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Candida - female genital - Management
How should I manage vulvovaginal candidiasis in women who are pregnant?

  • Treat symptomatic women with intravaginal clotrimazole or miconazole for at least 7 days.
  • Advise the woman that care should be taken when using an applicator during pregnancy to avoid injuring the cervix. Some women prefer to insert pessaries by hand when pregnant.
  • For vulval symptoms, consider using a topical imidazole cream (e.g. clotrimazole), in addition to an intravaginal imidazole.
  • Do not use oral antifungals such as fluconazole and itraconazole.
  • Advise the woman to return if:
    • Symptoms have not resolved within 7–14 days.
  • Refer to a genito-urinary medicine clinic if sexually transmitted infection is suspected.
Basis for recommendation
  • These recommendations are based on published expert opinion from the medical literature and a systematic review [Young and Jewell, 2001; CDC, 2006; FFPRHC and BASHH, 2006].
  • There is evidence that treatment with topical imidazoles are more effective than topical nystatin in the treatment of pregnant women with vulvovaginal candidiasis, and that longer courses (7 days) cured more than 90% of women whereas standard (4-day) courses only cured about half the cases [Young and Jewell, 2001].
  • Safety:
    • Oral triazoles (fluconazole and itraconazole) are contraindicated in pregnant women.
      • Animal studies have found that high doses of itraconazole cause fetal abnormalities, and there are concerns that fluconazole may cause congenital defects [Weiner and Buhimschi, 2004].
    • Topical imidazoles (clotrimazole or miconazole) are safe to use in pregnant women.
      • Systemic absorption of clotrimazole and miconazole is minimal [Micromedex, 2010].
      • The available data suggest that there is no evidence of an increased risk of spontaneous abortions or malformations with clotrimazole compared with the background rate [NTIS, 2008].
      • There are fewer data on exposure to miconazole during pregnancy, but the available data do not indicate an increased risk [Schaefer et al, 2007; Micromedex, 2010].
      • However, the manufacturer of econazole has recently updated the Summary of Product Characteristics to state that it is not recommended in pregnancy [ABPI Medicines Compendium, 2010]. In animals studies, econazole was not shown to be teratogenic, but was foetotoxic. The significance of this effect in humans is unknown.
  • Girls between 12 and 16 years old:
    • Intravaginal treatments are generally not recommended for girls between 12 and 16 years old unless, as in this situation, they are sexually active, or there is no other alternative [BNF for Children, 2007].

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