What is the recommended dose of Diflucan (fluconazole) for pregnant women?

Fluconazole (Diflucan) Use During Pregnancy

Fluconazole should not be used during pregnancy, especially in the first trimester, due to potential teratogenic effects. If antifungal treatment is absolutely necessary during pregnancy, topical azole preparations should be used instead of oral fluconazole. 1, 2

Risks of Fluconazole in Pregnancy

Fluconazole use during pregnancy carries significant risks:

• Four cases of infants born with craniofacial and skeletal abnormalities have been reported following prolonged in-utero exposure to high-dose fluconazole 1, 2
• The FDA has issued a warning that long-term, high-dose fluconazole (400-800 mg/day) during the first trimester is associated with birth defects 2
• Recent research shows fluconazole exposure during the first trimester is associated with:
  • Increased risk of musculoskeletal malformations (adjusted relative risk 1.30) 3
  • Increased risk of heart malformations, particularly tetralogy of Fallot 4, 5
  • Higher risk of spontaneous abortion (OR 1.99) 4

Recommendations by Trimester

First Trimester

• Avoid fluconazole completely 1, 2
• For vulvovaginal candidiasis: Use topical azole preparations or nystatin 6
• For systemic fungal infections: Consider intravenous amphotericin B if treatment is absolutely necessary 1

Second and Third Trimesters

• Still avoid fluconazole if possible 1
• If systemic antifungal therapy is absolutely necessary, consider:
  1. Amphotericin B (preferred option) 1
  2. Fluconazole only after careful risk-benefit assessment and patient education about potential risks 1

Special Considerations

• For women already on fluconazole who become pregnant: Discontinue fluconazole immediately 1
• For cryptococcal meningitis during pregnancy: Use amphotericin B with or without flucytosine during the first trimester; fluconazole may be considered after the first trimester only if absolutely necessary 1
• For limited and stable pulmonary cryptococcosis: Close follow-up and defer fluconazole until after delivery 1

Alternative Treatments During Pregnancy

• Topical azole preparations are considered safer during pregnancy, especially for vulvovaginal candidiasis 6
• Nystatin is minimally absorbed and effective for vaginal therapy 6
• Amphotericin B has been used during pregnancy with no reported teratogenic effects 6

The evidence clearly shows that the risks of fluconazole during pregnancy outweigh the benefits in most cases, with particular concern for first-trimester exposure. Healthcare providers should carefully consider alternative antifungal therapies with better safety profiles during pregnancy.