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Genotypic Prevalence of Human Papillomavirus Infection During Normal Pregnancy: A Cross-Sectional Study
Genotypic Prevalence of Human Papillomavirus Infection During Normal Pregnancy: A Cross-Sectional Study
doi:10.1111/jog.12155
Department of Obstetrics and Gynecology, Ewha Womans University School of Medicine, 2Department of Obstetrics and
Gynecology and 3Cancer Research Institute, Seoul National University College of Medicine, 4Department of Obstetrics and
Gynecology, Seoul Metropolitan Government Seoul National University Boramae Medical Center, 5Major in Biomodulation,
World Class University, Seoul National University, Seoul, 6Department of Obstetrics and Gynecology, Inje University College
of Medicine, Ilsan-Paik Hospital, Gyeonggi, 7Seoul Womens Hospital, Incheon, Korea; and 8Department of Obstetrics and
Gynecology, Tufts University School of Medicine, Boston, Massachusetts, USA
Abstract
Aim: Genital human papillomavirus (HPV) infection is a necessary factor in most cases of cervical cancer, but
malignant transformation requires the presence of additional cofactors such as pregnancy. Little is known
about the effect of pregnancy on genital HPV carriage. We therefore analyzed the prevalence and genotypic
patterns of genital HPV infections in normal pregnancies.
Methods: The prevalence of HPV infection was measured in 960 consecutive normal pregnant or post-partum
women by HPV-DNA chip analysis of cervical swabs. Data were analyzed by trimester and adjusted for
sociodemographic, reproductive and reported sexual history.
Results: The overall prevalence of HPV infection in the population was 24.3%. High-risk HPV genotypes were
detected in 68.2% of infected subjects, including HPV 16 (18.7%), 39 (16.4%), 53 (10.1%), and 56 (9.4%).
High-risk HPV genotypes were significantly more prevalent in the second trimester (23.8%) compared with the
other periods (first trimester, 13.2%; third trimester, 17.4%; post-partum, 15.1%; P = 0.010). However, the
high-risk HPV genotypes 16 or 18 were detected most frequently in the third trimester (7.2%) as compared to
the other periods (first trimester, 2.9%; second trimester, 5.2%; post-partum, 2.1%; P = 0.03). After adjusting for
confounding variables, overall HPV infection (odds ratio = 1.84, 95% confidence interval = 1.242.75) and
high-risk HPV genotypes (odds ratio = 1.94, 95% confidence interval = 1.233.05) were significantly more
common in the second trimester.
Conclusion: The second trimester may be the most vulnerable period in high-risk HPV infections, which
necessitates future investigations.
Key words: genotype, human papillomavirus, pregnancy, prevalence, risk factor.
Introduction
Genital human papillomavirus (HPV) infection is
regarded as a necessary factor in most cases of cervical
cancer,1 but is not sufficient to cause invasive disease.
Malignant transformation appears to require the pres-
200
Methods
We performed a prospective cross-sectional study of
healthy pregnant women presenting to a single obstetric clinic in Incheon, Korea. All women aged 18 years
or older with a sonographically confirmed intrauterine
pregnancy who visited the clinic for prenatal and/or
post-partum care between May 2009 and June 2010
were approached and offered inclusion in the study.
Subjects were excluded if they had evidence of immunosuppression (such as HIV infection, transplantation
or malignancy), a connective tissue disorder or were
receiving medications related to immune modulation
(such as corticosteroids). The study was approved by
the institutional review board (H-0901-030-268), and
written informed consent was obtained from all study
participants.
Each participant completed a comprehensive medical history questionnaire, which included questions
about sociodemographic characteristics, smoking,
drinking, Papanicolaou smear screening, reproductive
and sexual history, and use of contraception. Thereafter, all subjects underwent a routine gynecological
examination. Cervical swab samples were collected
using a liquid cytology device (SurePath Technology;
TriPath Imaging, Burlington, NC, USA). The 2001
Bethesda System terminology was used to report the
results of the cervical cytology.12 All women with
abnormal Papanicolaou test results were referred for
colposcopic examination and biopsy.
High- and low-risk HPV were classified according to
the consensus of the International Agency for Research
on Cancer (IARC).13 The presence of HPV-DNA in the
cervical swabs was detected using the GG HPV Genotyping Chip Kit (Goodgene, Seoul, Korea),14 which can
identify 40 HPV genotypes (6, 11, 16, 18, 26, 30, 3135,
39, 40, 4245, 5156, 58, 59, 61, 62, 6670, 72, 73, 8184,
90 and 91). The GG HPV Genotyping Chip Kit had a
Results
One thousand consecutive women were approached for
inclusion in the study. Of these, 40 (4.0%) declined to
participate and 960 women were enrolled (first trimester, n = 380; second trimester, n = 193; third trimester,
n = 195; post-partum, n = 192), representing an acceptance rate of 96.0%. All subjects were Korean, and the
median age was 31 years (range, 1946). There were
significant differences in parity, level of education,
smoking, drinking, previous screening of cervical cytology, age of sexual debut and number of previous sexual
partners among the four groups (P < 0.05; Table 1).
