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Canadian Family Physician logoLink to Canadian Family Physician
. 2009 Mar;55(3):255–256.

Vaginal yeast infections during pregnancy

Derrick Soong, Adrienne Einarson
PMCID: PMC2654841  PMID: 19282531

ABSTRACT

QUESTION My pregnant patients often present with symptomatic vaginal yeast infections. Are the medications commonly used for the management of yeast infections safe to use during pregnancy?

ANSWER Existing data indicate that exposure to oral and topical antifungals, topical antiseptics, or corticosteroids during pregnancy is not associated with increased risk of major malformations. Topical azole antifungals are the recommended treatment during pregnancy for at least 7 days owing to increased efficacy. Topical corticosteroids can be used for symptomatic relief.


Vulvovaginal candidiasis (VVC), often referred to as a yeast infection, is a common gynecologic ailment, affecting 3 out of 4 women in their lifetimes.1 More than 40% of affected women will have 2 or more VVC episodes,2,3 and infection occurs more frequently in pregnant women. It is believed that higher estrogen levels and higher glycogen content in vaginal secretions during pregnancy increase a woman’s risk of developing VVC.4 As VVC is so common in women during their childbearing years, it is important to understand the pathology of this disease as well as the safety or risks of drugs used to treat it during pregnancy.

Vulvovaginal candidiasis is caused by overabundant growth of yeast cells, belonging to the Candida species, in the vaginal mucosa. Candida albicans infection occurs in the vast majority (80% to 90%) of diagnosed VVC cases, while infection with other species, such as Candida glabrata or Candida tropicalis, occurs less frequently.5 With adequate pharmacotherapy and avoidance of contributing factors (eg, douching, wearing tight pants), VVC and associated symptoms resolve in a short period of time. There are several treatment options for Candida infection, such as antifungals and antiseptics, with corticosteroids as a useful addition for pruritus and erythema.

Antifungals

Antifungal agents commercially available for the treatment of VVC in Canada include the following: imidazole antifungals (eg, butoconazole, clotrimazole, miconazole), triazole antifungals (eg, fluconazole, terconazole), and polyene antifungals (eg, nystatin). These agents are available in oral and topical formulations. The topical formulations of imidazole and triazole antifungals, collectively known as azole antifungals, are considered the therapy of choice during pregnancy owing to the safety data collected from animals as well as humans. Prospective and observational studies involving the use of topical antifungals did not reveal an increased risk of major malformations when mothers were exposed any time during pregnancy, and the authors considered them generally safe.6 Systemic absorption of these topical medications is minimal, posing little risk of transfer to the unborn baby. Azole therapy should be recommended for 7 days instead of a shorter duration because of improved treatment success.7,8

Oral fluconazole should be considered as a second-line therapy to treat VVC. There have been case reports in which fluconazole has been associated with major malformations, but only at higher doses (≥ 400 mg/d).9,10 There is no increased risk of major malformations associated with short-term use of 150 mg of fluconazole to treat VVC.11

Topical nystatin is a safe alternative to azole anti-fungals that has been extensively studied in the first trimester of pregnancy. As nystatin has negligible systemic absorption, no associated risk of major malformations has been observed in numerous trials.6 The recommended dose of nystatin during pregnancy is 100 000 units intravaginally once daily for 2 weeks.1

Antiseptics

Boric acid has been studied in the treatment of VVC. Although it is not commercially available, boric acid is an alternative to the antifungal agents. There is little published information regarding the safety of boric acid in humans. A recent retrospective case-control study from Hungary suggested a weak association between boric acid exposure during pregnancy and major malformations, but the association did not reach statistical significance.12 Unless the vaginal epithelium is severely excoriated, only a limited amount of boric acid is systemically absorbed13; therefore, in most cases the amount absorbed through the vaginal mucosa is minimal and exposure risk to the unborn fetus is theoretical. The typical dose of boric acid is 600 mg intravaginally per night for 14 consecutive nights.14

