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Evaluation of treatment for Monilia in pregnancy
EVALUATION
OF TREATMENT I. KANTOR,
HERMAN
(Front
the
IlepcwtmPwts Southmesten~
FOR
of
Obstetrics
Metlicnl
M.D., n,nd
Branch
of
MONILIA DALLAS,
IN PREGNANCY Texas
Gynecoloyy of the l~~~~~iwrsity
Parkland IIospital of Texas)
ad
T
HIi; symptoms resulting from mycotic infection of the vagina in t,he pregnant woman are frequently more severe than in the nonpregnant. Leucorrhea, prurilus, mcl a burning sensation of the vulva may become bitter complaints from which the patient demands relief. The changes which occur in the va.gina during pregnancy arc responsible for the severity of the symptoms, as well as for the increased incidence of infection. Bland, Rakoff, and Pineusl inoculated experimentally the vaginas of pregnant and nonpregnant women with Monilia. Their material was obtained from patients with monilial vulrovaginitis and from newborn babies wit,h oral thrush. They reported the development, of infection in approximat,elp 80 per cent of the pregnant but only 30 per cent of the nonpregnant women. What arr thr changes which render the vagina. so susceptible to infection tluring pregnancy? A review of the investigations already carried oat offers an acceptable explanation. In 1934, Hesseltine, Borts, and Plass? proved that the fungi of Monilia may cause vaginal and vulva1 infection. These organisms grow best in the presence of sugars and in an acid medium. Cruickshank and Sharman:’ statch,“AR pregnancy advances, an increase in the glycogen content of The Dijderlein bacillus causes t,he the vaginal mucous membrane occurs.” fermentation of glycogen, producing lactic acid. Since the best environment, is thus provided, the vagina in pregnancy brcomes an ideal culture medium for Monilia. Moreover, for t,hese same reasons the infection is rendered less susceptible to treatment. l3ven the> time-honored gentian violet, so difficult to ap~)ly correctly by the patient, and so undesira.blc because of st,aining and reactions, frequent,ly fails. In 194’7, Alter, Jones, and Carter” suggested treatment with propionate vaginal jelly, which could t)r easily self-administered, and did not have the objectionable staining of the dyes. Their preliminary report indicated no sensitivity reactions. In view of these encouraging results, it st>emed advisable to evaluate furth(lr the response to treatment. wit11 this preparation. Since culture represents the most accurate method for the diagnosis of Monilia, this procedure, as well as the subjective relief from symptoms, \vas used in this st,udy.
Material
and Methods
(-'111tures were taken from t.he vaginas of I)at.ients at the initial visit to the prenatal rlinic of Parkland Hospital. These w\~crcinoc*ulated without delay on report,s these cultures Freshly prepared Sabonraud ‘s medium. 011~ lalwrxtory as “no growth,” or “light” “moderate,” or liheavy growth.” Seventy-two patients in whom Monilia was found were chosen for this investigation. Twenty-nine served as a control group, and received no treatment, of any kind. The: others were trcatcd, and. when possible, follow-up *clll7irt
Volume Number
62 I
EVALUATION
OF
TREATMENT
FOR
MONILIA
IN
PREGNANCY
171
tures were t,aken after treatment, and six weeks after delivery. Patients were questioned carefully regarding symptoms before treatment was instituted and again three or four weeks after completion. Treatment consisted of the vaginal instillation of one-half to three-fourths of an applicatorful of propionate jelly* nightly. The lesser amount was advised when the patient complained that the jelly “ran out” during the night. Also, an additional instillation was advised prior to intercourse, with the hope that reinfection might be curtailed. The patients were requested to continue this treatment for at least two and preferably three weeks. It was considered safe to start treatment through the thirtieth week of the pregnancy. Beyond this time, symptoms were treated by external application alone, and these patients are not included in this study. However, many said they did experience marked relief. Results Occasional complaints were offered that “the treatment was messy.” For the most part, these came from patients in whom symptoms were minimal or absent. A reduction in the quantity of jelly used generally made the treatment more acceptable. Among patients wit,h severe irritation, the welcome relief more than compensated for the “annoyance. ” Careful questioning led us to believe that most of the patients faithfully carried out the prescribed course. There were no manifestations of allergy or poor tolerance of the jelly. Several patients in whom the primary infection of the vulva was severe complained of a transient burning sensation. However, they were willing and anxious to continue the treatment. At the time of the visit six weeks post partum, the cultures from 28 of the 29 control patients were negative, and 1 showed light growth (Table I). As indicated previously, these patients were not given any specific treatment. TABLE FIRST
CULTURE
REPORT
I
I.
