Genital Warts During Pregnancy

Pregnancy and Genital Warts

Interestingly, genital warts grow quickly during pregnancy. They increase both in numbers and size.

Why do Genital Warts Increase During Pregnancy?

The reasons for this are; 1. High levels of estrogen during pregnancy, but this hasn’t been proven. 2. The increased vaginal leaking creates the perfect condition for general warts and condyloma to grow. 3. Due to the physiologic nature of pregnancy, immune system gets weaker.

This is due to the child carrying chromosomal products which originate from the father, being “homogreft” in a way. (Homogreft: a surgical transplant of tissue between genetically different individuals of the same species). It is claimed that the decreased immune system, which is necessary for the continuation of the pregnancy during the mother’s adaptation period, causes the general warts to increase. 4. During the pregnancy, the bleeding on pelvis base and increased vascularization, causes the warts to develop faster during pregnancy.

For whatever reason, the researchers have proven that during early pregnancy, the replication of HPV virus is increased.

Therefore, women who have been treated successfully for genital warts, are in risk of recurrence. But these warts might disappear quickle after birth, without treatment.

Complications Caused by General Warts during Pregnancy

The prevalence and increasing size of genital warts on the pregnant women is bad for hygiene before anything else. They might cause severe bleeding, due to their rapid growth. They might cause different complications, according to the area they are seen on. For example; when they are on urethra (where urine is passed), they cause burning and pain while urinating, when on anal area, they cause bleeding and difficulty during excreting.

The frequency of condylomas on vagina and cervix is increased during pregnancy. This might cause bleeding. But most importantly, it makes it harder to detect the source of vaginal bleeding on the pregnant women.

Another problem is; women with genital warts need episiotomy and if there are warts on the incision area, there might be excess bleeding, making it hard to suture and fix the incision area.

Other than these complications that might occur due to warts on birth canal, the patient needs to go through a smear test. Precursor cervical dysplasia and cervical cancer (such as CIN I, CIN II) has a higher chance of increasing on pregnant women. As mentioned above, all these changes in the immune system due to pregnancy, might trigger this problem. Therefore, a smear test done on the patient with warts and subsequent colposcopy or even cervical biopsy might be necessary.

The Complications, Risk of Recurring Larengeal Papillomatosis Caused by Genital Warts on Children and How the Birth Should Be?

Mothers with genital warts read many publications online and go to gynecologists in fear that they might infect their infant. According to research taken from the literature on this subject that make you scared, the rates of infection is between 1 in 80 and 1 in 500.

But these are rates seen on women that have fresh warts and give normal birth. In the population, meaning us mortals, the ratio of Recurring Larengeal Papillomatosisis between 1 to 4 in 100.000! According to data collected in the USA, the ratio is 4.3 in 100.000 for under 14-year old and 1.8 in 100.000 for over 15-year olds.

There is no conclusive data for pregnant women who were treated during or before their pregnancy that give normal births. But this group is thought to be similar to the normal population. Therefore, please bear in mind that it’s important you read and remember the following information correctly.

The most important complication seen on children born to women with genital warts is Recurring Larengeal Papillomatosis (RLP). It was first described in the 17th century by Marcellus Donalus as “Warts in the Throat”. The term papillomatosis was first used in 1871 by Sir Morell Mackenzie.

There is no difference in ratio of occurrence between boys and girls.

Although it is most frequently seen in children, it might also occur in older patients. It is categorized academically according to the age it occurs: 1) Juvenile RLP, seen on children of 12 and younger, 2) Adult RLP, seen on adults over 40.

The reason for RLP to develop, is the HPV types 6 and 11 passed on from themother. Although it is claimed that the infection occurs while passing through birth canal, it can not be said that ceasarean is conclusively protective for the child. In the casestudy published in 1999 by Wasserman and co., RLP was seen on the infant of a woman who had genital warts and had a ceasarean.

The chance of occurance is higher on the firstborn children. This can be explained by the fact that the first birth usually takes longer and the child waits in the birth canal for a longer period of time. But I still think that many unknown factors play a huge role during the infection of the infant by the HPV virus.

The research shows the differences in the types of diseases HPV types 6 and 11 causes. On RLP cases that developed due to HPV type 11, the frequency of medical operation and tracheostomy is around 70%, while the frequency drops to 20% for RLP cases that develop due to HPV type 6.

Studies conducted on children show that, frequency of HPV occurrence is 2,5% for under 1-year old, while 0,8% for children between 1 and 4 years.

