Impact of vulvovaginal candidiasis on parity and number of living children in pregnant and non-pregnant women

Introduction

Vulvovaginal candidiasis (VVC) is a common type of fungal infection in the lower genital tract of healthy women at reproductive age (1). It affects 75% of women once in a lifetime with millions of women each year (2). Pregnancy is one of several predisposing factors that contribute to the development of VVC (2). Several studies have investigated the distribution of VVC between pregnant and non-pregnant women. About 20–30% of non-pregnant women and 30% of pregnant women are often at a risk of Candida colonization, particularly during the third trimester (3). A study of Brazilian patients revealed that VVC was present in 34.5% of non-pregnant women and in about 44.8% of pregnant women (4).

The study of the relation between VVC and parity showed variable results ranging from the present or the absence of this relationship. A study on VVC in pregnant women revealed that the infection was higher in patients with multigravidae than in primigravidae (5). Otherwise, a non-significant association between parity and VVC is reported by other studies. Although women with multigravida are more affected by VVC, no significant relationship has been established between VVC prevalence and parity (6). Age is another factor that impacts the development of VVC. Most studies reported a positive association between age and prevalence of VVC, while a few studies found negative results (7). The risk of VVC is typically increased in women between the ages of 18 and 45 years (8).

The impact of VVC on parity and living children was studied in both pregnant and non-pregnant women. We present this article in accordance with the STROBE reporting checklist (available at https://jxym.amegroups.com/article/view/10.21037/jxym-23-36/rc).

Methods

Patients

Out of 734 vaginal infected women, 100 patients were clinically diagnosed with VVC. The positive VVC patients were divided into two main groups in a cross-section study: 50 pregnant women aged 20 to 42 years and 50 non-pregnant women aged 20 to 45 years. Patients enrolled in the study during visits to many private gynecological clinics between December 2020 and February 2021. Infection with VVC was primarily diagnosed by gynecologists based on clinical symptoms. The most common symptoms of VVC are edema and erythema in the vaginal region, along with a watery or cheese-like discharge. Itching, and pain in the vaginal region were also included in most cases. Fungal infection was confirmed in the hospital laboratory of microbiology when a yeast form was detected in a stained specimen from a Pap smear and vaginal swab. A questionnaire was created to gather information on patient history. Patients excluded from the study were those with a non-vagina fungal infection or other than fungal infection and those on immunosuppressive or hormone therapy.

Definitions

Parity refers to the number of times a woman of gestational age has delivered a child, regardless of whether the child was born alive or stillborn. Fetuses born after birth and growing to become children were separated from those who were stillborn. The children who were alive were counting.

Pregnant women were chosen to participate in this study for two main reasons. The first reason is that pregnancy is one of the predisposing factors that contribute to the development of VVC (2-4). The second reason is that there has been a rise in VVC infection in women who have more pregnancies (8,9).

Ethical approval

The study was conducted in accordance with the Declaration of Helsinki (as revised in 2013). The study was approved by the institutional ethics committee of University of Karbala (No. 116). All participants were voluntary and signed an informed consent form.

Statistical analysis

One-way analysis of variance (ANOVA) was used to analyze data of all tests by the Excel application in window 10. The minimum level of (P) value was <0.05 concerts as significant level.

Results

Relation of VVC with parity and age

The VVC was diagnosed in 50 pregnant women and 50 non-pregnant women. The disease was more frequent in patients aged 20–30 years and 31–40 years. Patients aged 41 to 50 years had less infection with VVC (Table 1).

The relationship between VVC and parity was investigated. The number of parities was higher among VVC patients with no significant difference between pregnant and non-pregnant patients (P=0.50). Most patients had parities of 1 to 3 and 4 to 6 (44% each), while nulliparous was found in only four patients (4%). Age 20–30 years was the most significant age group (P=0.02 for pregnant and P=0.01 for non-pregnant patients), with 1–3 parities in both patient groups. The age group of 31–40 years also had a higher number of parities ranging from 4–6 in pregnant patients (16%) and 6% in non-pregnant patients. Parity was reduced among older patients from all patient groups. Nulliparous was only observed in non-pregnant patients, while it was mostly found in 20–30 years old (3%) and less in 31–40 years (1%) of pregnant patients (Table 2).

Relation of VVC with living children number

The number of children who were still alive was determined for the participants of this study. The number was declined in patients with VVC, but with no significant difference between pregnant and non-pregnant patients (P=0.32). It was found that many patients had no to two children (45%), followed by patients with three to four children (36%) (Table 1). Patients in the 20–30 age group had a large number of children in both pregnant (22%) and non-pregnant patients (28%). A high number of children were also observed in patients aged 31 to 40 years (20% in pregnant women and 15% in non-pregnant women). Among pregnant patients, age 20–30 years was distinctly the highest age group with 0–2 children (17%), while one patient of the same age and another patient between the ages of 41 and 50 years had a larger number of children. In non-pregnant patients, the number of children was in the range of 0–2 (16%) and 3–4 (11%) in those 20–30 years old, while only one patient with the same age had more children (5–6 children) (Table 3).

