Kanagal et al.

, J Womens Health, Issues Care 2014, 3:6

http://dx.doi.org/10.4172/2325-9795.1000168

Journal of Womens
Health, Issues & Care

Commentary Article

Prevalence of Vaginal
Candidiasis in Pregnancy among
Coastal South Indian Women
Deepa V Kanagal1*, Vashe Keshava Vineeth1, Rashmi
Kundapur2, Harish Shetty1 and Aparna Rajesh1

Abstract
Background: Vulvovaginal candidiasis is characterized by curd
like vaginal discharge and itching. It is associated with considerable
distress to the patient. The incidence is increased in pregnancy and
may lead to complications like abortions, preterm delivery, candida
chorioamnionitis and others. This study was done to determine the
prevalence of vaginal candidiasis in pregnant women in Mangalore,
a coastal city in South India.
Methods: 118 pregnant women were included in the study. High
vaginal swab was taken from these women and subjected to gram
staining and culture to diagnose candidiasis.
Results: Among the 118 pregnant women analyzed, 50 were
positive for candidiasis giving a prevalence of 42.37%. Majority of
them were multigravidae (70%), were in the second trimester of
pregnancy (54%) and in the age group of 26-30 years (64%). 60%
of the pregnant women with vaginal candidiasis had risk factors like
diabetes, previous use of oral contraceptives, intra uterine devices,
oral antibiotics and past episodes of candidiasis. Species isolation
was done in 26 women. This showed predominantly candida
albicans (69.23%).
Conclusion: In view of such high prevalence of vulvovaginal
candidiasis especially in developing countries, we recommend
incorporation of a screening protocol in routine antenatal checkup
for early diagnosis of candidiasis and its treatment by cost effective
drugs.
Keywords: Pregnancy; Prevalence; Vulvovaginal candidiasis

Keywords: Pregnancy; Prevalence; Vulvovaginal candidiasis

Introduction
Vulvovaginal candidiasis is caused by overgrowth of candida
yeast species in the vagina and is characterized by curd like vaginal
discharge, itching and erythema [1]. Candida species are part of the
lower genital tract flora in 20 50% of healthy asymptomatic women
[2]. Carrier rates are higher in pregnant women, diabetic women,
women treated with broad spectrum antibiotics and women with
HIV/AIDS [2]. Approximately 75% of all women experience at least
one episode of vulvovaginal candidiasis during their lifetime and
*Corresponding author: Dr. Deepa V Kanagal, Associate Professor,
Department of OBG, K.S.Hegde Medical Academy, Mangalore, Karnataka, India,
Tel: 09980164615; E-mail: deepakanagal@yahoo.co.in
Received: July 26, 2014 Accepted: September 26, 2014 Published: October
01, 2014

International Publisher of Science,

Technology and Medicine

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50% of them suffer recurrent events [3]. Diagnosis of vulvovaginal
candidiasis is done by gram staining of the smears and culture.
In pregnancy, vaginal candidiasis is common due to altered pH
and sugar content in vaginal secretions. Increased estrogen level
during pregnancy produces more glycogen in the vagina and it also
has direct effect on yeast cells, causing it to grow faster and stick
more easily with the walls of vagina [4]. The incidence of candidiasis
is almost doubled in pregnant women particularly in the third
trimester compared to the non-pregnant women [5]. It has been
estimated that up to 40% of pregnant women worldwide may have
vaginal colonization by candida species [6]. There also seems to be
a trend for it to recur during pregnancy as a result of the increased
levels of estrogens and corticoids reducing the defense mechanisms
against such opportunistic infections [5]. Vulvovaginal candidiasis is
an important cause of morbidity in the pregnant population. It can
cause abortion, candida chorioamnionitis and subsequent preterm
delivery. Premature neonates are severely endangered by generalized
fungal infection because of their immature immune system. During
delivery, transmission can occur from the vagina of infected mother
to the newborn, giving rise to congenital candida infection [4]. Early
detection, early diagnosis and appropriate treatment may improve
the clinical condition of the women and neonates. In view of this,
the present study was undertaken to find out the prevalence of
vaginal candidiasis in pregnant women in and around Mangalore in
Karnataka, India.

Materials and Methods

The study was conducted in the Department of Obstetrics
and Gynecology and the department of Microbiology at a tertiary
hospital in Mangalore, south Karnataka, India. 118 pregnant
women irrespective of age, gravidity and trimester of pregnancy
were included in the study by convenient sampling. The aim of the
study was to determine the frequency of vaginal candidiasis during
pregnancy. Ethical Committee Clearance was obtained from the
university. After obtaining informed consent from all the subjects,
a detailed clinical history was taken followed by a complete clinical
examination. Information on demography, parity, trimester of
pregnancy, presence or absence of vaginal discharge associated with
itching, presence or absence of diabetes, presence of risk factors,
treatment history and relevant information were collected. Vulva
and vagina were inspected for signs of inflammation and discharge.
Sterile speculum examination was done and a high vaginal swab was
taken by a sterile swab stick. The swab stick was immediately replaced
in its casing and labeled appropriately. The swabs were subjected to
gram staining and KOH wet mount examined microscopically for the
diagnosis of candida. Swabs were cultured on Sabouraud Dextrose
Agar and incubated at 37 degree for 48 to 72 hours and examined
for creamy smooth white colonies of yeasts. Candida species was
identified by vitek method in some cases. The data was statistically
analyzed and interpreted using software SPSS version 20. Chi square
test was used to assess P value and a value of <0.05 was considered
to be statistically significant. Pregnant women with symptomatic and
asymptomatic candidiasis were considered separately. Women with
sexually transmitted diseases, other infectious diseases and recently
treated for candidiasis were excluded from the study.

