http://www.ijwhr.net doi 10.15296/ijwhr.2016.

19
http://www.ijwhr.net doi 10.15296/ijwhr.2015.27

Open Access
Open Access Case Report
Review
International
International Journal
Journal of Women’s
of Women’s HealthHealth and Reproduction
and Reproduction Sciences
Sciences
Vol.Vol.
3, No. 3, July
4, No. 2015,2016,
2, April 126–131
81–83
ISSN 2330- 
ISSN 4456
2330-  4456

WomenCervical
Giant on the Other Side of War
Condyloma and Pregnancy:
During Poverty: Its Effect
A Case
on the
Report Health of Reproduction
Ayse Cevirme
Ruben , Yasemin Hamlaci
1
Martínez-Cumplido 1* , Kevser Gonzalez-Bosquet
, Eduardo Ozdemir
2* 1 2

Abstract
Abstract
War and poverty are ‘extraordinary conditions created by human intervention’ and ‘preventable public health problems.’ War and
Introduction: Giant condyloma of the cervix (GCC) is an uncommon entity that has been poorly characterized in the literature,
poverty have many negative effects on human health, especially women’s health. Health problems arising due to war and poverty are
being even more uncommon during the pregnancy.
being observed as sexual abuse and rape, all kinds of violence and subsequent gynecologic and obstetrics problems with physiological
Case Presentation: The authors describe a case of GCC in a pregnant woman as well as reviewing the literature on the topic aiming
and psychological courses, and pregnancies as the result of undesired but forced or obliged marriages and even rapes. Certainly,
to reach a better understanding of the natural history of this entity. Our patient is a 27-year-old primigravida of Asian origin. The
unjust treatment such as being unable to gain footing on the land it is lived (asylum seeker, refugee, etc.) and being deprived of
patient has been diagnosed with cervical giant condyloma in a second trimester coitorrhage context.
social security, citizenship rights and human rights brings about the deprivation of access to health services and of provision of
Conclusion: A conservative treatment of the giant condyloma could be preferable during pregnancy, carrying surgical excision out
service intended for gynecology and obstetrics. The purpose of this article is to address effects of war and poverty on the health of
after birth.
reproduction of women and to offer scientific contribution and solutions.
Keywords: Giant condyloma, Papilloma virus, Pregnancy
Keywords: Poverty, Reproductive health, War

