What is the treatment for vaginal discharge during pregnancy?

Treatment of Vaginal Discharge During Pregnancy

All pregnant women with symptomatic vaginal discharge should be evaluated and treated based on the specific etiology, with bacterial vaginosis, vulvovaginal candidiasis, and trichomoniasis being the three most common causes requiring distinct treatment approaches. 1

Diagnostic Approach

The diagnosis requires pH testing and microscopic examination of vaginal discharge to differentiate between the three main causes: 1

• Vaginal pH >4.5 suggests bacterial vaginosis or trichomoniasis 1
• Saline microscopy identifies motile trichomonads or clue cells (bacterial vaginosis) 1
• KOH preparation reveals yeast/pseudohyphae (candidiasis) and produces a fishy odor with bacterial vaginosis 1
• Clinical criteria for bacterial vaginosis require 3 of 4 findings: homogeneous white discharge, clue cells, pH >4.5, positive whiff test 1

Treatment by Etiology

Bacterial Vaginosis in Pregnancy

All symptomatic pregnant women with bacterial vaginosis must be treated to relieve symptoms and potentially reduce adverse pregnancy outcomes. 1

Recommended regimens for pregnant women: 1

• Oral metronidazole 500 mg twice daily for 7 days (preferred)
• Oral metronidazole 250 mg three times daily for 7 days (alternative)
• Oral clindamycin 300 mg twice daily for 7 days (alternative)

Critical considerations:

• Treatment is associated with reduced risk of preterm birth in high-risk women (those with prior preterm delivery) 1
• Evidence does not support routine screening and treatment in low-risk asymptomatic pregnant women 1, 2
• Follow-up evaluation one month after treatment completion is recommended to verify cure due to adverse pregnancy outcomes 1
• Topical agents may be less effective than oral therapy in preventing adverse pregnancy outcomes 3

Vulvovaginal Candidiasis in Pregnancy

Only topical azole therapies for 7 days are recommended during pregnancy; oral fluconazole is contraindicated. 1, 4

Recommended regimens: 1

• Clotrimazole 2% cream, one applicator (5g) intravaginally at bedtime for 7 days
• Other topical azole preparations for 7 days (miconazole, terconazole)

Important caveats:

• Short-course topical formulations used in non-pregnant women are inadequate during pregnancy 1
• Treatment of sexual partners is not routinely recommended unless the partner has symptomatic balanitis 5
• Oil-based creams may weaken latex condoms and diaphragms 1

Trichomoniasis in Pregnancy

Symptomatic pregnant women should be treated with oral metronidazole to relieve symptoms, though treatment may not prevent adverse pregnancy outcomes. 1, 6

Recommended regimen: 1, 6

• Oral metronidazole 2 grams as a single dose (preferred for compliance)
• Alternative: Metronidazole 250 mg three times daily for 7 days

Critical warnings:

• The single-dose 2-gram regimen should NOT be used in the first trimester due to higher serum levels reaching fetal circulation 6
• If treatment is necessary in the first trimester, use the 7-day regimen only 6
• Sexual partners must be treated simultaneously to prevent reinfection 1
• Patients must avoid alcohol during treatment and for 24 hours after completion 1, 6

Special Pregnancy Considerations

Metronidazole dosing in pregnancy requires specific attention: 6

• Pregnant patients should not receive the single-dose regimen in the first trimester 6
• When repeat courses are needed, allow 4-6 weeks between courses with laboratory reconfirmation 6
• Monitor for adverse effects including nausea, which is common 1

Screening recommendations: 1, 2

• Routine screening for asymptomatic bacterial vaginosis is NOT recommended in low-risk pregnant women 1, 2
• Consider screening in high-risk women (prior preterm delivery) as treatment may reduce preterm birth risk 1

Common Pitfalls to Avoid

• Never use oral fluconazole during pregnancy—only topical azoles are safe 1, 4
• Never use short-course (1-3 day) topical antifungals in pregnancy—7-day courses are required 1
• Never give metronidazole 2g single dose in first trimester—use 7-day regimen if treatment is essential 6
• Do not assume all discharge is infectious—cervicitis from gonorrhea or chlamydia can present similarly and requires different treatment 1
• Do not treat asymptomatic bacterial vaginosis in low-risk women—evidence shows no benefit and potential harm 1