In recent years, the prevalence of human papillomavirus (HPV) infection has increased significantly and tends to be younger. Among them, women of childbearing age are among the high-risk groups for HPV infection. We often see patients who are preparing for pregnancy, who know little about HPV virus, and after finding out that they have tested positive for HPV virus, they are in anxiety about whether they can get pregnant or not. Will I still be able to get pregnant?
There are no guidelines recommended for the management of pregnancy in HPV-infected patients based on evidence-based medical evidence or consensus development. Given the impact of HPV infection, patients encountering HPV-positive patients should be evaluated for the combination of other infections of the lower genital tract, the need for cervical cancer screening, and the presence or absence of condyloma acuminata before deciding whether pregnancy is possible.
I. HPV virus typing
There are two major categories according to the oncogenicity of the virus.
1, low-risk HPV (non-cancer-related, LR-HPV): including HPV6, 11, 42, 43 and some new HPV, whose DNA is often diploid and polyploid, can cause cervical intraepithelial neoplasia Ⅰ (CIN Ⅰ) and some CIN Ⅱ, such lesions can generally be self These lesions usually resolve on their own, and it is rare to see LR-HPV infected patients develop CIN III or cervical cancer. Low-risk HPV is associated with condyloma acuminatum.
2, high-risk HPV (cancer-related, HR-HPV) including HPV16, 18, 31, 33, 35, 39, 45, 51, 52, 56, 58, 59, 68, 26, 53, 66, 68 and other types, the DNA is often aneuploidy, can not be self-regressed, rarely reversed, and CIN Ⅲ and invasive cervical cancer related. It is associated with CIN III and invasive cervical cancer. There are also reports of types 31 and 45.
High-risk HPV infection
High-risk HPV infection is closely related to the occurrence of cervical cancer, and the average time interval from the beginning of high-risk HPV infection to the development of cervical cancer is about 15 years. The 2007 SOGC guidelines suggest that there is no evidence that HPV infection during pregnancy affects the progression of cervical cancer.
1. Planning pregnancy in CINI patients
The ASCCP 2013 guidelines state that follow-up is preferred and treatment is not recommended for CINI in pregnant women.
2. Pregnancy planning in CIN II and III patients
For patients with CIN II and III, follow up after initial management and regular treatment according to the guidelines. If no higher grade lesions are found at screening, pregnancy can be considered within the safe period of screening. During pregnancy, cervical cytology and colposcopy need to be repeated at 12-week intervals, and if there is no significant progression, the pregnancy is able to continue to full term. Repeat biopsy is recommended only if the (colposcopic) lesion site presentation worsens or if cytology suggests invasive cancer. Postpone reassessment until at least 6 weeks after delivery. Reassessment is recommended for cytology combined with colposcopy and no less than 6 weeks postpartum.
III. Low-risk HPV infection
1, maternal condyloma acuminatum
Condyloma acuminatum is mainly caused by low-risk HPV infection. The increase in the level of steroid hormones during pregnancy makes the maternal immune function suppressed, the genital tract is rich in local blood circulation, increased secretions, so that the HPV infection during pregnancy presents the following characteristics:
(1) HPV infection during pregnancy is susceptible to condyloma acuminata.
(2) Condyloma acuminatum during pregnancy is prone to ulceration, bleeding and recurrence, which can increase the rate of reproductive system infection.
HPV infection during pregnancy may also increase the susceptibility of pregnant women to other pathogens. 2004 da Silva et al. studied 26 HPV-infected pregnant women and the same sample size of non-HPV-infected pregnant women and showed that the rates of bacterial vaginitis and Chlamydia trachomatis infection were higher in HPV-infected pregnant women than in non-HPV-infected pregnant women.
Viral eradication therapy is not necessary for pregnant women with asymptomatic HPV subclinical infection during pregnancy. Removal of warts may be considered in patients with warts that cause significant symptoms, interfere with delivery, or have warts that do not regress significantly after delivery. Although wart removal can be considered during pregnancy, the treatment of warts during pregnancy is not ideal and there is no evidence that treatment of warts reduces mother-to-child transmission and the occurrence of laryngeal papillomas in children, plus most wart lesions during pregnancy can rapidly regress postpartum eradication during pregnancy. The purpose of pregnancy condyloma treatment is to reduce the size of the lesion so as not to affect the delivery, reduce the patient discomfort and psychological burden.
2, neonatal HPV infection and its impact factors
The 2010 CDC Guidelines for Sexually Transmitted Diseases state that vertical transmission of HPV is not known and may include transplacental infection, infection during delivery and infection after birth. It has been found that vertical transmission of HPV can occur throughout pregnancy, not just during late gestation and delivery when direct contact with the infected birth canal and swallowing HPV-containing amniotic fluid, blood, or secretions was thought to be the only route of transmission, and this has been recognized by many authors. In recent years, many studies have found that congenital acromegaly and childhood laryngeal papilloma can also develop in children born by cesarean section without rupture of membranes. The placenta has a limited barrier effect on HPV. In addition to the above two routes, close contact between the newborn and viral carriers after birth may also result in neonatal HPV infection.
Whether vertical transmission of HPV infection during pregnancy causes fetal malformation, fetal distress, or stillbirth is controversial because of the lack of data from large samples. The main risk and most notable consequence of vertical transmission of HPV infection during pregnancy is the possibility of childhood laryngeal papilloma in the offspring. HPV-6 and 11 infections are the most common cause of laryngeal papilloma in children, and are frequent, recurrent, and difficult to treat, posing a significant health risk to children. However, the incidence of laryngeal papilloma in children is much lower than the incidence of acromegaly in pregnant women. The 2007 SOGC guidelines and the 2012 EADV European Guidelines for the Management of Acromegaly state that the risk of childhood laryngeal papilloma in the offspring of pregnant women with acromegaly is only 0.25% or less.
Therefore, careful examination of the vagina and cervix and routine cervical cytology should be performed to detect cervical squamous intraepithelial lesions in cases of vulvar condyloma. Those found to have warts should be treated aggressively before considering pregnancy. Treatment should only be aimed at removing the exophytic warts and improving the signs and symptoms.
In summary, most patients with HPV infection without histocytological changes do not need to wait for clearance of the virus before becoming pregnant. On the one hand, there is a lack of specific drugs for the treatment of HPV virus infection and it mainly depends on the body’s own immunity to clear it, which takes a long time.