A 32-year-old woman, gravida 3 para 2, at 38 weeks gestation is admitted to labor and delivery for contractions and vaginal spotting. The patient reports good fetal movement and no rupture of membranes. Her last prenatal visit was at 18 weeks gestation. She has no medical problems or previous surgeries. Her first 2 pregnancies ended in uncomplicated vaginal deliveries. The patient takes a prenatal vitamin daily. She smoked cigarettes occasionally prior to this pregnancy but does not use alcohol or illicit drugs. Temperature is 36.7 C (98 F), blood pressure is 110/80 mm Hg, and pulse is 76/min. The fetal heart rate tracing shows a baseline of 140/min, moderate variability, good accelerations, and no decelerations. The tocometer shows contractions every 3 minutes. On pelvic examination, several flesh-colored, hyperkeratotic papules are noted on the posterior introitus, labia majora, and labia minora. The papules are 1-2 cm in diameter, have a smooth surface, and are sessile. The cervix is 5 cm dilated and 90% effaced. The patient's sexually transmitted infection screen at her initial prenatal visit was negative. Which of the following is the best next step in management of this patient?

Question

A 32-year-old woman, gravida 3 para 2, at 38 weeks gestation is admitted to labor and delivery for contractions and vaginal spotting.  The patient reports good fetal movement and no rupture of membranes.  Her last prenatal visit was at 18 weeks gestation.  She has no medical problems or previous surgeries.  Her first 2 pregnancies ended in uncomplicated vaginal deliveries.  The patient takes a prenatal vitamin daily.  She smoked cigarettes occasionally prior to this pregnancy but does not use alcohol or illicit drugs.  Temperature is 36.7 C (98 F), blood pressure is 110/80 mm Hg, and pulse is 76/min.  The fetal heart rate tracing shows a baseline of 140/min, moderate variability, good accelerations, and no decelerations.  The tocometer shows contractions every 3 minutes.  On pelvic examination, several flesh-colored, hyperkeratotic papules are noted on the posterior introitus, labia majora, and labia minora.  The papules are 1-2 cm in diameter, have a smooth surface, and are sessile.  The cervix is 5 cm dilated and 90% effaced.  The patient's sexually transmitted infection screen at her initial prenatal visit was negative.  Which of the following is the best next step in management of this patient?

Quizplus · Accepted Answer

Explanation: 11ec2b69_c043_ec1a_8f63_3525b27ed9c3_MD0005_00 This patient presents in labor with extensive genital condyloma acuminata, the dermatologic manifestation of human papillomavirus (HPV) infection. HPV is primarily transmitted through sexual contact, and the most common areas affected in women include the vulva, vagina, cervix, perineum, and perianal region. Most condyloma acuminata are caused by HPV types with low oncogenic potential (eg, 6 and 11). HPV can be vertically transmitted. Children with vertically transmitted HPV typically present with lesions in the oropharynx, larynx, or trachea at age 2-5; the most severe manifestation is juvenile-onset respiratory papillomatosis (JRP). There is an association between JRP, childhood HPV disease, and maternal HPV disease. However, cesarean delivery does not prevent vertical transmission or decrease the risk for JRP or childhood HPV disease. Therefore, expectant management for vaginal delivery is the best management for this patient. (Choice A) Acyclovir is an antiviral agent used for herpes simplex virus but is not indicated for HPV. (Choices B and E) A tocolytic (eg, uterine contraction inhibition) for the purpose of prolonging pregnancy is indicated for preterm labor at <34 weeks gestation; this patient is at term. Excision of condyloma during pregnancy is indicated if lesions are large and obstruct the birth canal, but excision does not decrease the risk for vertical transmission. Excision of large obstructing condyloma during pregnancy is not always feasible due to the risk of bleeding complications. If excision of obstructing condyloma is not feasible, then cesarean delivery is indicated. This patient has small, nonobstructing lesions. (Choice C) Podophyllum is a topical medication used to treat condyloma acuminata. However, use is contraindicated during pregnancy due to an association with birth defects and intrauterine fetal demise. Educational objective: Cesarean delivery does not prevent vertical transmission of human papillomavirus. Women with condyloma acuminata can proceed with a vaginal delivery unless the condyloma are large and obstruct the birth canal. References: Human papillomavirus vertical transmission: review of current data. (http://www.ncbi.nlm.nih.gov/pubmed/23392393)

A 32-Year-Old Woman, Gravida 3 Para 2, at 38 Weeks