Treatment of Yeast Infections in Pregnancy
For pregnant women with vulvovaginal candidiasis, use topical azole antifungals for 7 days—this is the only recommended approach throughout pregnancy, with oral fluconazole strictly avoided, especially in the first trimester. 1, 2
First-Line Treatment Regimen
Topical azole therapy for 7 days is the standard of care for all trimesters. 1 The following intravaginal formulations are recommended:
- Clotrimazole 1% cream 5g intravaginally for 7-14 days 3
- Miconazole 2% cream 5g intravaginally for 7 days 3
- Butoconazole 2% cream 5g intravaginally for 3 days 3
- Terconazole 0.4% cream 5g intravaginally for 7 days 3, 1
The evidence strongly supports that imidazole drugs are significantly more effective than nystatin when treating vaginal candidiasis in pregnancy, with an odds ratio of 0.21 (95% CI 0.16-0.29). 4 A 1986 study demonstrated that miconazole nitrate achieved comparable cure rates in both pregnant and nonpregnant women and was superior to nystatin, clotrimazole, and butoconazole. 5
Duration of Treatment: Critical Difference from Non-Pregnant Women
Seven-day treatment courses are necessary in pregnancy, not the shorter 1-3 day regimens used in non-pregnant women. 4 Two trials involving 81 women showed that 4-day treatment was significantly less effective than 7-day treatment (OR 11.7,95% CI 4.21-29.15). 4 However, extending treatment beyond 7 days to 14 days provides no additional benefit (OR 0.41,95% CI 0.16-1.05). 4
What to Absolutely Avoid
Oral fluconazole and all systemic azole antifungals must be avoided during pregnancy, particularly in the first trimester, due to dose-dependent teratogenic effects. 1, 2 The FDA has issued specific warnings about high-dose fluconazole being associated with birth defects including:
- Craniosynostosis
- Characteristic facies
- Digital synostosis
- Limb contractures 2
While fluconazole appears safe at lower doses (≤150 mg/day), the evidence suggests dose-dependent teratogenicity, making topical therapy the only appropriate choice. 6
When Topical Therapy Fails
If symptoms persist after completing a full 7-day course of topical azole therapy, reevaluation is mandatory to confirm the diagnosis and exclude other causes of vaginal symptoms. 1 Do not simply extend or repeat treatment without reassessment.
For severe or refractory cases requiring systemic therapy:
- First trimester: Use intravenous amphotericin B if systemic treatment is absolutely necessary, as it has no reported teratogenesis. 2, 6
- Second and third trimesters: Oral azoles (fluconazole or itraconazole) may be considered with extreme caution only if topical therapy has definitively failed. 2
Amphotericin B remains the drug of choice for any systemic or invasive fungal infections in pregnancy, with the most extensive safety data available. 6, 7
Special Populations and Considerations
For pregnant women with HIV infection and vulvovaginal candidiasis, use the identical treatment approach as for HIV-negative pregnant women—7-day topical azole therapy. 1
Treatment of sexual partners is generally not necessary unless they are symptomatic. 2
Common Pitfalls to Avoid
- Do not use single-dose or short-course (1-3 day) topical azole regimens that are standard in non-pregnant women—these are inadequate in pregnancy. 4
- Do not prescribe oral fluconazole as a convenient alternative, even at low doses, particularly in the first trimester. 1, 2
- Do not use alternative treatments such as honey-based ointments, essential oils, or herbal remedies—these lack regulatory approval and are often inferior to prescribed medications. 2
- Do not overlook the potential association between vulvovaginal candidiasis and increased risk of preterm delivery, though more research is needed. 2
Clinical Diagnosis Confirmation
Diagnosis should be confirmed when a woman has signs and symptoms of vaginitis (pruritus, erythema, white discharge) and either:
- Wet preparation or Gram stain demonstrates yeasts or pseudohyphae, or
- Culture yields a positive result for a yeast species 3
The vaginal pH should be ≤4.5 in isolated Candida vaginitis. 3 Identifying Candida in asymptomatic women (10-20% of pregnant women harbor Candida) should not prompt treatment. 3