IN THE NAME OF ALLAH

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• IN THE NAME OF ALLAH

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Human Papilloma Virus in Pregnancy

• A.Mohammadzadeh (M.D)
• Avesina Reaserch Center

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Epidemiology

• HPV infection is one of the most common sexually
  transmitted infection in female genital tract
  .(up to 75 of sexually active women Groopman
  1999)
• According to the American Social Health
  Association, approximately 5.5 mill new cases of
  HPV infections are reported every year.
• At least 20 mill Americans are already infected.

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Virology

• HPV is a member of the papavirideae family.
• Papavirideae family
• 1-Simian V. and Polyoma V. 2- HPV
• 8000 KB with dsDNA.
• More than 80 types of HPV are identified .(DNA
  sequence lt50)
• HPV1 common skin wart
• HPV 5,14 verrocouse epidermolysis
• About 30 types are spread through sexual
  contact.
• HPV 6,11,16,18,31,35,50-60 genital tract

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Infection

• GenitalHPV is a sexually transmitted infection.
• About two-thirds of woman who have sexual contact
  with a infected partner ,will develop warts,
  usually within three months of contact.
• Age
• In women, vulve, vagina,CX and anus.
• In men.tip of penis ,scroutom and anus.
• Genital HPV often do not have obvious signs and
  symptoms(50)
• Even males with HPV in urethra, rarely have a
  discharge or visible lesions on the genital
  tract.
• Sometimes irritable symptoms are reported.
• The most common forms is genital warts
  (Condylomata Acuminata).

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• Fig1(A)colposcopic view of cervix with flat HPV
  lesion revealed as an area of white mucosa after
  application of weak acetic acid .(B) Peniscopy of
  partner of the above patient with HPV infection
  .note multiple flat lesions.

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Why HPV is important?

• It is a sexually transmitted disease.
• Some types of HPV can induce cancer.
• Low potential HPV6,11,35
• Condyloma , CIN1
• High potential HPV16,18,31,50-60)
• CIN2,3 and Invasive cancer.
• Two gene in HPV (E6,E7) can produce proteins that
  can attach to Rb and P53(which regulated cell
  division) and block their effect on regulating
  cell division (Massimi and Banks1997)
• Correlation with other STI. Tricomoniasis,
  Bacterial vaginosis
• High risk groups Multiple partner ,Teen age,
  HIV, Diabetics, Immune suppressed
• Special effect on pregnancy

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Clinical Aspects

• Direct inspection (warts).
• Soft pedanculated papules
• In the CX ,it is flat and bleed on contact
• single or clusters
• Autoinoculation.
• HPV is found in intact skins near the lesion.

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Laboratory Diagnosis

• Culture
• Skin biopsy
• papillomatosis, acantosis, thickening of rete
  peg, koilocytosis
• Pap smears
• koilocytosis
• LSILHPV CIN1
• HPV6,11
• HSILCIN2,3 CIS
• HPV16
• DNA assay
• Routine screening of pregnant women for HPV is
  not recommended.
• In 2002Prevelence between pregnant and non
  pregnant is similar. And a majority of them had
  normal Pap smears.

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• Fig2Flat condyloma due to HPV infection of
  cervical mucosa .the mucosa is thickened
  .Koilocytosis is present in the upper layers.

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• Fig3Kiolocytosis .this screening power
  magnification shows scattered mature squamus with
  well-defined clearing of cytoplasm around the
  nuclei and slight nuclear enlargement (MP)

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• Fig4Kiolocytosis in a cervical smear.these
  superficial cells shows a wide zone of
  perinuclear clearing with condensed peripheral
  cytoplasm .

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• Fig 5 typical Koilocytosis

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• Fig6 HPV infection with Koilocytosis

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• Fig7different types of CIN

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• Fig8HPV/CIN2-3(ciribriform and punctation
  pattern of HPV near SCJ

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• Fig9 CIN3white lesion , punctation and mosaism

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Treatment

• Depend on size and location
• Imiquimod an immune response cream
• Podophylline anti-mitotic solution
• 20 apply and washing
• 0.5 apply
• 5-fluorouracil cream 5
• Trichloroacetic acid (TCA) 10-30
• Removal of lesion
• Knife removal
• Cryosurgery
• Electrocuatery
• Laser
• Alpha interferon injected into the warts
• All of the methods can get rid of lesion, but not
  virus. Because HPV is still present in the intact
  skins.

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Special effect on pregnancy

• Prevalence in pregnancy between 5.4 and
  68.8(2002)
• Most pregnant women with HPV are asymptomatic.
• Symptoms pain ,irritable signs ,bleeding,
  difficult urination.
• In pregnancy, increasing size and number of
  condylomatas are seen.
• Usually regression in post partum.
• Very large condylomatas can obstruct the vagina
  or pose the risk of heavy hemorrhage.
• Maternal-Fetal transmission.
• In 2002HSIL in pregnancy is more common.HPV16
• Diabetic pregnant women is more vulnerable to
  HPV.

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Maternal-Fetal transmission.

• Aspiration of mothers discharge during labor is
  the main way of HPV transmission to newborn.
• Disappears within 6 months after birth.
• IN 2003After 5 W. in infected neonates ,viral
  DNA was not detectable. Neutralizing Ab. against
  HPV 6 in mother go through the placenta and enter
  to their infants.
• Juvenile laryngeal papillomatosis
• It is potentially life-threatening
• Obstruction of the breathing system
• Adequate follow up of neonate
• Frequent laser surgery
• Combination of laser and interferon

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NVD or C/s

• In 2003HPV in mothers28 In infants with
  C/S10 In NVD18 HPV 16 is the most common
  types in mother and infants .
• Findings1- C/S was not found protective for
  infants.
• 2- Infection in infants was
  cleared within 1 y.
• Cesarian section is recommended only for
  obstetrical indication.

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Treatment in pregnancy

• Indications
• pain ,bleeding ,infection.
• Possible obstruction of labor.
• For prevention of J.L.P
• TCA treatment of choice small or isolated warts
• Podophylline is contraindicated teratogen
• 5-FU is not used
• CO2 laser treatment of choice for large warts
  (gt2mm)

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• Advantage of laser to cautery
• Vulvular edema and bleeding is less
• Healing without scar
• Lesion in upper vagina is readily treated
• Interfrons are contraindicated
• F/W in post partum is important Pap or
  Colposcopy CIN