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Multimodal Management of Cervical Insufficiency Complicated by Intra-amniotic Candida albicans Infection
Andrew H Chon1,2, Martha A Monson1,3,4, Nicole G Gomez1
1Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Keck School of Medicine, University of Southern California, Los Angeles, California.
Introduction:
Bacteria are the most common pathogens implicated in ascending infections in patients with cervical insufficiency. However, Candida albicans is a rare and serious cause of intra-amniotic infection that should be considered on the differential diagnosis. Upon diagnosis following cerclage placement, patients are generally advised to undergo immediate cerclage removal and discontinuation of the pregnancy due to the high risk of maternal and fetal morbidity. However, some patients decline and instead elect to continue the pregnancy with or without treatment. Limited data exist to guide management of these high-risk patients.
Case Presentation:
We describe a case of previable intra-amniotic C. albicans infection diagnosed following physical examination-indicated cerclage placement. The patient declined pregnancy termination and subsequently underwent systemic antifungal therapy as well as serial intra-amniotic fluconazole instillations. Fetal blood sampling confirmed transplacental transfer of maternal systemic antifungal therapy. The fetus delivered preterm and without evidence of fungemia, despite persistently positive amniotic fluid cultures.
Conclusion:
In a well-counseled patient with culture-proven intra-amniotic C. albicans infection declining termination of pregnancy, multimodal antifungal therapy in the form of systemic and intra-amniotic fluconazole administration may prevent subsequent fetal or neonatal fungemia and improve postnatal outcomes.
Key Points:
· Candida is an uncommon cause of intra-amniotic infection in the setting of cervical insufficiency.. · Multimodal antifungal therapy may prevent fetal fungemia related to intra-amniotic Candida infection.. · Fetal blood sampling confirmed transplacental passage of fluconazole after maternal administration..
Insights
Candida albicans is a rare cause of intra-amniotic infection in patients with cervical insufficiency. Multimodal antifungal therapy, including systemic and intra-amniotic fluconazole, may prevent fetal fungemia and improve outcomes in high-risk pregnancies.
Area of Science:
- Obstetrics and Gynecology
- Infectious Diseases
- Neonatology
Background:
- Ascending infections in cervical insufficiency are typically bacterial.
- Intra-amniotic infection with Candida albicans is rare but serious.
- Current management often advises pregnancy termination due to high maternal and fetal risks.
Purpose of the Study:
- To describe a case of intra-amniotic Candida albicans infection in a patient with cervical insufficiency who declined pregnancy termination.
- To evaluate the efficacy of multimodal antifungal therapy in preventing fetal fungemia and improving outcomes.
- To assess transplacental transfer of antifungal medication.
Main Methods:
- Case presentation of a patient with previable intra-amniotic Candida albicans infection diagnosed after cerclage placement.
- Patient declined termination and received systemic antifungal therapy and serial intra-amniotic fluconazole instillations.
- Fetal blood sampling was performed to confirm transplacental drug transfer.
Main Results:
- The patient delivered preterm without evidence of fungemia, despite persistently positive amniotic fluid cultures.
- Fetal blood sampling confirmed transplacental transfer of maternal systemic antifungal therapy.
- Multimodal antifungal therapy was associated with a positive neonatal outcome.
Conclusions:
- Intra-amniotic Candida infection should be considered in the differential diagnosis of ascending infections with cervical insufficiency.
- Multimodal antifungal therapy may be a viable option for select patients declining pregnancy termination.
- This approach may prevent fetal or neonatal fungemia and improve postnatal outcomes.
