What is the recommended treatment for vaginal candidiasis (yeast vaginitis) in pregnancy?

Treatment of Yeast Vaginitis in Pregnancy

Topical azole therapies are the recommended first-line treatment for vaginal candidiasis during pregnancy, with clotrimazole and miconazole being the most effective and safest options. 1

Diagnosis

Vulvovaginal candidiasis (VVC) in pregnancy presents with:

• Pruritus and erythema in vulvovaginal area
• White vaginal discharge
• Normal vaginal pH (≤4.5)
• Possible vaginal soreness, vulvar burning, dyspareunia, and external dysuria

Diagnosis is confirmed when:

• Wet preparation (with 10% KOH) or Gram stain shows yeasts or pseudohyphae
• Culture yields a positive result for Candida species

Treatment Algorithm

First-line Treatment Options (Topical Azoles)

1. Clotrimazole:

   • 1% cream 5g intravaginally for 7-14 days, OR
   • 100mg vaginal tablet for 7 days, OR
   • 100mg vaginal tablet, two tablets for 3 days, OR
   • 500mg vaginal tablet, one tablet in a single application 1

2. Miconazole:

   • 2% cream 5g intravaginally for 7 days, OR
   • 200mg vaginal suppository, one suppository for 3 days, OR
   • 100mg vaginal suppository, one suppository for 7 days 1

3. Other Topical Options:

   • Butoconazole 2% cream 5g intravaginally for 3 days
   • Terconazole 0.4% cream 5g intravaginally for 7 days
   • Terconazole 0.8% cream 5g intravaginally for 3 days
   • Terconazole 80mg vaginal suppository, one suppository for 3 days 1

Duration of Treatment

• For uncomplicated cases: 3-7 day regimens are typically sufficient
• During pregnancy: Many experts recommend 7-day regimens for more complete treatment 1

Evidence Strength and Special Considerations

The CDC guidelines consistently recommend topical azole therapies as the treatment of choice for VVC during pregnancy 1. These recommendations are based on:

1. Safety profile: Topical azoles have minimal systemic absorption, making them safer for use during pregnancy.

2. Efficacy: Treatment with azoles results in relief of symptoms and negative cultures in 80-90% of patients who complete therapy 1.

3. Oral fluconazole: While effective for non-pregnant women, oral fluconazole (150mg single dose) is NOT recommended during pregnancy due to potential systemic effects 2.

Important Caveats

• Self-medication with OTC preparations should only be advised for women previously diagnosed with VVC who experience recurrence of the same symptoms 1.
• Any woman whose symptoms persist after using an OTC preparation or who experiences symptom recurrence within 2 months should seek medical care 1.
• VVC is not typically sexually transmitted, so routine treatment of sexual partners is not warranted unless the partner has symptoms 1.
• For severe or complicated VVC, multi-day regimens (3-7 days) are preferred over single-dose treatments 1.
• Nystatin is less effective than azole drugs and requires a longer treatment duration (14 days) 1.

By following these guidelines, clinicians can effectively manage vulvovaginal candidiasis in pregnant women while minimizing risks to both mother and fetus.