CONTROL
PATIENTS
NUMBER
Lizh-h Moderate growth Heavy growth
2 8 19
-Total
.__~~ -J AFTER DELIVERY
6 WEEKS
I
18 1 28 1
29
-
No No No Light No Light
growth growth growth growth growth growth
-
Their symptoms, when present, were fairly persistent. However, their mycotic infections disappeared spontaneously after the pregnancy terminated. Culture follow-up cannot be used, therefore, as a measure of the efficacy of treatment during pregnancy. Among 43 patients scheduled for t,reatment, only 9 were asymptomatir (Table II). Discharge was the most prominent symptom, and itching was present in approximately one-half. There was no relationship between the “heaviness” of the culture growth and the severity of symptoms. TABLE CULTURE
REPORT
/
Light Moderate Heavy Total *The
propionate
II.
NUMBER
8 2 33 43 jelly
(Propion-Gel)
TREATED 1
DISCHARGE
PATIENTS, 1
SYMPTOMS
ITCHING
OR BURNING
7 2 24 33 was
5 1 18 2% supplied
by
Wyeth
1
~-~X0
___..SYMPTOMS ___-
1 0 8 9
Incorporated.
~~
172
Am. J. Obst. k GY~c. July, 1951
KANTOR
Use of the propionate jelly exactly~ as prescribed was carried out by 38 patients (Table III). Of these, 29 showed improvement, usually quite prompt. Seven could see no change, and 2 considered their symptoms worse. TABLE I I / NUMBER 29 7 2 38
SYMPTOMS Improved No change Worst ___..__..~... Total
III.
RESPONSE
TO TREATMENT
CULTURE 6 WEEKS AFTER STARTING TREATMENT -___ NONE POSITIVE NEGATIVE OBTAINED 17 10 2 2 l’ 19
CULTURE --. POSITIVE 1
-6 WEEKS AFTER DELIVERY .___-__ NONE NEGATIVE OBTAINED 18 10 5 1 2 0 -__ 25 11
There was little correlation between the change in symptoms and the report of the cultures taken six weeks after starting treatment, three or four weeks after completion. Of the 29 patients who stated their symptoms were improved, for example, 17 still had positive cultures. On the other hand, both of the patients who thought their symptoms were worse had negative cultures after treatment. Several explanations may be offered for this apparent inconsistency : 1. The vaginal environment, altered by treatment, may inhibit the spread of the infection. Although symptomatic improvement may follow, the culture may remain positive. 2. The occurrence of reinfection is difficult to detect. 3. Symptoms produced by monilial vulvovaginitis are not specific. 4. The psychogenic value of this or any form of treatment must be considered. However, its role in the face of persistent symptomatic improvement seems minor. In this series, 15 of 34 patients in whom completed reports were obtained had negative cultures six weeks after starting vaginal treatment. As with the control series, nearly all of the patients had negative cultures six weeks after delivery. Conclusions 1. Propionate jelly is a satisfactory and relatively easy method for treating monilial infect,ion of the vulva and vagina during pregnancy. 2. Improvement in symptoms may be anticipated in approximately 75 per cent of patients. 3. Culture from the vagina taken six weeks after the propionate jelly treatment was started became negat.ive in almost 45 per cent of the patients. 4. There were no ill effects resulting from this treatment. 5. Among pregnant patients with positive cultures for Monilia, repent cultures six weeks after delivery will be negative in more than 90 per cent of patients, even if no treatment is given. this
I should manuscript
like
to record my appreciation and to Mrs. C. Green for
to Dr. W. F. Mengert for her technical assistance.
his advice
in preparing
References I. L’. Z. i.
