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Prevalence of Vulvovaginal Candidiasis in

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ISSN: 2449-1888 Vol. 4 (1), pp. 108-116, October, 2016
Copyright ©2016 Global Journal of Medicine and Medical Sciences
Author(s) retain the copyright of this article.
http://www.globalscienceresearchjournals.org/

Full Length Research Paper

Prevalence of Vulvovaginal Candidiasis in Pregnancy

*Khushbu Yadav1 and Satyam Prakash2
1*
Medical Microbiologist & Lecturer, Krishna Medical Technical Research Center, Purwanchal University,
Janakpurdham, Nepal
2
Assistant Professor, Department of Biochemistry, Janaki Medical College Teaching Hospital, Tribhuvan University,
Janakpurdham, Nepal

Accepted 4 October, 2016

Transmission of Candida infections can occur from the vagina of the infected mother to the newborn,
giving rise to congenital Candida infection. Vulvovaginal candidiasis (VVC) is an important cause of
morbidity in pregnant women. It has been related to emotional stress and suppression of immune
system which steps up the risk of Candida species overgrowth and become pathogenic which can
cause abortion, Candida chorioamnionitis and subsequent preterm delivery. Therefore, the present
study was focused to determine the contributory agent of VVC and to determine its prevalence among
pregnant women. A cross-sectional descriptive study comprised of 157 pregnant women of
reproductive age group was selected. Two high vaginal sterile cotton swabs were collected from the
pregnant women and were immediately brought to the laboratory. Culture media were prepared as
instructed by the manufacturer company (Hi-media) and processed according to standard methods. The
prevalence of vulvovaginal candidiasis was found to be 35%. The highest number of VVC was found
within the age group of 21-25 years with 40.44%. C. albicans was found to be predominant organism to
nd
cause candidiasis. Most of the respondents had suffered from candidiasis in 2 trimester of gestation
period of 55% and those who had symptoms of VVC. Most of the respondents had illiterate and
unemployed of high positive cases with 35.95% and 44.94% which was found to be statistically
significant (p= 0.001) and insignificant (p= 0.328) respectively. The prevalence of vulvovaginal
candidiasis in the pregnant women was in increasing trend. Therefore, routine medical examination,
adequate ante-natal services and appropriate treatment of the infected women should be recommended
which can prevent the complications associated with VVC.

Key words: Vulvovaginal candidiasis, Pregnancy, C. albicans, Gestation, Significant

INTRODUCTION

Women are considered as a supreme creature of God supplied to the growing fetus despite intermittent
undergoes through a variety of physiological changes maternal food intake (Butte, 2000; Prakash et al., 2015).
during pregnancy (Prakash and Yadav, 2015). Pregnancy The female genital tract (FGT) is considered as the point
is a dynamic state that normal fetal development needs of entry for number of pathogens for various sexually and
the availability of essential nutrients such as glucose, free non-sexually transmitted diseases that affect the FGT
fatty acids, long-chain polyunsaturated fatty acids, amino causing vaginal discharge. Vaginal discharge is a
acids, minerals and vitamins are to be continuously common symptom in gynecological clinic and is often

*Corresponding author. E-mail: [email protected]

Author(s) agreed that this article remain permanently open access under the terms of the Creative Commons Attribution License 4.0 International License
Glob. J. Med. Med. Sci. 109 Prevalence of Vulvovaginal Candidiasis in Pregnancy

