A 28 year old primigravid female at 20 weeks gestation presents for 2 days of vaginal irritation and discharge. Her pregnancy has been uncomplicated, and her only medication is prenatal vitamins. She denies any fever, vomiting, abdominal pain, vaginal bleeding, or dysuria. Vital signs are: HR 92, BP 110/70, T 37.3 C, RR 20, SpO2 98%. Pelvic exam reveals vulvar erythema and white vaginal discharge. Cervical os is closed. Wet mount is shown below. Which of the following is the appropriate treatment?
A: clindamycin vaginal cream
B: clotrimazole vaginal cream
C: PO metronidazole
D: PO fluconazole
Answer: clotrimazole vaginal cream
This patient is presenting with candida vulvovaginitis proven by her wet prep demonstrating budding yeasts and pseudohyphae. Candidal vaginitis infections in pregnant women should be treated with topical azoles. Oral fluconazole is the typical treatment of candida vaginitis in non-pregnant patients but should be avoided in pregnancy due to increased risk for congenital malformations and spontaneous abortion. Clindamycin vaginal cream is an alternative treatment option for bacterial vaginitis. Oral metronidazole is the treatment for either trichomonas or bacterial vaginitis.
| Treatment of Vaginitis in Pregnancy | |
| Bacterial | PO metronidazole or vaginal gel Clindamycin vaginal cream |
| Candida | Topical intravaginal azoles oral azoles contraindicated (category C) |
| Trichomonas | Metronidazole |
References:
Barclay-Buchanan C.J., & Barton M.A. (2020). Vulvovaginitis. Tintinalli J.E., & Ma O, & Yealy D.M., & Meckler G.D., & Stapczynski J, & Cline D.M., & Thomas S.H.(Eds.), Tintinalli’s Emergency Medicine: A Comprehensive Study Guide, 9e. McGraw Hill.
Mølgaard-Nielsen D, Svanström H, Melbye M, Hviid A, Pasternak B. Association Between Use of Oral Fluconazole During Pregnancy and Risk of Spontaneous Abortion and Stillbirth. JAMA. 2016;315(1):58–67. doi:10.1001/jama.2015.17844
