Treatment of Candidiasis in Pregnancy
Pregnant women with vulvovaginal candidiasis should be treated exclusively with topical azole antifungals (clotrimazole, miconazole, terconazole, or butoconazole) for 7 days, and oral fluconazole must be strictly avoided throughout pregnancy due to teratogenic risks. 1, 2
First-Line Treatment Regimens
The following topical azole regimens are recommended by the CDC and ACOG for pregnant women 1, 2:
- Clotrimazole 1% cream 5g intravaginally for 7-14 days 1, 2
- Miconazole 2% cream 5g intravaginally for 7 days 1, 2
- Terconazole 0.4% cream 5g intravaginally for 7 days 1
- Butoconazole 2% cream 5g intravaginally for 3 days 1
- Clotrimazole 100mg vaginal tablet for 7 days 2
Treatment Duration: Critical Consideration
Seven-day courses are significantly more effective than shorter regimens during pregnancy. 3, 4, 5 While non-pregnant women often respond to 1-3 day courses, pregnancy requires longer treatment duration:
- Four-day treatment is less effective than seven-day treatment (odds ratio 11.7,95% CI 4.21-29.15) 4
- Seven-day treatment achieves 80-90% cure rates in pregnant women 3, 1
- Treatment duration of 7 days versus 14 days shows no significant difference in efficacy 4, 5
What to Absolutely Avoid
Oral fluconazole and all systemic azoles are contraindicated throughout pregnancy, particularly in the first trimester. 1, 2, 6 The FDA has issued specific warnings about high-dose fluconazole (≥400 mg/day) causing:
- Craniosynostosis 1
- Characteristic facial abnormalities 1
- Digital synostosis 1
- Limb contractures 1
- Spontaneous abortion 2
- Cardiac malformations 2
Even lower doses of oral fluconazole should be avoided despite some evidence suggesting safety at ≤150 mg/day, as topical alternatives are equally effective and definitively safe 2, 7.
Confirming the Diagnosis
Before initiating treatment, confirm vulvovaginal candidiasis by 1, 2:
- Clinical symptoms: Vulvar pruritus, vaginal discharge (typically white), vaginal soreness, vulvar burning, dyspareunia, or external dysuria 3, 2
- Vaginal pH ≤4.5 (normal pH distinguishes candidiasis from bacterial vaginosis or trichomoniasis) 1, 2
- Microscopy: Wet preparation or Gram stain demonstrating yeasts or pseudohyphae 1, 2
- Culture: Positive for Candida species if microscopy is negative but clinical suspicion remains high 1
Critical pitfall: Do not treat asymptomatic colonization—10-20% of women harbor Candida without symptoms, and treatment is unnecessary 3, 2.
Treatment Efficacy and Follow-Up
- Topical azole therapy achieves symptom relief and negative cultures in 80-90% of patients 3, 1, 2
- Follow-up is unnecessary if symptoms resolve 2
- If symptoms persist after completing therapy, consider 2:
- Alternative diagnoses (bacterial vaginosis, trichomoniasis, contact dermatitis)
- Non-albicans Candida species (C. glabrata, C. krusei) requiring alternative treatment
- Repeat treatment with 7-14 day course for severe vulvovaginitis
Treatment of Sexual Partners
Routine treatment of sexual partners is not warranted, as vulvovaginal candidiasis is not typically sexually transmitted 2. However, partners with symptomatic balanitis may benefit from topical antifungal treatment 2.
Special Considerations for Complicated Cases
For recurrent vulvovaginal candidiasis (≥4 episodes per year) or severe infections 3:
- Extend initial treatment to 7-14 days 3, 2
- Consider non-albicans species requiring culture and sensitivity testing 3
- Evaluate for underlying conditions: uncontrolled diabetes, immunosuppression 3
If systemic antifungal therapy is absolutely necessary (rare in vulvovaginal candidiasis), intravenous amphotericin B is the only safe systemic option during pregnancy, though this is reserved for life-threatening invasive fungal infections 3, 1.
Why Topical Azoles Are Safe in Pregnancy
The teratogenic concerns with azoles apply only to systemic (oral) formulations 2. Topical clotrimazole, miconazole, and terconazole have minimal systemic absorption (5-16%) and extensive safety data throughout all trimesters of pregnancy 8, 7, 9. The FDA warning about azole teratogenicity specifically addressed long-term, high-dose oral fluconazole (400-800 mg/day), not topical formulations 2.