the second most common gynecological problem after Vulvovaginal candidiasis is an important cause of
menstrual disorders (Akinbami et al., 2015). morbidity in pregnancy which can cause abortion,
Vulvovaginal candidiasis (VVC) is also called candidal candida chorioamnionitis, subsequent preterm delivery,
vaginitis or monilial infection of the vulva which is caused emotional stress and suppression of immune system
by overgrowth of candida yeast species, most commonly (Sobel, 1997; Sobel, 1985; Singh, 2003). Vaginal
Candida albicans, C. glabrata and C. tropicalis symptoms are one of the most common reasons for
characterized by curd like vaginal discharge, itching, gynecological consultation accounting for approximately
erythema, burning, irritation of vulva and vagina usually 10 million office visits each year (Feyi-Waboso and
odourless with dysuria and dyspareunia (Akinbami et al., Amadi, 2001). Many women think their symptoms are
2015; Rathod et al., 2015; Nviriesy, 2008). Candida normal occurrence or are reluctant (Reed et al., 2003).
species that rarely cause infection include C. Although, the problem may seems small but for the
parapsilosis, C. pseudotropicalis, C. krusei, C. sufferer it is the immense physical and psychological
guilliermondi and C. stellatoidea (Cronje et al., 1994; problem that may require instant attention, which is
Mitchell, 2004). Candida species are almost universal in lacking in the most of the hospitals and clinics.
low numbers on healthy adult skin and are part of the In Nepal, very few studies have been implicated in the
normal flora of the mucous membrane of the respiratory, prevalence and therapeutic consideration of VVC. So, it
gastrointestinal and female genital tracts (20-50%). is troublesome to know how frequent this disease is
Overgrowth of these organisms can cause superficial common among Nepalese pregnant women due to the
infections such as vaginitis, most common form of dearth of information. It has been reported that one in
typically associated with an immuno-compromised state three women wants consultation for vaginal discharge
mucosal candidiasis (Azaz, 2005). (Sobel, 1985). But nowadays, the number of serious
Pregnant women are more vulnerable to VVC than opportunistic yeast infections, particularly in immuno-
healthy women with chronic recurrent candidiasis compromised patients, has dramatically increased
(Mitchell, 2004). The infection can be acute, chronic, (Richardson and Warnock, 2003). Therefore, the present
superficial or deep and has broad clinical spectrum. The study was focused to determine the prime importance of
increased estrogen level during pregnancy leads to the causative agent of VVC and prevalence of this disease
production of more glycogen in the vagina which allows among Nepalese pregnant women which may be helpful
for the proliferation of yeast cells on the wall of the vagina to disseminate knowledge regarding VVC as many are
(Parveen, 2008). However, any physiological changes unaware of it and for the prevention from re-infection,
that affect the beneficial bacteria in the vagina would alter stillbirth, abortion and sterility to the women.
H
the acidity of the vagina reducing its p to 5.0-6.5 by
enhancing the establishment of pathogenic organisms
H
such as Candida (Akinbiyi, 2008). Vaginal p may MATERIALS AND METHODS
increase with age, luteal phase of menstrual cycle, sexual
activity, oral contraception choice, pregnancy and use of Study Design
antibiotics (Ohmit et al., 2003; Leon et al., 2002;
Gonzalez et al., 2008). A cross-sectional descriptive study was done among the
It has been estimated that up to 40% of pregnant pregnant women in Department of Microbiology, Clinical
women worldwide may have VVC (Alo et al., 2012; Alli et Pathology Laboratory, Janaki Medical College Teaching
al., 2011). Nearly 75% of women have at least one Hospital, (JMCTH), Janakpur, Nepal from August 2014 to
episode of genital yeast infection in their reproductive January 2015. This study comprised of 157 women of
years and 10-20% of women have asymptomatic vaginal reproductive age group who were pregnant.
colonization with Candida species during their life time
(Azaz et al., 2005; Sobel, 2003; Aslam, 2008; Fidel and Ethical Consideration
Cutright, 2000). Several risk factors can be associated
with the increased role of colonization of vagina by Informed verbal consent was obtained from the
Candida species in women which includes compromised participants prior to the study before proceeding the
immune system, obesity, diabetes, prolonged use of questionnaire and specimen collection and work approval
broad spectrum of corticosteroids, HIV/AIDS, pregnancy, was taken from the institutional ethical committee of
poor dietary habits, use of high level of estrogens and JMCTH.
Oral Contraceptives Pills (OCPs), Intrauterine
Contraceptive Device (IUCDs), tight clothing, use of Acceptance Criteria of Respondents
vaginal douches, poor personal hygiene, use of sponge,
intrauterine devices, diaphragms, condoms, sexual Pregnant women on attending antenatal at the hospital
intercourse and diet with high glucose content (Akah et al ., were included while members of staff of the hospital,
2010; Reed et al., 2003). About 5-10% healthy women patients with previous history of preterm labor or
apparently suffer from recurrent vaginal candidiasis spontaneous abortion and those that did not give their
without any predisposing factors (Mitchell, 2004). consent were excluded from the study.
Prevalence of Vulvovaginal Candidiasis in Pregnancy Yadav and Prakash 110

