Human papillomavirus (HPV) infection and genital warts pose a special problem in pregnant women. There is risk of transmission to the fetus and during birth. Also, the changes that the body endures during pregnancy can stoke up a dormant HPV infection. Women with genital warts who are considering pregnancy or who are pregnant should be aware of several important facts about HPV. It is important to take steps to protect yourself and your baby.
Avoiding HPV infection
Genital warts are a sexually transmitted disease. In fact, HPV infection is the most common sexually transmitted disease in the United States. Fighting the disease begins with prevention. Heterosexual women are at increased risk for contracting genital warts over heterosexual men because of the mechanics of heterosexual intercourse. Participants that receive bodily fluids during intercourse are more likely to become infected with human papillomavirus and, as a result, develop genital warts and other diseases. Therefore the first step of protecting yourself and your unborn fetus is through prevention.
Unfortunately, barrier protection is only partially protective against HPV transmission. That is because the genital warts themselves have a significant amount of virus in them. Whether you use male or female condoms, various forms of sexual intercourse can still transmit HPV. While you should still use a condom during every sexual encounter, it is important to realize that condom use does not provide complete protection.
Abstinence is the only complete protection from HPV infection or inoculation. If total abstinence is not feasible, sexual contact should be avoided if one participant has visible, internal or external genital warts. This is especially true if the warts are bleeding, oozing, or the skin in or around the lesion is broken. However, genital warts can still shed virus when they appear dormant or stable. Thus the best solution is to postpone sexual relations until the infected party is treated. Even after treatment, the risk of sexual transmission of HPV is not zero.
Changes that occur during pregnancy and genital warts
If you ask any woman that has been pregnant, she will tell you how radically the body changes during pregnancy. From a physiological perspective, essentially every organ and cellular system in the body changes in some way during pregnancy. The skin and immune system are no different.
Several dermatologists and OB/GYN physicians have documented the changes that can occur with genital warts during pregnancy. Women that apparently have their HPV and genital warts under good control before pregnancy often notice a flare-up once they become pregnant. The immune system and skin go through major changes. Previously quiet or dormant genital warts can become active during pregnancy. In fact, it is not unusual for the most abundant and aggressive lesions to occur exclusively during pregnancy.
The prevalence of genital warts increases from the first to the third trimester. After birth, the lesions seem to “quiet” very quickly. Thus something about the HPV infection is fundamentally different during pregnancy. The risk of genital warts doubles during this time. If genital warts do occur during pregnancy, they can become very large, very rapidly. The growth of the genital warts is so rapid that the skin can break down. If this occurs, prompt medical or surgical treatment is usually required.
It is not clear whether women are more susceptible to contracting an HPV infection when they are pregnant. However, the rate of HPV infection certainly increases during pregnancy. Whether this increase represents new infection or simply the eruption of genital warts that were dormant or latent is not known. The prudent approach would be for women to be additionally careful about not contracting HPV during pregnancy.
HPV diagnosis during pregnancy
Pregnant women that receive appropriate prenatal care will be subjected to a battery of prenatal screening tests. These include blood type testing, sexually transmitted disease (STD) testing, along with testing for other infections. Despite this extensive testing process, human papillomavirus is not one of the STDs or infections that is tested.
This lack of testing is not an oversight, per se, but rather it is a matter of pragmatism and economics. The rate of HPV infection in the population is so high—approximately 24 million people in the United States have HPV—that diagnosis is not always needed. In most cases, unless there is an active genital wart lesion, the overall risk to the baby is low. However, under some circumstances, special considerations must be made.
First, it is possible to pass genital warts from mother to newborn, but the manner in which the virus is transmitted is not known. It does not seem that HPV crosses the placenta to any great degree. What is much more likely is that genital warts are passed to the newborn during vaginal delivery.
If genital warts are passed from mom to baby, the most worrisome outcome is childhood laryngeal papillomatosis or recurrent respiratory papillomatosis. This condition is rare but can be dangerous if it occurs. Large genital wart lesions in the airway can interfere with baby’s breathing.
In most cases, genital warts will not need to be removed prior to delivery, however if genital warts are on or near the cervix, inside the vagina, or on the vulva, it is reasonable to remove them prior to delivery. If it is not possible to remove all genital warts before delivery, the baby may be delivered through Cesarean section to avoid vaginal inoculation.
HPV treatment during pregnancy
Unfortunately many of the main drugs that are used to treat genital warts are not safe for use in pregnant women. They can cause irreparable damage to the developing infant or their effects on the unborn baby are not known. Therefore, genital warts treatment options are fairly limited during pregnancy.
In most cases, the treatment of choice for genital warts in pregnant woman is trichloroacetic acid or TCA. Trichloroacetic acid is a powerful caustic agent that burns the genital warts. It usually must be administered repeatedly over one to two months in order to achieve the desired result. Surrounding tissue (without warts) should be protected with petroleum jelly prior to treatment. The benefit of trichloroacetic acid is that very little of the substance is absorbed across the skin, if any.
If trichloroacetic acid does not destroy the genital warts as anticipated, the next best option for treatment is cryotherapy. Cryotherapy involves the use of liquid nitrogen or other highly cooled liquid/gas to freeze and destroy genital warts. After three months of therapy, about 75% of patients receiving cryotherapy will be free of genital warts.
Carbon dioxide laser therapy may also be an option for treatment of genital warts in pregnant women. The laser is selective enough that complications and side effects are rare and usually mild.