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 intraamniotic infection that should be considered on the differential. 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 exists to guide management of these high-risk patients. Case Presentation: We describe a case of previable intraamniotic 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 intraamniotic 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 intraamniotic Candida albicans infection declining termination of pregnancy, multi-modal antifungal therapy in the form of systemic and intraamniotic fluconazole administration may prevent subsequent fetal or neonatal fungemia and improve postnatal outcomes.