Corticosteroids

Symptoms such as itchiness and redness commonly occur in VVC, and topical corticosteroids can be prescribed to alleviate these acute symptoms. The safety of corticosteroid use during pregnancy has been discussed in a previous Motherisk Update.15 A meta-analysis conducted by Park-Wyllie et al, combining 5 prospective human studies, found that for mothers who were exposed to oral corticosteroids, there was a non-significant increased odds ratio for total major malformations. There was a small but statistically significant increased risk of cleft palate compared with controls (odds ratio 3.35, 95% confidence interval 1.97 to 5.69).16 For topical corticosteroids, approximately 3% of the dose applied onto the skin is systemically absorbed.17 Two population-based studies found no increased risk of major malformations in the babies of mothers who used topical corticosteroids during pregnancy.18,19

Conclusion

It is important to treat VVC infections in pregnant women, and there are safe medications that can be used. Topical azole antifungals are well studied, commercially available, and do not require a physician’s prescription. Seven days of therapy is highly recommended, as shorter duration of treatment is associated with treatment failures. Alternatives to topical azoles include topical nystatin and oral fluconazole. Topical nystatin or oral fluconazole should be used if a patient cannot use topical azole antifungals. For symptomatic relief of redness or itchiness, short-term use of a low-potency topical corticosteroid is considered safe to use in pregnancy.

MOTHERISK

Motherisk questions are prepared by the Motherisk Team at the Hospital for Sick Children in Toronto, Ont. Mr Soong is a doctoral candidate at the Leslie Dan Faculty of Pharmacy at the University of Toronto. Ms Einarson is Assistant Director of the Motherisk Program.

Do you have questions about the effects of drugs, chemicals, radiation, or infections in women who are pregnant or breastfeeding? We invite you to submit them to the Motherisk Program by fax at 416 813-7562; they will be addressed in future Motherisk Updates.

Published Motherisk Updates are available on the Canadian Family Physician website (www.cfp.ca) and also on the Motherisk website (www.motherisk.org).