All articles published in Journal of Womens Health, Issues & Care are the property of SciTechnol, and is protected by
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Citation: Kanagal DV, Vineeth VK, Kundapur R, Shetty H, Rajesh A (2014) Prevalence of Vaginal Candidiasis in Pregnancy among Coastal South Indian
Women. J Womens Health, Issues Care 3:6.

doi:http://dx.doi.org/10.4172/2325-9795.1000168

Results

Discussion

A total of 118 pregnant women in different trimesters

participated in the study. The subjects were analyzed according to
their age, parity, trimester of pregnancy, presence of risk factors like
diabetes, hypertension, previous urinary tract infection, previous
vaginal candidiasis, and use of antibiotics, oral contraceptive pills,
intrauterine contraceptive device usage and others.

Vulvovaginal candidiasis in pregnancy is a distressing infection.

Acute episodes can occur during pregnancy and has its consequences
on the outcome. The common presenting signs and symptoms are
vaginal discharge, pruritus and vaginal burning. The commonest
cause of vulva pruritus in pregnancy is vulvo vaginal candidiasis [7].
The hormonal milieu of the vagina during pregnancy can enhance
candida colonization and serve as risk factors. Progesterone has
suppressive effect on the anti-candida activity of neutrophils while
estrogen has been found to reduce the ability of vaginal epithelial
cells to inhibit the growth of candida albicans [3]. Moreover, a large
proportion of women with chronic recurrent candidiasis first present
with the infection during pregnancy. In pregnant women, vaginal
candidiasis has been related to emotional stress and suppression
of immune system which steps up the risk of Candida species
overgrowth and become pathogenic [8].

Among 118 subjects, 50 were positive for candida by gram staining

and culture, making a prevalence rate of 42.37%. 82% of candida
positive women were symptomatic and the remaining 18% were
asymptomatic whereas in the control candida negative group, 73.5%
were asymptomatic and the remaining 26.5% were symptomatic
which was statistically significant (Table 1). 70% of pregnant women
with candidiasis were multigravida and among controls 50% were
multigravidae which was statistically significant (P<0.05). The
trimester distribution of women with candidiasis was 54% in second
trimester, 30% in third trimester and 16% in first trimester. Among
the controls, 44.11% were in second trimester, another 44.11% were
in third trimester and 11.76% of women were in first trimester. This
trimester distribution was not statistically significant among cases
and controls. 60% of candida positive pregnant women had risk
factors like diabetes, previous candidiasis, use of antibiotics, oral
contraceptives and intra uterine contraceptive devices as against
14.7% in candida negative pregnant control women. This was
statistically highly significant (P<0.00001). The distribution of risk
factors is shown in Table 2. Candidiasis was common among cases
in the age group of 26 to 30 (64%) as compared to 44.1% in the same
age group among controls which was statistically significant (Table
3). Species identification of candida was done in 26 out of 50 women
positive for candida by vitek method which showed predominantly
candida albicans (18/26, 69.23%) followed by candida glabrata (6/26,
23.07%) and in only 2 cases candida tropicalis was isolated (7.69%).

The data on vaginal candidiasis in pregnant women in developing

countries is very scanty. This study was done to analyze the
prevalence of vaginal candidiasis among pregnant women attending
antenatal clinic of a medical college hospital in South India. The
study showed a prevalence of 42.37%. Higher prevalence was shown
in the study by Oyewole etal (70%) [9]. Another study by Parveen et
al showed a lower prevalence of 38% [4]. A study by Feyi Waboso
and Ahmadi showed prevalence similar to our study (42.9%) [10].
This high prevalence of vaginal candidiasis may lead to pregnancy
complications like abortions, premature birth, low birth weight and
other morbidities. Among these women, 82% had symptoms like
vaginal discharge, pruritus and vaginal burning whereas 18% of them
were asymptomatic. Aslam et al also noted similar symptoms in all
100% of their subjects [3].
Isolation of species was done in 26 of the 50 positive pregnant
women. Candida albicans was the predominant species (69.23%)

Signs & Symptoms

Number=50 (Positive)

Percentage

Number=68 (Negative)

