What is the recommended suppressive therapy for recurrent vulvovaginal candidiasis (yeast infection) during pregnancy?

Suppressive Therapy for Recurrent Vulvovaginal Candidiasis During Pregnancy

Topical antifungal therapy is the recommended suppressive treatment for recurrent vulvovaginal candidiasis during pregnancy, as systemic azoles should be avoided due to potential teratogenic risks.

First-Line Treatment Options

• Topical imidazoles (such as clotrimazole) are the preferred first-line suppressive therapy for recurrent vulvovaginal candidiasis during pregnancy 1
• Topical therapy is strongly preferred over oral therapy during pregnancy to minimize systemic exposure to medications 2
• A 7-day course of topical imidazole is recommended for each symptomatic episode during pregnancy 2

Contraindications to Systemic Therapy

• Systemic azole antifungals (fluconazole, itraconazole, etc.) should not be initiated during pregnancy for prophylaxis or suppression of vulvovaginal candidiasis 1
• If a woman becomes pregnant while on azole therapy for suppression of vulvovaginal candidiasis, the azole should be discontinued 1
• Reasons for avoiding systemic azoles during pregnancy include:
  • Four cases of infants born with craniofacial and skeletal abnormalities following prolonged in utero exposure to fluconazole have been documented 1
  • High-dose fluconazole (≥400 mg) has been associated with a syndrome of craniosynostosis, characteristic facies, digital synostosis, and limb contractures ("fluconazole embryopathy") 1
  • Recent research shows an increased risk of spontaneous abortion with oral fluconazole use during pregnancy (HR 1.48; 95% CI, 1.23-1.77) 3
  • Meta-analysis data indicates oral fluconazole during first trimester is associated with increased risk of heart malformations (OR 1.31,95% CI 1.09-1.57) and spontaneous abortion (OR 1.99,95% CI 1.38-2.88) 4

Alternative Options

• Nystatin (polyene antifungal) is minimally absorbed and is effective for vaginal therapy during pregnancy 5
• For severe or refractory cases where topical therapy is insufficient:
  • Amphotericin B is the systemic antifungal with the most safety data in pregnancy 5
  • There have been no reports of teratogenesis attributed to amphotericin B 5

Treatment Duration and Frequency

• For recurrent vulvovaginal candidiasis in pregnancy, treat each symptomatic episode individually rather than using continuous suppressive therapy 2
• Most clinicians do not offer long-term suppressive therapy in pregnancy as they would in non-pregnant women with recurrent vulvovaginal candidiasis 2
• If suppression is necessary due to frequent recurrences, use intermittent topical therapy timed around expected recurrences 2

Special Considerations

• Pregnancy increases the risk for vaginal colonization with Candida species, with prevalence rising to 30% in late pregnancy 6, 2
• Most episodes of symptomatic vulvovaginal candidiasis occur during the second and third trimesters 2
• Increased risk of VVC in pregnancy is likely due to pregnancy-related factors such as immunologic alterations, increased estrogen levels, and increased vaginal glycogen production 2
• Some evidence suggests that candidiasis in pregnancy may be associated with increased risk of pregnancy complications, including premature rupture of membranes, preterm labor, and chorioamnionitis 2

Monitoring and Follow-up

• Patients should be monitored for symptomatic relief after treatment 2
• For non-albicans Candida species (particularly C. glabrata), which may be resistant to standard topical therapies, consultation with an infectious disease specialist is recommended 6
• Effective birth control measures should be recommended to all women who might require systemic azole therapy after pregnancy 1