1. بسم الله الرحمن الرحیم
IN THE NAME OF ALLAH

2. Human Papilloma Virus in Pregnancy
A.Mohammadzadeh (M.D)
Avesina Reaserch Center

3. 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.

4. Virology HPV is a member of the papavirideae family.
1-Simian V. and Polyoma V HPV
8000 KB with dsDNA.
More than 80 types of HPV are identified .(DNA sequence <50%)
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

5. 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).

6. 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.

7. Why HPV is important? It is a sexually transmitted disease.
Some types of HPV can induce cancer.
Low potential HPV=6,11,35
Condyloma , CIN1
High potential HPV=16,18,31,50-60)
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

8. Clinical Aspects Direct inspection (warts). Autoinoculation.
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.

9. Laboratory Diagnosis Culture Skin biopsy; Pap smears; DNA assay
papillomatosis, acantosis, thickening of rete peg, koilocytosis
Pap smears;
koilocytosis
LSIL=HPV & CIN1
HPV6,11
HSIL=CIN2,3 & CIS
HPV16
DNA assay
Routine screening of pregnant women for HPV is not recommended.
In 2002;Prevelence between pregnant and non pregnant is similar. And a majority of them had normal Pap smears.

10. Fig2:Flat condyloma due to HPV infection of cervical mucosa
Fig2:Flat condyloma due to HPV infection of cervical mucosa .the mucosa is thickened .Koilocytosis is present in the upper layers.

11. Fig3:Kiolocytosis .this screening power magnification shows scattered mature squamus with well-defined clearing of cytoplasm around the nuclei and slight nuclear enlargement (MP)

12. Fig4:Kiolocytosis in a cervical smear
Fig4:Kiolocytosis in a cervical smear.these superficial cells shows a wide zone of perinuclear clearing with condensed peripheral cytoplasm .

13. Fig 5: typical Koilocytosis

14. Fig6: HPV infection with Koilocytosis

15. Fig7:different types of CIN

16. Fig8:HPV/CIN2-3(ciribriform and punctation pattern of HPV near SCJ

17. Fig9: CIN3:white lesion , punctation and mosaism

18. 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.

19. 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 2002;HSIL in pregnancy is more common.HPV16
Diabetic pregnant women is more vulnerable to HPV.

20. Maternal-Fetal transmission.
Aspiration of mother’s discharge during labor is the main way of HPV transmission to newborn.
Disappears within 6 months after birth.
IN 2003;After 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

21. NVD or C/s
In 2003;HPV in mothers=28% In infants with C/S=10% In NVD=18% HPV 16 is the most common types in mother and infants .
Findings;1- 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.

22. 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 (>2mm)

23. 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