Discussion

In the current study, VVC was investigated in pregnant and non-pregnant patients. Pregnancy is a risk factor for developing VVC (8,9). The highest rate of VVC may be developed among pregnant women (7-9). Pregnancy can increase VVC from 30% to 40% (9). Among pregnant patients with VVC, 27% had symptomatic infections and 11% were asymptomatic (10). Another study found that pregnant patients had 48.7% symptomatic VVC and 51.2% asymptomatic (6). Elevated estrogen levels are an important factor in increasing Candida infection in pregnant women (3). High levels of estrogens cause an increase in vaginal glycogen that considers a good source of carbon for the growth of Candida (9). However, VVC may develop progressively by increasing the length of pregnancy (5).

The results of this study indicated that VVC infection was associated with an increase in parity and a decrease in the number of children. This means that VVC has no effect on the health status of pregnant women, but it does have an effect on the health of infants born. Most studies have shown an increase in VVC infection in women with a higher number of parities. Pregnant women with multiparity were more colonized with Candida spp. in the vagina than nulliparous women (11). In women with multigravida and diabetes, VVC infection increases without affected by the age or trimester of pregnancy (10).

The number of live children has declined in VVC patients in this study, meaning that VVC has an effect on the health of newborns and may cause death in many cases. Candidiasis in preterm infants can cause septicemia and liver abscesses that reduce the chances of these infants living without probable treatment (12). In addition, infection with Candida spp. in pregnant women can increase the chance of having low birth weight babies, but no premature delivery (13). Patients with VVC experienced a higher rate of premature births with a lower newborn weight in the second trimester of pregnancy compared to those in the first trimester (14).

According to the results of this study, VVC was diagnosed more frequently in patients aged 20 to 30 years and 31 to 40 years. This result was also mentioned in a study of women with VVC at college age, which found that the common infection was in the 20–30 years age group and less in those low than 20 or more than 40 years (7). The VVC is usually common among women of childbearing age (9). Its prevalence in 106 patients in Iraq-Baghdad was reported high among 23–26 years of age (15). This increased prevalence is also observed among 18–25 years old (6) and 21–25 years old (8).

The rate of VVC can decrease with age and become very low at older ages. Colonization of Candida spp. is higher (65%) among women at 18–34 years old and declines to 35% among those over 35 years of age (11). The prevalence of VVC is higher among pregnant women aged 21 to 30 years and decreased after the age of 35 years (5). The dominant colonization of Candida spp. responsible for VVC is more prevalent among 21–25 years old and becomes less prevalent among 16–20 years old (8). However, many studies did not reveal any significant correlation between VVC and age (7).

Strength and limitation

The strength of our study is that we prospectively assumed that a positive effect of VVC on the health of newborns through a decreased number of children. Such effects are not significant on the parity of infected women. Another thing is that VVC was found to be decreased in old age among the involved women in this study. That means it is not useful to study the impact of VVC on the reproduction activity.

The main limitation of this study is that parity and the chance of having a new baby usually decrease with age. So, an investigation of the effect of VVC on the parity and the number of children will be difficult to perform in older women. Asymptotic infection with VVC is another challenge. Many infected women cannot even notice the reason for their limited ability to have a baby due to hidden infection with asymptomatic VVC. Early diagnosis and treatment of VVC can play an important role in reducing unpleasant risk factors in the reproductive state.

Conclusions

The VVC has no effect on parity, but it does have an effect on the number of live children. The number of children was reduced in patients with VVC. Young patients showed more affected by VVC on parity and number of children. Pregnancy status does not affect the impact of VVC on studied reproductive parameters. Treatment of VVC at an early stage is the most important for children’s health.

Acknowledgments

Funding: None.

Footnote

Reporting Checklist: The authors have completed the STROBE reporting checklist. Available at https://jxym.amegroups.com/article/view/10.21037/jxym-23-36/rc

Data Sharing Statement: Available at https://jxym.amegroups.com/article/view/10.21037/jxym-23-36/dss

Peer Review File: Available at https://jxym.amegroups.com/article/view/10.21037/jxym-23-36/prf

Conflicts of Interest: Both authors have completed the ICMJE uniform disclosure form (available at https://jxym.amegroups.com/article/view/10.21037/jxym-23-36/coif). The authors have no conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. The study was conducted in accordance with the Declaration of Helsinki (as revised in 2013). The study was approved by the institutional ethics committee of University of Karbala (No. 116). All participants were voluntary and signed an informed consent form.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

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