Bland, P. IL, Rakoff, A. E., and Pincus, I. J.: Arch. Dermat. & Syph. 36: ‘760, 1937. Hesseltine, H. C., Borts, I. C., and Plass, E. D.: AM. J. OBST. & GYNEC. 27: 112, 1934. Cruickshank, R., and Sharman, A.: J. Obst. & Gynaee. Brit. Emp. 41: 369, 1934. Alter, R. I,., Jones, C. P., and Carter, B.: AM. J. OBST. & GYNEC. 53: 241, 1947. 3534
UPLE
AVENUE
OF TREATMENT I. KANTOR,
HERMAN
(Front
the
IlepcwtmPwts Southmesten~
FOR
of
Obstetrics
Metlicnl
M.D., n,nd
Branch
of
MONILIA DALLAS,
IN PREGNANCY Texas
Gynecoloyy of the l~~~~~iwrsity
Parkland IIospital of Texas)
ad
T
HIi; symptoms resulting from mycotic infection of the vagina in t,he pregnant woman are frequently more severe than in the nonpregnant. Leucorrhea, prurilus, mcl a burning sensation of the vulva may become bitter complaints from which the patient demands relief. The changes which occur in the va.gina during pregnancy arc responsible for the severity of the symptoms, as well as for the increased incidence of infection. Bland, Rakoff, and Pineusl inoculated experimentally the vaginas of pregnant and nonpregnant women with Monilia. Their material was obtained from patients with monilial vulrovaginitis and from newborn babies wit,h oral thrush. They reported the development, of infection in approximat,elp 80 per cent of the pregnant but only 30 per cent of the nonpregnant women. What arr thr changes which render the vagina. so susceptible to infection tluring pregnancy? A review of the investigations already carried oat offers an acceptable explanation. In 1934, Hesseltine, Borts, and Plass? proved that the fungi of Monilia may cause vaginal and vulva1 infection. These organisms grow best in the presence of sugars and in an acid medium. Cruickshank and Sharman:’ statch,“AR pregnancy advances, an increase in the glycogen content of The Dijderlein bacillus causes t,he the vaginal mucous membrane occurs.” fermentation of glycogen, producing lactic acid. Since the best environment, is thus provided, the vagina in pregnancy brcomes an ideal culture medium for Monilia. Moreover, for t,hese same reasons the infection is rendered less susceptible to treatment. l3ven the> time-honored gentian violet, so difficult to ap~)ly correctly by the patient, and so undesira.blc because of st,aining and reactions, frequent,ly fails. In 194’7, Alter, Jones, and Carter” suggested treatment with propionate vaginal jelly, which could t)r easily self-administered, and did not have the objectionable staining of the dyes. Their preliminary report indicated no sensitivity reactions. In view of these encouraging results, it st>emed advisable to evaluate furth(lr the response to treatment. wit11 this preparation. Since culture represents the most accurate method for the diagnosis of Monilia, this procedure, as well as the subjective relief from symptoms, \vas used in this st,udy.
Material
and Methods
(-'111tures were taken from t.he vaginas of I)at.ients at the initial visit to the prenatal rlinic of Parkland Hospital. These w\~crcinoc*ulated without delay on report,s these cultures Freshly prepared Sabonraud ‘s medium. 011~ lalwrxtory as “no growth,” or “light” “moderate,” or liheavy growth.” Seventy-two patients in whom Monilia was found were chosen for this investigation. Twenty-nine served as a control group, and received no treatment, of any kind. The: others were trcatcd, and. when possible, follow-up *clll7irt
Volume Number
62 I
EVALUATION
OF
TREATMENT
FOR
MONILIA
IN
PREGNANCY
171
tures were t,aken after treatment, and six weeks after delivery. Patients were questioned carefully regarding symptoms before treatment was instituted and again three or four weeks after completion. Treatment consisted of the vaginal instillation of one-half to three-fourths of an applicatorful of propionate jelly* nightly. The lesser amount was advised when the patient complained that the jelly “ran out” during the night. Also, an additional instillation was advised prior to intercourse, with the hope that reinfection might be curtailed. The patients were requested to continue this treatment for at least two and preferably three weeks. It was considered safe to start treatment through the thirtieth week of the pregnancy. Beyond this time, symptoms were treated by external application alone, and these patients are not included in this study. However, many said they did experience marked relief. Results Occasional complaints were offered that “the treatment was messy.” For the most part, these came from patients in whom symptoms were minimal or absent. A reduction in the quantity of jelly used generally made the treatment more acceptable. Among patients wit,h severe irritation, the welcome relief more than compensated for the “annoyance. ” Careful questioning led us to believe that most of the patients faithfully carried out the prescribed course. There were no manifestations of allergy or poor tolerance of the jelly. Several patients in whom the primary infection of the vulva was severe complained of a transient burning sensation. However, they were willing and anxious to continue the treatment. At the time of the visit six weeks post partum, the cultures from 28 of the 29 control patients were negative, and 1 showed light growth (Table I). As indicated previously, these patients were not given any specific treatment. TABLE FIRST
CULTURE
REPORT
I
I.
