What is the most appropriate management for a pregnant woman with genital warts (Human Papillomavirus, HPV)?

Management of Genital Warts in Pregnancy

Cryotherapy with liquid nitrogen is the most appropriate management for this pregnant woman with genital warts. 1

Diagnosis

The clinical presentation of multiple flesh-colored exophytic papules on the labia, some pedunculated, ranging from 3-7 mm in size, is consistent with genital warts caused by Human Papillomavirus (HPV), typically types 6 and 11.

Treatment Algorithm for Genital Warts in Pregnancy

First-line Treatment

• Cryotherapy with liquid nitrogen
  • Apply to each wart individually
  • Can be repeated weekly if necessary
  • Safe during pregnancy
  • Efficacy: 63-88% with recurrence rates of 21-39% 1

Alternative Options (if cryotherapy fails)

• Trichloroacetic acid (TCA) 80-90%

  • Apply only to warts
  • Allow to dry until white "frosting" develops
  • Neutralize with talc or sodium bicarbonate
  • Can be repeated weekly as needed 1

• Surgical removal

  • Reserved for large or treatment-resistant warts
  • May be necessary if warts are obstructing the birth canal 1

Contraindicated Treatments in Pregnancy

• Podophyllin and podofilox - contraindicated due to potential systemic absorption and risk of teratogenicity 1
• Imiquimod - safety during pregnancy has not been established 2
• 5-fluorouracil - not recommended for genital warts and contraindicated in pregnancy 1

Treatment Considerations

Pregnancy-Specific Factors

• Genital warts may proliferate and become friable during pregnancy due to hormonal changes and relative immunosuppression 1
• Many experts advocate removal of visible warts during pregnancy to reduce complications during delivery 1
• Cesarean delivery is NOT indicated solely for prevention of HPV transmission to the newborn 1
• Cesarean delivery may be considered only if warts obstruct the birth canal or if vaginal delivery would result in excessive bleeding 1

Follow-Up

• Monitor for recurrence, which is common, especially in the first 3 months after treatment 1
• Assess treatment response and consider alternative approaches if no improvement after 3 sessions 3
• No need for colposcopy based solely on the presence of genital warts 1

Patient Education

• HPV infection is common and often transient 4
• Genital warts caused by HPV types 6 and 11 are not associated with cervical cancer 1
• Recurrence is common and usually indicates reactivation rather than reinfection 1
• The use of condoms may reduce transmission to uninfected partners 1

Common Pitfalls to Avoid

1. Using podophyllin, podofilox, or imiquimod in pregnant women
2. Performing unnecessary cesarean sections solely to prevent HPV transmission
3. Overtreatment leading to scarring or other complications
4. Failing to consider that warts may recur despite appropriate treatment
5. Not addressing patient concerns about transmission to the partner or newborn

By following this treatment approach, the patient's genital warts can be managed effectively while minimizing risks to both mother and fetus.