What is the recommended treatment for a vaginal yeast infection diagnosed at 16 weeks of pregnancy?

Treatment of Vaginal Yeast Infection at 16 Weeks Pregnancy

Use topical azole antifungals for 7 days as first-line treatment; oral fluconazole is contraindicated during pregnancy due to teratogenic risks. 1, 2

Recommended Treatment Regimens

The CDC and ACOG recommend the following topical azole options for vaginal candidiasis at 16 weeks gestation 1, 2:

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

Seven-day regimens are more effective than shorter courses during pregnancy 1, 2, 3. While non-pregnant women often use 1-3 day treatments, pregnancy requires longer duration therapy for adequate cure rates 3.

Critical Safety Considerations

Avoid all oral azole antifungals, particularly fluconazole, throughout pregnancy 1, 4:

• Fluconazole is associated with spontaneous abortion, craniofacial defects, and cardiac malformations when used during pregnancy 1
• The FDA drug label for fluconazole warns against use in pregnancy due to teratogenic effects 4
• Even though lower doses (≤150 mg/day) may appear safer, the CDC explicitly states only topical azoles should be used 1

Nystatin should be avoided as first-line therapy 2. Topical azoles achieve 80-90% cure rates compared to lower efficacy with nystatin 1, 2.

Confirming the Diagnosis

Before treating, confirm true infection rather than colonization 1, 2:

• Typical symptoms: vulvar pruritus, vaginal discharge, vaginal soreness, vulvar burning, dyspareunia, or external dysuria 1
• Vaginal pH remains normal (≤4.5) with Candida infection 1, 2
• Microscopy showing yeast or pseudohyphae on wet preparation or Gram stain, or positive culture 1, 2

Do not treat asymptomatic colonization found incidentally on Pap smear if the patient has no symptoms, as 10-20% of women harbor Candida without requiring treatment 1, 2.

Follow-Up and Persistent Symptoms

• Follow-up is unnecessary if symptoms resolve 1
• If symptoms persist after completing therapy, consider 1:
  • Alternative diagnoses
  • Non-albicans Candida species (which may require alternative treatments or longer courses)
  • Repeat treatment with 7-14 day course for severe vulvovaginitis

Partner Management

Do not treat sexual partners routinely 1, 2. Vaginal candidiasis is not typically sexually transmitted 2. Partners with symptomatic balanitis may benefit from topical antifungal treatment 1, 2.

Common Pitfalls to Avoid

• Never prescribe oral fluconazole during pregnancy, even though it is commonly used in non-pregnant women 1, 4
• Do not use shorter 1-3 day regimens that are effective outside pregnancy; pregnancy requires 7-day minimum treatment 1, 3
• Avoid treating asymptomatic yeast colonization found on Pap smear without confirming symptomatic infection 1, 2
• Do not assume treatment failure means resistant infection without first confirming medication adherence and proper application technique 1