from normal saline was streaked on Sabaraud Dextrose

Specimen Collection and Transportation Agar (SDA) plate. Plate was then incubated at 37ºC for
24 – 48 hours. The significant growth was observed and
Gynecologist, trained nurse and matron helped in colony morphology was noted. Grams staining were
collecting two high vaginal sterile cotton swabs from the performed. If the yeast cells were seen in staining then it
posterior fornix of the pregnant women. One swab was was proceed for the germ tube test.
inserted in the labeled sterile capped test tube and
capped tightly for whiff test. And another swab was Identification of Candida species
inserted in the labeled sterile test tube containing 0.5 ml
of normal saline for the culture, wet mount and gram Isolates from Saboraud dextrose agar (SDA) were
staining. The collected samples were immediately inoculated on CHROMagar (Oxoid, Basingstoke, UK)
o
brought to the laboratory and processed according to using an inoculating loop and incubated at 37 C for 48
standard methods. hours. Identification of yeast was done based on the
colour of each colony. Using this method, the following
Specimen Processing Candida species were identified; C. glabrata (wet dark
pink colonies), C. tropicalis and C. dublinensis (wet blue
Of two collected vaginal swab, one swab was used for colonies) and C. albicans (wet green colonies).
the preparation of whiff test and another swab was used
for culture, wet mount and gram stain. For Whiff test, the Germ tube test
swab was rolled on the clean, dry, grease free new slide
and a drop of 10% KOH was added to it. The slide was For Germ tube test, 500 µl of human serum was pipette
hold close to the nose to detect the amine odor. If fishy into small test tube. Using a sterile wire loop, the serum
smell noticed then the sample was considered as with a yeast colony from the SDA plate was inoculated.
positive. The specimen would quickly become odorless The tube was incubated at 35 - 37º C for 2-3 hours. Using
upon standing so the odor should be noted as soon as the Pasteur pipette, a drop of serum yeast culture was
possible. transferred to a glass slide and covered with a cover
Culture media were prepared as instructed by the glass. Tube-like outgrowths from the cells was examined
manufacturer company (Hi-media). A loopful of inoculum using the 10X and 40X objectives (Figure 1).

Figure 1: Germ tube test of C. albicans (D56) (40X)

Glob. J. Med. Med. Sci. 111 Prevalence of Vulvovaginal Candidiasis in Pregnancy

For wet mount, a drop of normal saline was added to the

center of the clean, dry, sterile, grease free slide and RESULT
covered with cover slip. Clue cells and yeast cells were
observed in microscopy. Prevalence of Candidiasis among total study
population
Safe disposal of sample and contaminated tools
A total number of 157 pregnant women were suspected
After handling of the specimen, it was discarded in the as vulvovaginal candidiasis by Gynecologist. Of total, the
specific container and all the equipments used was prevalence of vulvovaginal candidiasis was found to be
placed in the beaker containing lysol, cleaned and then 35%. The results are shown in Figure 2.
was sterilized. The swabs were incinerated.
Age wise distribution of pregnant women with
Statistical Analysis Positive cases

Opened self prepared questionnaire was administered to The highest numbers of positive cases were found to be
collect the data from pregnant women. The data were in 21-25 years age group of 40.44% followed by 26-30
analyzed using statistical package for SPSS 17.0 version years with 32.58%. The results are shown in Table 1.
and Microsoft excels 2007. The p-value < 0.05 was
considered as statistically significant.

Figure 2: Prevalence of candidiasis among pregnant woman

Table 1: Age wise distribution of positive cases among study population

Age group (yrs) Total (%) Positive cases (%)
15-20 29 (18.47) 17 (19.10)
21-25 67 (42.67) 36 (40.44)
26-30 42 (26.75) 29 (32.58)
>30 19 (12.10) 7 (7.86)
Total 157 89
Prevalence of Vulvovaginal Candidiasis in Pregnancy Yadav and Prakash 112

Frequency distribution of Candida Isolates candidiasis followed by C. glabarata. The results are
shown in Figure 3.
A total of 89 isolates were isolated in which 85 isolates
were identified as candidal isolates and rest of them were Distribution of Candidiasis according to Gestational
not identified. Of 85 candidal isolates, 57 (64.04%) were period
C. albicans, 11 (12.35%) were C. glabarata, 9 (10.11%) Most of the respondents had suffered from candidiasis in
were C. dublenesis, 5 (5.61%) were C. tropicalis and 3 nd
2 trimester of gestation period of 47 (55%) followed by
(3.37%) were C. krusei. Among all candida isolates, C. st
1 trimester with 29 (34.11%). The results are shown in
albicans was found to be predominant organism to cause Figure-4.

