What is the treatment for candidiasis (fungal infection) in the second trimester of pregnancy?

From the Guidelines

For treating candidiasis in the second trimester of pregnancy, topical azole antifungals are the recommended first-line treatment. The most effective and safe options include clotrimazole 1% cream applied vaginally for 7 days or clotrimazole 100mg vaginal tablets for 7 nights, as well as miconazole 2% cream for 7 days or miconazole 100mg vaginal suppositories for 7 days 1. These topical treatments are preferred due to their minimal systemic absorption, which reduces the potential risk to the developing fetus.

Key Considerations

• For severe or recurrent infections, a longer 14-day course of treatment may be necessary.
• Oral fluconazole (150mg single dose) should generally be avoided during pregnancy, especially in the first trimester, due to potential concerns about birth defects, though the risk is lower in the second trimester 1.
• Patients should complete the full course of treatment even if symptoms improve quickly.
• Sexual partners typically do not need treatment.

Prevention of Recurrence

To prevent recurrence, patients should:

• Avoid tight-fitting synthetic underwear
• Wear cotton underwear
• Avoid douching
• Limit sugar intake, which can promote yeast growth These infections are common during pregnancy due to elevated estrogen levels and increased vaginal glycogen, which create an environment favorable for candida overgrowth 1.

From the FDA Drug Label

(4) Potential for fetal harm: There are no adequate and well-controlled clinical trials of fluconazole in pregnant women Case reports describe a pattern of distinct congenital anomalies in infants exposed in utero to high dose maternal fluconazole (400 to 800 mg/day) during most or all of the first trimester. Epidemiological studies suggest a potential risk of spontaneous abortion and congenital abnormalities in infants whose mothers were treated with 150 mg of fluconazole as a single or repeated dose in the first trimester, but these epidemiological studies have limitations and these findings have not been confirmed in controlled clinical trials.

The treatment for candidiasis in the second trimester of pregnancy is not directly addressed in the provided drug label. The label discusses the potential risks of fluconazole use during pregnancy, particularly in the first trimester, but does not provide guidance on treatment in the second trimester 2.

From the Research

Treatment Options for Candidiasis in Pregnancy

The treatment for candidiasis (fungal infection) in the second trimester of pregnancy involves careful consideration of the benefits and risks of antifungal therapy.

• Topical antifungal agents such as clotrimazole, miconazole, and nystatin are considered safe for use during pregnancy 3, 4, 5, 6.
• Imidazoles are effective for vaginal therapy and are considered safe as topical therapy for fungal skin infections during pregnancy 3, 5, 6.
• Nystatin is minimally absorbed and is effective for vaginal therapy 3, 5.
• Systemic antifungal drugs such as amphotericin B have been used in pregnancy with no reports of teratogenesis attributed to this agent 3, 7.
• Fluconazole may be safe at lower doses (150 mg/day), but its use should be approached with caution due to potential dose-dependent teratogenic effects 3.
• Ketoconazole, flucytosine, and griseofulvin have been shown to be teratogenic and/or embryotoxic in animals and should be avoided during pregnancy 3, 7.

Duration of Treatment

• Treatment for seven days may be necessary in pregnancy rather than the shorter courses more commonly used in non-pregnant women 5.
• Single dose treatment was no more or less effective than three or four days treatment, but treatment lasting for four days was less effective than treatment for seven days 5.
• Topical imidazole appears to be more effective than nystatin for treating symptomatic vaginal candidiasis in pregnancy 5.

Safety Considerations

• The use of antifungals in pregnancy requires special consideration for the safety of the developing fetus 7.
• Although the use of azoles as topical agents for superficial infections is both efficacious and well tolerated, systemic azole therapy is not recommended in pregnancy 7.
• There is a need for additional safe and effective new antifungal agents for widespread use in pregnant women 7.