Footnotes

Competing interests

None declared

References

  • 1.Das Neves J, Pinto E, Teixeira B, Dias G, Rocha P, Cunha T, et al. Local treatment of vulvovaginal candidosis: general and practical considerations. Drugs. 2008;68(13):1787–802. doi: 10.2165/00003495-200868130-00002. [DOI] [PubMed] [Google Scholar]
  • 2.Ferrer J. Vaginal candidosis: epidemiological and etiological factors. Int J Gynaecol Obstet. 2000;71(Suppl 1):S21–7. doi: 10.1016/s0020-7292(00)00350-7. [DOI] [PubMed] [Google Scholar]
  • 3.Eschenbach DA. Chronic vulvovaginal candidiasis. N Engl J Med. 2004;351(9):851–2. doi: 10.1056/NEJMp048152. [DOI] [PubMed] [Google Scholar]
  • 4.Monif GR, Baker DA. Candida albicans. In: Monif GR, Baker DA, editors. Infectious diseases in obstetrics and gynecology. 5th ed. New York, NY: Parthenon Press; 2003. pp. 405–21. [Google Scholar]
  • 5.Baron EJ, Cassell GH, Duffy LB, Eschenbach JR, Greenwood SM, Harvey NE, et al. Laboratory diagnosis of female genital tract infections. In: Baron EJ, editor. Cumulative techniques and procedures in clinical microbiology (Cumitech) 17A. Washington, DC: ASM Press; 1993. pp. 1–28. [Google Scholar]
  • 6.King CT, Rogers PD, Cleary JD, Chapman SW. Antifungal therapy during pregnancy. Clin Infect Dis. 1998;27(5):1151–60. doi: 10.1086/514977. [DOI] [PubMed] [Google Scholar]
  • 7.Doering PL, Santiago TM. Drugs for treatment of vulvovaginal candidiasis: comparative efficacy of agents and regimens. DICP. 1990;24(11):1078–83. doi: 10.1177/106002809002401112. [DOI] [PubMed] [Google Scholar]
  • 8.Young GL, Jewell D. Topical treatment for vaginal candidiasis (thrush) in pregnancy. Cochrane Database Syst Rev. 2001;4:CD000225. doi: 10.1002/14651858.CD000225. [DOI] [PubMed] [Google Scholar]
  • 9.Lee BE, Feinberg M, Abraham JJ, Murthy AR. Congenital malformations in an infant born to a woman treated with fluconazole. Pediatr Infect Dis J. 1992;11(12):1062–4. [PubMed] [Google Scholar]
  • 10.Pursley TJ, Blomquist IK, Abraham J, Andersen HF, Bartley JA. Fluconazole-induced congenital anomalies in three infants. Clin Infect Dis. 1996;22(2):336–40. doi: 10.1093/clinids/22.2.336. [DOI] [PubMed] [Google Scholar]
  • 11.Nørgaard M, Pedersen L, Gislum M, Erichsen R, Søgaard KK, Schonheyder HC, et al. Maternal use of fluconazole and risk of congenital malformations: a Danish population-based cohort study. J Antimicrob Chemother. 2008;62(1):172–6. doi: 10.1093/jac/dkn157. Epub 2008 Apr 9. [DOI] [PubMed] [Google Scholar]
  • 12.Acs N, Bánhidy F, Puhó E, Czeizel AE. Teratogenic effects of vaginal boric acid treatment during pregnancy. Int J Gynaecol Obstet. 2006;93(1):55–6. doi: 10.1016/j.ijgo.2005.12.031. Epub 2006 Mar 10. [DOI] [PubMed] [Google Scholar]
  • 13.Fail PA, Chapin RE, Price CJ, Heindel JJ. General, reproductive, developmental and endocrine toxicity of boronated compounds. Reprod Toxicol. 1998;12(1):1–18. doi: 10.1016/s0890-6238(97)00095-6. [DOI] [PubMed] [Google Scholar]
  • 14.Pappas PG, Rex JH, Sobel JD, Filler SG, Dismukes WE, Walsh TJ, et al. Guidelines for the treatment of candidiasis. Clin Infect Dis. 2004;38(2):161–89. doi: 10.1086/380796. Epub 2003 Dec 19. [DOI] [PubMed] [Google Scholar]
  • 15.Oren D, Nulman I, Makhija M, Ito S, Koren G. Using corticosteroids during pregnancy. Are topical, inhaled, or systemic agents associated with risk? Can Fam Physician. 2004;50:1083–5. [PMC free article] [PubMed] [Google Scholar]
  • 16.Park-Wyllie L, Mazzotta P, Pastuszak A, Moretti ME, Beique L, Hunnisett L, et al. Birth defects after maternal exposure to corticosteroids: prospective cohort study and meta-analysis of epidemiological studies. Teratology. 2000;62(6):385–92. doi: 10.1002/1096-9926(200012)62:6<385::AID-TERA5>3.0.CO;2-Z. [DOI] [PubMed] [Google Scholar]
  • 17.Tauscher AE, Fleischer AB, Jr, Phelps KC, Feldman SR. Psoriasis and pregnancy. J Cutan Med Surg. 2002;6(6):561–70. doi: 10.1007/s10227-001-0147-1. Epub 2002 Oct 9. [DOI] [PubMed] [Google Scholar]
  • 18.Czeizel AE, Rockenbauer M. Population-based case-control study of teratogenic potential of corticosteroids. Teratology. 1997;56(5):335–40. doi: 10.1002/(SICI)1096-9926(199711)56:5<335::AID-TERA7>3.0.CO;2-W. [DOI] [PubMed] [Google Scholar]
  • 19.Mygind H, Thulstrup AM, Pedersen L, Larsen H. Risk of intrauterine growth retardation, malformations and other birth outcomes in children after topical use of corticosteroid in pregnancy. Acta Obstet Gynecol Scand. 2002;81(3):234–9. doi: 10.1034/j.1600-0412.2002.810308.x. [DOI] [PubMed] [Google Scholar]

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