201
Y. H. Kim et al.
First
trimester
n = 380
Second
trimester
n = 193
Third
trimester
n = 195
Postpartum
n = 192
P-value*
31.1 4.0
14.2 1.4
28.5 4.0
28.6 3.5
182 (47.9)
156 (41.1)
42 (11.1)
70 (18.4)
88 (23.2)
120 (31.7)
233 (61.5)
26 (6.9)
65 (17.1)
87 (22.9)
276 (72.6)
55 (29.4)
66 (35.3)
66 (35.3)
94 (51.4)
89 (48.6)
160 (86.5)
24 (13.0)
1 (0.5)
80 (43.0)
15 (8.1)
86 (46.2)
5 (2.7)
31.4 4.1
14.3 1.3
28.6 4.1
28.6 3.0
132 (68.4)
41 (21.2)
20 (10.4)
24 (12.4)
45 (23.3)
75 (38.9)
101 (52.3)
17 (8.8)
4 (2.1)
32 (16.6)
113 (58.6)
33 (21.6)
42 (27.5)
78 (51.0)
84 (54.9)
69 (45.1)
122 (79.7)
29 (19.0)
2 (1.3)
56 (36.6)
23 (15.0)
71 (46.4)
3 (2.0)
30.9 3.6
14.3 1.3
28.9 3.7
28.5 2.7
146 (74.9)
42 (21.5)
7 (3.6)
28 (14.4)
35 (18.0)
76 (39.0)
109 (55.9)
10 (5.1)
11 (5.6)
23 (11.8)
131 (67.2)
26 (16.1)
55 (34.0)
81 (50.0)
106 (65.4)
56 (34.6)
139 (85.8)
20 (12.4)
3 (1.9)
53 (32.7)
14 (8.6)
94 (58.0)
1 (0.60)
31.5 3.9
14.4 1.3
28.8 3.7
28.9 2.9
0 (0.0)
141 (73.4)
51 (26.6)
28 (14.6)
38 (19.8)
57 (29.7)
121 (63.0)
14 (7.3)
18 (9.4)
53 (27.6)
133 (69.3)
38 (22.9)
60 (36.1)
68 (41.0)
58 (34.9)
108 (65.1)
142 (85.5)
23 (13.9)
1 (0.6)
59 (35.5)
20 (12.1)
81 (48.8)
6 (3.6)
0.41
0.42
0.70
0.70
<0.01*
0.25
0.43
0.17
<0.01*
<0.01*
0.01*
0.01*
<0.01*
0.50
0.12
anova for continuous variables and Pearson c2-test for categorical variables. *P < 0.05. IUD, intrauterine device; OCP, oral contraceptive pill;
SD, standard deviation.
202
HPV infection
High-risk HPV genotype
Genotype 16 or 18
Low-risk HPV genotype
Multiple HPV infection
First
trimester
n = 380
Second
trimester
n = 193
Third
trimester
n = 195
Postpartum
n = 192
P-value*
78
50
11
37
14
66
46
10
26
12
45
34
14
17
11
44
29
4
20
6
<0.01*
0.01*
0.03*
0.44
0.39
(20.5)
(13.2)
(2.9)
(9.7)
(3.7)
(34.2)
(23.8)
(5.2)
(13.5)
(6.2)
(23.1)
(17.4)
(7.2)
(8.7)
(5.6)
(22.9)
(15.1)
(2.1)
(10.4)
(3.1)
All data are shown as n (%). Pearson c2-test. *P < 0.05. HPV, human papillomavirus.
Figure 1 Pattern of human papilloma virus (HPV) prevalence in relation to gestational age in normal pregnancy.
, HPV infection;
, high-risk HPV;
, genotype
16 or 18.
Discussion
This study was designed to evaluate HPV prevalence
and genotypic pattern during normal pregnancy and
post-partum. The results revealed that overall infection
with HPV and with high-risk HPV genotypes is
highest during the second trimester of pregnancy.
Among the high-risk HPV genotypes, infection with
HPV 16 or 18 is seen most commonly during the third
trimester of pregnancy.
