Treatment of Vaginal Candidiasis During Pregnancy
Topical azole antifungals for 7 days are the recommended first-line treatment for vaginal candidiasis during pregnancy, with oral fluconazole and other systemic azoles contraindicated due to teratogenic risks. 1, 2
First-Line Treatment Regimens
The following topical azole regimens are recommended by the CDC and ACOG 2:
- Clotrimazole 1% cream 5g intravaginally for 7-14 days 2
- Clotrimazole 100mg vaginal tablet daily for 7 days 2
- Miconazole 2% cream 5g intravaginally for 7 days 2, 3
- Terconazole 0.8% cream 5g intravaginally for 3 days 2
Seven-day treatment courses are more effective than shorter regimens during pregnancy, unlike in non-pregnant women where shorter courses suffice. 4, 5 Two trials involving 81 women demonstrated that 4-day treatment was significantly less effective than 7-day treatment (odds ratio 11.7). 4
Why Topical Therapy Only
Oral azole antifungals must be avoided during pregnancy, particularly in the first trimester. 1, 2 Fluconazole during pregnancy has been associated with spontaneous abortion, craniofacial defects, and cardiac malformations. 1 While there is evidence suggesting dose-dependent teratogenic effects with fluconazole appearing safer at lower doses (≤150 mg/day), the CDC explicitly recommends only topical azole therapies during pregnancy. 2, 6
Treatment Efficacy
Topical azole treatments achieve symptom relief and negative cultures in 80-90% of patients after completing therapy. 2 Imidazole drugs are significantly more effective than nystatin for treating symptomatic vaginal candidiasis in pregnancy (odds ratio 0.21). 4, 5
Clinical Diagnosis
Confirm diagnosis before treatment by identifying 2:
- Symptoms: Vulvar pruritus (most specific), vaginal discharge, soreness, burning, dyspareunia, or external dysuria
- Laboratory confirmation: Wet preparation/Gram stain showing yeast or pseudohyphae, OR positive Candida culture
- Normal vaginal pH (≤4.5) 2
Treatment During Menstruation
Continue treatment through menstrual periods. 3 Many women develop vaginal yeast infections just before their period due to hormonal changes. 3 Use deodorant-free sanitary napkins instead of tampons, as tampons may remove medication from the vagina. 3
Partner Treatment
Routine treatment of sexual partners is not warranted, as vaginal candidiasis is not typically sexually transmitted. 2 However, partners with symptomatic balanitis (rash, itching, or genital discomfort) may benefit from topical antifungal treatment. 2
Follow-Up and Treatment Failure
Follow-up is unnecessary if symptoms resolve. 2 If symptoms persist after completing therapy, consider 2:
- Alternative diagnoses
- Non-albicans Candida species (may require alternative treatments such as boric acid in non-pregnant patients, though data in pregnancy are limited)
- Repeat treatment with a 7-14 day course for severe vulvovaginitis 2
Critical Pitfalls to Avoid
- Never prescribe oral fluconazole or other systemic azoles during pregnancy, especially in the first trimester 1, 2
- Do not use shorter 1-3 day courses commonly prescribed for non-pregnant women, as 7-day regimens are necessary for adequate efficacy in pregnancy 4, 5
- Avoid concurrent use of spermicides, douches, or tampons during treatment as they interfere with medication efficacy 3
- Do not use condoms or diaphragms during treatment, as azole creams can damage latex and cause contraceptive failure 3