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Question
Which treatment choices for vaginal yeast infections are safe and efficient in the pregnant patient?
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Response from Michael Postelnick, BPharm Lecturer, Department of Medical Education, Northwestern University Feinberg School of Medicine; Senior Infectious Illness Pharmacist, Clinical Manager, Northwestern Memorial Hospital Department of Pharmacy, Chicago, Illinois |
Vaginal candidiasis, frequently called “yeast infection,” is relatively common throughout pregnancy, along with an estimated prevalence of 10%-75%.[1,2] The patient usually presents along with vulvar pruritus, burning, soreness, and irritation, along with occasional dysuria.[3]
Pregnancy sets off increased levels of progesterone and estrogen.[2] Progesterone suppresses the ability of neutrophils to combat Candida, and estrogen disrupts the integrity of vaginal epithelial cells versus such pathogens as Candida and decreases immunoglobulins in vaginal secretions. These issues, which go on throughout pregnancy, lend themselves to multiple recurrences of infection.
Treatment is directed at symptom relief. Topical imidazoles are the majority of frequently recommended. Despite the fact that the two miconazole and clotrimazole are readily available free of a prescription, pregnant patients must never ever self-medicate and must just usage these products under the direction of a healthcare provider.
Miconazole is classified by the US Meals and Drug Administration (FDA) as pregnancy risk category C; however, the topical vaginal formulation achieves minimal systemic absorption. In clinical trials that included patients in the very first trimester, no harm was demonstrated to the mother or fetus.[4]
Clotrimazole vaginal formulations are classified pregnancy risk category B. Studies in the second and 3rd trimesters have actually not demonstrated edge outcomes on the mother or fetus. Data are unsatisfactory to categorize risk in the very first trimester.[5]
Vaginal candidiasis is much more tough to eradicate throughout pregnancy, and prolonged durations of treatment ranging from 7 to 14 days are recommended. Multiple formulations and strengths of topical imidazoles are readily available that affect the duration of therapy for nonpregnant patients; however, throughout pregnancy, just the dosage forms made for prolonged-duration therapy must be used.
Appropriate miconazole formulations contain the 100-mg vaginal suppository or the 2% vaginal lotion applied for a 7-day road of therapy. Clotrimazole 2% vaginal lotion must be used for 7 days. Recurrent infections must be treated for 14 days.
Data in pregnancy for various other topical antifungal agents are limited, making miconazole and clotrimazole the favored topical agents in pregnancy.
Given its ease of usage and great efficacy, oral fluconazole is frequently used for the treatment of vaginal candidiasis in nonpregnant patients. However, usage of fluconazole in pregnancy has actually been controversial.
Animal data suggest that high-dose fluconazole is associated along with craniofacial malformations.[6] An analysis of 1079 women from North Denmark that had a live birth or stillbirth after twenty weeks’ gestation discovered no association in between short-term fluconazole usage in the very first trimester and congenital malformations.[7] However, outcomes from a significantly bigger Danish cohort suggested that patients that receive also reduced doses of fluconazole have actually a 48% better risk for spontaneous abortion compared to those not exposed to fluconazole. Women that received fluconazole had a 62% better risk for spontaneous abortion compared to women treated along with topical azoles.[1] This study prompted the FDA to issue a safety alert for the prescribing of oral fluconazole throughout pregnancy.[8]
In summary, treatment of vaginal candidiasis in pregnancy must just be undertaken along with tips from a healthcare provider. Topical imidazoles (miconazole and clotrimazole) have actually the largest physique of evidence about safety for the two the mother and the fetus throughout pregnancy. Owing to the physiologic modifications that occur throughout pregnancy that compromise host defenses versus Candida, therapy must be continued for a total 7- to 14-day course.
Although fluconazole was previously considered safe in the dosages used to handle vaginal candidiasis, recently published data suggest a significantly greater incidence of miscarriage in patients that receive oral fluconazole for vaginal candidiasis compared along with untreated patients and those treated along with topical imidazoles. On the basis of these data, it would certainly be prudent to steer clear of fluconazole throughout pregnancy if at every one of possible.
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