Guidance on COVID-19 Vaccine Including Pregnancy

SUMMARY: 

The CDC does not currently recommend COVID-19 vaccination during pregnancy and the lactation period in the absence of other risk factors. However, ACOG and SMFM continues to recommend vaccination during pregnancy and lactation to mitigate the significant risks associated with COVID. 

• Pregnancy Counseling Points
• Maternal and Obstetric Risk
• Considerations for Administration During Pregnancy
• Fetal Considerations
• CDC Adverse Event Data
• Breastfeeding
• Antibody Titers in Pregnancy

Pregnancy Counseling Points  

• Counseling should include the following elements 
  • Available data on vaccine safety 
  • Potential side effects (e.g., site pain, headache, fatigue, fever and rarely allergic reactions including anaphylaxis)
    • Risk of side effects not increased in pregnancy
  • Pregnant patients have higher risk of moderate to severe disease 
  • Level of COVID-19 community transmission 

Maternal and Obstetric Risk  

• With symptomatic COVID-19, pregnancy is an independent risk factor compared to symptomatic non-pregnant patients for 
  • ICU admission: 3-fold increase 
  • Mechanical ventilation 
  • ECMO: 2 to 4 fold increase 
  • Death: 1.7 fold increase 
  • May increase preterm birth and stillbirth 
• Other risk factors for severe COVID-19 disease include 
  • Cancer | Chronic kidney disease | COPD | Heart conditions | Immunocompromised state | Sickle cell disease | Smoking 
• Hispanic or Latinx and Black patients are disproportionally affected by higher prevalence of COVID-19 
  • More severe maternal morbidity | Higher risk of death 

Considerations for Administration During Pregnancy  

• Pregnancy test prior to vaccination is not recommended 
• No need to delay pregnancy following vaccine administration 
• No trimester-specific indications at this time 

Fetal Considerations 

• mRNA vaccines 
  • Available data suggests low risk 
  • Rapid degradation (approximately 10 to 20 days) 
  • Does not enter the cell’s nucleus or become integrated into the DNA; therefore, “no risk of genetic modification to people receiving the vaccine” 
• Maternal antibodies cross the placenta | May provide neonatal protection 

CDC Adverse Event Data    

• Healthcare providers are required to report certain adverse events following COVID-19 vaccination to the Vaccine Adverse Event Reporting System (VAERS)
• “Anyone can submit a report to VAERS – healthcare professionals, vaccine manufacturers, and the general public. VAERS welcomes all reports, regardless of seriousness, and regardless of how likely the vaccine may have been to have caused the adverse event.”

Breastfeeding  

• Vaccination is recommended during lactation
• Counseling should provide balance with respect to lack of data vs the patients’ individual risk for infection and severe disease 
• Although there is a lack of data “the theoretical risks regarding the safety of vaccinating lactating people do not outweigh the potential benefits of the vaccine” 

Antibody Titers in Pregnancy 

• Studies have demonstrated vaccine-induced antibody titers to be similar in pregnant women compared to nonpregnant women 
• Transfer of antibodies to newborns following maternal vaccination may confer neonatal protection 
  • Vaccine-induced IgG is transferred to the neonate 
  • Higher umbilical cord blood titers are associated with longer time intervals from vaccination 
  • Second vaccine dose increases cord blood IgG levels 

KEY POINTS: 

• The COVID-19 vaccine should be recommended to all pregnant and lactating patients 
• There is no preference for any particular approved vaccine
• Providers should discuss individual risks and benefits of the vaccine during pregnancy 
• Safety profile from the CDC Adverse Event Monitoring site shows no increased risk of worse pregnancy outcomes post-vaccination
• COVID-19 vaccines and other vaccines may be administered together (e.g., flu or Tdap)

Learn More – Primary Resources 

SMFM: Provider Considerations for Engaging in COVID-19 Vaccine Counseling With Pregnant and Lactating Patients 

SMFM: COVID_Vaccine

SMFM Reaffirms COVID-19 Vaccination Recommendations During Pregnancy

CDC: COVID-19 Vaccines 

ACOG Practice Advisory: COVID-19 Vaccination Considerations for Obstetric–Gynecologic Care 

CDC: Vaccine Adverse Event Reporting System (VAERS) 

mRNA-Based COVID-19 Vaccines Induce Robust, Persistent Immune Responses in Humans

