Vaccination in Pregnancy: Professional Recommendations

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)

• 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 – 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

Note: Do not wait for lab results to return prior to starting antiviral meds | Treat regardless of maternal vaccination status

Hepatitis B (HepB)

• 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

Respiratory Syncytial Virus (RSV)

• Single dose between 32w0d and 36w6d
  • No planned delivery within 2 weeks
  • Did not receive RSV vaccine during previous pregnancy
  • Not planning to have infant receive monoclonal antibody (nirsevimab or clesrovimab)
• For prevention of RSV lower respiratory tract infection in infants
• Use seasonal administration (September through January)
• 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
  • 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

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

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

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: Pregnancy Guidelines and Recommendations by Vaccine

ACIP: Use of 15-Valent Pneumococcal Conjugate Vaccine and 20-Valent Pneumococcal Conjugate Vaccine Among U.S. Adults)

ACOG Committee Opinion 741: Maternal Immunization

ACOG Practice Advisory: Influenza in Pregnancy: Prevention and Treatment

ACOG Practice Advisory: Maternal Respiratory Syncytial Virus Vaccination

ACOG: Maternal RSV Vaccination FAQs 

Vaccine Adverse Event Reporting System

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

ACOG Practice Advisory: Maternal Immunization

SMFM: RSV Toolkit