Treatment of Candidal Vaginal Infection in Pregnancy
Use topical azole antifungals for 7 days as first-line treatment; oral fluconazole and other systemic azoles are contraindicated in pregnancy due to teratogenic risks. 1, 2
Recommended First-Line Regimens
The following topical azole options are equally effective and safe during pregnancy 3, 1, 2:
- Clotrimazole 1% cream 5g intravaginally for 7-14 days 1, 2
- Clotrimazole 100mg vaginal tablet once daily for 7 days 1, 2
- Miconazole 2% cream 5g intravaginally for 7 days 3, 1, 2
- Miconazole 100mg vaginal suppository once daily for 7 days 2
- Terconazole 0.4% cream 5g intravaginally for 7 days 2
These regimens achieve 80-90% cure rates in pregnant women. 3, 1
Duration of Therapy
Seven-day courses are significantly more effective than shorter 3-4 day regimens during pregnancy. 4 A Cochrane review demonstrated that 4-day treatment was substantially less effective than 7-day treatment (odds ratio 11.7,95% CI 4.21-29.15). 4 The American College of Obstetricians and Gynecologists specifically recommends 7-day regimens as more effective than shorter courses in pregnant women. 1, 2
Extending treatment to 14 days provides no additional benefit over 7 days. 4
Critical Safety Considerations
Oral azole antifungals must be avoided during pregnancy, particularly in the first trimester. 1, 5 Fluconazole has been associated with spontaneous abortion, craniofacial defects, and cardiac malformations. 1 While lower doses (≤150 mg/day) may appear safer, the CDC explicitly states that only topical azole therapies should be used during pregnancy. 1, 6
Nystatin is less effective than azoles and should not be used as first-line therapy. 2, 4 Imidazole drugs demonstrated superior efficacy compared to nystatin (odds ratio 0.21,95% CI 0.16-0.29). 4
Diagnosis Confirmation
Before initiating treatment, confirm the diagnosis with 1, 2:
- Typical symptoms: vulvar pruritus, vaginal discharge, vaginal soreness, vulvar burning, dyspareunia, or external dysuria
- Normal vaginal pH (≤4.5)
- Wet mount with 10% KOH showing yeasts or pseudohyphae, OR positive culture for Candida species
Do not treat asymptomatic colonization, as 10-20% of women harbor Candida without symptoms and treatment is unnecessary. 1, 2
Management of Treatment Failure
If symptoms persist after completing therapy 1, 2:
- Consider alternative diagnoses
- Suspect non-albicans Candida species (which may require alternative treatments)
- Repeat treatment with a 7-14 day course for severe vulvovaginitis
Partner Management
Routine treatment of sexual partners is not warranted, as vaginal candidiasis is not typically sexually transmitted. 3, 1, 2 However, partners with symptomatic balanitis (erythematous areas on the glans with pruritus) may benefit from topical antifungal treatment. 3, 1
Follow-Up
Follow-up is unnecessary if symptoms resolve. 1, 2 Patients should return only if symptoms persist or recur, at which point alternative diagnoses or resistant organisms should be considered. 1, 2