BACKGROUND AND PURPOSE: 

• The mRNA-based COVID-19 vaccines are 95% effective at preventing COVID-19, but immune system dynamics induced by the vaccines are not clear 
• Turner et al. (Nature, 2021) examined antigen-specific B cell responses in peripheral blood and lymph nodes in individuals who received 2 doses of the Pfizer vaccine 

METHODS: 

• Observational study 
• Participants 
  • Healthy US adults who received both doses of Pfizer’s COVID-19 vaccine 
• Study design 
  • Blood samples were collected at baseline (before first dose), and at weeks 3 (pre-second dose), 4, 5, 7, and 15 
  • Fine needle aspirates of the draining axillary lymph nodes were also collected from some participants 
  • An enzyme linked immune absorbent spot assay was used to measure antibody-secreting plasmablasts (cells that differentiate into non-dividing plasma cells [aka antibody-secreting cells]) 

RESULTS

• 41 adults 
  • Evidence of previous SARS-CoV-2 infection: 8 participants 
  • Aspirates collected from lymph nodes: 14 participants 
• Circulating IgG- and IgA-secreting plasmablasts peaked one week after the second dose and then declined | Undetectable 3 weeks later 
  • Plasmablasts exhibited neutralizing activity against the early circulating SARS-CoV-2 strain and emerging variants 
  • Previously infected participants had the most robust serological response 
• Aspirates from the draining axillary lymph nodes identified germinal center B cells that bound the SARS-CoV-2 spike protein in all participants who had received first dose 
  • The draining lymph nodes sustained high levels of spike-binding germinal center B cells and plasmablasts for at least 12 weeks after the second dose 
• Spike-binding monoclonal antibodies derived from germinal center B cells mostly targeted the receptor-binding domain of the spike protein  
  • Fewer clones did cross-react and bind to the N-terminal domain or to epitopes shared with the spike proteins of human betacoronaviruses 
  • These cross-reactive clones had higher levels of somatic hypermutation vs those specific to SARS-CoV-2 spike protein, suggesting a memory B cell origin 

CONCLUSION

• mRNA-based COVID-19 vaccines induce a persistent germinal center B cell response, which leads to robust humoral immunity 
• The authors state 

To our knowledge, this is the first study to provide direct evidence for the induction of a persistent antigen-specific germinal centre B cell response after vaccination in humans 

Elicitation of high affinity and durable protective antibody responses is a hallmark of a successful humoral immune response to vaccination 

By inducing robust germinal centre reactions, SARS-CoV-2 mRNA-based vaccines are on track for achieving this outcome 

Learn More – Primary Sources: 

SARS-CoV-2 mRNA vaccines induce persistent human germinal centre responses 

mRNA COVID-19 Vaccine Safety in Pregnant Women

BACKGROUND AND PURPOSE:

• The clinical trials for mRNA-based COVID-19 vaccines did not include any pregnant women, so safety data in this group was initially limited
  • However, many pregnant women in the general population have since received these vaccines, providing a cohort in which to assess safety data
• Shimabukuro et al. (NEJM, 2021) reported preliminary findings regarding mRNA COVID-19 vaccine safety in pregnant persons from three U.S. vaccine safety monitoring systems

METHODS:

• Setting
  • United States
  • Data from December 14, 2020, to February 28, 2021
• Data sources
  • The “V-safe after vaccination health checker” surveillance system
  • The V-safe pregnancy registry | Telephone-based survey collects detailed information
  • The Vaccine Adverse Event Reporting System (VAERS)
• Primary outcomes
  • Non–pregnancy-specific adverse events
  • Pregnancy- and neonatal-specific adverse events

Note: Pregnancy and neonatal outcomes were derived from patients who enrolled in the registry

RESULTS:

• 35,691 v-safe participants self-identified as pregnant
  • Majority of the participants were
    • Between 25 to 34 years of age | Non-Hispanic White (approximately 75%)
• 3958 participants were enrolled in the registry

Vaccine-related side effects (V-safe)

• Injection-site pain was reported more frequently among pregnant women than among nonpregnant women
• The following were reported less frequently among pregnant women
  • Headache
  • Myalgia
  • Chills
  • Fever

