What is the best treatment for a 3rd trimester pregnant woman (G3P1AB1) presenting with vomiting and weakness, and urinalysis results showing negative Leukocyte esterase and negative Nitrites, but 5-10 white blood cells (WBC), few bacteria, and moderate yeast?

Treatment for a Pregnant Woman with Vomiting, Weakness, and Urinalysis Showing Moderate Yeast

The best treatment for this G3P1AB1 pregnant woman with vomiting, weakness, and urinalysis showing moderate yeast is oral fluconazole for vulvovaginal candidiasis, while also evaluating for other causes of her symptoms.

Assessment of Urinalysis Results

The urinalysis results show:

• Negative leukocyte esterase and negative nitrites
• WBC 5-10
• Few bacteria
• Moderate yeast

These findings suggest:

1. No evidence of bacterial UTI: The negative leukocyte esterase and negative nitrites strongly argue against a bacterial urinary tract infection 1. When both tests are negative, the negative predictive value for UTI is very high (94-99%) 1, 2.

2. Presence of vulvovaginal candidiasis: The moderate yeast in the urine sample likely represents vaginal contamination from vulvovaginal candidiasis, which is common during pregnancy.

3. Few bacteria with negative screening tests: The presence of "few bacteria" without positive nitrites or leukocyte esterase represents colonization or contamination rather than infection 1.

Treatment Recommendations

Primary Treatment: Vulvovaginal Candidiasis

Fluconazole is indicated for vaginal candidiasis (yeast infections due to Candida) 3. However, timing in pregnancy is crucial:

• First trimester: Avoid fluconazole due to potential teratogenicity 4

  • Alternative: Topical antifungal agents (clotrimazole, miconazole)

• Second and third trimester: Oral fluconazole can be considered 4

  • Standard dose: 150 mg one-time dose

Management of Vomiting and Weakness

The patient's vomiting and weakness require additional evaluation as they may not be related to the yeast infection:

1. Assess for hyperemesis gravidarum

   • Evaluate hydration status
   • Check electrolytes
   • Consider antiemetics approved for pregnancy

2. Rule out other infections

   • Check vital signs for fever
   • Consider complete blood count
   • Evaluate for other sources of infection

3. Consider obstetric complications

   • Preeclampsia screening
   • Assess fetal well-being

Important Considerations

1. Do not treat for bacterial UTI: The European Association of Urology guidelines clearly state that asymptomatic bacteriuria in pregnancy should be treated 4, but this patient does not have evidence of bacteriuria (negative nitrites, negative leukocyte esterase).

2. Avoid unnecessary antibiotics: Treating without clear evidence of bacterial infection contributes to antibiotic resistance and may cause adverse effects 1.

3. Pregnancy-specific approach: Treatment decisions must consider both maternal symptoms and fetal safety, particularly regarding antifungal medication timing 4.

4. Follow-up: Re-evaluate symptoms after treatment of vulvovaginal candidiasis. If vomiting and weakness persist, further workup is necessary.

Pitfalls to Avoid

1. Misinterpreting "few bacteria" as requiring antibiotic treatment when screening tests are negative
2. Failing to recognize vulvovaginal candidiasis as a common cause of yeast in urine during pregnancy
3. Overlooking other potential causes of vomiting and weakness in a pregnant woman
4. Using fluconazole in the first trimester of pregnancy

By addressing the vulvovaginal candidiasis while evaluating for other causes of her symptoms, this approach provides targeted treatment while avoiding unnecessary antibiotics.