Abstract
Vulvitis and vaginitis is defined as a spectrum of conditions that cause vulval and/or vaginal symptoms. Candida is the most common cause of vulvovaginal complaints for which women seek medical advice, especially during pregnancy.
Vulvovaginal candidiasis (VVC) is an opportunistic mucosal mycosis, and one of the most common causes of vulvovaginal itching and discharge caused by Candida species (C. albicans, C. glabrata. C. krusei, C. parapsilosis and C. tropicalis).
Candida albicans causes 80–90 per cent of vaginal fungal infection.
Ten to twenty per cent of reproductive-age women who harbour Candida species are asymptomatic and do not require therapy.
Vaginal candidiasis, commonly called ‘yeast infection, or moniliasis’, is relatively common during pregnancy (especially during the second trimester). with an estimated prevalence of 10–75 per cent.
Approximately 75 per cent of all pregnant women experience at least one episode of VVC during their lifetime, and 50 per cent of them suffer recurrent events.
Vulvitis and vaginitis is defined as a spectrum of conditions that cause vulval and/or vaginal symptoms. Candida is the most common cause of vulvovaginal complaints for which women seek medical advice, especially during pregnancy.
Vulvovaginal candidiasis (VVC) is an opportunistic mucosal mycosis, and one of the most common causes of vulvovaginal itching and discharge caused by Candida species (C. albicans, C. glabrata. C. krusei, C. parapsilosis and C. tropicalis).1, 2
Candida albicans causes 80–90 per cent of vaginal fungal infection.3, 4
Ten to twenty per cent of reproductive-age women who harbour Candida species are asymptomatic and do not require therapy. 5
Vaginal candidiasis, commonly called ‘yeast infection, or moniliasis’, is relatively common during pregnancy (especially during the second trimester). with an estimated prevalence of 10–75 per cent.
Approximately 75 per cent of all pregnant women experience at least one episode of VVC during their lifetime, and 50 per cent of them suffer recurrent events.7
The Candida is harboured in the vagina as part of the body’s beneficial flora. About 20 per cent of women have Candida in their vagina normally. That number goes up to 30 per cent during pregnancy. When the vaginal environment changes, it allows for the fungus to proliferate and cause problems.6
Hormone fluctuations cause alteration in vaginal environment/pH.
The causes of Candida colonisation during pregnancy are complex.
Pregnancy causes increased levels of progesterone and oestrogen.
Progesterone suppresses the ability of neutrophils to combat Candida.
Oestrogen disrupts the integrity of vaginal epithelial cells against Candida and decreases immunoglobulins in vaginal secretions.
Multiple recurrences of infection continue throughout the pregnancy.7
The increased glycogen content under the influence of reproductive hormones serves as a nutritional source for proliferating yeast.
Factors like gestational diabetes, frequent antibiotic therapy, HIV, contraceptives, reproductive hormones also predispose women to acute and chronic VVC. It is also common for women to get a yeast infection when they are taking antibiotics because they kill off a number of the other factors that keep the yeast in balance and control.
Candida infection is more likely to be associated with a retained intrauterine contraceptive device in early gestation, assisted reproduction techniques, history of amniocentesis, or cervical cerclage and preterm delivery.
Maternal Symptoms
May include one or more of the following:
Increased discharge usually thin white/grey/greenish or yellowish, similar to cottage cheese and may smell like yeast/bread
Redness, itching, or irritation of the lips of the vulva and vagina
Burning sensation during urination or intercourse
Effect on Pregnancy
In pregnancy, yeast infections do not usually cause adverse effects for either the mother or her baby. However, they often cause significant discomfort which may be difficult to control.
The incidence of VVC is doubled in the third trimester of pregnancy, and multigravida suffer significantly more than primigravida.
Fetal Implication
Rarely the infection spreads into the bloodstream of the mother and therefore to the baby. This is a serious condition which is sometimes fatal and can affect the heart, eyes, bones or brain.
It is often caused by using contaminated objects and by poor hygiene. These women are often immunocompromised, including HIV, presenting as chills and persistent fever.
Candida chorioamnionitis is rare but can lead to neonatal infection, high perinatal mortality and neurodevelopmental impairment.8
Despite the high incidence of vulvovaginal candidiasis during pregnancy (13–20 per cent), candidal chorioamnionitis is a rare occurrence. The prevalence of C. chorioamnionitis is 0.3–0.5 per cent of all pregnant women.
• Preterm birth and Stillbirth
Systematic review found two trials comparing the treatment of asymptomatic vaginal candidiasis in pregnancy for the outcome of preterm birth. These trials suggested Candida infection may manifest as preterm labour, preterm rupture of membranes (PROM) without fever or even stillbirth.9 [EL 1]
The exact mechanism of premature labour is unknown. It is thought that the acid pH of the vagina has some effect on the hormones that trigger labour. In a recent study, it was shown that 25 per cent of women with preterm labour were suffering from a yeast infection.
In a literature search of 14 eligible studies, the Johns Hopkins study investigators found a significant association between growth restriction and Candida albicans colonisation (odds ratio 1.9).
Therefore, constant check-ups regarding Candida infection and immediate treatment are advised for any mother-to-be.10
Urinary tract yeast infection during postpartum period occurs in 6.8 per cent of patients, and risk increases in patients with compromised immune system, catheterisation and the use of antibiotics.
Neonatal Implications
Congenital Candidiasis
Transmission of Candida may be vertical (from maternal vaginal infection) or nosocomial.11
Two forms of neonatal infection have been described:
1) Congenital cutaneous candidiasis in which an extensive skin rash presents within 12 hours of birth. A macular erythema that may evolve from a pustular, papular or vesicular phase finally results in extensive desquamation. Rash appears shortly after birth and it is essentially benign and self-limiting.
2) Congenital systemic candidiasis is a serious and common cause of late-onset sepsis, with a high mortality rate (25–35 per cent), especially in very low-birthweight (VLBW) infants. At least 50 per cent of babies present with a cutaneous rash, pneumonia (most common), meningitis, candiduria and/or candidemia. C. albicans and C. parapsilosis are the most common species found in neonates.
The usual therapeutic agents are amphotericin and fluconazole. Amphotericin B is recommended as the first-line treatment in cases of invasive candidiasis in pregnant women and neonatal candidiasis. It crosses the placenta but has no reported adverse effects in humans.
Neonatal thrush is not life-threatening but it can make swallowing uncomfortable and hinder feed if present inside the mouth of the baby. If the mother breastfeeds, infected breasts can easily pass the infection on to the child or vice versa.
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