Thursday, October 23, 2008

Got Gardasil?

NewFNP had two HPV-related teen pregnancy issues today.  Both were really sad and unsatisfying, both to her patients and to herself.

NewFNP's first HPV lady is a 16-year old 259-pound 35 weeker.  She has gained 47 pounds this pregnancy, far surpassing the 0-15 pounds newFNP recommended at the outset.  At pregnancy diagnosis, she had chlamydia and a low grade lesion on her pap.  NewFNP referred her for colposcopy - she didn't go.  She was scared, which is understandable, and her mom counseled her against going, which is less so.

After several visits of encouraging her to get the colposcopy to no avail, newFNP said fuck it and repeated her pap, hoping that her youth would wrestle that HPV into submission and normalize her pap.

Alas, it's now a high grade lesion.  

NewFNP resubmitted the colpo referral, acknowledged fears, stressed patients' rights and informed consent and strongly encouraged this young woman to not blow off this evaluation.  

The second 16-year old HPV lady also had chlamydia at pregnancy diagnosis and has recently been diagnosed with external condyloma acuminata, or genital warts.  You may recall newFNP noting how she had newFNP pulled out of the exam room to share this "emergency" with her.

She returned to clinic today, concerned that she had a yeast infection.  NewFNP placed her in the lithotomy position, noted the external warts - which now seem quite petite - and placed the speculum.

What greeted newFNP briefly forced her to consider that her knowledge of the female genital anatomy was really, really inadequate or like maybe she was in the wrong body cavity - a cavity she has never before seen.  The exam begged the question: what percentage of the surface area of the vaginal and cervix can be covered with condyloma before one considers c-section?  

Greater than fifty percent?  Seventy-five?  Fifty percent vag, fifty percent cervix?  This is something that is not in newFNP's textbooks.  It is likely something that one picks up from a wise mentor with years/decades of OB/GYN experience or years of your own OB/GYN clinical experience.  

NewFNP knows that there is a chance of extensive laceration and poor ability to suture the lesions during a vaginal delivery.  She assumes that this risk is increased when one's cervix is almost unrecognizable due the presence of extensive large verrucae.  And then, once the baby exits the cervix, it must make its way down the cobblestone canal-o- vaginal warts. 

Baby, keep that little toothless mouth closed!  Not that laryngeal papillomata are so common, but newFNP is just sayin'!  An ounce of prevention, ya know.  

As newFNP does not do deliveries, she arranged a consultation with the team that does.  

These young women just can't catch a break.  They have fucked up lives, fucked up parents, fucked up partners (neither of whom stuck around to support these girls during their pregnancies) and multiple STDs.  

And they're 16 and pregnant.  Mercy.


DamselFish said...

I'd love to hear a mother's argument for skipping the colpo. That's just child abuse right there.

npsusan said...

Does your patient have HIV???

newFNP said...

Her HIV test was negative.

There are anecdotal reports of condyloma worsening in pregnancy which is thought to be because one's cell mediated immunity is decreased, allowing for progression of viral infections. NewFNP thought that she read something about the change in vaginal discharge playing a role, but now she can't find that source. Balls!

LilSass said...

All I can say is Dear Gawd in Heaven .... pregnant and 16 is tragic enough for me. All these other things? Ugh. Horrific

Shelby said...
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