Immediate Postpartum Management of a Giant Vaginal Condyloma in an Adolescent

Dr. Giovana Charite, Dr. Saida Bowe, Dr. Andrew Taylor, Dr. Shamanique Bodie-Williams

Rand Memorial Hospital, Grand Bahama, Bahamas

Objective

To review the management of 16 yo with a symptomatic giant vaginal condyloma in the postpartum period.

Case Report

A 16 yo primigravida was seen when she was referred from the community clinic to the specialty clinic.  She was noted to have multiple lesions in the vagina.   On initial speculum and vaginal exam, the lesion seemed to be obstructing the vaginal canal. The patient did not have any itching or discharge from the vagina.  She had some bleeding with wiping. Her gynecologic history included menarche at 11 with regular cycles coitarche at 14 with 3 male lifetime partners.  She had no history of other sexually transmitted infections. She had not used the any contraceptive methods.  She has no medical illness. She did not smoke, use alcohol or recreational drugs. Her serologies including VDRL, HIV, HepBsAgb and chlamydia were negative.

Otherwise, the patient had an uneventful antenatal course. She progressed to term.  She was delivered via cesarean section at the onset of labour.  Post cesarean delivery, the vagina was inspected in theater and a large mass approximately 5 cm * 4 cm was noted to be arising from the vaginal mucosa adjacent to the bladder.  Given the size of this lesion and the fact that it originated from a stalk, and because it was bleeding the decision to excise it was made.  The remaining smaller lesions were cauterized.  The patient received the Gardasil HPV vaccination in the post partum period.

Discussion

 Adolescent Pregnancy

Adolescent pregnancies are defined a pregnancy where the young lady is 15 to 19 years old. The complications that may be encountered include increased risks of eclampsia, puerperal endometritis and systemic infections. They also face increased risk of preterm birth, low birth weights and neonatal complications than their counterparts that are in the 20 to 24 age group.  Complications during pregnancy and childbirth are the leading cause of death for female adolescents between 15 to 19.

HPV in Adolescents and  Pregnancy

The HPV virus is a member of the Papillomaviridae family, a family of small double-stranded DNA viruses. HPV infections can be noted to be latent or clinically evident as in this case.  The clinically evident forms of HPV virus include warts on the vulva, urethra, vagina, cervix and anus and cervical cancer.  HPV infections may be subclinical; however, this infection can also cause genital warts. The risk factors include immune suppression and early age of first intercourse.  HPV- DNA detection in one study was noted to be 6.5%.  It was also noted that the risk of vertical transmission was low.  Visible warts are estimated to be present in about 1% of the population

HPV in Adolescents is estimated at 50-80%. Genital warts may increase during pregnancy as the immune system is suppressed. Diagnosis is made by clinical exam but is confirmed  with biopsy.  There is no evidence that HPV testing is necessary for visible warts. Patients with condyloma in pregnancy may be fast growing and patients may have difficulty with compliance with treatment.  Treatments that have been tested and recommended include cryotherapy, electrocautery, proanthocyanidins and surgical excision.

HPV (Human Papilloma Vaccine)

The purpose of the HPV vaccine is designed to prevent HPV infection.    Clinical indications for the HPV vaccine include history of an abnormal pap test, genital warts  or evidence of high risk HPV.  The HPV Vaccines that are currently available include the Cervarix and the Gardasil. The contraindication to the HPV vaccine is an allergic reaction  to a vaccine component or an allergic reaction to a previous dose of the vaccine.  As the quadrivalent vaccines are produced in Saccharomyces cervesisisiae (Baker’s) Yeast – a previous hypersensitivity to the yeast is also a contraindication.  Pregnancy is also a contraindication to the vaccine.  HPV Vaccine can be given in a patient even if breast feeding.

Conclusion

The above case presents a rare case of giant vaginal condyloma in an adolescent pregnancy.  The case demonstrates impact that HPV and  its possible manifestations  can have on the impact of managing a pregnancy. The case also outlines the management of large condylomas and post delivery management  inclusive of the administration of the HPV vaccine.