What is the recommended treatment for a yeast infection during pregnancy?

Treatment of Yeast Infection During Pregnancy

Topical azole antifungals are the recommended first-line treatment for vulvovaginal candidiasis during pregnancy, with a 7-day treatment course being preferred over shorter regimens. 1

First-Line Treatment Options

Recommended Topical Treatments

• Clotrimazole (preferred option):

  • 1% cream: 5g intravaginally for 7 days, OR
  • 100mg vaginal tablet: one tablet daily for 7 days 2, 1

• Miconazole:

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

• Terconazole:

  • 0.4% cream: 5g intravaginally for 7 days, OR
  • 0.4% cream: 5g intravaginally for 3 days, OR
  • 80mg vaginal suppository: one suppository for 3 days 2

• Nystatin:

  • 100,000-unit vaginal tablet: one tablet for 14 days 2
  • Note: While safe, nystatin is generally less effective than azole antifungals 1, 3

Treatment Duration

Evidence strongly supports using a full 7-day course for pregnant women, even if symptoms improve earlier 1, 3. Research shows that:

• 4-day treatments are significantly less effective than 7-day treatments during pregnancy 3
• Single-dose treatments should be avoided during pregnancy 1
• For severe infections, treatment may be extended to 10-14 days 1

Important Considerations and Precautions

Avoid Oral Antifungals

• Oral fluconazole should be avoided, particularly in the first trimester, due to potential teratogenic effects 2, 1, 4
• There is evidence suggesting dose-dependent teratogenic effects with fluconazole; high doses (≥400mg) have been associated with a syndrome of craniosynostosis, characteristic facies, digital synostosis, and limb contractures 2

Safety of Topical Treatments

• Topical azole antifungals have minimal systemic absorption and are considered safe throughout pregnancy 1, 4
• Clinical studies have demonstrated the safety and efficacy of clotrimazole in pregnancy, with success rates of 84-89% 5, 6

For Refractory Cases

• If topical treatment fails, reassess the diagnosis before considering systemic therapy
• For severe or systemic fungal infections that require systemic treatment, amphotericin B is the drug of choice during pregnancy 2, 4
• Avoid ketoconazole, flucytosine, and griseofulvin during pregnancy as they have been shown to be teratogenic in animals 4, 7

Follow-up Recommendations

• No special follow-up is needed if symptoms resolve completely 1
• Persistent symptoms despite treatment may indicate resistant infection or misdiagnosis and warrant further evaluation 1
• Partners generally do not require treatment unless they are symptomatic 6

Treatment Algorithm

1. Confirm diagnosis (clinical symptoms plus microscopy/culture if available)
2. Start with 7-day course of topical azole (preferably clotrimazole)
3. Complete full treatment course even if symptoms resolve earlier
4. If symptoms persist after treatment, reassess diagnosis and consider extending treatment to 14 days
5. For severe refractory cases requiring systemic therapy, consult with specialist for consideration of amphotericin B

The evidence clearly demonstrates that topical imidazoles are more effective than nystatin for treating symptomatic vaginal candidiasis in pregnancy 3, and that a 7-day treatment course is necessary for optimal efficacy during pregnancy 1, 3.