A number of studies have suggested that pregnancy
may increase susceptibility to HPV infection. In one
publication from Mexico, screening of 274 pregnant
and 1060 age-matched non-pregnant patients showed a
3.5-fold increased risk of high-risk HPV infection
during pregnancy (37.2% vs 14.2%).7 A similar study
from Turkey confirmed a higher prevalence of HPV
infection (29.2% vs 19.6%) and high-risk HPV genotypes (14.6% vs 9.6%) among pregnant compared with
non-pregnant women.15 The current study in a Korean
203
204
0.01
0.04
0.04
<0.01
1.00
0.67 (0.490.92)#
1.00
0.82 (0.561.20)
0.73 (0.421.29)
1.00
0.72 (0.331.56)
0.69 (0.321.48)
0.50 (0.221.15)
1.00
1.84 (1.242.75)#
1.06 (0.691.63)
1.32 (0.832.09)
HPV
OR (95% CI)
0.35
0.41
0.12
0.04
0.06
1.00
0.72 (0.471.12)
0.64 (0.341.20)
1.00
1.94 (1.233.05)#
1.27 (0.782.07)
1.41 (0.822.44)
High-risk genotypes
OR (95% CI)
0.01
0.05
0.34
0.06
0.03
0.21
1.00
2.84 (1.246.54)#
1.00
1.52 (0.613.77)
0.46 (0.063.75)
1.00
2.88 (0.8210.11)
4.51 (1.3515.04)#
0.88 (0.213.72)
Genotypes 16 or 18
OR (95% CI)
0.03
0.28
0.50
0.03
0.14
0.29
1.00
0.63 (0.420.96)#
Low-risk genotypes
OR (95% CI)
0.44
0.48
0.26
0.03
0.01
0.40
1.00
0.49 (0.270.90)#
1.00
0.57 (0.301.10)
0.12 (0.020.89)#
Multiple infection
OR (95% CI)
0.34
Pearson c2-test. c2-Test for trend. Adjusted for stage of pregnancy, age, parity, education (logistic regression analysis). Adjusted for stage of pregnancy, parity (logistic regression
analysis). Adjusted for stage of pregnancy, parity and number of previous partners (logistic regression analysis). Adjusted for parity, education (logistic regression analysis).
#P < 0.05. CI, confidence interval; HPV, human papillomavirus; OR, odds ratio.
Education
High school
College
Parity
0
1
2
Age (years)
24
2529
3034
35
Stage of pregnancy
First trimester
Second trimester
Third trimester
Post-partum
Characteristic
Y. H. Kim et al.
Acknowledgment
This study was supported by the Basic Science Research
Program through the National Research Foundation of
Korea (NRF) funded by the Ministry of Education,
Science and Technology (20090074892), Korea.
References
1. Bosch FX, Lorincz A, Munoz N, Meijer CJ, Shah KV. The
causal relation between human papillomavirus and cervical
cancer. J Clin Pathol 2002; 55: 244265.
2. Castellsague X, Munoz N. Chapter 3: Cofactors in human
papillomavirus carcinogenesis role of parity, oral contraceptives, and tobacco smoking. J Natl Cancer Inst Monogr 2003;
31: 2028.
205
Y. H. Kim et al.
Type 16 and 18
OR
95% CI
Low-risk genotypes
OR
95% CI
Multiple infection
OR
95% CI
1.00
0.372.17
0.311.76
0.221.46
c2 for trend, P = 0.06
1.00
0.40
0.111.51
0.51
0.141.80
0.23
0.051.06
c2 for trend, P = 0.21
1.00
0.37*
0.150.88
0.36*
0.160.85
0.35*
0.140.88
c2 for trend, P = 0.29
1.00
0.55
0.152.01
0.41
0.111.47
0.53
0.132.05
c2 for trend, P = 0.40
Education (years)
12
1.00
1316
0.66*
0.480.90
17
0.71
0.381.34
2
c for trend, P = 0.02*
1.00
0.75
0.521.07
0.57
0.261.26
2
c for trend, P = 0.07
1.00
0.57
0.291.12
0.25
0.031.93
2
c for trend, P = 0.06
1.00
0.63*
0.400.98
0.93
0.412.10
2
c for trend, P = 0.11
1.00
0.56
0.301.05
0.23
0.031.72
2
c for trend, P = 0.03*
Alcohol
Never
Ever
1.00
0.84
0.511.40
1.00
0.61
0.321.17
1.00
0.99
0.342.86
1.00
1.01
0.502.01
1.00
0.43
0.101.80
Smoking
Never
Ever
1.00
1.18
0.831.70
1.00
0.95
0.621.46
1.00
1.38
0.652.92
1.00
1.33
0.812.16
1.00
1.43
0.722.85
Previous Pap
Never
1.00
Ever
0.81
0.591.11
1.00
0.74
0.521.06
1.00
0.56
0.291.08
1.00
0.82
0.531.28
1.00
0.58
0.311.07
OR
HPV
95% CI
Logistic regression analysis and c -test for trend. *P < 0.05. Reference category. CI, confidence interval; HPV, human papillomavirus; OR, odds ratio.
