Vulvovaginitis Candidiasis Recurrence During Pregnancy
Vulvovaginitis is the most common gynecologic condition seen
by practitioners rendering primary care to women. Vulvovaginitis Candidiasis
(VVC) is the most common type of vaginitis and this study aimed at specifying
VVC recurrence during pregnancy. In this prospective study, 150 pregnant women
suffering from vaginal excretion, morsus and itching were studied. Initially,
the patients were treated using clotrimazole local cream (5 g) for 7 successive
days. After initial treatment, the patients were freely visited once a month
until delivery considering vaginitis symptoms and VVC recurrence was examined
during pregnancy. Mean age of the understudy mothers was 27.26±3.76.
Mean of recurrence number was 0.17±0.48 during the first trimester. Mean
of recurrence number was 0.92±0.76 during the second trimester. Mean
of recurrence number was 2.16±0.63 during the third trimester. Statistically
significant difference was between recurrences during three trimesters of pregnancy
(p<0.001). There is statistically significant difference between mean number
of recurrences during three trimesters of pregnancy.
January 01, 2012; Accepted: July 19, 2012;
Published: September 03, 2012
Vaginitis is an inflammation of the vagina. It can result in discharge, itching
and pain and is often associated with an irritation or infection of the vulva
(Hanna, 1995; Kukner et al.,
1995). It is of common causes of womens referring to clinics. Vulvovaginitis
candidiasis (VVC) is the most common type of vaginitis and it is estimated that
75% of women suffer from candidiasis vulvovaginitis at least once in their life
and 45% of women suffer from VVC infection for two or more times (Mylonas
and Friese, 2007; Quan, 2010). Candida vaginitis
is a result of Candida albicans in 85-90% of cases but other Candida
species such as Candida glabrata, Candida tropicalis may also
lead to appearing of vulvovaginitis (Chong et al.,
2007). Due to decrease of immunity quality with cellular mediator, pregnancy
may provide conditions to suffer from vulvovaginitis candidature. Although VVC
has no proved effect on embryo during pregnancy; excretion, morsus, dyspareunia,
itching and valve incitement lead to discomfort of the patient and should be
treated. Corsello et al. (2003), Grigoriou
et al. (2006) During pregnancy, acute infection is treated using
local ointment for 7 days. Sufficient studies have been conducted considering
prevalence of relapsing VVC in non pregnant women. Nancy Bohannon introduced
pregnancy, diabetes, consumption drugs with high estrogen, obesity and addiction
as risk factors leading to suffering from recurrent VVC (Marrazzo,
2002). Due to high prevalence of vaginal candidiasis during pregnancy, sufficient
researches have not been done regarding recurrence of the disease during this
period such that there is no information considering VVC or vagina recurrent
candidiasis during pregnancy. In the present, VVC recurrence during pregnancy
was assessed to evaluate the need to supporting treatment during pregnancy.
MATERIALS AND METHODS
In this prospective study, 150 pregnant women suffering from vaginal excretion,
morsus and itching were primarily selected until completion of the sample. They
referred to specialized clinics of Tabriz University of Medical Sciences and
the gynecologist diagnosed VVC in their clinical examination. Research method
including registering examination data, testing vaginal excretion and free periodic
examinations were described to the patients. After accepting the conditions
and submitting letter of satisfaction, they entered the study. To have a definite
diagnose, all selected patients were referred to Alzahra hospital of Tabriz
to test direct vision with KOH. In case of obtaining positive results, they
entered the study. If there was strong clinical doubt but direct vision of the
excretions was negative, the samples were sent to cultivation test of vaginal
excretions and the positive cases entered the study. Other inclusion criteria
of the study were: not suffering from diabetes, suffering from chronic dermatosis
in perineum and non-rupture of the hydatid. Exclusion criteria were: Non-consumption
of drugs during initial infection, sensitivity to steroid, manifestation of
other lower genital infections such as herpes and dissatisfaction of the patient
to continue the research. At first, the patients were treated using clotrimazole
cream for 7 successive days. After initial treatment, the patients were freely
visited once a month until delivery considering vaginitis symptoms (pregnancy
control visits were not regarded as the related ones). Also, they were advised
to refer to the physician early in case of appearing the symptoms. Reappearing
of Candida excretion in vagina or vulva and laboratory confirmation was
regarded as recurrence. Considering the mentioned symptoms, numbers of the patients
recurrence were registered until delivery. The registered cases included patients
personal particulars, records of background disease, records of drug consumption
and also medical features such as laboratory diagnosis and registered recurrence
Statistical analysis: The results of the study were statistically analyzed
using SPSS, version 16. To account for statistical differences in two groups,
a chi-square test or Fisher's exact test was used, as appropriate. A p-value
of <0.05 was considered significant.
