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

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

Ethical Approval

The study protocol was approved by the local committee on human research.

Patient Consent

Informed consent was obtained from the patient for publication of the details of the medical case.

Publikationsverlauf

Eingereicht: 25. September 2022

Angenommen: 24. Februar 2023

Accepted Manuscript online:
09. März 2023

Artikel online veröffentlicht:
16. Mai 2023

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