Treatment of Yeast Infections During Pregnancy
Use topical azole antifungals for 7 days as first-line treatment for vaginal candidiasis during pregnancy, and strictly avoid oral azole medications (especially fluconazole) throughout pregnancy due to teratogenic risks. 1
First-Line Treatment Regimens
The following topical azole options are recommended by the CDC and ACOG 1:
- Clotrimazole 1% cream 5g intravaginally for 7-14 days 1
- Miconazole 2% cream 5g intravaginally for 7 days 1
- Clotrimazole 100mg vaginal tablet daily for 7 days 1
- Terconazole 0.8% cream 5g intravaginally for 3 days (alternative option) 1
Topical azole treatments achieve symptom relief and negative cultures in 80-90% of patients after completing therapy 1. Seven-day regimens are more effective than shorter courses during pregnancy 1, 2.
Critical Safety Considerations
Oral azole antifungals must be completely avoided during pregnancy, particularly in the first trimester, due to associations with 1:
- Spontaneous abortion
- Craniofacial defects and craniosynostosis
- Cardiac malformations
- Skeletal abnormalities
High-dose fluconazole (≥400 mg daily) causes a specific teratogenic syndrome including craniosynostosis, characteristic facies, digital synostosis, and limb contractures 3. Even lower doses carry dose-dependent teratogenic risks 4, 5.
Treatment Duration Considerations
- Standard infections: 7-day courses are necessary in pregnancy, unlike the shorter 1-3 day courses used in non-pregnant women 1, 2
- Severe vulvovaginitis: Extend treatment to 7-14 days 1
- Four-day treatment courses are significantly less effective than seven-day regimens (odds ratio 11.7) 2
Management of Treatment Failure
If symptoms persist after completing therapy 1:
- Consider alternative diagnoses (bacterial vaginosis, trichomoniasis)
- Evaluate for non-albicans Candida species, which may require alternative topical treatments
- Repeat treatment with a 7-14 day course for severe cases
- Confirm diagnosis with microscopy showing yeast/pseudohyphae or positive culture
Partner Treatment
- Routine treatment of sexual partners is not warranted, as vaginal candidiasis is not typically sexually transmitted 1
- Treat partners only if they have symptomatic balanitis, using topical antifungal agents 1
Common Pitfalls to Avoid
- Never prescribe oral fluconazole during pregnancy - this is the most critical error to avoid 1, 3
- Do not use shorter 1-3 day treatment courses that are standard in non-pregnant women 2
- Do not treat asymptomatic colonization - approximately 10-20% of women harbor Candida without symptoms, which does not require treatment 1
- Ensure patients complete the full 7-day course even if symptoms resolve earlier 3
Follow-Up
Follow-up is generally unnecessary if symptoms resolve 1. Vaginal pH remains normal (≤4.5) with Candida infection, which helps distinguish it from other causes of vaginitis 1.