Pregnancy Outcomes

• 827 participants completed pregnancy
  • Live birth: 86.1%
  • Spontaneous abortion: 12.6%
  • Stillbirth (0.1%)
  • Other outcomes (induced abortion and ectopic pregnancy): 1.2% 

Neonatal Outcomes

• Preterm birth: 9.4%
• Small for gestational age: 3.2%
• There were no neonatal deaths

Adverse Events (VAERS)

• 221 reports
  • Nonpregnant related: 70.1%
  • Pregnancy related: 29.9%
• Most frequently reported pregnancy-related adverse events
  • Spontaneous abortion (37 first trimester, 2 second trimester, 7 unknown or not reported)
  • No congenital anomalies (EUA reporting requirement)

CONCLUSION:

• While not directly comparable, the proportions of adverse outcomes in vaccinated women were similar to those reported in studies involving pregnant women before the pandemic
• Further longitudinal study is important, especially in women vaccinated in the first trimester
• The authors conclude that

Early data from the v-safe surveillance system, the v-safe pregnancy registry, and the VAERS do not indicate any obvious safety signals with respect to pregnancy or neonatal outcomes associated with Covid-19 vaccination in the third trimester of pregnancy

Learn More – Primary Sources:

Preliminary Findings of mRNA Covid-19 Vaccine Safety in Pregnant Persons

Does COVID-19 Vaccination in Breastfeeding Women Produce Detectable Levels of Antibodies in Breast Milk?

BACKGROUND AND PURPOSE:

• Breastfeeding women were not included in COVID-19 vaccine trials, so there are limited data on vaccine-related safety in this group
• Perl et al. (JAMA, 2021) investigated whether maternal immunization led to detection of SARS-CoV-2 antibodies in breast milk

METHODS:

• Prospective cohort study
• Setting
  • Israel, between December 23, 2020, and January 15, 2021
• Participants
  • Breastfeeding women (exclusive or partial)
  • Elected to be vaccinated
• Exposure
  • All participants fully vaccinated with Pfizer-BioNTech vaccine
• Study design
  • Participants were recruited through advertisements and social media
  • Breast milk samples were collected
    • Before administration of the vaccine
    • Once weekly for 6 weeks starting at week 2 after the first dose
  • IgG and IgA antibody levels were assessed
  • Weekly questionnaires coupled to breast milk collection asked participants for information about interim well-being and vaccine-related adverse events
• Primary outcomes
  • Presence and levels of SARS-CoV-2 antibodies in breast milk

RESULTS:

• 84 women | 504 breast milk samples
  • Women: mean age 34 years
  • Infants: mean age 10.32 months
• Mean levels of SARS-CoV-2- IgA antibodies in breast milk increased rapidly and remained elevated throughout follow-up
  • 2 weeks after first dose: 61.8% of samples tested positive
  • 4 weeks after first dose: 86.1% of samples tested positive
  • 6 weeks after first dose: 65.7% of samples tested positive
• IgG antibodies remained low for the first 3 weeks, with an increase at week 4, which remained high throughout follow-up
  • 4 weeks after first dose: 91.7% of samples tested positive (P=0.004)
  • 5 and 6 weeks after first dose: 97% of samples tested positive
• Adverse events were experienced by a majority of women, but were generally mild, with local pain being the most common complaint
  • Reported events after the first dose: 55.9% of women
  • Reported events after the second dose: 61.9% of women
• No mother or infant experienced any serious vaccine-related adverse event
• Four infants developed a fever after maternal vaccination

CONCLUSION:

• Both IgA and IgG SARS-CoV-2 antibodies were detected in breast milk of vaccinated mothers
  • IgA presence was evident as early as 2 weeks after the first vaccine dose
  • IgG spiked 4 weeks after the first dose
  • IgA and IgG levels remained elevated throughout the follow-up period
• No major adverse events in mothers or infants were reported
• The authors conclude

Antibodies found in breast milk of these women showed strong neutralizing effects, suggesting a potential protective effect against infection in the infant 

Learn More – Primary Sources:

SARS-CoV-2–Specific Antibodies in Breast Milk After COVID-19 Vaccination of Breastfeeding Women

Potential Pathology Behind AstraZeneca COVID-19 Vaccination and Blood Clots

BACKGROUND AND PURPOSE:

