What is the treatment for fungal infections during pregnancy using Mycomin (antifungal medication)?

Treatment of Fungal Infections During Pregnancy

For systemic or severe fungal infections during pregnancy, amphotericin B (conventional or lipid formulations) is the preferred treatment across all trimesters due to its FDA pregnancy category B rating and extensive safety data showing no teratogenicity. 1

Treatment Approach by Infection Type and Trimester

Superficial Fungal Infections (Vulvovaginal Candidiasis)

First-line therapy: Topical azole antifungals are the safest and most effective option throughout pregnancy 2, 3:

• Clotrimazole vaginal cream/suppositories (7-day regimen) 2, 3
• Miconazole vaginal cream/suppositories (7-day regimen) 3
• Nystatin is also safe but less effective than topical azoles 4

Critical caveat: Oral fluconazole 150 mg should be avoided during the first trimester due to potential teratogenic effects, though epidemiological data on single low-dose exposure remain controversial 3, 5. After the first trimester, oral azoles may be considered if topical therapy fails, but topical agents remain preferred 3.

Systemic Fungal Infections (Cryptococcosis, Coccidioidomycosis, Disseminated Disease)

First Trimester Management

For CNS or disseminated disease:

• Amphotericin B deoxycholate (AmBd) or lipid formulations of amphotericin B (LFAmB) are the drugs of choice 1
• AmBd achieves umbilical cord blood concentrations of 33-100% of maternal serum levels with no documented teratogenicity 1
• Flucytosine may be added for severe cryptococcal disease, but use cautiously as it is pregnancy category C with potential teratogenicity in animal studies 1

For nonmeningeal coccidioidomycosis:

• Intravenous amphotericin B is recommended 1
• Alternative: Close clinical and serological monitoring without treatment if disease is limited and stable, though this carries risk 1

For coccidioidal meningitis:

• Intrathecal amphotericin B is the preferred approach 1

Second and Third Trimester Management

For nonmeningeal infections:

• Azole antifungals (fluconazole 400 mg daily or itraconazole 400 mg daily) can be considered after the first trimester 1
• Amphotericin B remains a safe alternative throughout pregnancy if clinicians or patients prefer to avoid azoles 1

For meningeal infections:

• Azole antifungals are recommended after the first trimester 1
• Intrathecal amphotericin B may be continued if azoles are declined 1

For limited pulmonary cryptococcosis:

• Close follow-up without treatment during pregnancy, with fluconazole initiated after delivery 1

Critical Safety Considerations

High-Dose Fluconazole Teratogenicity

Fluconazole 400-800 mg/day during the first trimester is associated with a distinct pattern of congenital anomalies 5:

• Brachycephaly and abnormal calvarial development
• Abnormal facies and cleft palate
• Femoral bowing, thin ribs, and long bones
• Arthrogryposis and congenital heart disease
• Craniofacial ossification defects and renal pelvis defects 1

Women of childbearing age receiving fluconazole 400-800 mg/day should use effective contraception during treatment and for approximately 1 week (5-6 half-lives) after the final dose 5.

Postpartum Immune Reconstitution

Monitor for immune reconstitution inflammatory syndrome (IRIS) in the postpartum period 1:

• Pregnancy creates a Th2/Th3-dominant immunosuppressive state that reverses rapidly after delivery 1
• Nearly 45% of cryptococcosis cases in pregnancy may manifest or worsen postpartum 1
• Severe coccidioidomycosis is more likely when infection is acquired during late pregnancy and manifests postpartum 1

Management of Women on Antifungal Therapy Who Become Pregnant

For Women on Azole Therapy with Controlled Nonmeningeal Disease

Option 1 (preferred): Discontinue azole therapy and monitor clinically with serological testing every 4-6 weeks during the first trimester; if reactivation occurs, initiate intravenous amphotericin B 1

Option 2: Switch to intravenous amphotericin B for the first trimester, then resume azole therapy in the second trimester 1

Option 3: Continue azole therapy with informed maternal consent regarding teratogenic risks (not recommended) 1

For Women on Azole Therapy for Meningeal Disease

This scenario is particularly challenging 1:

• Stopping azole therapy carries significant risk of relapse 1
• Intrathecal amphotericin B during the first trimester is an option 1
• Continuing azole therapy with informed maternal consent is an alternative, though not ideal 1

Breastfeeding Considerations

• Fluconazole: Compatible with breastfeeding per the American Academy of Pediatrics, though 85% of plasma concentration appears in breast milk 1
• Itraconazole, posaconazole, voriconazole: Breastfeeding not recommended due to accumulation or lack of data 1
• Amphotericin B: Limited data, but systemic absorption from breast milk is expected to be minimal

Monitoring for Women at Risk

For pregnant women with prior fungal infections in remission:

• Serological testing at initial prenatal visit and every 6-12 weeks throughout pregnancy 1
• Antifungal prophylaxis is not recommended 1
• Risk of reactivation is low but requires vigilance 1