Percentage

P value

Asymptomatic

18%

50

73.5%

<0.01*

Vaginal discharge

20

40%

07

10.3%

Pruritus with discharge

12

24%

06

8.8%

Vaginal burning

18%

05

7.4%

*P Value - Significant
Table 1: Signs and symptoms of vaginal candidiasis.
Risk Factors

N=30(positive)

Percentage

N=10(Negative)

Percentage

Diabetes

10

33.33%

20%

Previous Candidiasis

23.33%

10%

Previous antibiotics

16.66%

50%

Oral Contraceptives

13.33%

20%

Previous Intrauterine Devices

13.33%

P value- <0.001*

*P value Significant
Table 2: Risk Factors (N= 30).
N = 50

Positive

N=68

Negative

P value

Age

Number

Percentage

Number

Percentage

<0.01*

20-25

09

18%

27

39.7%

26-30

32

64%

30

44.11%

30-35

06

12%

08

11.76%

>35

03

06%

03

4.41%

*P value - Significant
Table 3: Age Distribution.
Volume 3 Issue 6 1000168

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Citation: Kanagal DV, Vineeth VK, Kundapur R, Shetty H, Rajesh A (2014) Prevalence of Vaginal Candidiasis in Pregnancy among Coastal South Indian
Women. J Womens Health, Issues Care 3:6.

doi:http://dx.doi.org/10.4172/2325-9795.1000168
followed by candida glabrata (23.07%) and candida tropicalis
(7.69%). Candida glabrata and tropicalis were found only in second
and third trimester. Nelson et al showed candida albicans as the
most common vaginal candida species followed by candida glabrata
causing vaginal candidiasis among pregnant women [8]. Oyewole
et al., showed highest occurrence of candida albicans (50%) followed
by glabrata (21.4%), tropicalis (14.3%), krusei (11.9%) and candida
pseudotropicalis (2.4%). They said that candida albicans is a leading
causative agent of the reproductive tract yeast infections in women
of child bearing age and this may be due to its virulent factors which
include dimorphism and phenotypic switching. Also candida albicans
produces protease and phosphatase which enhance its attachment to
human epithelium [9].

References

70% of vaginal candidiasis positive pregnant women were

multigravidae in contrast to only 30% primigravidae which was
statistically significant. Other studies also noted a higher prevalence in
multigravidae 59.5%, 60% and 82.72% respectively [3,4,9]. Parveen,
et al., explained that as multigravida have longer sexual history and
also number of pregnancies that make them more prone to develop
vaginal candidiasis than primigravidae who have less sexual exposure
[4].

5. Fernndez Limia O1, Lantero MI, Betancourt A, de Armas E, Villoch A (2004)

Prevalence of Candida albicans and Trichomonas vaginalis in pregnant
women in Havana City by an immunologic latex agglutination test. See
comment in PubMed Commons below MedGenMed 6: 50.

60% of pregnant women with vaginal candidiasis had risk factors

like diabetes, previous candidiasis infection, use of antibiotics, oral
contraceptive pills and intra uterine contraceptive devices which
was statistically significant. This is in consent with the findings that
candidiasis affects women with these risk factors.
Candidiasis was more common in women of age group 26 to
30 (64%). Nelson et al showed a 60% frequency of candidiasis in
pregnant women of 2635 years. They gave an opinion that a higher
infection rate in this age group was because of indiscriminate drug
usage and use of contraceptives [8]. In our study, 54% prevalence was
in second trimester compared to 30% in third trimester and 16% in
first trimester. Similar to our study, Oyewole et al. found the highest
incidence in second trimester (61%) followed by third trimester
(21.4%) and first trimester (16.7%) [9]. Nelson et al., found that third
trimester had the highest prevalence of candidiasis (68.09%) followed
by second trimester (21.28%) and the least in first trimester (10.63%)
[8].
In view of the high prevalence of candidiasis in pregnancy and the
complications associated with it, identification of high risk pregnant
women and their routine screening for candidiasis is recommended.
This is especially helpful in developing countries. Early diagnosis and
treatment can prevent the complications associated with candidiasis.
A study by Roberts, et al., showed that there was a tendency towards
reduction in spontaneous preterm birth among women with
asymptomatic candidiasis who were treated with antifungal agent
[11]. So, we recommend incorporation of a screening protocol in
routine antenatal checkup for early diagnosis of candidiasis and its
treatment by cost effective drugs.

1. Rathod SD, Klausner JD, Krupp K, Reingold AL, Madhivanan P (2012)

Epidemiologic Features of Vulvovaginal Candidiasis among ReproductiveAge Women in India. Hindawi Publishing Corporation, Infect Dis Obstet
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Microbiol 3: 264-272.
9. Oyewole OA, Okoliegbe IN, Alkhalil S, Isah P (2013) Prevalence of Vaginal
Candidiasis among Pregnant Women Attending Federal University of
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18.

Author Affiliations
1

Top

Department of OBG, K.S.Hegde Medical Academy, India

Department of Community Medicine, K.S.Hegde Medical Academy,

Karnataka, India

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