What is the recommended treatment for vaginal candidiasis during pregnancy?

Treatment of Vaginal Candidiasis During Pregnancy

Topical azole antifungals are the recommended first-line treatment for vaginal candidiasis during pregnancy, with 7-day regimens being more effective than shorter courses. 1, 2

Recommended Treatment Options

First-Line Treatments (Topical Azoles)

• Clotrimazole 1% cream 5g intravaginally for 7-14 days 1
• Clotrimazole 100mg vaginal tablet daily for 7 days 1
• Miconazole 2% cream 5g intravaginally for 7 days 1
• Miconazole 100mg vaginal suppository daily for 7 days 1
• Terconazole 0.4% cream 5g intravaginally for 7 days 1
• Terconazole 0.8% cream 5g intravaginally for 3 days 1

Key Treatment Considerations

• Seven-day regimens are significantly more effective than shorter 3-4 day treatments during pregnancy (odds ratio 11.7,95% CI 4.21-29.15) 2
• Topical imidazole drugs (clotrimazole, miconazole, terconazole) are more effective than nystatin for treating symptomatic vaginal candidiasis in pregnancy 2
• Single-dose treatments should be avoided during pregnancy, as longer courses are generally more effective 1, 2

Clinical Diagnosis

• Typical symptoms include vulvar pruritus, vaginal discharge, vaginal soreness, vulvar burning, dyspareunia, and external dysuria 1
• Diagnosis is confirmed by presence of symptoms plus either:
  • Wet preparation/Gram stain showing yeast or pseudohyphae 1
  • Positive culture for Candida species 1
• Normal vaginal pH (≤4.5) is typically present with Candida infection 1

Treatment Efficacy and Considerations

• Topical azole treatments result in relief of symptoms and negative cultures in 80-90% of patients after therapy completion 1
• Imidazole drugs have demonstrated superior efficacy compared to nystatin in pregnancy (odds ratio 0.21,95% CI 0.16-0.29) 2
• Recent research shows miconazole, amphotericin B, and itraconazole are highly effective against Candida isolates in pregnant women 3
• Some Candida species are showing resistance to fluconazole, ketoconazole, and clotrimazole, highlighting the importance of appropriate treatment selection 3

Special Considerations During Pregnancy

• Vaginal candidiasis is more common during pregnancy due to hormonal changes 1, 3
• Clotrimazole has been shown to be effective and safe during pregnancy with no reported side effects 4
• A single 500mg clotrimazole vaginal pessary achieved 83.3% cure rate after one week in second and third-trimester pregnant women 5
• Risk factors for vaginal candidiasis during pregnancy include:
  • History of contraceptive use 3
  • Past vaginal candidiasis 3
  • HIV infection 3
  • Diabetes mellitus 3
  • Recent antibiotic use 3
  • Third trimester of pregnancy 3

Important Precautions

• Do not use tampons during treatment as they may remove medication from the vagina 6
• Avoid douching during treatment 6
• Avoid sexual intercourse during treatment 6
• Condoms and diaphragms may be damaged by these products and fail to prevent pregnancy or STDs 6
• Keep the genital area cool and dry to prevent recurrence 6
• Wear cotton underwear and loose-fitting clothes 6

Treatment Failure

• If symptoms persist after initial treatment, a second course of therapy may be warranted 4, 5
• Consider alternative azole preparations if initial treatment fails 1
• For recurrent infections, evaluate for underlying conditions such as diabetes or immunosuppression 6, 3