• Schultz et al. (NEJM, 2021) describes 5 cases of severe thrombosis and thrombocytopenia following vaccination with the ChAdOx1 (AstraZeneca) COVID-19 vaccine

METHODS:

• Case reports
• Setting
  • Oslo University Hospital, Norway
• Cases included
  • 5 healthcare workers
  • 32 to 54 years old
• Study design
  • Serum antibodies tested (ELISA)
    • Platelet factor 4 (PF4)-polyanion complexes
    • SARS-CoV-2 spike and nucleocapsid proteins

RESULTS:

• 4 patients had severe cerebral venous thrombosis with intracranial hemorrhage | Fatal in 3 patients
• At time of admission
  • Levels of D-dimer were elevated in all patients
  • Screening for thrombophilia with proteins C and S and antithrombin was negative
• Platelet immunologic testing
  • All five patients had high levels of IgG antibodies to PF4–polyanion complexes
  • Platelets in serum from Patients 1, 3, 4, and 5 were clearly activated in the absence of added heparin
• All patients were negative for SARS-CoV-2 antibodies, suggesting previous infection was unlikely

CONCLUSION:

• 5 individuals developed severe venous thromboembolism in unusual sites and concomitant thrombocytopenia 7 to 10 days after vaccination (AstraZeneca)
• All 5 patients had a high level of antibodies to PF4–polyanion complexes
• The authors suggest

…that these cases represent a vaccine-related variant of spontaneous heparin-induced thrombocytopenia that we refer to as vaccine-induced immune thrombotic thrombocytopenia (VITT)

Learn More – Primary Sources:

Thrombosis and Thrombocytopenia after ChAdOx1 nCoV-19 Vaccination

COVID-19 mRNA Vaccine Effectiveness in the Real World Including in Those Partially Immunized

BACKGROUND AND PURPOSE:

• Both mRNA COVID-19 vaccines (Moderna and Pfizer/BioNTech) have been shown to be effective at preventing symptomatic COVID-19 in phase III trials
• Thompson et al. (CDC MMWR, 2021) quantified SARS-CoV-2 infections among vaccinated, partially-vaccinated, and non-vaccinated essential personnel every week for 12 weeks

METHODS:

• Prospective cohort study (December 14, 2020 to March 13, 2021)
• Setting
  • Eight locations in the US
• Participants
  • Health care personnel | First responders | Other essential and frontline workers
  • No previous laboratory documentation of SARS-CoV-2 infection
• Exposure
  • Vaccination status
    • Fully immunized (≥14 days after second dose)
    • Partially immunized (≥14 days after first dose and before second dose)
    • Unvaccinated
• Study design
  • The CDC tested for SARS-CoV-2 infections
    • Every week regardless of symptom status and
    • At the onset of symptoms consistent with COVID-19–associated illness
  • SARS-CoV-2 infections were confirmed by RT-PCR
• Statistical analysis
  • Authors accounted for time-varying vaccination status
  • Results adjusted for site

RESULTS:

• 3,950 participants with no previous SARS-CoV-2 infection
  • Fully immunized: 62.8%
  • Partially immunized: 12.1%
• SARS-CoV-2 infection
  • Unvaccinated: 1.38 infections per 1,000 person-days
  • Fully immunized: 0.04 infections per 1,000 person-days
  • Partially immunized: 0.19 infections per 1,000 person-days
• Estimated mRNA vaccine effectiveness for prevention of infection
  • Full immunization: 90%
  • Partial immunization: 80%

CONCLUSION:

• Both mRNA COVID-19 vaccines are effective at preventing infection, both symptomatic and asymptomatic, in essential personnel in real world conditions
• The authors conclude

These interim vaccine effectiveness findings for both Pfizer-BioNTech’s and Moderna’s mRNA vaccines in real-world conditions complement and expand upon the vaccine effectiveness estimates from other recent studies and demonstrate that current vaccination efforts are resulting in substantial preventive benefits among working-age adults

They reinforce CDC’s recommendation of full 2-dose immunization with mRNA vaccines

COVID-19 vaccination is recommended for all eligible persons 

Learn More – Primary Sources:

Interim Estimates of Vaccine Effectiveness of BNT162b2 and mRNA-1273 COVID-19 Vaccines in Preventing SARS-CoV-2 Infection Among Health Care Personnel, First Responders, and Other Essential and Frontline Workers — Eight U.S. Locations, December 2020–March 2021