Introduction and used oral contraception for 18 months prior to the

Introduction
Human papilloma virus (HPV) infection of the cervix thought that severe
pregnancy. Themilitary
patientconflicts in Africa
presented to ourshorten
hospital at 18
Throughout
manifests inthe history of
a variety of morphologic
the world, the alterations
ones who had of the the expected
weeks oflifetime for more
pregnancy withthancoitorrhage
2 years. In general,
and no further
confronted the bitterest face of poverty and war had al- WHO had calculated that 269 thousand people had died
epithelium, both squamous and glandular, mature and symptomatology. Speculum examination showed a 3x2x3
ways been the women. As known poverty and war affects in 1999 due to the effect of wars and that loss of 8.44 mil-
immature. Although most lesions are flat, some have an
human health either directly or indirectly, the effects of
cm exophytic lesion at the upper cervical lip that partially
lion healthy years of life had occurred (2,3).
exophytic growth
this condition on healthwith acanthosis
and status ofandwomen
hyperkeratosis
in the so- and Warsoccupied
negatively the
affectexternal cervical
the provision orificeservices.
of health without active
verrucous
ciety should not be ignored. This study intends the
architecture. Giant condyloma of cervix
to cast bleeding (Figure 1).
Health institutions such as hospitals, laboratories and
(GCC) arises from the confluences of multiple
light on the effects of war and poverty on the reproductive condyloma Cervicovaginal
health centers are direct cytology,
targets ofcervical biopsythe
war. Moreover, and genotyping
wars
acuminate. HPV For
health of women. serotypes 6 andthe
this purpose, 11face
represent the most
of war affect- of HPV by polymerase chain reaction
cause the migration of qualified health employees, and (PCR) were
commonly
ing the women,found theand their lesions
problem displays absent
of immigration, or weak
inequalities thus performed. The hitches.
the health services patient Assessments
follow-up madewas done
indi- by the
in distribution
p16 expressionofbyincome based on gender and(1,2).
immunohistochemistry the effects cate that the effect
cervical of destruction
pathology unit. Theinresults
the infrastructure of
included a low-degree
of allmost
The these on the reproductive
common risk factorshealth of women with
associated will beHPV health continues for 5-10
intraepithelial lesion years evencytology,
in the after the finalization
a positive PCR for
addressed.
are: diabetes, low socioeconomic status, smoking, oral of conflicts
serotype(3).6 Due to resource requirements
and condyloma acuminatumin in the
the re-
histological
contraception, drug abuse, immunosuppression, and structuring
study ofinvestments
the biopsy.after war, the share allocated to
War and Women’s Health health has decreased (1).
other venereal diseases. However it is been noted that Given the patient current pregnancy status and the size
Famine, synonymous with war and poverty, is clearer for
HPV rates are highly detected among pregnant women,
women; war means deep disadvantages such as full de-
of the condyloma, we advised the patient to postpone any
Mortalities and Morbidities
relating
struction,this
lossfact to theand
of future alteration in the
uncertainty forimmune
women. response
Wars surgical
The ones who intervention
are most affectedfor from
fear of cervical
wars bleeding
are women and that may
during pregnancy (2-4).
are conflicts that destroy families, societies and cultures endanger the patient’s pregnancy, performing
children. While deaths depending on direct violence af- a cesarean
Patients who affect
that negatively present this entity
the health are usually
of community young,
and cause section because of the risk of neonatal
fect the male population, the indirect deaths kill children, infection in a
presenting vaginal bleeding and/or mass
violation of human rights. According to the data of World effect. Biopsy vaginal delivery.
women and elders more. In Iraq between 1990-1994, in-
reveals
Health aOrganization
uniformly bland, (WHO)exophytic
and World squamous
Bank, in epithelial
2002 At postpartum
fant deaths had shown control, 30 days
this reality after
in its delivery,
more a significant
bare form
wars had been
proliferation among
with viralthe first ten reasons
cytopathic changeswhich killed of
and absence with decrease
an increaseinofthe
600% (4). The
lesion was war taking five
observed years2) and a
(Figure
the mostinvasion
stromal and caused (1).disabilities. Civil losses are at the rate increases the child
surgical deaths
excision of under age of 5 bywas
the condyloma 13%.successfully
Also 47% carried
of 90% within all losses (1). of allout
the refugees in the world
by diathermic loop.andThe 50% of asylumreport
pathology seekersshowed a
War has
Case many negative effects on human health. One of
Presentation and displaced
low-degree people are women
squamous and girls and
intraepithelial 44%condyloma.
lesion, ref-
The patient is a 27-year-old primigravida of Chinese ugees and asylum seekers are children under the age of
these is its effect of shortening the average human life.
According to the data of WHO, the average human life is 18 (5).
origin without a relevant medical record. However, in her Discussion
68.1 years for males and 72.7 years for females. It is being As the result of wars and armed conflicts, women are
gynecological and obstetric record it is noted that she is a The giant condyloma from ano-genital region was
primigravida with a history of vulvar condyloma, which described by Abraham Buschke and Ludwig Lowenstein
was treated
Received successfully
12 December topically
2014, Accepted oneAvailable
25 April 2015, year prior
online 1to
Julythis
2015 in 1896. It was later named Buschke-Lowenstein tumor
pregnancy.
1
She presents
Department of Nursing, with regular
Sakarya University, cycles
Sakarya, Turkey. 2
and started
Department (BLT)University,
of Midwifery, Sakarya after Sakarya,
them.Turkey.
Multiple cases in anus, penis and
*Corresponding author: Yasemin Hamlaci, Department of Midwifery, Sakarya University, Sakarya, Turkey. Tel: +905556080628,
sexual intercourse at 19 years. She had 3 sexual partners perineum have been reported since then, being very rarely
Email: yaseminhamlaci@gmail.com

