurred (eg, reduction in abdominal tenderness and cervical motion tenderness) Those who have no clinical improvement after this period warrant 1) further diagnostic evaluation for complications (eg, pelvic abscesses) or for alternate diagnoses. 2) hospitalization and parenteral therapy.

توضیح الگوریتم IgE: immunoglobulin E. * Ask the following: ​ 1. What exactly were the symptoms? ​ 1. Raised, red, itchy spots with each lesion lasting less than 24 hours (hives/urticaria)? 2. Swelling of the mouth, eyes, lips, or tongue (angioedema)? 3. Blisters or ulcers involving the lips, mouth, eyes, urethra, vagina, or peeling skin (seen in SJS, TEN, other severe type IV reactions)? 4. Respiratory or hemodynamic changes (anaphylaxis)? 5. Joint pains (seen in serum sickness)? 6. Did the reaction involve organs like the kidneys, lungs, or liver (seen in DRESS, other severe type IV reactions)? 2. What was the timing of the reaction after taking penicillin: Minutes, hours, or days later? Was it after the first dose or after multiple doses? 3. How long ago did the reaction happen? (After 10 years of avoidance, only 20% of patients with IgE-mediated penicillin allergy will still be allergic). 4. How was the reaction treated? Was there a need for urgent care or was adrenaline/epinephrine administered? 5. Has the patient tolerated similar medications, such as ampicillin, amoxicillin, or cephalexin since the penicillin reaction? ¶ Isolated mild hives, without other symptoms of an IgE-mediated reaction, can often occur in the setting of an infection. Patients with this history, especially if it occurred in childhood or >10 years ago, may also be considered to be at minimal risk for a recurrent serious reaction. Δ This algorithm is intended for use in conjunction with additional UpToDate content. For a description of how to safely perform a TEST DOSE PROCEDURE, refer to the UpToDate topic on choice of antibiotics in penicillin-allergic hospitalized patients. ◊ Consult allergist to perform skin testing. If skin testing is not possible, patient may still be able to receive penicillins or first- or second-generation cephalosporins using a desensitization (also known as tolerance induction) procedure. Refer to the UpToDate topic on rapid drug desensitization for immed

Complication?