Mean age of the understudy patients was 27.26±3.76. The youngest mother
was 18 and the oldest one was 35 years. Most of the women in this study were
28 years old and more than 50% of the understudy women were 28 years old or
below 28 years. Correlation exhibited that there is no statistically significant
relationship between mothers age and recurrence rate during first trimester
of pregnancy (p = 0.792). The correlation test demonstrated that there is no
statistically significant relationship between mothers age and recurrence
rate during second trimester of pregnancy (p = 0.611). The same trend also obtained
in correlation from the third trimester of pregnancy (p = 0.272). Three (2%)
patients had records of drug consumption (immunosuppressive) and 26 (17.3%)
patients cases had records of antibiotic consumption. Statistically significant
relationship between antibiotic consumption and recurrence during first and
third trimester of pregnancy (p = 0.021) and (p = 0.043).
|| Demographic characteristics of the study population
|| Relationship between recurrence rate and time of pregnancy
The second trimester of pregnancy did not show any statistically significant
relationship between antibiotic consumption and recurrence (p = 0.690) (Table
1). In this study, mean of recurrence number was 0.17±0.48 during
the first trimester. The least number of recurrences was zero and the greatest
one was 3 during the first trimester of pregnancy. Most of women did not experience
recurrence during first trimester of pregnancy. Mean of recurrence number was
0.92±0.76 during the second trimester. The least number of recurrences
was zero and the greatest one was 3 during the second trimester of pregnancy.
Most of women experienced 1 recurrence during second trimester of pregnancy.
Mean of recurrence number was 2.16±0.63 during the third trimester. The
least number of recurrences was 1 and the greatest one was 4 during the third
trimester of pregnancy. Most of women experienced 2 recurrences during third
trimester of pregnancy. There is statistically significant difference between
mean number of recurrences during three trimesters of pregnancy (p<0.001);
it was different in all the three groups. Comparing other periods, more recurrences
were observed during the third trimester (Table 2). Mean recurrence
was 1.08±1.04 among pregnant women suffering from VVC during pregnancy.
Each women experienced recurrence at least once. Most of them, i.e., 50%, experienced
it more than once.
There have been conducted sufficient studies considering prevalence rate of
recurrent VVC in nonpregnant women (Goode et al.,
1994; Kukner et al., 1995) but, no research
with the same subject has been done on rate or recurrent mean of VVC during
pregnancy. Therefore, results of this study are not comparable with other studies.
This is a prospective, comparative and analytical study comparing recurrent
rate of VVC during first, second and third trimester of pregnancy and studying
total mean of VVC recurrent in this period. In this study, mean age of the understudy
pregnant women was 27.26±3.76 and most of them were in the age group
of 24-29 years. The correlation test results demonstrated that there is no statistically
significant relationship considering mothers age and recurrence rate during
first trimester of pregnancy (p = 0.792). The same is true for the second and
third trimesters (p = 0.611 and p = 0.272, respectively). In their study conducted
on risk factors of suffering from recurrent VVC, Patel et
al. (2004) stated that age less than 40 had a positive relationship
with marked periods of VVC. Mean of previous pregnancy times was 1.81±0.75
in the understudy mothers. Most of them experienced two previous pregnancies.
It seems that there is no positive relationship between previous pregnancy times
and recurrent rate during present pregnancy. Diabetes, pregnancy and wide use
of antibiotics as well as any reason result in decreasing cellular immunity
system efficiency were regarded as the risk factors of suffering from recurrent
VVC in all reference books and conducted researches (Reed,
1992; Sobel, 1985, 1989).
As mentioned, consumption of antibiotics and every other factor leading to weakening
of cellular immunity increase VVC recurrence (Lindeque and
Van Niekerk, 1984; Merkus, 1990). In the present
study, 2% of pregnant women had records of immunosuppressive and 17.3% of them
had records of antibiotic consumption. According to the study, there is statistically
significant relationship between records of antibiotic consumption and recurrence
of the problem during the first and three trimester of the pregnancy. The results
demonstrate that there is no statistically significant relationship between
antibiotic consumption and recurrence during second trimester of pregnancy (p
= 0.690). Most of the researchers state that 75% of women suffer from VVC at
least once in their life, 45-50% of women suffer from it for two or more times
and 5% suffer from recurrent VVC (Eschenbach, 1983;
Lebherz and Ford, 1982). Any of the references did not
refer to VVC recurrent rate or mean during pregnancy (Eliot
et al., 1979; Lebherz et al., 1983).
In the present study, mean recurrent was 0.17±0.48 during first trimester
of pregnancy. Most of the understudy women did not experience recurrent during
first trimester. In these women, mean of recurrent times was 0.92±0.76
during the second trimester. Most cases experienced recurrence once during the
second trimester. Mean recurrent was 2.16±0.63 during the third trimester
and most of them experienced recurrent twice during the third trimester of pregnancy.
There is no positive relationship between times of previous pregnancy and recurrent
rate of vaginitis during present pregnancy. Statistically significant difference
is between mean number of recurrences during three trimesters of pregnancy.
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