Received 17 October 2015, Accepted 14 January 2016, Available online 5 February 2016
1
Department of Obstetrics and Gynecology, Sant Joan de Déu Hospital, Barcelona, Spain.
*Corresponding author: Ruben Martínez-Cumplido, Department of Obstetrics and Gynecology, Sant Joan de Déu Hospital, Barcelona, Spain.
Tel: +34645924754, Email: rubenmartinez@hsjdbcn.org
Martínez-Cumplido and Gonzalez-Bosquet
Figure 1. Speculum examination showing an exophytic lesion
at the upper cervical lip partially occupying the external cervical
orifice without active bleeding. The features of the camera were:
Nikon D800E; 60 mm Lens; 125 Shutter speed; f-29; ISO 100;
Flash ring.
Figure 2. A significant decrease in the lesion was observed. The
features of the camera were: Nikon D800E; 60mm Lens; 125
Shutter speed; f-29; ISO 100; Flash ring.
present in the cervix (5).
Condyloma acuminate are frequently located on the
external genitalia and perineal zone. They tend to
increase and spread after any alteration of the immune
system. Condyloma acuminate tend to spread and
proliferate quickly during pregnancy and then decrease
during puerperium (6). It is known the most risk factors
of HPV infection in the literature are diabetes, low
socioeconomic status, multiple sexual partners, smoking,
oral contraception, drug abuse, immunosuppression,
and other veneral diseases (2,3). In our case, the risk
factors were young age, three sexual partners and oral
contraception. Although we found the condyloma
acuminate in a less frequent location, mainly in the
cervix, the clinical course of the lesion corresponded to
those described above: proliferation during the pregnancy
followed by a spontaneous decrease during puerperium.
The cases of a localized lesion of HPV developing into an
invasive BLT are scarce (6,7).
Large size condylomata may be treated to prevent
obstruction/mass effect in the delivery canal, to prevent
newborn infections and the possible progression to
preneoplastic or neoplastic lesions (1). Reported cases
show that some lesions can increases rapidly in size during
82 International Journal of Women’s Health and Reproduction Sciences, Vol. 4, No. 2, April 2016
the pregnancy producing bleeding and mass effect by
mechanical obstruction (8). Therefore, we need to asses
every single case individually by considering the risks and
benefits of management i.e. not only by the characteristics
of the lesion but also the best way of delivery (8). In our
case, vaginal bleeding was the reason for seeking medical
assistance. It was at the exploration when we could note
the partial obstruction of the external cervical orifice
(1,4,6,9).
The transmission risk to the fetus and the partner should
not be underestimated. The estimated risk of transmission
to the partner after sexual intercourse is 66%. The
estimated transmission risk from fomites is unknown.
On the other hand, fetal transmission risk is estimated
at a 20%. The manner of delivery (vaginal or cesarean
section) does not seem to influence neonatal infection rate
(10). Generally the newborn becomes clear of the HPV
infection after the first year of life; the development of
HPV lesions after that period is very rare (11).
An important reason for the treatment of these lesions in
a pregnant woman is the threat of potential progression
to cancer (12). Methods that have been used for the
treatment of BLT include immunotherapy, radiotherapy,
podophyllin and CO2 laser, but none of them treats the
lesion successfully (13). Surgical excision is the treatment
with the best results (14-16). Nevertheless, it is important
to highlight the possibility of more conservative treatments
based on the serotype found in the biopsies, being more
conservative in low risk serotypes.
Considering the literature review as well as our experience
in this case, the authors conclude that this lesion should be
treated, due to its features alongside its risk of malignant
progression (12-14). The preferred treatment is surgical
excision. Nonetheless, given the natural history of these
lesions during the pregnancy (6), a conservative treatment
could be preferable, finishing the treatment with a surgical
excision after birth.
Ethical Issues
There is no ethical issue in this paper.
Conflict of Interests
The authors declare no conflict of interests.
Financial Support
The researchers received no financial support or grant
from any funding agency in the public and commercial
sectors.
Acknowledgments
The authors would like to thank the personnel of the Image
and Sound Department of Sant Joan de Déu Hospital for
their support and pictures.
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International Journal of Women’s Health and Reproduction Sciences, Vol. 4, No. 2, April 2016 83