Multimodal Management of Cervical Insufficiency Complicated by Intra-amniotic Candida albicans Infection

Andrew H. Chon; Martha A. Monson; Nicole G. Gomez; Susan M. Butler-Wu; Ramen H. Chmait

doi:10.1055/a-2051-2353

American Journal of Perinatology, Inhaltsverzeichnis

Am J Perinatol 2024; 41(S 01): e1463-e1469
DOI: 10.1055/a-2051-2353

Case Report

Multimodal Management of Cervical Insufficiency Complicated by Intra-amniotic Candida albicans Infection

Autor*innen

Andrew H. Chon

¹Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Keck School of Medicine, University of Southern California, Los Angeles, California

²Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Oregon Health & Science University, Portland, Oregon
Martha A. Monson

¹Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Keck School of Medicine, University of Southern California, Los Angeles, California

³Department of Obstetrics and Gynecology, Intermountain Healthcare, Salt Lake City, Utah

⁴Department of Obstetrics and Gynecology, University of Utah Health, Salt Lake City, Utah
Nicole G. Gomez

¹Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Keck School of Medicine, University of Southern California, Los Angeles, California
Susan M. Butler-Wu

⁵Clinical Microbiology Laboratory, Los Angeles County-University of Southern California Medical Center, Los Angeles, California
Ramen H. Chmait

¹Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Keck School of Medicine, University of Southern California, Los Angeles, California

Abstract

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.

Keywords

Candida - cerclage - cervical insufficiency - fluconazole - intra-amniotic infection

Volltext

Referenzen

References
1 American College of Obstetricians Gynecologists. ACOG Practice Bulletin No.142: Cerclage for the management of cervical insufficiency. Obstet Gynecol 2014; 123 (2 pt 1): 372-379
2 Roman A, Suhag A, Berghella V. Overview of cervical insufficiency: diagnosis, etiologies, and risk factors. Clin Obstet Gynecol 2016; 59 (02) 237-240
3 Han Y, Li M, Ma H, Yang H. Cervical insufficiency: a noteworthy disease with controversies. J Perinat Med 2020; 48 (07) 648-655
4 Robertson JE, Lisonkova S, Lee T. et al; Canadian Perinatal Network and Canadian Neonatal Network Collaborative Groups. Fetal, infant and maternal outcomes among women with prolapsed membranes admitted before 29 weeks gestation. PLoS One 2016; 11 (12) e0168285
5 Ehsanipoor RM, Seligman NS, Saccone G. et al. Physical examination-indicated cerclage: a systematic review and meta-analysis. Obstet Gynecol 2015; 126 (01) 125-135
6 Mays JK, Figueroa R, Shah J, Khakoo H, Kaminsky S, Tejani N. Amniocentesis for selection before rescue cerclage. Obstet Gynecol 2000; 95 (05) 652-655
7 Namouz S, Porat S, Okun N, Windrim R, Farine D. Emergency cerclage: literature review. Obstet Gynecol Surv 2013; 68 (05) 379-388
8 Mönckeberg M, Valdés R, Kusanovic JP. et al. Patients with acute cervical insufficiency without intra-amniotic infection/inflammation treated with cerclage have a good prognosis. J Perinat Med 2019; 47 (05) 500-509
9 Chalupska M, Kacerovsky M, Stranik J. et al. Intra-amniotic infection and sterile intra-amniotic inflammation in cervical insufficiency with prolapsed fetal membranes: clinical implications. Fetal Diagn Ther 2021; 48 (01) 58-69
10 Romero R, Gonzalez R, Sepulveda W. et al. Infection and labor. VIII. Microbial invasion of the amniotic cavity in patients with suspected cervical incompetence: prevalence and clinical significance. Am J Obstet Gynecol 1992; 167 (4 pt 1): 1086-1091
11 Oh KJ, Romero R, Park JY. et al. Evidence that antibiotic administration is effective in the treatment of a subset of patients with intra-amniotic infection/inflammation presenting with cervical insufficiency. Am J Obstet Gynecol 2019; 221 (02) 140.e1-140.e18
12 Diago Almela VJ, Martinez-Varea A, Perales-Puchalt A, Alonso-Diaz R, Perales A. Good prognosis of cerclage in cases of cervical insufficiency when intra-amniotic inflammation/infection is ruled out. J Matern Fetal Neonatal Med 2015; 28 (13) 1563-1568
13 Bean LM, Jackson JR, Dobak WJ, Beiswenger TR, Thorp JA. Intra-amniotic fluconazole therapy for Candida albicans intra-amniotic infection. Obstet Gynecol 2013; 121 (2 pt 2, suppl 1): 452-454
14 Poliquin V, Al-Sulmi E, Menticoglou S. Intra-amniotic infection involving Candida albicans subsequent to emergency cerclage: a case series. Can J Infect Dis Med Microbiol 2015; 26 (05) 245-246
15 Marangoni A, Laghi L, Zagonari S. et al. New insights into vaginal environment during pregnancy. Front Mol Biosci 2021; 8: 656844
16 Cotch MF, Hillier SL, Gibbs RS, Eschenbach DA. Vaginal Infections and Prematurity Study Group. Epidemiology and outcomes associated with moderate to heavy Candida colonization during pregnancy. Am J Obstet Gynecol 1998; 178 (02) 374-380
17 Farr A, Kiss H, Holzer I, Husslein P, Hagmann M, Petricevic L. Effect of asymptomatic vaginal colonization with Candida albicans on pregnancy outcome. Acta Obstet Gynecol Scand 2015; 94 (09) 989-996
18 Maki Y, Fujisaki M, Sato Y, Sameshima H. Candida chorioamnionitis leads to preterm birth and adverse fetal-neonatal outcome. Infect Dis Obstet Gynecol 2017; 2017: 9060138
19 Schuster HJ, de Jonghe BA, Limpens J, Budding AE, Painter RC. Asymptomatic vaginal Candida colonization and adverse pregnancy outcomes including preterm birth: a systematic review and meta-analysis. Am J Obstet Gynecol MFM 2020; 2 (03) 100163
20 Roberts CL, Algert CS, Rickard KL, Morris JM. Treatment of vaginal candidiasis for the prevention of preterm birth: a systematic review and meta-analysis. Syst Rev 2015; 4: 31
21 Lee BE, Feinberg M, Abraham JJ, Murthy AR. Congenital malformations in an infant born to a woman treated with fluconazole. Pediatr Infect Dis J 1992; 11 (12) 1062-1064
22 Pursley TJ, Blomquist IK, Abraham J, Andersen HF, Bartley JA. Fluconazole-induced congenital anomalies in three infants. Clin Infect Dis 1996; 22 (02) 336-340
23 Aleck KA, Bartley DL. Multiple malformation syndrome following fluconazole use in pregnancy: report of an additional patient. Am J Med Genet 1997; 72 (03) 253-256
24 Lopez-Rangel E, Van Allen MI. Prenatal exposure to fluconazole: an identifiable dysmorphic phenotype. Birth Defects Res A Clin Mol Teratol 2005; 73 (11) 919-923
25 Howley MM, Carter TC, Browne ML, Romitti PA, Cunniff CM, Druschel CM. National Birth Defects Prevention Study. Fluconazole use and birth defects in the National Birth Defects Prevention Study. Am J Obstet Gynecol 2016; 214 (05) 657.e1-657.e9
26 Aguin E, Aguin T, Cordoba M. et al. Amniotic fluid inflammation with negative culture and outcome after cervical cerclage. J Matern Fetal Neonatal Med 2012; 25 (10) 1990-1994