Figure 3: Pattern of Candidal isolates

Figure 4: Candidiasis distribution in terms of gestation period

Glob. J. Med. Med. Sci. 113 Prevalence of Vulvovaginal Candidiasis in Pregnancy

Pattern of Sign and Symptoms of Vaginal Candidiasis which was found to be statistically insignificant (p =
0.125). The results are shown in Table 3.
The highest number of positive cases was observed in
those of the respondents who had symptoms of vaginal Educational and Occupational Distribution of
candidiasis. The results was found to be statistically Pregnant women with Positive cases
significant (p = 0.001) which are shown in Table 2.
Most of the respondents had illiterate and unemployed of
Distribution of Risk factors among Study population high positive cases with 35.95% and 44.94% followed by
primary level and employed with 29.21% and 34.83%
The highest number of positive cases was found in those which was found to be statistically significant and
respondents who had none of the below risk factors insignificant respectively. The results are shown in Table 4.

Table 2: Frequency distribution of cases in terms of sign and symptoms

Sign & Symptoms Positive Cases Negative Cases Total p- value
Number (%) Number (%)
Asymptomatic 22 (24.71) 41 (60.29) 63 (40.12)
Symptomatic 67 (75.28) 27 (39.70) 94 (59.87) 0.001
Total 89 68 157

Table 3: Risk factors distribution among study population

Risk Factors Positive Cases (%) Negative Cases (%) Total (%) p-value
Diabetes 6 (6.74) 1 (1.47) 7 (4.45)
Previous 21 (23.59) 14 (20.58) 28 (17.83)
Candidiasis
Previous Antibiotic 19 (21.34) 9 (13.23) 35 (22.29)
Oral 6 (6.74) 2 (2.94) 8 (5.09)
Contraceptives 0.125
Previous 14 (15.73) 5 (7.35) 19 (12.10)
Intrauterine
HIV/ AIDS 1 (1.12) 0 (0) 1 (0.63)
None 22 (24.71) 37 (54.41) 59 (37.57)
Total 89 68 157

Table 4: Distribution of respondents with positive cases in terms of Education level and Occupation
n=157
Educational level Total no (%) Positive Cases (%) p-value
Illiterate 67 (42.67) 32 (35.95)
Primary 42 (26.75) 26 (29.21) 0.001
Secondary 19 (12.10) 12 (13.48)
Higher 29 (18.47) 19 (21.34)
Occupation
Unemployed 83 (52.86) 40 (44.94)
Employed 41 (26.11) 31 (34.83) 0.328
Student 33 (21.01) 18 (20.22)
Prevalence of Vulvovaginal Candidiasis in Pregnancy Yadav and Prakash 114

DISCUSSION The present study highlights that C. albicans (64.04%)

