What is the recommended treatment for Human Papillomavirus (HPV) in pregnant patients?

Treatment of HPV in Pregnant Patients

For pregnant women with visible genital warts, safe treatment options include cryotherapy with liquid nitrogen or surgical removal, while podophyllin, podofilox, imiquimod, and sinecatechins are strictly contraindicated during pregnancy. 1, 2

Treatment Approach for Visible Genital Warts

Safe Treatment Modalities

• Cryotherapy with liquid nitrogen is the first-line safe option for treating visible genital warts during pregnancy 1, 2
• Surgical excision can be performed when indicated 1
• Laser ablation is an acceptable alternative for larger or more extensive lesions 2
• Trichloroacetic acid (TCA) 80-90% can be applied directly to warts, though this is more commonly used for anal warts; the treatment area should be powdered with talc or sodium bicarbonate to remove unreacted acid 1, 3

Strictly Contraindicated Treatments

• Podophyllin is absolutely contraindicated due to concerns about systemic absorption and potential fetal toxicity 1, 2, 3
• Podofilox (podophyllotoxin) must not be used during pregnancy 1, 2, 3
• Imiquimod should not be used in pregnant women 1, 2
• Sinecatechins are contraindicated during pregnancy 2

Clinical Considerations Specific to Pregnancy

Natural History During Pregnancy

• Genital warts have a tendency to proliferate and become friable during pregnancy, which is why many experts advocate for their removal 1, 2, 4
• Treatment resolution may be incomplete until after delivery, and this should be discussed with patients 2
• The prevalence of HPV infection in pregnancy ranges from 5.5% to 65% and may increase with gestational age 3

Delivery Planning

• Cesarean section should NOT be performed solely to prevent HPV transmission to the newborn, as the preventive value is unknown and laryngeal papillomatosis has occurred even in infants delivered by cesarean 1, 2
• Cesarean delivery is indicated only in two specific scenarios: when genital warts physically obstruct the pelvic outlet or when vaginal delivery would result in excessive bleeding 1, 2

Counseling About Vertical Transmission

• Pregnant women with genital warts should be counseled about the low risk of juvenile-onset recurrent respiratory papillomatosis (JORRP) in their infants, caused by HPV types 6 and 11 2
• The route of transmission (transplacental, perinatal through birth canal, or postnatal) remains incompletely understood 1, 2
• Despite the theoretical risk, the actual incidence of JORRP is very low and does not justify routine cesarean delivery 2

Management of Asymptomatic HPV Infection

Subclinical Infection Without Visible Warts

• No treatment is indicated for subclinical HPV infection detected only by DNA testing or Pap smear changes during pregnancy 1
• Cervical cytology abnormalities attributed to HPV often regress spontaneously without treatment 1
• Management of abnormal cervical cytology during pregnancy should follow standard guidelines for cervical cancer screening in pregnancy 3

Cervical Screening

• Annual cytologic screening is recommended for women with or without genital warts 1
• The presence of genital warts alone is not an indication for colposcopy 1

Follow-Up and Monitoring

• After visible warts have cleared with treatment, routine follow-up is not mandatory 1
• Patients should be counseled to watch for recurrences, which occur most frequently during the first 3 months postpartum 1
• A follow-up evaluation 3 months after treatment may be offered to document wart-free status and provide patient education 1

Important Caveats

• Treatment does not eliminate HPV infection; patients may remain infectious even after visible warts are removed 1
• Immunosuppressed pregnant women (including those with HIV) may not respond as well to therapy and may experience more frequent recurrences 1
• HPV vaccination is not currently recommended during pregnancy, though inadvertent vaccination has not shown adverse effects on mother or fetus 3