Vulvovaginal Candidiasis in Pregnancy

Vulvovaginal candidiasis in pregnancy is candida infection of the vulva and vagina during pregnancy. It is common because high oestrogen and glycogen levels favour yeast growth.

• It is most frequent in the second and third trimesters.
• Only symptomatic women need treatment.
• Longer courses of topical azole than in non-pregnant women are used; oral fluconazole is avoided.

Vulval itching, burning, thick white curdy discharge, dyspareunia and external dysuria.

• Vulval erythema, oedema, fissures and satellite lesions.
• Differential diagnosis: bacterial vaginosis, trichomoniasis, aerobic vaginitis, contact dermatitis, herpes genitalis, leakage of liquor.
• Complications: recurrence, thrush in the newborn at vaginal delivery, and stronger symptoms in women with diabetes.

Diagnosis is clinical, with microscopy to confirm yeast and exclude other causes.

• Speculum examination and vaginal pH (below 4.5).
• Potassium hydroxide 10 percent microscopy; vaginal swab culture if treatment fails.
• Oral glucose tolerance test if recurrent or severe.
• Exclude trichomoniasis, bacterial vaginosis and ruptured membranes.
• HIV and syphilis tests as part of antenatal care.

Use a topical azole for 7 days or longer, and avoid oral fluconazole.

• Supportive: cotton underwear; avoid douching and scented products; avoid irritants; wipe front to back; reassure that treatment is safe for the fetus.
• Pharmacological: clotrimazole 100 mg pessary intravaginal nightly for 7 days, or clotrimazole 200 mg pessary nightly for 3 nights, or clotrimazole 1 percent cream applied to the vulva twice daily for 7 days. Alternative: nystatin 100,000 unit pessary intravaginal nightly for 14 days. Avoid oral fluconazole at all stages of pregnancy. Use pessaries without an applicator after 34 weeks if the applicator is uncomfortable.
• Procedures: none.
• Special groups: in diabetes in pregnancy keep fasting glucose at 4 to 5.3 mmol/L and 1-hour post-meal glucose below 7.8 mmol/L. In HIV infection, treat for 14 days if symptoms recur.
• Red flags: foul or blood-stained discharge, fever, lower abdominal pain, leakage of fluid, reduced fetal movements.
• Follow-up: review at 1 to 2 weeks if symptoms persist; repeat culture; for newborns with oral thrush give nystatin 100,000 units oral 6-hourly for 7 days.