An Update on COVID-19 Vaccine Related Anaphylaxis: Cases Remain Rare

BACKGROUND AND PURPOSE:

• Initial reporting rates of anaphylaxis in the US
  • Moderna: 2.5 cases per million doses (December 14 to 23, 2020)
  • Pfizer-BioNTech: 11.1 cases per million doses (December 21 to January 10, 2021)
• Shimabukuro et al. (JAMA, 2021) provide an update regarding anaphylaxis rates following vaccination

METHODS:

• Data sources
  • Vaccine Adverse Event Reporting System (VAERS)

RESULTS:

• Doses administered in US between December 14, 2020 and January 18, 2021
  • Moderna: 7,581,429 doses
  • Pfizer-BioNTech: 9,943,247 doses
• There were 66 total anaphylaxis cases after vaccine administration
  • Moderna: 19 total cases
    • Reporting rate 2.5 cases per million doses
  • Pfizer-BioNTech: 47 total cases
    • Reporting rate 4.7 cases per million doses
• Anaphylaxis case characteristics
  • Median (range) minutes to symptom onset
    • Moderna: 10 minutes (1 to 45 minutes)
    • Pfizer-BioNTech: 10 minutes (<1 minute to 19 hours)
  • Occurred in persons with a history of allergic reactions
    • Moderna: 84%
    • Pfizer-BioNTech: 77%
  • Occurred in persons with a history of anaphylaxis
    • Moderna: 26%
    • Pfizer-BioNTech: 34%
• No deaths have been reported due to vaccine-related anaphylaxis

CONCLUSION:

• Millions of doses of the Moderna and Pfizer-BioNTech COVID-19 vaccines have been administered in the US
  • Anaphylaxis is a rare event
  • The reporting rate is 2.5 (Moderna) and 4.7 (Pfizer-BioNTech) cases per million doses
• Immediate epinephrine administration is indicated for all cases of anaphylaxis
• The authors conclude

When considered in the context of morbidity and mortality from COVID-19, the benefits of vaccination far outweigh the risk of anaphylaxis, which is treatable 

Learn More – Primary Sources:

Reports of Anaphylaxis After Receipt of mRNA COVID-19 Vaccines in the US—December 14, 2020-January 18, 2021

Vaccination in Pregnancy: Professional Recommendations

CLINICAL ACTIONS:

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 mRNA-derived vaccines, inactivated virus vaccines, bacterial vaccines, or toxoids

Recommended for all women

Tdap (Tetanus, Diphtheria and Pertussis)

• Vaccinate as early in the 27 to 36 week 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 to 36 weeks gestation
• Health-care personnel should administer a dose of Tdap during each pregnancy irrespective of the patient’s prior history of receiving Tdap

Influenza (inactivated or recombinant)

• Routine influenza vaccination (inactivated influenza vaccine or recombinant influenza vaccine) is strongly recommended for all women who are or will become pregnant (in any trimester) during influenza season
• Live-attenuated intranasally administered vaccine
  • Not approved for use in pregnancy
  • Can be used in the postpartum period, including if breastfeeding
• In the United States, usually September through late April | Vaccine should be administered as soon as possible
  • Benefit to mother as well as passive immunity for newborn
• Safe to administer at the same time with other vaccines
• If patient declines flu vaccine during pregnancy, encourage postpartum
  • Benefits patient and infants still received passive immunity if breast feeding
• If patient presents with signs and symptoms of respiratory illness consider
  • Influenza
  • COVID-19
  • RSV
• If flu suspected during pregnancy
  • begin empiric antiviral treatment ASAP | Optimal within 48 hours
  • Do not wait for lab results to return prior to starting antiviral meds | Treat regardless of maternal vaccination status

Respiratory Syncytial Virus (RSV)

• Single dose between 32w0d and 36w6d
  • No planned delivery within 2 weeks
  • Given seasonally in first pregnancy
    • Did not receive RSV vaccine during previous pregnancy
    • Administered September through January
  • Not planning to have infant receive monoclonal antibody (nirsevimab or clesrovimab)
• For prevention of RSV lower respiratory tract infection in infants
• May be administered with other vaccines routinely advised for use during pregnancy
• Immediate protection for infant if maternal vaccination at least 14 days before birth

