CLINICAL ACTIONS:

ACOG has released a Committee Opinion on Maternal Immunization. During pregnancy, all women should be evaluated for vaccination requirements. Acceptance of vaccination during pregnancy is much higher when the recommendation comes from a woman’s obstetrician or obstetrical provider. The Committee Opinion states

There is no evidence of adverse fetal effects from vaccinating pregnant women with inactivated virus, bacterial vaccines, or toxoids, and a growing body of data demonstrate the safety of such use.

Recommended for all women

• Tdap (Tetanus, Diphtheria and Pertussis), as early in the 27 to 36 weeks gestation window as possible to maximize maternal antibody response and passive antibody transfer to the infant (see ‘Related ObG Topics’ below for evidence of newborn protection through first year of life)
  • If not vaccinated previously before or during pregnancy, administer vaccine immediately postpartum
  • Wound management: administer Tdap if indicated
  • If unknown tetanus vaccine status: administer 3 vaccinations containing tetanus and reduced diphtheria toxoids at 0, 4 weeks and 6 to 12 months; Tdap should replace one dose of Td, preferably given between 27 – 36 weeks gestation
• Influenza (inactivated or recombinant)
  • Routine influenza vaccination is recommended for all women who are or will become pregnant (in any trimester) during influenza season
  • In the United States, usually early October through late March

Consider vaccination if indicated or under some circumstances

• Hepatitis A (HepA) –  should be given if
  • Travel to or work in countries with high or intermediate hepatitis A endemicity
  • Users of illegal drugs
  • Anticipate having close personal contact with an international adoptee from a country of higher or intermediate endemic during the first 60 days following the adoptee’s arrival to the U.S.
  • If receiving clotting factor concentrates
  • People who work with hepatitis A virus (HAV) in research lab settings
  • Chronic liver disease
  • Post-exposure to HAV (recent, within 2 weeks): if 40 years of age or younger
    • If over age 40, immune globulin is preferred
• Hepatitis B (HepB) –  pregnant women considered at high risk for Hepatitis B virus (HBV) include
  • Sexually active and not in a long-term, mutually monogamous relationship (e.g. more than one sex partner during the previous 6 months)
  • Recent or current injection drug use
  • Seeking STD evaluation or treatment
  • Have had an HBsAg-positive sex partner
  • People at risk for infection by exposure to blood
  • People who share needles, syringes, or other drug preparation equipment
  • International travelers to countries where hepatitis B is common
  • People living with someone who has active hepatitis B infection
  • People with end-stage kidney disease (or on dialysis), diabetes, chronic liver disease (such as hepatitis C infection, alcoholic liver disease, or cirrhosis), or HIV infection
  • Staff and clients in sexually transmitted disease treatment, HIV, drug abuse, hemodialysis, developmental disabilities, or correctional facilities
• Meningococcal (MenACWY or MPSV4) – should be given if
  • Anatomic or functional asplenic or persistent complement deficiency
  • Travel to countries in which meningococcal disease is hyper-endemic or epidemic (e.g., the “meningitis belt” of Sub-Saharan Africa)
  • Microbiologists routinely exposed to isolates of N. mengitidis
  • First-year college students through age 21 who live in residence halls and not previously vaccinated or received their first dose prior to age 16 years
  • Military recruits
  • HIV infection
• Polio – Inactivated Polio Vaccine (IPV) can be used if needed
  • If at risk for infection and immediate protection is required

The following vaccines are not recommended in pregnancy

• Human Papillomavirus (HPV)
  • If series started prior to pregnancy, delay remainder of 3-dose series until after completion of pregnancy
  • No intervention is necessary if dose administered during pregnancy

The following vaccines are contraindicated in pregnancy

• Live attenuated Influenza vaccine (LAIV), also known as the “nasal spray” flu vaccine
• Mumps-Measles-Rubella (MMR)
• Varicella
• Zoster
  • Live-attenuated VZV-based vaccine
  • Recombinant Zoster (Shingles) Vaccine

SYNOPSIS:

There is no evidence that there is risk to a fetus with inactivated virus or bacterial vaccines or toxoids. Live vaccines are contraindicated during pregnancy due to a theoretical risk. The CDC and ACOG website links below provide additional information to dosing and further contraindications and precautions. Currently, there is inadequate data for specific recommendations for pneumococcal conjugate (PCV13) or Pneumococcal Polysaccharide (PPSV23) vaccine during pregnancy.

KEY POINTS:

• CDC guidance has been updated to include the use of recombinant influenza vaccines in addition to inactivated
• Contraindications to vaccination include a history of a serious reaction or anaphylaxis to a previous vaccine or component of a vaccine
• Precautions include a more debate or severe acute illness with or without fever
• See IAC summary below for additional contraindications and precautions
• Report adverse reactions or concerns  to vaccination to the Vaccine Adverse Event Reporting System (VAERS) – link in ‘learn more’ below

Learn More – Primary Sources:

CDC Principles of Vaccination

ACOG Committee Opinion 741: Maternal Immunization

CDC MMWR: Prevention and Control of Seasonal Influenza with Vaccines: Recommendations of the Advisory Committee on Immunization Practices — United States, 2017–18 Influenza Season

Vaccine Adverse Event Reporting System

ACOG Committee Opinion 718: Update on Immunization and Pregnancy-Tetanus, Diphtheria and Pertussis Vaccination

ACOG Committee Opinion 732: Influenza Vaccination During Pregnancy

ACOG Immunization Coding Resources

ACNM Position Statement – Immunization in Pregnancy and Postpartum

Related ObG Topics:

Does Prenatal Tdap Vaccine Protect Infants From Pertussis? 

Are Tdap and Polio Vaccines Safe During Pregnancy?

Does Flu Vaccine During Pregnancy Have Long Term Adverse Effects on Children?

New 2018 / 2019 CDC Flu Vaccine Guidance: Updated Recommendations Including Use in Persons with Egg Allergy

CDC and ACOG Respond to Flu Vaccine and Miscarriage Concerns