The revised Guidelines for the Prevention of Opportunistic Infections include new recommendations regarding the use of antifungal drugs during pregnancy. In short, the Guidelines recommend that the oral "azole" antifungals [including fluconazole (Diflucan®), itraconazole (Sporanox®) and ketoconazole (Nizoral®)] not be started during pregnancy. The Guidelines further state that these drugs be discontinued in HIV-positive women who become pregnant and that women receiving these drugs take effective birth control.

In animal studies, use of itraconazole and/or ketoconazole during pregnancy caused birth defects. In addition, there have been four reported cases of infants born with severe skeletal abnormalities to women who used fluconazole for an extended period of time while pregnant. It is presumed that these same potential risks apply to other oral azole antifungals.

For the treatment or prevention of oral or vaginal candidiasis, topical antifungal therapies such as nystatin (Mycostatin®, Pedi-Dri®) may be preferable for pregnant women. For the treatment or prevention of other fungal infections, such as cryptococcosis or histoplasmosis, the Guidelines suggest amphotericin B (Fungizone®), especially in the first trimester. Amphotericin B is also approved for the treatment of oral candida. Although no formal studies have been performed, amphotericin B has been used by pregnant women without apparent harm to their unborn children. While amphotericin B may be preferable to azole therapy in pregnant women, it is not without potentially severe side effects, including kidney toxicity and anemia. In addition, the intravenous (in the vein) suspension of the drug may not be feasible for some women.

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