Note: Two monoclonal antibodies (nirsevimab or clesrovimab) are available for infants if maternal RSV vaccination has not occurred or vaccine was given but delivery was prior to 34 weeks | Monoclonal antibody is considered safe and effective for the prevention of RSV in infants | ACOG recommends that patients should be counseled regarding monoclonal antibodies as an alternative at birth including whether the antibodies will be available

• Key Counseling points
  • Maternal RSV Vaccine Benefits: Newborn has immediate protection at birth | Fewer vaccines required at birth
  • Monoclonal Antibody Benefits: Protection may last longer | Direct placental delivery vs passive transfer
  • Infant monoclonal antibody should offered in subsequent pregnancies if patient already received vaccine
  • FDA’s January 2025 requirement for safety labeling describing an increased risk of Guillain-Barré syndrome (GBS) with Abrysvo (only approved RSV vaccine in pregnancy)
    • Based on observational studies in patients ≥65 years | Not reported following vaccination in pregnancy

Note: COVID-19 is also routinely recommended during pregnancy – See section below for more details

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)

• Review vaccination history
• Pregnancy is not a contraindication to vaccination
• Available vaccines contain noninfectious HBsAg and should cause no risk of infection to the fetus
• If pregnant and not already vaccinated: Vaccinate with HepB since all adults 19 through 59 years of age are recommended to receive HepB vaccination

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

Pneumococcal vaccination

• ACOG recommends the following pneumococcal vaccines may be given to pregnant individuals at high risk of severe illness from pneumococcal disease
  • Pneumococcal conjugate vaccines: PCV15 and PCV20
  • Pneumococcal polysaccharide vaccine: PPSV23
• CDC recommends that individuals aged 19 to 64 years with certain underlying medical conditions or other risk factors who have not previously received PCV or whose previous vaccination history is unknown should receive 1 dose of PCV (either PCV20 or PCV15) and if PCV15 is used, it should be followed by a dose of PPSV23
• High risk includes
  • Alcoholism | Chronic heart disease | Chronic liver disease | Chronic lung disease | Cigarette smoking | Diabetes mellitus | Cochlear implant | CSF leak | Congenital or acquired asplenia | Sickle cell disease or other hemoglobinopathies | Chronic renal failure | Congenital or acquired immunodeficiencies | Generalized malignancy | HIV infection | Hodgkin disease | Iatrogenic immunosuppression | Leukemia | Lymphoma | Multiple myeloma | Nephrotic syndrome | Solid organ transplant

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
• Can be initiated while breastfeeding and during postpartum period

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.

COVID-19

• ACOG addresses the topic of COVID-19 vaccination in pregnancy and recommends that

ACOG strongly recommends that all eligible persons receive a COVID-19 vaccine or vaccine series. Obstetrician-gynecologists and other women’s health care practitioners should lead by example by being vaccinated and encouraging eligible patients to be vaccinated as well
ACOG recommends that pregnant individuals be vaccinated against COVID-19
ACOG recommends that lactating individuals be vaccinated against COVID-19
While a conversation with a clinician may be helpful, it is not a requirement prior to vaccination, as this may cause unnecessary barriers to access

Note: For additional information on this topic, see ‘Learn More – Primary Sources’ and ‘Related ObG Topics’, below

KEY POINTS:

• ACOG has updated recommendations to include hepatitis B vaccination for all unvaccinated pregnant adults and pneumococcal vaccination for pregnant individuals at increased risk of severe pneumococcal disease
• Contraindications to vaccination include a history of a serious reaction or anaphylaxis to a previous vaccine or component of a vaccine
• 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: The Epidemiology and Prevention of Vaccine-Preventable Diseases (Pink Book)

CDC: Guidelines for Vaccinating Pregnant Women

ACOG Committee Statement 26: Maternal Immunizations

ACOG Practice Advisory: Influenza in Pregnancy: Prevention and Treatment

ACOG Practice Advisory: Maternal Respiratory Syncytial Virus Vaccination

ACOG: Maternal RSV Vaccination FAQs 

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

ACOG: Immunization, Infectious Disease, and Public Health Preparedness Program

ACOG Practice Advisory: Vaccinating Pregnant and Lactating Patients Against COVID-19

ACOG Statement on HHS Recommendations Regarding the COVID Vaccine During Pregnancy

SMFM: RSV Toolkit