Candida glabrata chorioamnionitis and fungaemia complicating pregnancy following intrauterine insemination: Case report and review of the literature

Abstract

Case report: A 32-year-old healthy primigravida, with a trichorionic-triamniotic triplet pregnancy conceived by intrauterine insemination (IUI), presented at 16 weeks of gestation with rupture of membranes and fever. Empirical intravenous broad-spectrum antibiotics were given for presumptive bacterial chorioamnionitis. In view of the poor prognosis and risk of maternal sepsis, medical abortion with misoprostol was decided after counselling. Complete abortion was achieved and her fever subsided. Two days later, blood culture and vaginal swab revealed presence of Candida glabrata. Intravenous anidulafungin was given for 2 weeks. A second blood culture 3 days after abortion was negative. She remained well. Tests for immunodeficiency were negative. Histological examination of the placentae confirmed acute fungal chorioamnionitis. Literature review: C. glabrata is a common vaginal colonizer, but C. glabrata chorioamnionitis is rare. In the literature, we found 22 cases of C. glabrata chorioamnionitis, 15 of which were associated with in-vitro fertilisation and 4 associated with foreign bodies (intrauterine contraceptive device or cervical cerclage). Only 32% (7/22) of the published affected pregnancies had neonatal survival, as they usually presented with rupture of membranes or preterm labour in the second or early third trimester. The increasing use of assisted reproductive technologies appears to be an important factor in the growing number of reports. To our knowledge, this is the first reported case of C. glabrata chorioamnionitis and fungaemia in a pregnancy following IUI. The present case supports the hypothesis that C. glabrata is inoculated into the uterus during uterine instrumentation. Currently, no guidelines exist for screening and treatment for asymptomatic fungal colonization before assisted reproductive procedures. Conclusion: The possibility of C. glabrata chorioamnionitis should be considered in women who develop chorioamnionitis after assisted reproductive techniques. Further research is needed to determine the incidence of fungal infection related adverse outcomes and the cost-effectiveness of screen-and-treat approach prior to assisted reproduction.