95% of all children have it on their throats, while only 52% of all occurrences are on throats. It shows itself with frequently lowered voice in children, in what ENT doctors call dysphonia. In cases where it effects lungs, more distinct symptoms like bloody phlegm.

Endoscopy has to be applied for diagnosis, while biopsies should be carried out on brownish, purplish, ragged and cracked lesions that are seen on throat region, in addition to a HPV DNA test which will help determine the type of the virus.

The problem is mainly caused by the recurring nature of the disease. Although warts seen on the throat that block the air-tubes can be removed by laser, cautery, criocautery and chemical compounds, they still have a high chance of recurrence. This is because of the fact that, on the examination done by laryngoscope, it is seen that even the normal cells that are located near the papillomatosis have been infected by HPV viruses. Therefore, follow-up controls are very important.
If it reoccurs more than 4 or 5 times a year, a destructive treatment is suggested. (Ex: ribavirin, MTX, cidofovir, interferon injections etc.)

What Should We Do for Protection? How to Give Birth?

AGOC (The American College of Obstetricians and Gynecologists) suggest that even though women have warts, if they can give normal birth, then that’s what they should be doing.

In fact, the three main risk factors for Recurring Larengeal Papillomatosis are:

  1. Being the first-born that is born with natural birth
  2. Giving natural birth
  3. Becoming a mother under the age of 20 and giving birth (Low socio-economic class can also be added to this risk factor)

The reason AGOC still recommends normal birth despite these risk factors is; that caesarean does not provide a full protection and the frequency of the disease is very low. But the management of the situation for pregnant women with genital warts, should be determined after speaking to the patient and their partner.

For a pregnant patient with genital warts, at least one smear test should be applied and subsequently all the warts should be treated. After these steps, the way of birth should be determined after evaluating with the patient. Not forcing a patient with prevalent warts to give normal birth and sharing the above statistics is the right way. Patients mostly prefer caesarean.

If the warts in both the vagina and vulva could be treated, no recurrence have been observed and the disease did not show up again, the risks should be communicated with the patient and normal birth should be selected. Ultimately, in both situations the gynecologist has to share correct information with the patient and the decision should be left to the patient and the partner.

It should be noted that, while the information on how the disease is passed onto the infant is limited and caesarean is not a definitive solution in order to prevent RLP development, the decision should be made by both the mother and the father after the correct information is shared.

Genital Warts Treatment on Pregnant Women

In light of all this information, it is safe to say that pregnant women with genital warts have to be treated. Although different treatment schemes are present, the optimal treatment option is the one chosen after evaluation between the doctor, the mother and the father.

There is a very good treatment scheme, published by Canadian Family Practitioners Magazine in 2013.

It includes %5 imiquimod, %25 podophillin, %0.05 podophyllotoxin. While there is no detailed research on sinecatechins, this medicine is not suggested for pregnant women.

On the mentioned treatment scheme, the first choice during pregnancy should be thricloracetic acid (TCA) and criocautery. Electrocautery and laser can be presented as 2nd options if the pain is unbearable for the patient. My personal choice is electrocautery. Especially, while it’s not practical to apply acid or cautery treatments on the vagina. But it is important to emphasize one more time that; the doctor’s decision should be made after evaluations with the couple.

If the warts are scarce and not prevalent, observing the route of the disease without an operation is the third option. But, the patient must get the prevalence of their warts checked during their pregnancy examination.

A smear test should be done. If the patient has anal condylomas or warts, an anal smear should be carried out. The way of birth should be discussed, after observing how the patient reacts to the treatment.

 Sources

  1. F. Gary Cunningham, Kenneth J. Leveno et al. Williams Obstetrics, 23th ed. Chapter 59.
  2. https://www.medscape.com/viewarticle/763580_3
  3. https://www.hu.ufsc.br/projeto_hpv/Epidemiology%20of%20recurrent%20respiratory%20papillomatosis.pdf
  4. https://emedicine.medscape.com/article/302648-overview#a0104
  5. https://www.ncbi.nlm.nih.gov/pubmed/12474680
  6. https://www.ncbi.nlm.nih.gov/pubmed/17721381
  7. www.ctf.edu.tr/…/REKuRREN%20LARENGEAL%20PAPiLLOMATOZiS (Dr.Hasan Mercan’ın Sunusu)
  8. https://www.ncbi.nlm.nih.gov/pubmed/23851535

 

 

 

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