2
206
OR
Age at menarche (years)
14
1.00
15
0.98
0.731.33
High-risk genotypes
OR
95% CI
Genotypes 16 and 18
OR
95% CI
Low-risk genotypes
OR
95% CI
Multiple infection
OR
95% CI
1.00
0.99
1.00
1.35
1.00
1.01
1.00
1.24
0.701.41
0.702.60
0.661.54
0.672.27
1.00
1.37
0.642.92
1.12
0.492.54
c2 for trend, P = 0.18
1.00
0.50
0.171.45
0.45
0.131.48
c2 for trend, P = 0.11
1.00
1.88
0.635.59
2.66
0.848.42
c2 for trend, P = 0.53
1.00
1.18
0.324.32
0.98
0.244.04
c2 for trend, P = 0.58
1.00
0.86
0.501.45
0.66
0.371.17
2
c for trend, P = 0.03*
1.00
0.51
0.191.38
0.84
0.302.31
2
c for trend, P = 0.62
1.00
0.74
0.371.48
1.09
0.532.22
2
c for trend, P = 0.81
1.00
0.88
0.322.42
1.14
0.393.33
2
c for trend, P = 0.77
1.00
0.72
0.491.04
0.73
0.401.32
c2 for trend, P = 0.04*
1.00
0.72
0.361.42
0.17
0.021.32
c2 for trend, P = 0.03*
1.00
0.90
0.581.41
0.56
0.251.25
c2 for trend, P = 0.14
1.00
0.57
0.291.11
0.11*
0.010.87
c2 for trend, P = 0.01*
No. of births
0
1
2
1.00
0.79
0.571.09
0.75
0.451.26
c2 for trend, P = 0.04*
Spontaneous abortion
Never
1.00
Ever
0.71
0.461.11
1.00
0.68
0.401.16
1.00
1.07
0.432.61
1.00
0.89
0.491.62
1.00
0.86
0.352.10
Induced abortion
Never
Ever
1.00
1.16
0.811.65
1.00
1.32
0.891.97
1.00
0.96
0.432.12
1.00
0.77
0.451.33
1.00
0.67
0.291.53
Stage of pregnancy
First trimester
Second trimester
Third trimester
Post-partum
1.00
1.94*
1.15
1.16
1.322.87
0.761.74
0.761.76
1.00
2.13*
1.41
1.21
1.363.33
0.882.27
0.741.98
1.00
1.83
2.67*
0.75
0.764.41
1.196.01
0.232.39
1.00
1.40
0.88
1.08
0.822.40
0.481.60
0.611.91
1.00
1.64
1.47
0.80
0.753.58
0.663.27
0.302.09
Logistic regression analysis and c2-test for trend. *P < 0.05. Reference category. CI, confidence interval; HPV, human papillomavirus; OR, odds ratio.
OR
1.00
1.57
0.982.52
0.89
0.511.54
2
c for trend, P = 0.41
1.00
1.33
0.493.63
0.76
0.262.28
2
c for trend, P = 0.34
1.00
1.36
0.712.62
0.89
0.451.76
2
c for trend, P = 0.50
1.00
0.89
0.352.26
0.78
0.302.05
2
c for trend, P = 0.26
1.00
1.23
1.00
2.40*
1.00
1.33
1.00
1.36
1.00
0.88
0.481.61
0.87
0.107.36
c2 for trend, P = 0.57
1.00
1.08
0.363.21
4.63
0.5240.98
c2 for trend, P = 0.51
1.00
1.51
0.822.79
1.38
0.1611.71
c2 for trend, P = 0.21
1.00
1.40
0.563.53
Contraception
None
OCP
Condom
IUD
1.00
1.49
0.80
0.38
1.00
1.19
1.27
2.49
1.00
1.14
0.86
0.51
1.00
2.13
0.44
1.11
OR
Age at sexual
20
2123
24
HPV
95% CI
debut (years)
1.00
1.27
0.792.07
0.93
0.571.53
2
c for trend, P = 0.28
1.00
1.19
0.92
0.50
0.662.14
0.621.34
0.112.32
OR
High-risk
95% CI
0.821.86
0.792.83
0.511.26
0.053.02
1.065.42
0.314.54
0.543.00
0.2822.21
Low-risk
95% CI
0.822.15
0.532.47
0.511.44
0.064.07
Multiple infection
OR
95% CI
0.672.76
0.855.35
0.191.03
0.139.38
Logistic regression analysis and c2-test for trend. *P < 0.05. Reference category. CI, confidence interval; IUD, intrauterine device; OCP, oral contraceptive
pill; OR, odds ratio.
207