CONTROL
PATIENTS
NUMBER
Lizh-h Moderate growth Heavy growth
2 8 19
-Total
.__~~ -J AFTER DELIVERY
6 WEEKS
I
18 1 28 1
29
-
No No No Light No Light
growth growth growth growth growth growth
-
Their symptoms, when present, were fairly persistent. However, their mycotic infections disappeared spontaneously after the pregnancy terminated. Culture follow-up cannot be used, therefore, as a measure of the efficacy of treatment during pregnancy. Among 43 patients scheduled for t,reatment, only 9 were asymptomatir (Table II). Discharge was the most prominent symptom, and itching was present in approximately one-half. There was no relationship between the “heaviness” of the culture growth and the severity of symptoms. TABLE CULTURE
REPORT
/
Light Moderate Heavy Total *The
propionate
II.
NUMBER
8 2 33 43 jelly
(Propion-Gel)
TREATED 1
DISCHARGE
PATIENTS, 1
SYMPTOMS
ITCHING
OR BURNING
7 2 24 33 was
5 1 18 2% supplied
by
Wyeth
1
~-~X0
___..SYMPTOMS ___-
1 0 8 9
Incorporated.
~~
172
Am. J. Obst. k GY~c. July, 1951
KANTOR
Use of the propionate jelly exactly~ as prescribed was carried out by 38 patients (Table III). Of these, 29 showed improvement, usually quite prompt. Seven could see no change, and 2 considered their symptoms worse. TABLE I I / NUMBER 29 7 2 38
SYMPTOMS Improved No change Worst ___..__..~... Total
III.
RESPONSE
TO TREATMENT
CULTURE 6 WEEKS AFTER STARTING TREATMENT -___ NONE POSITIVE NEGATIVE OBTAINED 17 10 2 2 l’ 19
CULTURE --. POSITIVE 1
-6 WEEKS AFTER DELIVERY .___-__ NONE NEGATIVE OBTAINED 18 10 5 1 2 0 -__ 25 11
There was little correlation between the change in symptoms and the report of the cultures taken six weeks after starting treatment, three or four weeks after completion. Of the 29 patients who stated their symptoms were improved, for example, 17 still had positive cultures. On the other hand, both of the patients who thought their symptoms were worse had negative cultures after treatment. Several explanations may be offered for this apparent inconsistency : 1. The vaginal environment, altered by treatment, may inhibit the spread of the infection. Although symptomatic improvement may follow, the culture may remain positive. 2. The occurrence of reinfection is difficult to detect. 3. Symptoms produced by monilial vulvovaginitis are not specific. 4. The psychogenic value of this or any form of treatment must be considered. However, its role in the face of persistent symptomatic improvement seems minor. In this series, 15 of 34 patients in whom completed reports were obtained had negative cultures six weeks after starting vaginal treatment. As with the control series, nearly all of the patients had negative cultures six weeks after delivery. Conclusions 1. Propionate jelly is a satisfactory and relatively easy method for treating monilial infect,ion of the vulva and vagina during pregnancy. 2. Improvement in symptoms may be anticipated in approximately 75 per cent of patients. 3. Culture from the vagina taken six weeks after the propionate jelly treatment was started became negat.ive in almost 45 per cent of the patients. 4. There were no ill effects resulting from this treatment. 5. Among pregnant patients with positive cultures for Monilia, repent cultures six weeks after delivery will be negative in more than 90 per cent of patients, even if no treatment is given. this
I should manuscript
like
to record my appreciation and to Mrs. C. Green for
to Dr. W. F. Mengert for her technical assistance.
his advice
in preparing
References I. L’. Z. i.
Bland, P. IL, Rakoff, A. E., and Pincus, I. J.: Arch. Dermat. & Syph. 36: ‘760, 1937. Hesseltine, H. C., Borts, I. C., and Plass, E. D.: AM. J. OBST. & GYNEC. 27: 112, 1934. Cruickshank, R., and Sharman, A.: J. Obst. & Gynaee. Brit. Emp. 41: 369, 1934. Alter, R. I,., Jones, C. P., and Carter, B.: AM. J. OBST. & GYNEC. 53: 241, 1947. 3534
UPLE
AVENUE