Mahanti S*, Chaudhari HK **.
(* Senior Resident, ** Associate Professor, Department of Obstetrics and Gynecology, Seth G S Medical College and K E M Hospital, Mumbai, India.)
Genital warts are commonly acquired viral genital mucosal lesions. These lesions generally get aggravated during pregnancy due to the increased mucosal vascularity and the apparent suppressed cell-mediated immunity. Here we present a case of a young primigravida at 18 weeks of gestation who presented with complaints of swelling in the genital region on routine antenatal examination which was diagnosed as genital warts or condyloma acuminata. The maternal and perinatal outcome of the same has been elaborated here.
Warts are cauliflower like growths that affect mucosal surfaces including the oral cavity, larynx, anal canal, vaginal canal, cervix and uncommonly the nasal cavity. Warts are caused by Human Papilloma Virus (HPV) and are a part of the spectrum that range from benign papilloma to precancerous lesions of the cervix including low and high grade squamous intraepithelial lesion to obvious malignant lesions of the cervix and vagina. Here we have described a case of florid genital warts in second trimester pregnancy and its management.
A 24 year old primigravida at 18 weeks of gestation presented to the antenatal out-patient department (OPD) with complaints of leukorrhea. She had registered at 10 weeks of gestation, but had no gross perineal lesions or complaints. General, cardiovascular and respiratory system examination was within normal limits. On abdominal examination, uterus was 16 weeks size corresponding to the period of gestation. On local perineal examination, two papillomatous whorled growths of around 4 cm largest dimension consistent with genital warts were seen in the posterior commissural area extending up to the anal margin. In view of her complaints of leukorrhea, a speculum examination was done which revealed florid papillomatous growth involving the cervix and vagina.[Fig. 1,2] The growths were coated with a layer of white discharge which was non-foul smelling. She was admitted for the management of florid genital warts. The diagnosis was established on visual examination alone. Dermatology opinion was taken and they confirmed the diagnosis and she was advised to follow up for local cryotherapy with liquid nitrogen of the larger lesions and local application of tri-chloroacetic acid on the smaller lesions. She underwent six sessions of local cryotherapy at weekly intervals each lasting around 15-20 minutes as provided by the dermatologists. She also followed up in antenatal OPD for the entire duration of pregnancy. At around 32 weeks, after completion of all the sessions of cryotherapy and treatment from dermatological point of view, patient was re-examined. On local examination, the two large whorled warts of 4cm largest dimension involving the posterior commissure had resolved completely.[Fig.3]On speculum examination, there were no growths in the vagina or at the cervical os.[Fig.4] However, vaginal pessaries of clotrimazole were advised for vaginal candidiasis and metronidazole tablets for 7 days for bacterial vaginosis. Fetal growth was corresponding to the period of gestation and she appreciated good fetal movements. At 37 completed weeks, dermatology reference was taken. In view of complete resolution of genital and perianal lesions, they opined that she could be given trial of normal labor. She went into spontaneous labor at 40 weeks. However, emergency lower segment cesarean section was done in view of thick meconium stained amniotic fluid with fetal distress in first stage of labor. Patient and the neonate had an uneventful postnatal course. The neonate did not have any lesions on gross physical examination and was advised to follow up in OPD after 6 months or earlier if symptoms such as hoarse cry or respiratory difficulty or the presence of fleshy growths on nasal and oral mucosa was noted. Patient was discharged on the fifth postoperative day with advice to follow up in OPD for Pap smear and HPV DNA testing after 6 weeks. Pap smear was inflammatory and HPV DNA was negative for the high-risk types.
Genital warts are benign lesions most often caused by HPV types 6 or 11, which are categorized as the ‘low risk’ type of Human Papilloma Viruses; implying low risk of progression to frank malignancy. Detection of high risk type of HPV from these lesions, i.e. type 16, 18, 31, 33, or 35 are usually associated with type 6 or 11 coinfection. The diagnosis of genital warts is however made on visual inspection only and serological testing or HPV DNA testing is usually not recommended since they are expensive tests and do not alter the clinical course or management of the patient. Biopsy is not recommended for the diagnosis alone and only indicated in the atypical appearances of warts, excessive friability with bleeding on touch, non-responsive to usual line of management or worsening despite therapy. Biopsy performed in such cases comes with the significant risk of bleeding from these lesions however, becomes necessary in order to rule out occult malignancy. Exophytic cervical warts may undergo biopsy to rule out malignancy before empiric treatment is initiated and specially in cases where there is no response to empirical management. This patient had multiple florid condylomata acuminata which subsided on empirical management alone and hence biopsy was not performed. Cesarean delivery does not lower the risk of neonatal or juvenile laryngeal papillomatosis.[4,5] Cesarean section may be indicated in cases where there is obstruction of the vaginal outlet with warts or the presence of gross cervical and vaginal warts, but such cases are very rare. Congenital HPV infection from vertical transmission apart from temporary skin colonization is quite unheard of. Conjunctival, perianal or oropharyngeal warts in the first three years of life is most often due to perinatal vertical transmission of maternal HPV serotypes. Juvenile-onset recurrent respiratory papillomatosis (JoRRP) is a benign neoplasm of the larynx that causes hoarseness and respiratory distress in children and is caused by HPV 6 or 11. Risks for infection are maternal genital HPV infection and prolonged labor. The rate of vertical transmission of HPV to the neonate from mothers with subclinical infection with HPV can be 1-18%. However, elective cesarean section in these cases does not reduce the risk of infection. There is a role of serial follow up of neonates born to mothers with genital HPV infection but they rarely demonstrate persistent HPV DNA positivity. HPV vaccination may ultimately decrease rates of JoRRP in the future. Symptomatic management of the genital warts is necessary for the amelioration of symptoms such as leukorrhea or pruritis. This does not eradicate the infectivity of HPV associated with these lesions and the patients should be explained about the need for regular screening procedures such as Pap smear and liquid based cytology with HPV DNA testing. Management of the genital warts is categorized to patient and provider applied treatments. This patient was managed with provider based applications of cryotherapy with a cryoprobe and trichloroacetic acid 80 to 90 percent solution, and it resulted in complete resolution of the lesions. Alternative methods of treatment in pregnancy include laser ablation and surgical excision of the lesion. Podophyllin, podophyllotoxin and sinecatechins are not recommended for treatment of anogenital warts during pregnancy. The eradication of the genital warts in pregnancy is not essential unless it is symptomatic and therapy is aimed at managing the symptomatic warts with minimal maternal and fetal toxicity. Even if the management is suboptimal and lesions do not subside completely during pregnancy, the lesions most often regress rapidly in the postpartum period possibly due to recovery of cell mediated immunity.
Condylomata acuminata are benign lesions of the lower genital tract that are seen in the reproductive age group and is the benign manifestation of Human Papilloma Virus infection. Pregnant women with genital warts may vertically transmit it to the neonate but the chances of such transmission are very less. Adequate treatment of the lesions is required to ameliorate symptoms of the mother. There is a need for educating all women of the reproductive age group of the clinical spectrum of HPV infections ranging from subclinical infection to carcinoma cervix and emphasize on the role of effective screening procedures available.
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Mahanti S, Chaudhari HK. Florid Genital Warts In Pregnancy. JPGO 2019. Vol. 6 No. 6. Available from: https://www.jpgo.org/2019/06/florid-genital-warts-in-pregnancy.html