was found to be predominant organism to cause VVC in
Candidiasis is the most common opportunistic fungal pregnancy followed by C. glabarata. The results of this
infection and is responsible for 90% of the cases of study was in accordance with Nurat et al., 2015, Samuel
infectious vaginitis (Hedayati and Shafiei, 2010; Adad et et al., 2015, Akortha et al., 2009 and Nelson et al., 2013.
al., 2001). Increased secretion of reproductive hormones Pregnant women were more prone to Candidal infection.
both progesterones and estrogens during pregnancy During pregnancy, which is listed as a risk factor, vagina
favors the formation of infection. Progesterone has is more sensitive, and the infections occur significantly
suppressive effects on the anti-candida activity of more often. The high incidence of vaginitis in pregnant
neutrophils (Adad et al., 2001) while estrogen has been women is related to levels of estrogens, which is in turn
found to reduce the ability of the vaginal epithelial cells to considered the primary factor for the observed
inhibit the growth of Candida albicans and also decrease Vulvovaginal candidiasis was more prevalent in women
immunoglobulins in vaginal secretions resulting in (Sobel, 2012).
increased vulnerability of pregnant women to vaginitis The hormonal environment of the vagina during
(Anorlu et al., 2004). pregnancy can enhance candida colonization and serve
This study reveals the prevalence of vulvovaginal as risk factors. Progesterone has suppressive effect on
candidiasis among pregnant women was found to be the anti-candida activity of neutrophils while estrogen has
35%. Nurat et al., 2015 conducted the same study at been found to reduce the ability of vaginal epithelial cells
LAUTECH Teaching Hospital in Ogbomoso and reported to inhibit the growth of Candida albicans (Aslam et al.,
the prevalence of VVC was 25%. This prevalence rate is 2008). Moreover, a large proportion of women with
in tandem with 26% reported in Ibadan (Anorlu et al., chronic recurrent candidiasis first present with the
2004) which is almost double the rate reported in Burkina infection during pregnancy. In pregnant women, vaginal
Faso (14%). The differences could be due to geographic, candidiasis has been related to emotional stress and
ethnic and socioeconomic factors, as well as differences suppression of immune system which steps up the risk of
in sampling and culturing techniques. Variations may also Candida species overgrowth and become pathogenic
reflect differences in sexual practice and environmental (Nelson et al., 2013).
factors such as hygiene and nutrition (Hansen et al., This present study revealed that most of the
2004; Busetti et al., 2007). The prevalence reported in respondents had suffered from candidiasis in 2
nd

this study is higher than the 30.7% reported in Jamaica trimester of gestation period of 55% followed by 1
st
(Kamara et al., 2000) and the rate of 30% reported in trimester with 34.11%. Nurat et al., 2015 reported 54.3%
Nnewi, a town in Nigeria (Okonkwo and Umeanaeto, prevalence of VVC was observed in the second trimester
2010) which shows the increasing trend of VVC in followed by 25.7% in first trimester and 20% in the third
pregnancy. This high prevalence of vaginal candidiasis trimester. Deepa et al., 2014 reported 54% prevalence in
may lead to pregnancy complications like abortions, second trimester, 30% in third trimester and 16% in first
premature birth, low birth weight and other morbidities. trimester. The study conducted by Oyewol et al., 2013
This study found the highest numbers of VVC were in also observed the highest incidence of vaginal
21-25 years age group (40.44%) followed by 26-30 years candidiasis among pregnant women in their second
with 32.58% which is almost similar to the study reported trimester (61%), which is almost in accordance with this
by Nurat et al., 2015. The age group contains women study.
who are younger and are sexually active have low This study reflected the highest number of VVC was
vaginal defense mechanisms against Candida species observed in those of the respondents who had symptoms
(Kent, 1991). They also have the habit of using of vaginal candidiasis and was found to be statistically
contraceptives especially the emergency pills to prevent significant (p = 0.001). A similar study was conducted by
pregnancy. They also misuse drugs especially antibiotics Kanagal et al., 2014 reported 82% of candida positive
for treatment of such infections. The frequency was also women were symptomatic and the remaining 18% were
high within this age group in this study because of sexual asymptomatic which was statistically significant (p< 0.01),
promiscuity and the use of contraceptives that are was in accordance with the present study.
predisposing factors of vaginal candidiasis. The misuse The highest number of VVC was found in those
of drugs results to drug resistance especially to the respondents who had no any kinds of risk factors like
common antifungal agents used for the treatment of diabetes, previous Candidiasis, previous antibiotic, oral
vaginal candidiasis. This might have also contributed to contraceptives, previous intrauterine, HIV/ AIDS which
the high frequency of the infection in this age group. This was found to be statistically insignificant (p = 0.125). But
study also found as the increased in ages of women VVC Kanagal et al., 2014 highlights 60% of pregnant women
was less prevalence. Women in the age group 41-45 with vaginal candidiasis had risk factors like diabetes,
years are close to their menopause and are less active previous candidiasis infection, use of antibiotics, oral
sexually. They also rarely use contraceptives to prevent contraceptive pills and intra uterine contraceptive devices
pregnancy and have increased vaginal immunity due to which was statistically significant. This is not in concurred
decreased levels of estrogens and corticoids. with this study (Kanagal et al., 2014).
Glob. J. Med. Med. Sci. 115 Prevalence of Vulvovaginal Candidiasis in Pregnancy

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